Citation Nr: 18147696 Decision Date: 11/06/18 Archive Date: 11/05/18 DOCKET NO. 16-40 651 DATE: November 6, 2018 ORDER A timely notice of disagreement (NOD) was not received on August 13, 2015 with regard to ratings in excess of 10 percent for peripheral neuropathy of the right and left lower extremities. A timely NOD was not received on August 13, 2015 with regard to service connection for a left knee disorder. A timely NOD was not received on August 13, 2015 with regard to whether new and material evidence has been received to reopen a previously denied claim of service connection for a right knee disorder. As new and material evidence has been received, the claim of entitlement to service connection for a right knee disorder is reopened. Service connection for bilateral eye disorder (other than service-connected diabetic retinopathy) as secondary to service-connected diabetes mellitus, type II, is granted. A rating in excess of 20 percent for diabetes mellitus, type II, with associated erectile dysfunction and diabetic retinopathy is denied. REMANDED Entitlement to service connection for a right knee disorder is remanded. Entitlement to service connection for a left knee disorder is remanded. Entitlement to service connection for Alzheimer’s, to include as due to herbicide exposure or secondary to a service-connected disability, is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. Entitlement to special monthly compensation (SMC) based on a need for regular aid and attendance of another person is remanded. Entitlement to SMC based on being housebound is remanded. FINDINGS OF FACT 1. In an April 2007 VA rating decision, service connection for peripheral neuropathy of the right and left lower extremities was granted. 2. In December 2011 and June 2013 VA rating decisions, the claims for ratings in excess of 10 percent for peripheral neuropathy of the right and left lower extremities were denied; the Veteran was notified of these actions and of his appellate rights and filed a timely NOD in February 2014; the RO issued a SOC in July 2014; and the Veteran submitted a timely substantive appeal in July 2014. 3. In a February 2015 written correspondence, prior to the promulgation of a decision in the appeal, the Veteran withdrew the claims for ratings in excess of 10 percent for peripheral neuropathy of the right and left lower extremities. 4. There was no pending VA rating decision for ratings in excess of 10 percent for peripheral neuropathy of the right and left lower extremities at the time of the Veteran’s submission of the August 13, 2015 NOD. 5. There was no pending VA rating decision for service connection for a left knee disorder at the time of the Veteran’s submission of the August 13, 2015 NOD. 6. In a September 2007 Board decision, the claim for entitlement to service connection for a right knee disorder was denied. 7. In an August 2010 VA rating decision, the claim to reopen service connection for a right knee disorder was denied; the Veteran was notified of this action and of his appellate rights and filed a timely NOD in August 2010; the Regional Office (RO) issued a statement of the case (SOC) in April 2012; and the Veteran submitted a timely substantive appeal in May 2012. 8. In a February 2015 written correspondence, prior to the promulgation of a decision in the appeal, the Veteran withdrew the claim to reopen service connection for a right knee disorder. 9. There was no pending VA rating decision to reopen a previously denied claim of service connection for a right knee disorder at the time of the Veteran’s submission of the August 13, 2015 NOD. 10. The evidence received since the August 2010 VA rating decision regarding service connection for a right knee disorder is not cumulative or redundant and raises the possibility of substantiating the claim. 11. The Veteran’s current bilateral eye disorder, diagnosed as pseudophakia, is as likely as not caused by his service-connected diabetes mellitus, type II. 12. For the entire rating period, the Veteran’s service-connected diabetes mellitus, type II, with associated erectile dysfunction and diabetic retinopathy has not been manifested by the requirement of insulin, restricted diet, and regulation of activities nor has erectile dysfunction been manifested by penile deformity with loss of erectile power. CONCLUSIONS OF LAW 1. A timely NOD was not received on August 13, 2015 with regard to ratings in excess of 10 percent for peripheral neuropathy of the right and left lower extremities. 38 U.S.C. § 7105 (2012); 38 C.F.R. §§ 20.200, 20.201(b), 20.204 (2018). 2. A timely NOD was not received on August 13, 2015 with regard to service connection for a left knee disorder. 38 U.S.C. § 7105; 38 C.F.R. §§ 20.200, 20.201(b). 3. A timely NOD was not received on August 13, 2015 with regard to whether new and material evidence has been received to reopen a previously denied claim of service connection for a right knee disorder. 38 U.S.C. § 7105; 38 C.F.R. §§ 20.200, 20.201(b), 20.204. 4. The September 2007 Board decision, decision denying entitlement to service connection for a right knee disorder is final. 38 U.S.C. § 7104 (2012); 38 C.F.R. §§ 3.104, 20.302, 20.1100 (2018). 5. The August 2010 VA rating decision denying the reopening of entitlement to service connection for a right knee disorder is final. 38 U.S.C. § 7105(b), (d); 38 C.F.R. §§ 3.104, 20.302, 20.1103 (2018). 6. New and material evidence has been received since the August 2010 VA rating decision to reopen the claim for service connection for a right knee disorder. 38 U.S.C. §§ 1110, 5108, 7104(b) (2012); 38 C.F.R. §§ 3.156, 3.303 (2018). 7. With resolution of reasonable doubt in the Veteran’s favor, the criteria for entitlement to service connection for a bilateral eye disorder (other than service-connected diabetic retinopathy) as secondary to service-connected diabetes mellitus, type II, have been met. 38 U.S.C. § 5107 (2012); 38 C.F.R. §§ 3.102, 3.310 (2018). 8. The criteria for entitlement to a rating in excess of 20 percent for diabetes mellitus, type II, with associated erectile dysfunction and diabetic retinopathy have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.21, 4.31, 4.115b, Diagnostic Code 7522, 4.119, Diagnostic Code 7913 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Navy from June 1961 to June 1962 and in the United States Army from June 1962 to June 1965. In an August 2016 substantive appeal, VA Form 9, the Veteran requested a hearing before the Board for the issues on appeal for timeliness of NOD and service connection for bilateral knee and eye disorders. In an April 2017 written brief, the Veteran’s representative reiterated the Veteran’s request for a hearing before the Board for these issues on appeal. Most recently, in a September 2018 written brief, the Veteran’s representative clarified the April 2017 correspondence was in error and requested the Board proceed with review of the appeal based on the written record. Accordingly, his request for a hearing is considered withdrawn. 38 C.F.R. § 20.704(d) (2018). Before reaching the merits of the claim for a right knee disorder, the Board must first determine whether new and material evidence has been received to reopen this previously denied claim. Jackson v. Principi, 265 F.3d 1366, 1369 (Fed. Cir. 2001). Therefore, the Board has recharacterized this issue accordingly. Neither the Veteran nor his representative has raised any other issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that “the Board’s obligation to read filings in a liberal manner does not require the Board... to search the record and address procedural arguments when the veteran fails to raise them before the Board.”); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Timeliness of NOD An appeal consists of a timely filed NOD, and, after a Statement of the Case has been furnished, a timely filed substantive appeal. 38 U.S.C. § 7105; 38 C.F.R. § 20.200. In cases where a form was not provided by the Agency of Original Jurisdiction (AOJ) for the purpose of initiating an appeal, a notice of disagreement is a written communication from a claimant expressing dissatisfaction or disagreement with an adjudicative determination by the AOJ and a desire to contest the result. 38 C.F.R. § 20.201(b). 1. Whether a timely NOD was received on August 13, 2015 with regard to ratings in excess of 10 percent for peripheral neuropathy of the right and left lower extremities In an April 2008 VA rating decision, the AOJ, in part, granted service connection for peripheral neuropathy of the right and left lower extremities, each assigned at 10 percent disabling effective from September 5, 2007. The Veteran was notified of this action and of his appellate rights, and while he submitted a June 2008 statement disagreeing with the April 2008 VA rating decision, he specified in a subsequent June 2008 VA Form 21-4138 that he disagreed with the proposed reduction for his service-connected hypertension. As such, the Board finds the Veteran did not file a timely NOD with the April 2008 VA rating decision for higher initial ratings for peripheral neuropathy of the right and left lower extremities, or submit new and material evidence within a year thereafter. Therefore, the April 2008 VA rating decision is final. See 38 U.S.C. § 7105(b), (d); 38 C.F.R. §§ 20.302, 20.1103. In August 2010, the Veteran requested higher ratings for his service-connected peripheral neuropathy of the right and left lower extremities. In December 2011 and June 2013 VA ratings decisions, ratings in excess of 10 percent were denied. The Veteran was notified of these actions and of his appellate rights and filed a timely NOD in February 2014. The RO issued a SOC in July 2014, and the Veteran submitted a timely substantive appeal in July 2014. In a February 2015 written correspondence, prior to the promulgation of a decision by the Board, the Veteran withdrew these claims. See 38 C.F.R. § 20.204. Therefore, the June 2013 VA rating decision is final. See 38 U.S.C. § 7105(b), (d); 38 C.F.R. §§ 20.302, 20.1103. On August 13, 2015, the Veteran’s submission of a VA Form 21-0958 (NOD) was obtained and associated with the record. The Veteran raised the issue of higher ratings for his service-connected peripheral neuropathy of the right and left lower extremities. After review of the record, the Board finds that there was no pending VA rating decision for higher ratings for his service-connected peripheral neuropathy of the right and left lower extremities at the time of the Veteran’s submission of the August 13, 2015 NOD. Moreover, the August 13, 2015 NOD cannot serve to reinstate the withdrawn appeal in February 2015. See 38 C.F.R. § 20.204. As a result, a timely NOD was not received on August 13, 2015 with regard to ratings in excess of 10 percent for peripheral neuropathy of the right and left lower extremities. 2. Whether a timely NOD was received on August 13, 2015 with regard to service connection for a left knee disorder On August 13, 2015, the Veteran’s submission of a VA Form 21-0958 (NOD) was obtained and associated with the record. The Veteran raised the issue of service connection for a left knee disorder. After review of the record, the Board finds that there was no pending VA rating decision for service connection for a left knee disorder at the time of the Veteran’s submission of the August 13, 2015 NOD. As a result, a timely NOD was not received on August 13, 2015 with regard to service connection for a left knee disorder. 3. Whether a timely NOD was received on August 13, 2015 with regard to whether new and material evidence has been received to reopen a previously denied claim of service connection for a right knee disorder In the September 2007 Board decision, service connection for a right knee disorder was denied because the preponderance of the probative medical evidence did not show the Veteran’s right knee disorder was due to any event or incident of service and arthritis did not manifest to a compensable degree within one year following his separation from active service. The Veteran was notified of this action and of his appellate rights, but did not file an appeal for the September 2007 Board decision. Therefore, the September 2007 Board decision is final. See 38 U.S.C. § 7105(b), (d); 38 C.F.R. §§ 20.302, 20.1103. In a September 2009 VA Form 9, the Veteran raised the issue of reopening service connection for a right knee disorder. In an August 2010 VA rating decision, the claim to reopen service connection for a right knee disorder was denied because new and material evidence had not been received. The Veteran was notified of this action and of his appellate rights and filed a timely NOD in August 2010. The RO issued a SOC in April 2012, and the Veteran submitted a timely substantive appeal in May 2012. In a February 2015 written correspondence, prior to the promulgation of a decision by the Board, the Veteran withdrew the claim. See 38 C.F.R. § 20.204. Therefore, the August 2010 VA rating decision is final. See 38 U.S.C. § 7105(b), (d); 38 C.F.R. §§ 20.204, 20.302, 20.1103. On August 13, 2015, the Veteran’s submission of a VA Form 21-0958 (NOD) was obtained and associated with the record. The Veteran raised the issue of reopening service connection for a right knee disorder. After review of the record, the Board finds that there was no pending VA rating decision to reopen a previously denied claim of service connection for a right knee disorder at the time of the Veteran’s submission of the August 13, 2015 NOD. Moreover, the August 13, 2015 NOD cannot serve to reinstate the withdrawn appeal in February 2015. As a result, a timely NOD was not received on August 13, 2015 with regard to whether new and material evidence has been received to reopen a previously denied claim of service connection for a right knee disorder. New and Material 4. Whether new and material evidence has been received to reopen a previously denied claim of service connection for a right knee disorder The Board has no jurisdiction to consider a claim based on the same factual basis as a previously disallowed claim. 38 U.S.C. § 7104(b); King v. Shinseki, 23 Vet. App. 464 (2010); DiCarlo v. Nicholson, 20 Vet. App. 52, 55 (2006). However, the finality of a previously disallowed claim can be overcome by the submission of new and material evidence. See 38 U.S.C. § 5108. New evidence means existing evidence not previously submitted to agency decision makers. Evidence that is merely cumulative of other evidence in the record cannot be new and material even if that evidence had not been previously presented to the Board. Anglin v. West, 203 F.3d 1343 (Fed. Cir. 2000). Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). Evidence received since the August 2010 VA rating decision includes August 2015 VA Form 21-0958, September 2015 VA Form 21-526EZ, January 2016 VA Form 21-0958, August 2016 VA Form 9, and September 2016 VA Form 9, which document the Veteran’s repeated assertions of an additional right knee injury during his second period of active service while on a parachute jump at Fort Bragg in North Carolina. The Board finds that this evidence is new and material to the element of establishing an additional in-service occurrence, which was not considered at the time of the August 2010 VA rating decision. As a result, this claim is reopened. 38 U.S.C. §§ 1110, 5108; 38 C.F.R. §§ 3.156(a), 3.303. Service Connection 5. Entitlement to service connection for bilateral eye disorder (other than service-connected diabetic retinopathy) Service connection may be established on a secondary basis for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Secondary service connection may also be established for a nonservice-connected disability which is aggravated by a service-connected disability. In such an instance, a veteran may be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. 38 C.F.R. § 3.310(b); see Allen v. Brown, 7 Vet. App. 439, 448 (1995). In order to establish entitlement to service connection on a secondary basis, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical evidence establishing a nexus between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). In an August 2001 VA rating decision, service connection for diabetes mellitus, type II, was granted. In September 2015, the Veteran requested service connection for a bilateral eye disorder (other than service-connected diabetic retinopathy). Review of the record during the appeal period shows that a June 2016 VA DBQ examination report for eye conditions included a diagnosis of bilateral pseudophakia, which the examiner noted as a new and separate condition. Following the clinical evaluation and accurate review of the Veteran’s medical history, the VA examiner explained why the Veteran’s of bilateral pseudophakia is most likely caused by or a result of his diabetes mellitus. There is no probative contrary medical opinion of record. For the reasons and bases discussed above and after resolving all reasonable doubt in favor of the Veteran, the Board finds that the Veteran’s current bilateral pseudophakia is secondary to his service-connected diabetes mellitus, type II, thus service connection is warranted for a bilateral eye disorder (other than service-connected diabetic retinopathy). See 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 3.310. Increased Rating 6. Entitlement to a rating in excess of 20 percent for diabetes mellitus, type II Disability ratings are determined by applying the criteria set forth in VA’s Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When reasonable doubt arises as to the degree of disability, such doubt will be resolved in the veteran’s favor. 38 C.F.R. § 4.3. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, such as for the service-connected diabetes mellitus, type II, in this case, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability to make a more accurate evaluation, the regulations do not give past medical reports precedence over current findings. 38 C.F.R. § 4.2; Francisco v. Brown, 7 Vet. App. 55, 58 (1994). As noted above, in the August 2001 VA rating decision, service connection for diabetes mellitus, type II, was granted based on presumptive exposure to herbicides during his service in Vietnam. The Veteran was assigned a 40 percent disability rating effective from July 9, 2001. See 38 C.F.R. § 4.119, Diagnostic Code 7913. In an April 2008 VA rating decision, the 40 percent disability rating was continued. Id. In an April 2015 VA rating decision, the disability rating was decreased to 20 percent, effective from July 1, 2015. Id. While the Veteran submitted a timely NOD in April 2015 and the RO issued a SOC in January 2016, the Veteran did not submit a timely substantive appeal. Therefore, the April 2015 VA rating decision is final. See 38 C.F.R. § 20.302 (2018). In May 2016, VA initiated a routine examination of the Veteran’s service-connected diabetes mellitus, type II. On June 1, 2016, the Veteran underwent a VA DBQ examination for diabetes mellitus. As such, the Board considers whether a rating in excess of 20 percent for diabetes mellitus, type II, is warranted at any time since June 1, 2016. Relevant to this appeal, the criteria for rating diabetes are “successive.” Camacho v. Nicholson, 21 Vet. App. 360, 366 (2007). “Successive” criteria exist where the evaluation for each higher disability rating includes the criteria of each lower disability rating, such that if a component is not met at any one level, the Veteran can only be rated at the level that does not require the missing component. Tatum v. Shinseki, 23 Vet. App. 152, 156 (2008). Here, the Veteran’s Type II diabetes mellitus is rated as 20 percent disabling, which requires either insulin or an oral hypoglycemic agent and a restricted diet. 38 C.F.R. § 4.119, Diagnostic Code 7913. The next-higher evaluation, 40 percent, requires insulin, a restricted diet, and regulation of activities. Id. The term “regulation of activities” is specifically defined as “avoidance of strenuous occupational and recreational activities.” Camacho, 21 Vet. App. at 363. Medical evidence is required to support this criterion for a 40 percent rating. Id. at 364. In other words, a medical provider must indicate that the claimant’s “diabetes is of such severity that he should curtail his activities such as to avoid strenuous activity.” Id. Although VA regulations under 38 C.F.R. §§ 4.7, 4.21 generally provide that symptoms need only more nearly approximate the criteria for a higher rating in order to warrant such a rating, those regulations do not apply where the rating schedule establishes successive criteria. Complications of diabetes mellitus are to be evaluated separately unless they are part of the criteria used to support a 100 percent evaluation. Noncompensable (0 percent) complications are considered part of the diabetic process under Diagnostic Code 7913. 38 C.F.R. § 4.119, Diagnostic Code 7913, Note (1). In this case, service connection was granted for erectile dysfunction in April 2008 and for diabetic retinopathy in December 2011, both as secondary to service-connected diabetes mellitus, type II, and assigned as noncompensable. As such, the RO characterized this service-connected disability as diabetes mellitus, type II, with (noncompensable) associated erectile dysfunction and diabetic retinopathy. Pursuant to the rating criteria for the genitourinary system, deformity of the penis with loss of erectile power warrants a compensable 20 percent rating, the only and maximum available. 38 C.F.R. § 4.115b, Diagnostic Code 7522. Where the schedular criteria does not provide for a noncompensable rating, such a rating shall be assigned when the requirements for a compensable rating are not met. 38 C.F.R. § 4.31. The Board notes that in the April 2008 VA rating decision, service connection for peripheral neuropathy of the right and left lower extremities as secondary to service-connected diabetes mellitus, type II, was also granted, each assigned at 10 percent disabling. The issue of entitlement to higher ratings for these service-connected disabilities is not currently on appeal and will not be considered in this case. Review of the evidentiary record since June 1, 2016 documents the following symptomatology of diabetes mellitus, type II, with associated erectile dysfunction and diabetic retinopathy. Upon clinical evaluation at the June 1, 2016 VA DBQ examination for diabetes mellitus, the examiner noted the Veteran’s current treatment included prescribed oral medication and insulin injection more than once per day, and the Veteran does not require regulation of activities as part of his medical management of diabetes mellitus. Review of his medical history noted monthly or less often frequency of visits to a diabetic care provider for episodes of ketoacidosis and hypoglycemia, and there were no findings of hospitalizations for episodes of ketoacidosis or hypoglycemia over the past 12 months nor progressive unintentional weight loss or loss of strength attributable to diabetes mellitus. The VA examiner further noted diabetic peripheral neuropathy and erectile dysfunction as recognized complications of the Veteran’s diabetes mellitus. On June 1, 2016, the Veteran also underwent a VA DBQ examination for male reproductive system conditions. The Veteran reported his condition persists and is unable to attain an erection without medication. The VA examiner noted the Veteran’s current treatment plan does not including taking continuous medication for erectile dysfunction there were no findings of penile deformity upon clinical evaluation. On June 13, 2016, the Veteran underwent a VA DBQ examination for eye conditions. Following the clinical evaluation, the VA examiner concluded there were no findings of diabetic retinopathy on evaluation. VA treatment records dated since June 1, 2016 of record show ongoing treatment for diabetes mellitus, type II, and are silent for any indication that his activities are regulated as a result of the service-connected diabetes mellitus, type II, nor any penile abnormality or diabetic retinopathy. After review of the evidence of record discussed above, the Board finds the most probative evidence of record does not show a regulation of activities due to diabetes mellitus at any time during the appeal period. Moreover, separate compensable ratings for the associated erectile dysfunction and diabetic retinopathy are not warranted at any time during the appeal period. The June 2016 VA DBQ examination reports are probative as the examiners reviewed the claims file, considered the Veteran’s medical history and lay statements, and provided sufficient rationale for the conclusions provided. Accordingly, these reports are found to carry a higher weight than the Veteran’s reported effects of his diabetes mellitus, type II, on his daily activities, erectile dysfunction, and diabetic retinopathy. As such, the Board finds that a rating in excess of 20 percent for the service-connected diabetes mellitus, type II, to include consideration of separate compensable ratings for associated erectile dysfunction and diabetic retinopathy, is not warranted in this case. See 38 C.F.R. §§ 4.31, 4.115b, Diagnostic Code 7522, 4.119, Diagnostic Code 7913. The Board considers the Veteran’s reported history of symptomatology related to the service-connected diabetes mellitus, type II, with associated erectile dysfunction and diabetic retinopathy. He is competent to report such symptoms and observations because this requires only personal knowledge as it comes through one’s senses. Layno v. Brown, 6 Vet. App. 465, 470 (1994). In this case, although the descriptions of his symptoms are competent and credible, they do not show that the criteria for a higher rating for his diabetes mellitus, type II, have been met. Kahana v. Shinseki, 24 Vet. App. 428 (2011). In this case, competent evidence concerning the nature and extent of the Veteran’s disability has been provided in the medical evidence of record. As such, the Board finds these records to be more probative than the Veteran’s subjective reported worsened symptomatology. See Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991). The Board has considered the possibility of staged ratings and finds that the proper rating for diabetes mellitus, type II, with associated erectile dysfunction and diabetic retinopathy has been in effect for the entire appeal period. Accordingly, staged ratings are inapplicable. See Hart v. Mansfield, 21 Vet. App. 505 (2007). REASONS FOR REMAND 1. Entitlement to service connection for a right knee disorder 2. Entitlement to service connection for a left knee disorder Due to the similar dispositions for the claims on appeal, the Board will address them in a common discussion below. Review of the Veteran’s service personnel records shows he completed Army Airborne Course at Fort Benning in Georgia in February 1963. During the course of the appeal, the Veteran underwent a VA DBQ examination for knee and lower leg conditions in June 2016. Following the clinical evaluation, the VA examiner rendered a diagnosis of bilateral knee joint osteoarthritis; however, a medical opinion regarding the etiology of this diagnosis on a direct basis was not provided, to include consideration of the Veteran’s assertions of injury during his second period of active service while on a parachute jump at Fort Bragg in North Carolina. Additionally, the Board notes the Veteran’s assertion of service connection for a left knee disorder as due to his right knee injury. As such, the Board finds that additional development is needed to determine the etiology of the Veteran’s right knee and left knee disorders. See 38 U.S.C. § 1110; 38 C.F.R. §§ 3.303, 3.310; McLendon v. Nicholson, 20 Vet. App. 79 (2006). 3. Entitlement to service connection for Alzheimer’s, to include as due to herbicide exposure or secondary to a service-connected disability In September 2015, the Veteran requested service connection for Alzheimer’s due to his exposure to Agent Orange while in Vietnam during active service and/or a service-connected disability. During the appeal period, the RO noted in the October 2016 VA rating decision that the evidence of record showed current symptoms of Alzheimer’s. Review of VA treatment records document the Veteran’s daughter’s observations and concern regarding his memory. Additionally, the Veteran reported having memory problems in an August 2016 VA Form 21-2680 (Examination for Housebound or permanent need for regular Aid and Attendance). The Board acknowledges that while the Veteran’s in-service herbicide exposure has been conceded by VA, Alzheimer’s is not listed or contemplated among the diseases associated with certain herbicide agents under 38 C.F.R. § 3.309(e), thus consideration of service connection for Alzheimer’s on a presumptive basis due to herbicide exposure is not warranted in this case. Nevertheless, the Board finds that additional development is needed to determine the existence and etiology of the Veteran’s claimed Alzheimer’s on direct and secondary bases. See 38 U.S.C. § 1110; 38 C.F.R. §§ 3.303, 3.310; McLendon, 20 Vet. App. at 79. 4. Entitlement to a TDIU 5. Entitlement to SMC based on a need for regular aid and attendance of another person 6. Entitlement to SMC based on being housebound Due to the similar dispositions for the claims on appeal, the Board will address them in a common discussion below. During the course of the appeal, the Veteran contends, in part, that his bilateral knee and eye disorders prevent him from securing or following any substantially gainful occupation and restrict his activities and functions. While the Board remands the case for additional evidentiary development for the issues of entitlement to service connection for right and left knee disorders, as discussed above, that decision may impact these claims for TDIU and SMC based on a need for regular aid and attendance and/or being housebound. As such, these issues are inextricably intertwined. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). The matters are REMANDED for the following actions: 1. Return the Veteran’s claims file to the examiner who conducted the June 2016 VA DBQ examination for knee and lower leg conditions so a supplemental opinion may be provided. If that examiner is no longer available, provide the Veteran’s claims file to a similarly qualified clinician. The entire claims file and a copy of this remand must be made available to the examiner for review, and the examiner must specifically acknowledge receipt and review of these materials in any reports generated. A new examination is only required if deemed necessary by the examiner. The examiner must provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s right and left knee disorders (diagnosed as bilateral osteoarthritis) began during active service, is related to an incident of service, to include parachute jumps during active service, or began within one year after discharge from active service. If, and only if, a positive opinion was provided for the right knee disorder and a negative opinion was provided for the left knee disorder, the examiner must also opine as to the following: (a.) Whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s left knee disorder was proximately due to or the result of his right knee disorder. (b.) Whether it is at least as likely as not that the Veteran’s left knee disorder was aggravated beyond its natural progression by his right knee disorder. The examiner must provide all findings, along with a complete rationale for his or her opinion(s) in the examination report. If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such conclusion. 2. Schedule the Veteran for an examination with an appropriate clinician for his claimed Alzheimer’s. The entire claims file and a copy of this remand must be made available to the examiner for review, and the examiner must specifically acknowledge receipt and review of these materials in any reports generated. The examiner must opine as to the following: (a.) Whether the Veteran has been diagnosed with a current disability attributable to any memory impairment at any time since September 2014. (b.) If a current disability exists, whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s disability began during active service or is related to an incident of service, to include herbicide exposure. (c.) Whether it is at least as likely as not that the Veteran’s disability was proximately due to or the result of a service-connected disability, to include any medication taken therefore. (d.) Whether it is at least as likely as not that disability was aggravated beyond its natural progression by a service-connected disability, to include any medication taken therefore. The Veteran is currently service-connected for the following disabilities: PTSD, coronary artery disease, diabetes mellitus, type II, peripheral neuropathy of the bilateral lower extremities, and hypertension. The examiner must provide all findings, along with a complete rationale for his or her opinion(s) in the examination report. If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such conclusion. 3. Then, review the examination reports and medical opinions to ensure that the requested information was provided. If any report or opinion is deficient in any manner, the AOJ must implement corrective procedures. 4. Then, readjudicate the claims. If any decision is adverse to the Veteran, issue a Supplemental Statement of the Case and allow the applicable time for response. Then, return the case to the Board. D.C. SPICKLER Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD T. Carter, Counsel