Citation Nr: 18154445 Decision Date: 11/29/18 Archive Date: 11/29/18 DOCKET NO. 15-00 570 DATE: November 29, 2018 ORDER New and material evidence has been received and the claim for entitlement to service connection for hypertension is reopened. New and material evidence has been received and the claim for entitlement to service connection for a low back disability is reopened. Service connection for a low back disability is granted. Service connection for bilateral hearing loss disability is denied. Service connection for tinnitus is denied. Service connection for diverticulosis is denied. Entitlement to non-service connected pension benefits is denied. Entitlement to special monthly pension (SMP) is denied.   REMANDED Entitlement to service connection for diabetes mellitus type II (diabetes), claimed as related to herbicide agent exposure, is remanded Entitlement to service connection for erectile dysfunction, claimed as secondary to diabetes, is remanded. Entitlement to service connection for an eye disability, claimed as secondary to diabetes, is remanded. Entitlement to service connection for bilateral upper and lower extremity peripheral neuropathy, claimed as secondary to diabetes, is remanded. Entitlement to service connection for hypertension is remanded. Entitlement to service connection for a heart disability is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. A June 1971 rating decision that denied the Veteran’s original service connection claim for a blood condition (to include hypertension) and a back condition is final. 2. Evidence received since the last final decision is both new and material to the claims of service connection for hypertension and a low back disability. 3. With resolution of all reasonable doubt in the Veteran’s favor, his low back disability manifested within one year of his separation from active service and has been continuous since service. 4. The Veteran’s audiogram results do not meet the auditory threshold requirements to establish he has a hearing loss disability for VA disability purposes. 5. The Veteran’s current tinnitus is not related to, or caused by, noise exposure during active military service. 6. The Veteran’s current diverticulosis is not related to, or caused by, his active military service. 7. The Veteran’s countable income for VA purposes for year 2013 exceeded the applicable income limits for the receipt of non-service-connected pension benefits. 8. The Veteran is not blind, or nearly blind, is not institutionalized, or in a nursing home on account of physical or mental incapacity, does not need or rely on the aid and attendance (A&A) of another person to perform the routine activities of daily living, and is not substantially confined to his home, or otherwise housebound. CONCLUSIONS OF LAW 1. The June 1971 rating decision that denied the Veteran’s original service connection claims for a blood condition (to include hypertension) and a back condition is final. See 38 U.S.C. §§ 7103, 7104 (2012); 38 C.F.R. §§ 3.156, 20.1100 (2017). 2. Evidence received subsequent to the last final decision is new and material, and the claims of service connection for hypertension and a low back disability are reopened. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156(a) (2017). 3. Resolving reasonable doubt in the Veteran’s favor, the criteria for service connection for a low back disability have been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2017). 4. The criteria for service connection for bilateral hearing loss disability are not met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.385 (2017). 5. The criteria for service-connection for tinnitus are not met. 38 U.S.C. §§ 1110, 1112, 1113, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2017). 6. The criteria for service connection for diverticulosis are not met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). 7. The Veteran’s countable income is excessive for receipt of VA non-service-connected pension benefits for year 2013. 38 U.S.C. §§ 1502, 1503, 1513, 1521, 1522 (2012); 38 C.F.R. §§ 3.3, 3.23, 3.271, 3.272 (2017). 8. The criteria for SMP based on the need for regular A&A or by reason of being housebound are not met. 38 U.S.C. §§ 1513, 1521, 1541, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.351, 3.352 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran, who is the appellant in this case, served on active duty March 1969 to October 1970. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from multiple rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in San Juan, the Commonwealth of Puerto Rico. In a June 2014 rating decision, the RO denied entitlement to service connection for diabetes, erectile dysfunction, a heart condition, diverticulitis, an eye condition, bilateral upper and lower extremity peripheral neuropathy, and a bilateral hearing loss disability, as well as entitlement to a TDIU, non-service connected pension, and SMP. The RO also denied the application to reopen the previously denied claim of entitlement to service connection for hypertension. In an October 2015 rating decision, the RO denied entitlement to service connection for a low back disability. In a May 2016 rating decision, the RO denied entitlement to service connection for tinnitus. In October 2018, the Veteran executed a new power-of-attorney appointing Patricia Flores Feliciano, Esquire, as his representative. This new appointment effectively revoked the Veteran’s prior appointment of Disabled American Veterans. See 38 C.F.R. § 14.631(f)(1). The Board has limited the discussion below to the relevant evidence required to support its finding of fact and conclusion of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016). New and Material Evidence Regardless of any RO determinations on the applications to reopen, the Board has a jurisdictional responsibility to consider whether it is proper for the claims to be reopened. See Jackson v. Principi, 265 F.3d 1366, 1369 (Fed. Cir. 2001). The Board determines that the June 1971 rating decision that denied service connection for a blood condition (to include hypertension) and a back condition is the last final rating decision on these matters. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. On review, the Board reopens the hypertension and low back disability claims based on subsequent medical evidence showing current diagnoses of hypertension and lumbosacral spondylosis. See March 2015 VA treatment record. This new evidence, coupled with the evidence already in the file, raises a reasonable possibility of substantiating the claims. 38 C.F.R. § 3.156(a). Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease incurred in service. 38 C.F.R. § 3.303(d). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Sensorineural hearing loss and tinnitus, as organic diseases of the nervous system, as well as arthritis (degenerative joint disease), are listed as “chronic” diseases under 38 C.F.R. § 3.309(a); therefore, the presumptive service connection provisions under 38 C.F.R. § 3.303(b) for service connection based on “chronic” symptoms in service and “continuous” symptoms since service are applicable. See Fountain v. McDonald, 27 Vet. App. 258 (2015) (tinnitus is an “organic disease of the nervous system” subject to presumptive service connection under 38 C.F.R. §§ 3.303(b), 3.307, and 3.309 where there is evidence of acoustic trauma and nerve damage); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. With chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. If a condition noted during service is not shown to be chronic, then generally, a showing of continuity of symptoms after service is required for service connection. 38 C.F.R. § 3.303(b). A claimant can establish continuity of symptomatology with competent evidence showing: (1) that a condition was “noted” during service; (2) post-service continuity of the same symptomatology; and (3) a nexus between a current disability and the post-service symptomatology. Savage v. Gober, 10 Vet. App. 488, 495-96 (1997); 38 C.F.R. § 3.303 (b) (2017). Service connection may also be established with certain chronic diseases, including sensorineural hearing loss, tinnitus, and arthritis, based upon a legal presumption by showing that the disorder manifested itself to a degree of 10 percent disabling or more within one year from the date of separation from active service. Such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of active service. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309(a). While the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994). In the case of conflicting medical opinions, the Board must weigh the credibility and probative value of the medical opinions, and in so doing, the Board may favor one medical opinion over the other. See Evans v. West, 12 Vet. App. 22, 30 (1998). The probative value of medical opinion evidence is based on the medical expert’s personal examination of the patient, the physician’s knowledge and skill in analyzing the data, and the medical conclusion the physician reaches. Guerrieri v. Brown, 4 Vet. App. 467, 470 (1993). Other factors affecting the probative value of a medical opinion include thoroughness and degree of detail, and a well-reasoned rationale. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000). The credibility and weight to be attached to these opinions is within the province of the Board. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 1. Entitlement to service connection for a low back disability. The Veteran essentially contends that his low back disability initially manifested during service or within one year after separation from service and has been continuous since service. As an initial matter, the medical evidence shows that the Veteran is diagnosed with arthritis of the lumbar spine. See September 2014, December 2014, and February 2015 VA treatment notes. In March 1971, within one year of separation from active service, the Veteran filed an initial claim of service connection for a back condition. A January 2015 VA treatment record indicated that the Veteran reported falling while in active service and having chronic low back pain for many years. The Board notes that no fall or back injury is documented in the Veteran’s service treatment records. However, the Veteran is competent to report falling during service and continuous back pain since service. The Veteran’s credibility in this matter is bolstered by the fact that he initially filed a claim for service connection within one year of his separation from service. The Board notes that the record contains no contradictory statements regarding the onset of the Veteran’s low back pain. In light of the Veteran’s report of a back injury related to a fall during service, his initial claim of service connection for a back condition within one year of his separation from service, and his competent and credible reports of continuous low back disability symptoms since service, the Board finds that the Veteran’s current low back disability had its onset in service and has been continuous since service. Accordingly, service connection for a low back disability is granted. 2. Entitlement to service connection for a bilateral hearing loss disability. The Veteran contends that he is entitled to service connection for bilateral hearing loss related to noise exposure during service. For purposes of applying VA laws, impaired hearing is considered a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, and 4000 hertz (Hz) is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, and 4000 Hz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. In May 2014, the Veteran was afforded a VA audiology examination. Pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 15 20 20 25 25 LEFT 15 20 25 20 25 Speech audiometry revealed speech recognition ability of 100 percent in the right ear and of 100 percent in the left ear. In May 2016, the Veteran was afforded a VA audiology examination. Pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 25 20 25 30 30 LEFT 20 20 20 25 25 Speech audiometry revealed speech recognition ability of 100 percent, bilaterally. The most fundamental requirement for any claim for service connection is that the Veteran must first establish he has the condition claimed. See Degmetich v. Brown, 8 Vet. App. 208 (1995). In this case, a current hearing loss disability for VA purposes is not shown in either of the Veteran’s ears. As noted above, a hearing loss disability is defined by regulation, i.e., 38 C.F.R. § 3.385, and the May 2014 and May 2016 VA audiometry findings did not produce findings that meet the above-stated regulatory definition of a hearing loss disability in either ear. There are no other audiometric findings in the claims file dated since the Veteran filed his initial claim for service connection for bilateral hearing loss. As the record does not demonstrate that the Veteran has a bilateral hearing loss disability within VA standards since the filing of the claim, there is no valid claim of service connection for bilateral hearing loss. Brammer v. Derwinski, 3 Vet. App. 223 (1992). In so concluding, the Board recognizes that the Veteran is competent to report his hearing difficulty; however, his statements are not competent to establish that he has a bilateral hearing loss disability which as noted, must be shown by official audiometry. The preponderance of the evidence is therefore against the service connection claim for a bilateral hearing loss disability, and, as such, the claim must be denied. 3. Entitlement to service connection for tinnitus. The Veteran also contends that his current tinnitus is related to, or caused by, noise exposure during his military service. As an initial matter, the Board finds that the Veteran has a current diagnosis of tinnitus. See May 2016 VA examination report. Indeed, tinnitus is a disability capable of lay observation. Next, the Veteran reported being exposed to high frequency fire arm noise and heavy and industrial construction equipment during service. See June 2013 letter from private physician. Therefore, the Board finds that the Veteran’s statements are consistent with the circumstances of his military service, and therefore finds that he experienced acoustic trauma during his active military service. Turning to the issue of etiology, the Veteran was afforded a VA audiology examination in May 2014. During the examination, he reported that he had intermittent tinnitus that began one year prior. He could not indicate the circumstance of onset of the tinnitus. The VA examiner, an audiologist, opined that the Veteran’s tinnitus is at least as likely as not a symptom associated with the Veteran’s non-service connected hearing loss, as tinnitus is known to be a symptom associated with hearing loss. The Veteran was afforded an additional VA audiology examination in May 2016 where he reported that he had had intermittent tinnitus that began two to three years prior. He could not establish the circumstance of the onset of his tinnitus. The VA examiner opined that the Veteran’s tinnitus was less likely than not caused by, or a result of, military noise exposure. The VA examiner stated that the Veteran first complained of tinnitus over 40 years after his release from active military service, his hearing loss was first identified in 2014, and tinnitus is a symptom known to be associated with clinical hearing loss. Based on a review of the evidence, both lay and medical, the Board finds that the Veteran’s current tinnitus is not related to, or caused by, his military service. Although in-service noise exposure is conceded, there is no evidence of any treatment, diagnosis, or complaints of tinnitus in the service treatment records or for many years thereafter. In fact, the Veteran himself has consistently stated that his tinnitus began many years after service. His complaints of tinnitus appear to be first reflected in his claim for compensation at issue here. The Board concludes that the criteria to establish presumptive service connection based on “chronic” in service symptoms and “continuous” post-service symptoms are not met. Moreover, the Veteran’s tinnitus as an organic disease of the nervous system did not manifest within one year from the date of his separation from active service. In addition, the opinions from the May 2014 and May 2016 VA examiners are highly probative as to the etiology of the Veteran’s tinnitus, as they are authored by audiologists, and based on a detailed medical history and examination of the Veteran. The opinions also considered the Veteran’s lay statements, and are supported by adequate rationale. Therefore, the probative medical evidence in this case is against the claim. The Veteran has not submitted competent and probative evidence relating his tinnitus to his military service. For these reasons, the Board finds that the weight of the evidence is against the claim. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. 38 U.S.C. §5107(b); 38 C.F.R. § 4.3. Therefore, the claim of service connection for tinnitus must be denied. 4. Entitlement to service connection for diverticulosis. The Veteran essentially maintains that his diverticulosis, claimed as colon ulcers, is related to service. As an initial matter, the Veteran has been diagnosed with diverticulosis within the appeal period. See February 2015 VA treatment record. However, there is no evidence of gastrointestinal problems during service. His service treatment records are negative for any complaints of diverticulosis or related symptoms, and the Veteran himself does not assert otherwise. Moreover, the record is negative for any probative evidence associating the current diverticulosis with the Veteran’ active service. Unfortunately, in this case, the Veteran has not expressed why he believes his current diverticulosis is related to his military service. Based on this body of evidence, the Board finds that the weight of the evidence is against the claim. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. 38 U.S.C. §5107(b); 38 C.F.R. § 4.3. Therefore, the claim of service connection for diverticulosis must be denied. 5. Entitlement to NSC Pension Disability pension will be paid to a veteran of a period of war who meets statutorily-defined service, net worth, and annual income requirements; and who is permanently and totally disabled from non-service-connected disability not the result of willful misconduct. 38 U.S.C. §§ 1502, 1503, 1521. Pension is also payable to each veteran of a period of war who is 65 years of age or older and who meets the service requirements of 38 U.S.C. § 1521 and under the conditions (other than the permanent and total disability requirement) applicable to pension paid under that section. 38 U.S.C. § 1513. The purpose of VA pension benefits is to provide a subsistence income for veterans of a period of war who are totally disabled and who are otherwise unable to maintain a basic, minimal income level. Pension benefits are based upon total family income and the amount of pension benefits is adjusted based upon the number of dependents the veteran supports. Recipients of pension income are required to report any changes in income and number or status of their dependents in a timely fashion. 38 U.S.C. §§ 1521, 1522. In this case, the RO denied entitlement to nonservice-connected pension benefits, finding that the Veteran’s income was excessive for VA pension purposes. Basic entitlement to pension exists if, among other things, the veteran’s income is not in excess of the applicable maximum allowable pension rate (MAPR) specified in 38 C.F.R. § 3.23, as changed periodically and reported in the Federal Register. See 38 U.S.C. § 1521; 38 C.F.R. § 3.3(a)(3). The MAPR is periodically increased from year to year. See 38 C.F.R. § 3.23(a). The maximum rates for improved pension shall be reduced by the amount of the countable annual income of the veteran. See 38 U.S.C. § 1521; 38 C.F.R. § 3.23(b). In determining annual income, all payments of any kind or from any source (including salary, retirement or annuity payments, or similar income, which has been waived) shall be included except for listed exclusions. See 38 U.S.C. § 1503(a); 38 C.F.R. §§ 3.260, 3.261, 3.262, 3.271(a). Income from the Social Security Administration (SSA) and VA compensation benefits are not specifically excluded under 38 C.F.R. § 3.272. Such income is therefore included as countable income. Medical expenses in excess of five percent of the MAPR, which have been paid, may be excluded from an individual’s income for the same 12-month annualization period to the extent they were paid. See 38 C.F.R. § 3.272(g)(1)(iii). Under 38 C.F.R. § 3.272, the following shall be excluded from countable income for the purpose of determining entitlement to improved pension: welfare; maintenance; VA pension benefits, payments under Chapter 15, including accrued pension benefits; reimbursement for casualty loss; profit from sale of property; joint accounts (accounts in joint accounts in banks and similar institutions acquired by reason of death of the other joint owner); and medical expenses in excess of five percent of the MAPR, which have been paid. Based on the Veteran’s income and medical expense records available in the claims file, the Veteran’s countable income has exceeded the applicable income limits for receipt of non-service-connected pension. For 2013, the MAPR for a veteran with one dependent was $16,569. With regard to total income for 2013, the income received by the Veteran was derived from two sources: SSA benefits received on a monthly basis and United States Civil Service benefits received on a monthly basis. The Veteran’s spouse also received SSA benefits on a monthly basis. On his VA Form 21-526 submitted in February 2014, the Veteran reported monthly income consisting of $749.00 in SSA benefits and $200.00 in Civil Service benefits. The Veteran also reported that his spouse’s monthly income consisted of $1132.00 in SSA benefits. Thus, the Veteran’s reported annual income for 2013 was $24,972.00, which exceeded the MAPR of $16, 569.00 in effect at that time. The law does provide that a claimant’s income for pension purposes may be reduced by payment of unreimbursed medical expenses. On his February 2014 VA Form 21-526, the Veteran reported unreimbursed medical expenses in 2013 for health insurance premiums, VA medical treatment deductibles, medicine, and eyeglasses, for a total of $5760.00 in unreimbursed medical expenses. As these expenses are in excess of $828.00, which is five percent of the MAPR for a veteran with one dependent, they can be deducted from the Veteran’s countable income for pension purposes. Nonetheless, even with consideration of his medical expenses for the year 2013, the Veteran’s remaining countable annual income of $19,212.00 exceeds the MAPR of $16,569, in effect for non-service connected pension eligibility for 2013, as outline above. Because the Veteran’s household income exceeded the income limits for purposes of payment of non-service-connected pension benefits for the 12-month annualization period on appeal, the Veteran does not meet the eligibility requirements for pension. The Board makes no finding as to the Veteran’s entitlement to pension payments beyond 2013, as the Veteran must furnish evidence to support his claim for entitlement to pension. 6. Entitlement to SMP. The Veteran seeks SMP based on the need for regular A&A or housebound status due to his disorders. VA laws and regulations provide for an increased rate of pension, in the form of an SMP, when an eligible veteran is in need of regular A&A or has a disability rated as permanent and total, and (1) has an additional disability or disabilities ratable at 60 percent, or (2) is permanently housebound. See 38 U.S.C. § 152(d), (e); see also 38 C.F.R. § 3.351(b), (c), (d). A veteran will be considered in need of regular A&A if he or she: (1) is blind or so nearly blind as to have corrected visual acuity of 5/200 or less, in both eyes, or concentric contraction of the visual field to 5 degrees or less; or (2) is a patient in a nursing home because of mental or physical incapacity; or (3) establishes a factual need for A&A under the criteria set forth in 38 C.F.R. § 3.352(a). 38 C.F.R. § 3.351(c). Determinations as to the need for A&A on a factual basis must be based on actual requirements of personal assistance from others. In making such determinations, consideration is given to such conditions as: inability of the Veteran to dress and undress himself or to keep himself ordinarily clean and presentable; frequent need of adjustment of any special prosthetic or orthopedic appliance; inability of the Veteran to feed himself through loss of coordination of the upper extremities or through extreme weakness; inability to tend to the wants of nature; or incapacity, physical or mental, which requires care and assistance on a regular basis to protect the Veteran from the hazards or dangers incident to his daily environment. See 38 C.F.R. § 3.352(a). Bedridden status will be a proper basis for a determination of the need for regular A&A. Bedridden means that condition which, through its essential character, actually requires that the Veteran remain in bed. The fact that a veteran has voluntarily taken to bed or that a physician has prescribed rest in bed for the greater or lesser part of the day to promote convalescence or cure will not suffice. See id. It is not required that all of the disabling conditions enumerated in the provisions of 38 C.F.R. § 3.352(a) be found to exist to establish eligibility for A&A or that such eligibility requires at least one of the enumerated factors to be present. The particular personal function which a veteran is unable to perform should be considered in connection with his or her condition as a whole. It is only necessary that the evidence establish that a veteran is so helpless as to need regular A&A, not that there be a constant need. Id.; Turco v. Brown, 9 Vet. App. 222 (1996). In addition, any determination that a veteran is so helpless as to be in need of regular A&A will not be based solely upon an opinion that a veteran’s condition is such as would require him to be in bed. The determination must be based on the actual requirement of personal assistance from others. See 38 C.F.R. § 3.352(a). Housebound benefits are warranted if, in addition to having a single permanent disability rated 100 percent disabling under VA’s Schedule for Rating Disabilities (not including ratings based upon unemployability under 38 C.F.R. § 4.17), the veteran: (1) has additional disability or disabilities independently ratable at 60 percent or more, separate and distinct from the permanent disability rated as 100 percent disabling and involving different anatomical segments or bodily systems, or, (2) is “permanently housebound” by reason of disability or disabilities. The “permanently housebound” requirement is met when a veteran is substantially confined to his or her dwelling and the immediate premises or, if institutionalized, to the ward or clinical area, and it is reasonably certain that the disability or disabilities and resultant confinement will continue throughout his or her lifetime. 38 C.F.R. § 3.351(d). As an initial matter, the evidence does not reflect that the Veteran is blind or nearly blind. VA treatment records dated in March 2016 and August 2016 reflect that the Veteran’s vision is not 5/200 or worse in either eye. Additionally, there is no indication that the Veteran was hospitalized or was a patient in a nursing home due to either mental or physical incapacity during the appellate period. The evidence shows that the Veteran lives in his own home. See July 2015 VA Social Work Risk Assessment Screening Note. Therefore, the dispositive issue is whether there is a factual need for A&A or whether housebound status is established. The evidence shows that the Veteran does not require the A&A of another person to perform the routine activities of daily living. Specifically, a February 2015 VA treatment record indicates that the Veteran ambulates without assistive devices and is independent in activities of daily living. A June 2015 VA treatment record indicated that the Veteran’s back pain was exacerbated recently after gardening at home. Moreover, the evidence does not demonstrate that he is restricted to his home or immediate facilities. Thus, the Board concludes that the Veteran is not substantially confined to his home, or otherwise housebound, and does not have a factual need for A&A. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt rule does not apply, and the Veteran’s SMP claim must be denied. REASONS FOR REMAND 7. Entitlement to service connection for diabetes, erectile dysfunction, an eye condition, and bilateral upper and lower extremity peripheral neuropathy are remanded. The Veteran is currently diagnosed with type II diabetes. See e.g., June 2013 VA examination report. A veteran who had active service in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, will be presumed to have been exposed to an herbicide agent during such service unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service. See 38 U.S.C. § 1116(f); 38 C.F.R. § 3.307(a)(6)(iii). VA laws and regulations provide that, if a Veteran was exposed to herbicide agents during service, certain diseases, including diabetes, are presumptively service-connected. 38 U.S.C. § 1116 (a)(1); 38 C.F.R. § 3.309(e). The Veteran asserts that he was exposed to herbicide agents during claimed Vietnam and/or confirmed Thailand service. In February 2014, the Veteran reported that he went to Vietnam before arriving in Thailand for duty. In August 2016, the RO issued a formal finding of lack of information required to corroborate exposure to herbicide agents. This finding was based on the service department’s February 2014 response that it was unable to determine whether the Veteran served in Vietnam and the fact that there are no records of his exposure to herbicide agents outside of Vietnam. The RO indicated further that the Veteran did not respond to a February 2015 letter requesting more detailed information about the Veteran’s claimed exposure to herbicide agents. The Veteran’s military personnel records do not reflect that the Veteran both served on a Royal Thai Air Force Base (RTAFB) and “as an Air Force security policeman, security patrol dog handler, member of the security police squadron, or otherwise near the air base perimeter as shown by evidence of daily work duties, performance evaluation reports, or other credible evidence; or as in an United States Army base as a member of a military police unity or with a military police occupational specialty.” However, the record does not reflect that a request was sent to the Joint Services Records Research Center (JSRRC) for verification of exposure to herbicide agents. In addition, it does not appear that the Veteran’s complete military personnel records are in the claims folder, as there are no performance evaluations or travel orders related to the Veteran’s travel to Thailand. Based on the Veteran’s report of setting foot in Vietnam before arriving for duty in Thailand in addition to the incomplete information of record regarding the Veteran’s service in Thailand, further development is required to determine whether he had qualifying service in either Vietnam or Thailand. The Board notes that the Veteran has not provided 60-day windows for the dates of his claimed service in Vietnam, which is required by the JSRRC before it will begin research. However, the AOJ must submit multiple requests to the JSRRC to cover the relevant time window in 60-day increments because VA’s duty to assist is not bound by the JSRRC’s 60-day limitation. See Gagne v. McDonald, 27 Vet. App. 397 (2015). 8. Entitlement to service connection for hypertension. Current VA regulations do not provide hypertension as a presumptive disability associated with herbicide exposure. However, the National Academy of Sciences (NAS), in 2006 and 2008 updates, concluded that there was “limited or suggestive evidence of an association” between hypertension and herbicide exposure. See 75 Fed. Reg. 32,540, 32,549 (June 8, 2010); 75 Fed. Reg. 81,332, 81,333 (December 27, 2010). As noted above, the Board is remanding several claims for development regarding the Veteran’s exposure to herbicide agents during service. If herbicide agent exposure is verified, a VA opinion must then be obtained to ascertain whether the Veteran’s hypertension is related to, or caused by, such exposure. 9. Entitlement to service connection for a heart disability. Every veteran is presumed to have been in sound condition at entry into service except as to defects, infirmities, or disorders noted at the time of such entry, or where clear and unmistakable evidence demonstrates that the injury or disease existed before entry and was not aggravated by such service. 38 U.S.C. § 1111. The term “noted,” in 38 U.S.C. § 1111, refers to “[o]nly such conditions as are recorded in examination reports.” 38 C.F.R. § 3.304(b). While a history of a heart murmur was reported upon the Veteran’s entry to service, the June 1968 Report of Medical History specifically stated that no heart murmur was found. In addition, a June 1968 letter from a physician indicated that the Veteran was treated for rheumatic fever in 1964 and a systolic heart murmur was present at that time, but had since disappeared, and there was no present evidence of heart disease or rheumatic activity. Therefore, the Board finds that a heart murmur was not “noted” upon the Veteran’s entry to service and the presumption of soundness applies. In order to rebut this presumption of soundness on entry into service, VA must show by clear and unmistakable evidence both that the disease or injury existed prior to service and that the disease or injury was not aggravated by service. See Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004). The Veteran was afforded a VA heart examination in June 2013 for compensation purposes. The June 2013 VA examiner opined that the Veteran’s current heart murmur was a pre-existing condition that was not aggravated by military service because the service medical record is totally silent for any cardiac-related issues. The Board finds this opinion inadequate, as the VA examiner did not apply the “clear and unmistakable evidence” standard in opining that the Veteran’s heart murmur existed prior to service and did not provide any reason for this opinion, other than the history of a heart murmur that was reported on the Veteran’s entrance examination. Indeed, a mere history of pre-service existence of conditions recorded at the time of examination does not constitute a notation of such conditions. See 38 C.F.R. § 3.304(b)(1); Crowe v. Brown, 7 Vet. App. 238 (1995). In other words, the VA examiner did not address the significance, if any, of other evidence that the Veteran did not have a heart murmur upon entrance to service. Once VA undertakes the effort to provide an examination when developing a service-connection claim, even if not statutorily obligated to do so, it must provide an adequate one. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Therefore, remand is required to obtain an adequate opinion as to the etiology of the Veteran’s heart murmur. 10. Entitlement to a TDIU is remanded. Finally, the Board finds that it must defer consideration of the issue of entitlement to a TDIU, as it is inextricably intertwined with the service connection issues remanded herein. See Smith (Daniel) v. Gober, 236 F.3d 1370, 1373 (Fed. Cir. 2001). The matters are REMANDED for the following action: 1. Obtain and associate with the claims folder the Veteran’s complete military personnel record, to include any and all performance evaluations and travel orders. 2. Send a request to the JSRRC and/or other appropriate repository in an effort to substantiate claimed service in Vietnam and any herbicide agent exposure while stationed in Thailand. Consider requesting unit histories, daily logs, and any other relevant information from the Veteran’s unit(s) during the relevant time period. Any response received should be documented in the claims file, and any recommended follow-up action undertaken. 3. If, and only if, herbicide agent exposure during service is substantiated, obtain a medical opinion as to whether the Veteran’s hypertension is etiologically related to such exposure. The entire claims file, including a copy of the Remand, should be made available to, and be reviewed by, the VA examiner. Specifically, the examiner is asked to: Provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s hypertension is related to, or caused by, his active service, specifically to include any exposure to herbicide agents. In providing the above-opinion, the examiner should consider the NAS 2006 and 2008 updates which concluded that there was “limited or suggestive evidence of an association” between hypertension and herbicide exposure. See 75 Fed. Reg. 32,540, 32,549 (June 8, 2010); 75 Fed. Reg. 81,332, 81,333 (December 27, 2010). A complete rationale should be provided for the opinion rendered. If the examiner cannot provide the requested information without resort to speculation, he or she must state the reasons why. 4. Obtain an addendum medical opinion regarding the nature and etiology of the Veteran’s diagnosed heart murmur. The entire claims file, including a copy of the Remand, should be made available to, and be reviewed by, the VA examiner. Another examination is not required; however, if the examiner indicates that he or she cannot respond to the Board’s questions without examination of the Veteran, another examination should be afforded to the Veteran. Following review of the claims file, the examiner must provide the following opinions: (a) Whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s diagnosed heart murmur was related to or caused by service, including exposure to herbicide agents. (b) Whether the diagnosed heart murmur clearly and unmistakably preexisted service and, if so, whether such preexisting disorder clearly and unmistakably was not aggravated by service. The examiner’s attention is called to the following evidence: **The June 1968 letter from a physician indicating that the Veteran had a history of treatment for rheumatic fever and a heart murmur, but no current evidence of a heart murmur or symptoms of rheumatic fever. **The June 1968 Report of Medical Examination indicating that the Veteran did not have a current heart murmur. A detailed rationale should be provided for the opinions rendered. If the examiner cannot provide the requested information without resort to speculation, he or she must state the reasons why. 5. Then, readjudicate the remanded issues on appeal. S. B. MAYS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M. Thomas, Counsel