Citation Nr: 18154501 Decision Date: 11/30/18 Archive Date: 11/30/18 DOCKET NO. 16-03 015 DATE: November 30, 2018 REMANDED Entitlement to an aid and attendance allowance for Veteran's spouse is remanded. REASONS FOR REMAND The Veteran served on active duty in the U.S. Army from December 1965 to December 1969. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an October 2013 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). In an October 2018 statement, the Veteran withdrew his request for a Board hearing. 1. Entitlement to an aid and attendance allowance for Veteran's spouse is remanded. In a February 2013 VA Form 21-2680, Examination for Housebound Status or Permanent Need for Regular Aid and Attendance, a private physician identified the spouse’s complete diagnoses as spinal burst fracture, chronic right knee pain status post previous surgeries, and fibromyalgia. The private physician noted that the Veteran’s spouse was able to feed herself and did not require assistance bathing or tending to other hygiene needs, but she was not able to prepare her own meals. She was not confined to bed, did not require nursing home care and did not require medication management. She used a cane, because she could not stand for more than three minutes without increased pain. She had chronic mild dizziness and mild memory impairments. Other private treatment records that existed at the time also show that the Veteran’s spouse also had diagnoses for lumbar radiculopathy, chronic bilateral knee pain status post total knee replacement of bilateral knees, right hip pain status post hip fracture, depression, sleep disturbance, hypothyroidism, and osteoporosis. In a May 2013 statement, the Veteran explained that his wife was unable to dress herself, and that the multiple surgeries she had undergone had limited her ability to perform housework and maintain personal care. He also indicated that they employed two young ladies to help. Since the Veteran’s spouse was last denied aid and attendance in a December 2015 statement of the case, the Veteran has submitted additional private treatment records showing that the Veteran’s spouse had fallen in October 2016 after her knee gave out and she sustained a left forearm fracture. Radiological testing revealed that in addition to the forearm fracture, the Veteran’s spouse had cervical spine degenerative arthritis. In 2018, the Veteran’s spouse was diagnosed with right breast carcinoma and underwent chemotherapy. There is evidence suggesting that the Veteran’s spouse may now meet the requirements for spousal aid and attendance benefits, but the evidence of record is unclear. Accordingly, a remand is required to obtain a VA examination to determine whether the Veteran’s spouse meets the requirements for spousal aid and attendance. See 38 C.F.R. §§ 3.326, 3.351, 3.352. The matter is REMANDED for the following actions: Afford the Veteran’s spouse a VA examination with an appropriate clinician to provide an evaluation concerning the extent to which the Veteran’s spouse needs regular aid and attendance of another person. All pertinent symptomatology and findings must be reported in detail. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner should indicate the underlying disability or disabilities causing the Veteran's spouse's impairment(s) and address resulting limitations from the identified disability or disabilities. At a minimum, the examination should address the following: the Veteran's spouse's ability or inability to dress or undress herself, keep herself ordinarily clean and presentable, feed herself through loss of coordination of upper extremities or through extreme weakness, and attend to the wants of nature; whether the Veteran's spouse has an incapacity, physical or mental, which requires care or assistance on a regular basis to protect her from hazards or dangers incident to her daily environment; and whether there is frequent need of adjustment of any special prosthetic or orthopedic appliances, which by reason of the particular disability, cannot be done without aid. The examiner should reconcile any opinion with all other clinical evidence of record to include the February 2013 VA Form 21-2680, Examination for Housebound Status or Permanent Need for Regular Aid and Attendance. (Continued on the next page)   A rationale must be provided for any opinion reached. LESLEY A. REIN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Journet Shaw