Citation Nr: 18149286 Decision Date: 11/09/18 Archive Date: 11/09/18 DOCKET NO. 12-25 480 DATE: November 9, 2018 ORDER The issue of entitlement to service connection for numbness and tingling of the hands and feet, to include as due to herbicide exposure, is denied. The issue of entitlement to service connection for a heart disability, to include ischemic heart disease, to include as due to herbicide exposure, is denied. The issue of entitlement to special monthly compensation (SMC) based on the need for aid and attendance or on account of being housebound is denied. FINDINGS OF FACT 1. The Veteran’s numbness and tingling of the hands and feet did not manifest to a compensable degree within an applicable presumptive period; continuity of symptomatology is not established; and the disability is not otherwise etiologically related to an in-service injury, event, or disease, including herbicide exposure. 2. The most probative competent evidence does not demonstrate that the Veteran has a heart disability, to include ischemic heart disease, etiologically related to service. 3. As a result of service-connected disability, the Veteran is not blind or nearly blind in both eyes; is not institutionalized in, or confined to, a nursing home or other facility due to physical or mental incapacity; and does not need regular aid and attendance to perform activities necessary for daily living. He is not permanently and substantially confined to his immediate premises due solely to service-connected disability. CONCLUSIONS OF LAW 1. The criteria for service connection for numbness and tingling of the hands and feet, to include as due to herbicide exposure, are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1137, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a)-(b), (d), 3.307, 3.309(a). 2. The criteria for service connection for a heart disability, to include as due to herbicide exposure, are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1137, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a)-(b), (d), 3.307, 3.309(a). 3. The criteria for SMC based on the need for the regular aid and attendance of another person or based on housebound status have not been met. 38 U.S.C. §§ 1114, 5107; 38 C.F.R. §§ 3.350, 3.352. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The appellant is a Veteran who served on active duty from March 1968 to April 1970. These matters are before the Board of Veterans’ Appeals (Board) on appeal from December 2009 and December 2010 rating decisions of the Phoenix, Arizona, Department of Veterans Affairs (VA) Regional Office (RO). The Board remanded this claim in August 2016 and August 2017.   Service Connection 1. Entitlement to service connection for numbness and tingling of the hands and feet, to include as due to herbicide exposure. The Veteran contends that he has numbness and tingling of the hands and feet due to active duty, to include exposure to herbicide. The question for the Board is whether the Veteran has a current disability related to numbness and tingling of the hands and feet that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that, while the Veteran has current numbness and tingling of the hands and feet, and in-service exposure to herbicide is presumed, the preponderance of the evidence weighs against finding that this numbness and tingling began during service or are otherwise related to an in-service injury, event, or disease. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d); 3.307 (6)(ii); 3.309 (e). The Veteran served in the Republic of Vietnam during the relevant period, so exposure to herbicide is presumed. 38 C.F.R. § 3.307 (a). Thus, early-onset peripheral neuropathy that became manifest to a degree of 10 percent or more within a year after the last date on which the veteran was exposed to an herbicide agent during active military, naval, or air service shall be service-connected. 38 C.F.R. §§ 3.307 (6)(ii); 3.309 (e). If the regulatory presumption is not applicable, service connection could still be established on a direct basis. Combee v. Brown, 34 F.3d 1039 (Fed.Cir.1994) The evidence shows that the Veteran does not have peripheral neuropathy. As a result, presumptive service connection is not warranted. The report of an October 2017 VA Peripheral Nerves Condition Disability Benefits Questionnaire (DBQ) states that the Veteran does not have a peripheral nerve condition or peripheral neuropathy. The Veteran did not have a diagnosis for the symptoms of numbness and tingling of the hands and feet. A review of the Veteran’s entire medical record did not reveal these complaints or a diagnosis for these complaints. The October 2017 VA examiner opined that after a review of the Veteran’s entire record, including the remand and all available medical records, the Veteran’s complaints of numbness and tingling of the hand and feet were less likely than not (less than 50 percent probability) incurred in, related to or caused by herbicide agent exposure or other events in the Veteran’s service. The rationale was that the Veteran never complained of these symptoms in service or within 7 years of leaving service. The Veteran stated that the onset of the numbness and tingling in his hands and feet was five years earlier, in 2012. The Veteran denied pain. He had not been seen or evaluated for these symptoms. He reported that the symptoms “come and go.” There was no diagnosis of radiculopathy of the upper extremities or lower extremities. The examiner noted that there were many reasons for a person to have numbness and tingling, and explained that the Veteran did not have any of them. The examiner’s opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The Board finds it significant that there is no medical opinion to the contrary of the examiner’s opinion. While the Veteran believes his numbness and tingling of the hands and feet are related to an in-service injury, event, or disease, including herbicide exposure, he is not competent to provide a nexus opinion in this case. This issue is medically complex, as it requires knowledge of the interaction between multiple organ systems in the body and interpretation of complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the October 2017 medical opinion.   2. Entitlement to service connection for a heart disability, to include ischemic heart disease, to include as due to herbicide exposure. The question for the Board is whether the Veteran has a current heart disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that, while the Veteran has a diagnosis of bradycardia, and in-service exposure to herbicide is presumed, the preponderance of the evidence weighs against finding that the bradycardia began during service or are otherwise related to an in-service injury, event, or disease. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton, supra. 38 C.F.R. § 3.303(a), (d); 3.307 (6)(ii); 3.309 (e). As the Veteran’s exposure to herbicides is presumed, if ischemic heart disease became manifest to a degree of 10 percent or more at any time after service, service connection would be warranted. 38 C.F.R. §§ 3.307 (6)(ii); 3.309 (e). The evidence shows that the Veteran does not have ischemic heart disease. As a result, presumptive service connection is not warranted. The report of an October 2017 VA Heart Conditions DBQ states that the Veteran had a diagnosis of bradycardia, and did not have any heart condition that qualified as ischemic heart disease. A review of all available records did not reveal ischemic heart disease. The examiner specifically noted that a non-specific ST/T wave abnormality in September 2009 was a transitory symptom and not indicative of ischemic heart disease. The October 2017 VA examiner opined that it was less likely as not (less than 50 percent probability) that the Veteran had ischemic heart disease or that the ST/T changes were incurred in, related to, or caused by herbicide agents exposure or other events in the Veteran's service. The VA examiner stated that it was more likely than not that the Veteran's October 2008 complaints of chest pain originated from scapular pain. The VA examiner noted that the etiology of the Veteran's bradycardia was unknown. The Veteran had never complained of dizziness, fatigue, shortness of breath or near fainting episodes. In this case, bradycardia was a transitory issue that had not caused problems for the Veteran. It was less likely than not (less than 50 percent probability) caused by herbicide agent exposure or other events in the Veteran's service. The examiner’s opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez, supra. The Board finds it significant that there is no medical opinion to the contrary of the examiner’s opinion. While the Veteran believes his heart condition is related to an in-service injury, event, or disease, including herbicide exposure, he is not competent to provide a nexus opinion in this case. This issue is medically complex, as it requires knowledge of the interaction between multiple organ systems in the body and interpretation of complicated diagnostic medical testing. Jandreau, supra. Consequently, the Board gives more probative weight to the October 2017 medical opinion. 3. Entitlement to SMC based on the need for aid and attendance or on account of being housebound. The Veteran seeks SMC based on the need for the aid and attendance of another person or on housebound status. SMC at the aid and attendance rate is payable to a Veteran for anatomical loss or loss of use of both feet or one hand and one foot, blindness in both eyes with visual acuity of 5/200 or less, or being permanently bedridden or so helpless as a result of service-connected disability that he or she is in need of the regular aid and attendance of another person. 38 U.S.C. § 1114 (l); 38 C.F.R. § 3.350 (b). Factors considered to determine whether regular aid and attendance is needed include: inability to dress or undress himself, or to keep himself ordinarily clean and presentable; frequent need to adjust special prosthetic or orthopedic appliances which by reason of the particular disability requires aid (this does not include adjustment of appliances that persons without any such disability would be unable to adjust without aid, such as supports, belts, lacing at the back, etc.); inability to feed himself through loss of coordination of upper extremities or through extreme weakness; inability to attend to wants of nature; or incapacity, physical or mental, which requires care or assistance on a regular basis to protect a claimant from the hazards or dangers incident to his daily environment. 38 C.F.R. § 3.352 (a). It is not required that all the disabling conditions enumerated in 38 C.F.R. § 3.352 (a) be found to exist before a favorable decision is permissible. Particular personal functions which the Veteran is unable to perform should be considered in connection with his condition as a whole. It is only necessary that the evidence establish that he is so helpless as to need regular aid and attendance, not that there is a constant need. 38 C.F.R. § 3.352 (a); Turco v. Brown, 9 Vet. App. 222 (1996). It is logical to infer, however, a threshold requirement that “at least one of the enumerated factors be present.” Id. at 224. “Bedridden” will be that condition which, by virtue of its essential character, actually requires that the claimant remain in bed. The fact that a claimant has voluntarily taken to bed or that a doctor has prescribed rest in bed for a greater or lesser part of the day to promote convalescence or cure is insufficient. 38 C.F.R. § 3.352 (a). To establish entitlement to SMC based on housebound status under 38 U.S.C. § 1114 (s), the evidence must show that a veteran has a single service-connected disability evaluated as 100 percent disabling and an additional service-connected disability, or disabilities, evaluated as 60 percent or more disabling that is separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems; or, the veteran has a single service-connected disability evaluated as 100 percent disabling and due solely to service-connected disability or disabilities, the Veteran is permanently and substantially confined to his or her immediate premises. 38 C.F.R. § 3.350 (i). TDIU premised on a single disability may satisfy the requirements for entitlement to SMC under 38 U.S.C. § 1114 (s). See Bradley v. Shinseki, 22 Vet. App. 280, 293 (2008); see also Buie v. Shinseki, 24 Vet. App. 242, 249-250 (2010). In this case, the Veteran has not asserted, and none of the medical evidence of record suggests, that he has anatomical loss or loss of use of both feet, one hand and one foot, or service-connected blindness in both eyes with visual acuity of 5/200 or less. Moreover, the medical evidence does not show that the Veteran is bedridden or so helpless as a result of service-connected disability that he needs the regular aid and attendance of another person. The report of a November 2009 VA Aid and Attendance or Housebound Examination relates that the Veteran’s wife handled their routine financial affairs, but the Veteran stated he could do so if he had to. The Veteran was not permanently bedridden, and could travel beyond his current domicile. The Veteran’s ability to leave his home was unrestricted. He could walk one mile without the assistance of another person. The Veteran could perform all self-care functions. The pertinent diagnosis was PTSD, not impairing basic ADL self-functioning. The Board has reviewed subsequently dated medical evidence of record, including the report of an August 2010 VA mental examination which notes that the Veteran was able to maintain minimum personal hygiene and had no problem with activities of daily living. However, this medical evidence is simply negative for any indication that the Veteran is bedridden or so helpless as a result of service-connected disability that he needs the regular aid and attendance of another person. Thus, entitlement to SMC based on the need for regular aid and attendance is denied. Turning to the issue of whether the Veteran is housebound, the Board observes that he is service-connected for bilateral hearing loss and erectile dysfunction, each evaluated as noncompensable. He is also service-connected for PTSD, evaluated as 70 percent disabling from November 16, 2007, and as 100 percent disabling from August 23, 1010. The Veteran had a TDIU from July 1, 2008, to August 23, 2010. The November 2009 VA examination report and the remaining medical evidence simply do not show that the Veteran is permanently and substantially confined to his immediate premises due solely to service-connected disability or disabilities. Thus, entitlement to SMC on account of the Veteran being housebound is denied. The Board recognizes that he had a TDIU from July 1, 2008, to August 23, 2010. However, this award did not reflect housebound status. See Bradley, supra; see also Buie, supra. The April 2009 rating decision that granted the TDIU explained the award by noting that a VA examination found that all types of employment would be limited due to the Veteran’s PTSD, and even employment in a loosely supervised situation requiring little interaction with the public would be precluded. In conclusion, the evidence does not support the Veteran’s claim for SMC by reason of the need for regular aid and attendance of another person or by reason of being housebound. As the weight of the evidence is against his claim for entitlement to SMC, the appeal is denied. M. E. LARKIN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD J. Davitian, Counsel