Citation Nr: 18159478 Decision Date: 12/19/18 Archive Date: 12/19/18 DOCKET NO. 15-44 275 DATE: December 19, 2018 ORDER A rating of 100 percent for joint involvement associated with rheumatic paraneoplastic syndrome from September 2, 2015 and thereafter is granted. A rating in excess of 10 percent for service-connected limitation of motion of the right knee prior to September 2, 2015 is denied. A rating in excess of 10 percent for service-connected limitation of motion of the left knee prior to September 2, 2015 is denied. A rating in excess of 10 percent for service-connected limitation of motion of the right wrist prior to September 2, 2015 is denied. A rating in excess of 10 percent for service-connected limitation of motion of the left wrist prior to September 2, 2015 is denied. A rating in excess of 10 percent for service-connected limitation of motion of the right hand fingers prior to September 2, 2015 is denied. A rating in excess of 10 percent for service-connected limitation of motion of the left hand fingers prior to September 2, 2015 is denied. A rating in excess of 10 percent for service-connected limitation of motion of the right shoulder prior to September 2, 2015 is denied. A rating in excess of 10 percent for service-connected limitation of motion of the left shoulder prior to September 2, 2015 is denied. A rating in excess of 10 percent for service-connected limitation of motion of the cervical spine prior to September 2, 2015 is denied. A rating in excess of 10 percent for service-connected limitation of motion of the right elbow prior to September 2, 2015 is denied. A rating in excess of 10 percent for service-connected limitation of motion of the left elbow prior to September 2, 2015 is denied. A rating in excess of 10 percent for service-connected limitation of motion of the right hip prior to September 2, 2015 is denied. A rating in excess of 10 percent for service-connected limitation of motion of the left hip prior to September 2, 2015 is denied. An earlier effective date of April 24, 2013 for the grant of service connection for limitation of motion of the right knee is granted. An earlier effective date of April 24, 2013 for the grant of service connection for limitation of motion of the left knee is granted. An earlier effective date of April 24, 2013 for the grant of service connection for limitation of motion of the right wrist is granted. An earlier effective date of April 24, 2013 for the grant of service connection for limitation of motion of the left wrist is granted. An earlier effective date of April 24, 2013 for the grant of service connection for limitation of motion of the right hand fingers is granted. An earlier effective date of April 24, 2013 for the grant of service connection for limitation of motion of the left hand fingers is granted. An earlier effective date of April 24, 2013 for the grant of service connection for limitation of motion of the right shoulder is granted. An effective date prior to October 29, 2014 for the grant of service connection for limitation of motion of the left shoulder is denied. An earlier effective date of January 22, 2014 for the award of service connection for limitation of motion of the cervical spine is granted. An effective date prior to April 1, 2015 for the grant of service connection for limitation of motion of the right elbow is denied. An effective date prior to April 1, 2015 for the grant of service connection for limitation of motion of the left elbow is denied. An effective date prior to April 1, 2015 for the grant of service connection for limitation of motion of the right hip is denied. An effective date prior to April 1, 2015 for the grant of service connection for limitation of motion of the left hip is denied. An effective date prior to March 1, 2014 for the grant of basic eligibility to Dependents’ Educational Assistance (DEA) is denied. Special Monthly Compensation (SMC) based on the loss of use of both hands is denied. SMC based on the need for aid and attendance of another person is granted, subject to the laws and regulations governing the payment of monetary benefits. FINDINGS OF FACT 1. For the period from September 2, 2015 and thereafter, the Veteran’s rheumatic paraneoplastic syndrome produced active process with constitutional manifestations associated with active joint involvement that is totally incapacitating. 2. For the period prior to September 2, 2015, the preponderance of the evidence does not show the Veteran’s rheumatic paraneoplastic syndrome produced active process with constitutional manifestations associated with active joint involvement that is totally incapacitating, nor does the preponderance of the evidence show the limitation of motion of any involved joint warranted a rating in excess of 10 percent. 3. Prior to the April 24, 2013 claim, it is shown the Veteran had bilateral knee, bilateral wrist, bilateral hand, and right shoulder joint involvement associated with his rheumatic paraneoplastic syndrome. 4. The first evidence of left shoulder joint involvement associated with his rheumatic paraneoplastic syndrome was on October 29, 2014. 5. The first evidence of cervical spine joint involvement associated with his rheumatic paraneoplastic syndrome was on January 22, 2014. 6. The first evidence of bilateral elbow and bilateral hip joint involvement associated with his rheumatic paraneoplastic syndrome was on April 1, 2015. 7. A permanent and total disability rating was not assigned until March 1, 2014. 8. The joint involvement of the Veteran’s hands associated with rheumatic paraneoplastic syndrome would not be equally well-served by amputation with use of a suitable prosthetic appliance. 9. The Veteran’s service-connected disabilities render him unable to care for his daily needs without requiring the regular aid and attendance of another person. CONCLUSIONS OF LAW 1. The criteria for a 100 percent rating for joint involvement associated with his rheumatic paraneoplastic syndrome from September 2, 2105 and thereafter have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.71a, Diagnostic Code (DC) 5002. 2. The criteria for a rating in excess of 10 percent for limited motion of the right knee prior to September 2, 2015 have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.71a, DC 5002. 3. The criteria for a rating in excess of 10 percent for limited motion of the left knee prior to September 2, 2015 have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.71a, DC 5002. 4. The criteria for a rating in excess of 10 percent for limited motion of the right wrist prior to September 2, 2015 have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.71a, DC 5002. 5. The criteria for a rating in excess of 10 percent for limited motion of the left wrist prior to September 2, 2015 have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.71a, DC 5002. 6. The criteria for a rating in excess of 10 percent for limited motion of the right hand fingers prior to September 2, 2015 have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.71a, DC 5002. 7. The criteria for a rating in excess of 10 percent for limited motion of the left hand fingers prior to September 2, 2015 have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.71a, DC 5002. 8. The criteria for a rating in excess of 10 percent for limited motion of the right shoulder prior to September 2, 2015 have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.71a, DC 5002. 9. The criteria for a rating in excess of 10 percent for limited motion of the left shoulder prior to September 2, 2015 have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.71a, DC 5002. 10. The criteria for a rating in excess of 10 percent for limited motion of the cervical spine prior to September 2, 2015 have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.71a, DC 5002. 11. The criteria for a rating in excess of 10 percent for limited motion of the right elbow prior to September 2, 2015 have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.71a, DC 5002. 12. The criteria for a rating in excess of 10 percent for limited motion of the left elbow prior to September 2, 2015 have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.71a, DC 5002. 13. The criteria for a rating in excess of 10 percent for limited motion of the right hip prior to September 2, 2015 have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.71a, DC 5002. 14. The criteria for a rating in excess of 10 percent for limited motion of the left hip prior to September 2, 2015 have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.71a, DC 5002. 15. The criteria for an earlier effective date of April 24, 2013 for the grant of service connection for limitation of motion of the right knee have been met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. § 3.400. 16. The criteria for an earlier effective date of April 24, 2013 for the grant of service connection for limitation of motion of the left knee have been met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. § 3.400. 17. The criteria for an earlier effective date of April 24, 2013 for the grant of service connection for limitation of motion of the right wrist have been met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. § 3.400. 18. The criteria for an earlier effective date of April 24, 2013 for the grant of service connection for limitation of motion of the right left wrist have been met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. § 3.400. 19. The criteria for an earlier effective date of April 24, 2013 for the grant of service connection for limitation of motion of the right hand fingers have been met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. § 3.400. 20. The criteria for an earlier effective date of April 24, 2013 for the grant of service connection for limitation of motion of the left hand fingers have been met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. § 3.400. 21. The criteria for an earlier effective date of April 24, 2013 for the grant of service connection for limitation of motion of the right shoulder have been met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. § 3.400. 22. The criteria for an effective date prior to October 29, 2014 for the grant of service connection for limitation of motion of the left shoulder have not been met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. § 3.400. 23. The criteria for an earlier effective date of January 22, 2014 for the grant of service connection for limitation of motion of the cervical spine have been met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. § 3.400. 24. The criteria for an effective date prior to April 1, 2015 for the grant of service connection for limitation of motion of the right elbow have not been met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. § 3.400. 25. The criteria for an effective date prior to April 1, 2015 for the grant of service connection for limitation of motion of the left elbow have not been met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. § 3.400. 26. The criteria for an effective date prior to April 1, 2015 for the grant of service connection for limitation of motion of the right hip have not been met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. § 3.400. 27. The criteria for an effective date prior to April 1, 2015 for the grant of service connection for limitation of motion of the left hip have not been met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. § 3.400. 28. The criteria for an effective date prior to March 1, 2014 for the grant of basic eligibility to DEA benefits have not been met. 38 U.S.C. §§ 3500, 3501, 3510; 38 C.F.R. § 21.3021. 29. The criteria for SMC based on loss of use of both hands have not been met. 38 U.S.C. § 1114; 38 C.F.R. § 3.350. 30. The criteria for SMC based on the need for regular aid and attendance of another person have been met. 38 U.S.C. § 1114; 38 C.F.R. §§ 3.350, 3.352. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served in the United States Navy from May 1960 to October 1963. An October 2017 Board decision remanded the above issues for further development. Increased Rating An October 2015 rating decision granted service connection for limitation of motion of the right knee, left knee, right wrist, left wrist, right hand fingers, left hand fingers, right shoulder, left shoulder, cervical spine, right elbow, left elbow, right hip and left hip, associated with service-connected rheumatic paraneoplastic syndrome, each rated at 10 percent under DC 5002, arthritis rheumatoid. The Veteran contends he is entitled to a higher rating for his joint involvement associated with his rheumatic paraneoplastic syndrome. Specifically, his attorney contends his joint involvement warrants a 100 percent rating under DC 5002. See October 2018 attorney statement. The Veteran’s joint involvement associated with his rheumatic paraneoplastic syndrome is rated by analogy under the diagnostic code for rheumatoid arthritis, DC 5002. Under DC 5002, an active process with constitutional manifestations associated with active joint involvement that is totally incapacitating warrants a 100 percent disability rating. In the alternative, for chronic residuals such as limitation of motion or ankylosis, the disability is rated under the appropriate diagnostic codes for the specific joints involved. The ratings for active process will not be combined with the residual ratings for limitation of motion or ankylosis; rather, the higher evaluation should be assigned. 38 C.F.R. § 4.71a. Resolving reasonable doubt in favor of the Veteran, the Board finds the evidence supports the joint involvement associated with his rheumatic paraneoplastic syndrome was totally incapacitating to warrant a 100 percent rating from September 2, 2015 and thereafter. Prior to September 2, 2015, the Board finds the evidence does not show the Veteran’s joint involvement associated with his rheumatic paraneoplastic syndrome was totally incapacitating, nor does the evidence show the limitation of motion of any involved joint warranted a rating in excess of 10 percent. 1. A rating of 100 percent for joint involvement associated with rheumatic paraneoplastic syndrome from September 2, 2015 and thereafter is granted. For the period from September 2, 2015 and thereafter, the Board finds the Veteran’s rheumatic paraneoplastic syndrome produced active process with constitutional manifestations associated with active joint involvement that is totally incapacitating. At a September 2, 2015 VA treatment visit, a treating physician noted the Veteran had apparent synovitis and joint pain that was “more dramatic and severe than seen in the past” and “is now significantly disabling.” A December 2015 private treatment letter stated the Veteran’s arthritis was diagnosed in February 2015 and had been manageable until a few months prior. He noted stiffness and swelling, most marked in the hands. He observed the Veteran could not make a fist. He reported difficulties with activities of daily living, dropping things, and buttoning a shirt. He exhibited a slow and shuffling gait due to the pain in his knees and ankles. The examiner observed swelling and tenderness of the wrists, fingers, ankles, and right knee. A May 2016 VA examination diagnosed status post chemotherapy and radiation for lung cancer, rheumatoid arthritis, gait abnormality, and hypertension. The examiner stated the Veteran was able to feed himself, but needed assistance to prepare a meal, bathe, or tend to hygiene. The examiner stated the Veteran could not walk without assistance. A November 2017 VA physical therapy visit noted pain in the right knee, bilateral hands, bilateral shoulders, bilateral elbows, bilateral hands, and thoracic spine. It was noted that his wife assists with shower transfers, toileting, and walking without walker. The Veteran brushed his own teeth. His wife performed all cooking and cleaning. At a January 2018 examination for aid and attendance, the examiner stated that there are sufficient medical treatment records suggesting the Veteran’s current issues are related to rheumatic paraneoplastic syndrome. He opined the Veteran’s increased reliability on others for daily living, decreased muscle strength, and decreased fine motor movements are at least as likely related to his rheumatic paraneoplastic syndrome. In an October 2018 private treatment opinion, Dr. M.S. opined the Veteran’s hypertrophic osteoarthritis as a result of his lung cancer, by itself, causes joint disease that is totally incapacitating. He stated the joint disease not only causes severe limitation of motion in the affected joints, but is also associated with incapacitating pain with acute exacerbations often on a monthly or weekly basis. The examiner noted the Veteran suffered the symptoms of hypoxia, weight loss, weakness, and fatigue. The examiner stated the Veteran’s articular deterioration and constitutional symptoms will worsen overtime, despite the appropriate medical management. The Board gives great probative weight to the October 2018 medical opinion of Dr. M.S that the Veteran’s joint disease is totally incapacitating. The opinion is credible because he discussed the medical evidence of record and considered the Veteran’s lay statements as to the severity of his symptoms, abilities, and limitations. The opinion is consistent with treatment records during the time period and the January 2018 VA examination opinion. Accordingly, for the period from September 2, 2015 and thereafter, a 100 percent rating for joint involvement associated with rheumatic paraneoplastic syndrome is warranted. 2. A rating in excess of 10 percent for limitation of motion of the right knee prior to September 2, 2015 is denied. 3. A rating in excess of 10 percent for limitation of motion of the left knee prior to September 2, 2015 is denied. 4. A rating in excess of 10 percent for limitation of motion of the right wrist prior to September 2, 2015 is denied. 5. A rating in excess of 10 percent for limitation of motion of the left wrist prior to September 2, 2015 is denied. 6. A rating in excess of 10 percent for limitation of motion of the right hand fingers prior to September 2, 2015 is denied. 7. A rating in excess of 10 percent for limitation of motion of the left hand fingers prior to September 2, 2015 is denied. 8. A rating in excess of 10 percent for limitation of motion of the right shoulder prior to September 2, 2015 is denied. 9. A rating in excess of 10 percent for limitation of motion of the left shoulder prior to September 2, 2015 is denied. 10. A rating in excess of 10 percent for limitation of motion of the cervical spine prior to September 2, 2015 is denied. 11. A rating in excess of 10 percent for limitation of motion of the right elbow prior to September 2, 2015 is denied. 12. A rating in excess of 10 percent for limitation of motion of the left elbow prior to September 2, 2015 is denied. 13. A rating in excess of 10 percent for limitation of motion of the right hip prior to September 2, 2015 is denied. 14. A rating in excess of 10 percent for limitation of motion of the left hip prior to September 2, 2015 is denied. For the period prior to September 2, 2015, the Board finds the evidence does not show the Veteran’s joint involvement associated with his rheumatic paraneoplastic syndrome produced active process with constitutional manifestations associated with active joint involvement that is totally incapacitating. During this period, evidence shows the Veteran’s joint involvement associated with his rheumatic paraneoplastic syndrome was not totally incapacitating. At an October 2014 VA examination, the Veteran reported being able to perform activities of daily living with pain. He reported he was no longer able to do stained glass work or open jars due to hand pain. The Veteran reported needing to sit after walking short distances due to his breathing. He stated he was unable to hold a pen or use a keyboard. An April 2015 VA examination reported pain and limitation of motion attributable to his arthritis condition in the cervical spine, shoulders, elbows, wrists, hands/fingers, hips, knees, and ankles. The Veteran did not use an assistive device. The examiner noted the Veteran was not experiencing constitutional manifestations associated with active joint involvement that were totally incapacitating. The Board gives great probative weight to the April 2015 VA examination opinion that the Veteran was not experiencing constitutional manifestations associated with active joint involvement which were totally incapacitating. The opinion is consistent with Dr. D.D.’s December 2015 statement that the Veteran’s arthritis was manageable until a few months prior. The opinion is consistent with his treating physician noting in September 2015 that the Veteran’s apparent synovitis and joint pain was more dramatic and severe than in the past and had become significantly disabling. The Board gives limited probative weight to the October 2018 opinion of Dr. M.S. that the Veteran’s severe active joint involvement associated with rheumatic paraneoplastic syndrome rendered him incapacitated since 2012. The finding lacks credibility because it is not consistent with treatment records or the Veteran’s reported functioning during this time period, which showed the Veteran was able to perform some activities of daily living and chores. The Veteran was noted to be shoveling snow in December 2013, he was noted to be using his chainsaw in March 2014, and he was noted to be able to cut trees in October 2014. The Veteran reported he started using a walker in May 2015. See October 2015 statement. The Board did not otherwise find evidence to support a rating in excess of 10 percent for the limitation of motion of the Veteran’s bilateral knees, bilateral wrists, bilateral hands, bilateral shoulders, bilateral elbows, bilateral hips, or cervical spine. Specifically, prior to September 2, 2015, the Board does not find evidence of either knee producing flexion limited to 30 degrees or extension limited to 15 degrees; ankylosis of the wrist; ankylosis of the fingers or limitation of motion of the thumb with a gap of more than two inches between the thumb pad and the fingers with the thumb attempting to oppose the fingers; shoulder arm motion limited to shoulder level; elbow producing forearm flexion limited to 90 degrees, forearm extension limited to 75 degrees, or bony fusion with the hand fixed near the middle of the arc, or in moderate pronation, or when pronation is lost beyond the last quarter of the arc and the hand does not approach full pronation; hip ankylosis, limitation of flexion of thigh to 30 degrees, or limitation of adduction of the thigh beyond 10 degrees; or cervical forward flexion greater than 15 degrees but not greater than 30 degrees, or combined range of motion of the cervical spine not greater than 170 degrees. Accordingly, for the period prior to September 2, 2015, a rating in excess of 10 percent for limitation of motion of the right knee, left knee, right wrist, left wrist, right hand fingers, left hand fingers, right shoulder, left shoulder, cervical spine, right elbow, left elbow, right hip and left hip, associated with service-connected rheumatic paraneoplastic syndrome, is not warranted. Effective Date An October 2015 rating decision granted service connection for limitation of motion of the bilateral knees, bilateral wrists, and bilateral hands, effective May 9, 2013; granted service connection for limitation of motion of the bilateral shoulders and cervical spine, effective October 29, 2014; and granted service connection for limitation of motion of the bilateral elbows and bilateral hips, effective April 1, 2015. The Veteran claims he is entitled to an earlier effective date for these limitations. Unless specifically provided otherwise, the effective date of an award based on an original claim shall be fixed in accordance with the facts found, but shall not be earlier than the date of receipt of the application. 38 U.S.C. § 5110(a). The statutory provision is implemented by regulation, which provides that the effective date for an evaluation and award of compensation based on an original claim will be the date of receipt of the claim or the date entitlement arose, whichever is later. 38 C.F.R. § 3.400. First, the Board finds the claim received by VA on April 24, 2013 for lung cancer and radiation is the appropriate claim date for the Veteran’s service connection claims for joint involvement associated with rheumatic paraneoplastic syndrome. A review of the procedural evidence shows the Veteran filed an application for service connection for lung cancer with radiation on April 24, 2013. An October 2014 rating decision granted service connection for lung cancer. In November 2014, the Veteran filed a timely appeal for an initial increased rating due to his paraneoplastic syndrome and rheumatoid arthritis. An April 2015 rating decision granted service connection for rheumatic paraneoplastic syndrome with an evaluation of 0 percent. The Veteran filed a timely notice of disagreement and statement regarding his joint pain as a result of his rheumatic paraneoplastic syndrome. An October 2015 rating decision granted service connection for limitation of motion of the bilateral knees, bilateral wrists, and bilateral hands, effective May 9, 2013; granted service connection for limitation of motion of the bilateral shoulders and cervical spine, effective October 29. 2014; and granted service connection for limitation of motion of the bilateral elbows and hips, effective April 1, 2015. The Board finds the Veteran timely notified VA of his contention that he had joint involvement associated with his lung cancer and treatment. There is no evidence that VA received any other formal or informal claims for service connection for joint involvement associated with rheumatic paraneoplastic syndrome prior to April 24, 2013. 38 C.F.R. § 3.1(p). The Board considered the Veteran’s attorney’s contention that the Veteran submitted a claim for service connection for rheumatic paraneoplastic syndrome in August 2012. See October 2018 attorney statement. The Board finds this contention is not supported by the record. The Veteran’s August 2012 claim for compensation was for radiation related to brain tumor. There was no mention of lung cancer, rheumatic paraneoplastic syndrome, or joint involvement. The Veteran’s brain tumor and treatment are not service-connected. As the Board has determined the date of claim, it must evaluate the date entitlement arose for each service-connected joint involved to determine the appropriate effective date. 15. An earlier effective date of April 24, 2013 for the award of service connection for limitation of motion of the right knee is granted. 16. An earlier effective date of April 24, 2013 for the award of service connection for limitation of motion of the left knee is granted. 17. An earlier effective date of April 24, 2013 for the award of service connection for limitation of motion of the right wrist is granted. 18. An earlier effective date of April 24, 2013 for the award of service connection for limitation of motion of the left wrist is granted. 19. An earlier effective date of April 24, 2013 for the award of service connection for limitation of motion of the right hand fingers is granted. 20. An earlier effective date of April 24, 2013 for the award of service connection for limitation of motion of the left hand fingers is granted. 21. An earlier effective date of April 24, 2013 for the award of service connection for limitation of motion of the right shoulder is granted. The October 2015 rating decision granted service connection for the Veteran’s joint involvement of the bilateral knees, bilateral wrists, and bilateral hands, effective May 9, 2013, the date a VA treatment visit assessed the Veteran’s joint pain was probably hypertrophic osteoarthropathy, a paraneoplastic process that is common in lung cancer. The October 2015 rating decision granted service connection for his joint involvement of the right shoulder, effective October 29, 2014, the date of a VA examination that found severe arthralgia of the shoulders due to paraneoplastic pain syndrome. The Board finds the evidence of record supports the Veteran’s joint involvement of the bilateral knees, bilateral wrists, bilateral hands, and right shoulder existed prior to his April 24, 2013 claim. Prior to April 24, 2013, treatment records show complaints of pain, burning, and stiffness of the bilateral knees, bilateral wrists, bilateral thumbs, and right shoulder. See January 2013 and March 2013 VA treatment visits. A March 20, 2013 VA treatment visit assessed his joint complaints could be an antineoplastic reaction, specifically hypertrophic pulmonary osteopathy. The Board finds this is sufficient evidence of entitlement prior to the April 24, 2013 claim. Therefore, as the effective date for an evaluation and award of compensation will be the date of receipt of the claim or the date entitlement arose, whichever is later, an earlier effective date of April 24, 2013, the date of his claim, is warranted for the award of service connection for limited motion of the bilateral knees, bilateral wrists, bilateral hands, and right shoulder. 22. An effective date prior to October 29, 2014 for the award of service connection for limitation of motion of the left shoulder is denied. The October 2015 rating decision granted service connection for joint involvement of the Veteran’s left shoulder, effective October 29, 2014, the date of a VA examination that found severe arthralgia of the shoulders due to paraneoplastic pain syndrome. The Board finds the first evidence of joint involvement of the left shoulder was at the October 29, 2014 VA examination. Therefore, as the effective date for an evaluation and award of compensation will be the date of receipt of the claim or the date entitlement arose, whichever is later, an effective date prior to October 29, 2014 for the award of service connection for limitation of motion of the shoulder is not warranted. 23. An earlier effective date of January 22, 2014 for the award of service connection for limitation of motion of the cervical spine is granted. The October 2015 rating decision granted service connection for the Veteran’s joint involvement of the cervical spine, effective October 29, 2014, the date of a VA examination that found severe arthralgia of the neck due to paraneoplastic pain syndrome. The Board finds the evidence of record supports the joint involvement of the Veteran’s neck existed prior to the October 29, 2014 VA examination. A January 22, 2014 VA treatment visit noted neck pain with an assessment of paraneoplastic syndrome with chronic pain. Therefore, as the effective date for an evaluation and award of compensation will be the date of receipt of the claim or the date entitlement arose, whichever is later, an earlier effective date of January 22, 2014, the date entitlement arose, is warranted for the award of service connection for the cervical spine. 24. An effective date prior to April 1, 2015 for the award of service connection for limitation of motion of the right elbow is denied. 25. An effective date prior to April 1, 2015 for the award of service connection for limitation of motion of the left elbow is denied. 26. An effective date prior to April 1, 2015 for the award of service connection for limitation of motion of the right hip is denied. 27. An effective date prior to April 1, 2015 for the award of service connection for limitation of motion of the left hip is denied. The October 2015 rating decision granted service connection for joint involvement of the Veteran’s bilateral elbows and bilateral hips, effective April 1, 2015, the date of a VA examination that diagnosed joint involvement of the bilateral elbows and hips. The Board finds the first evidence of joint involvement of the bilateral elbows and bilateral hips was at the April 1, 2015 VA examination. Therefore, as the effective date for an evaluation and award of compensation will be the date of receipt of the claim or the date entitlement arose, whichever is later, an effective date prior to April 1, 2015 for the award of service connection for limitation of motion of the bilateral elbows or bilateral hips is not warranted. 28. Entitlement to an effective date prior to March 1, 2014 for the grant of basic eligibility for DEA benefits is denied. An October 2015 rating decision established basic eligibility to DEA, effective March 1, 2014, or the date entitlement to a permanent and total disability rating based on individual employability was established. For the purposes of educational assistance under 38 U.S.C. Chapter 35, the child or surviving spouse of a veteran will have basic eligibility if the following conditions are met: (1) the veteran was discharged from service under conditions other than dishonorable, or died in service; and (2) the veteran has a permanent total service-connected disability; or (3) a permanent total service-connected disability was in existence at the date of the veteran's death; or (4) the veteran died as a result of a service-connected disability. An October 2017 Board decision denied entitlement to an effective date prior to March 1, 2014 for total disability rating based on individual unemployability (TDIU). DEA benefits may not be awarded prior to the effective date of an award for a permanent and total disability rating. Accordingly, entitlement to an effective date prior to March 1, 2014 for DEA benefits is denied. SMC Benefits 29. SMC for loss of use of use of both hands is denied. SMC will be awarded for the anatomical loss of a hand, or where there is “loss of use” of the hand. 38 U.S.C. § 1114(k); 38 C.F.R. §§ 3.350 (a)(2); 4.63. “Loss of use of the hand” means that no effective function remains other than that which would be equally well-served by an amputation stump below the elbow with use of a suitable prosthetic appliance. Id., Tucker v. West, 11 Vet. App. 369, 373 (1998). 38 C.F.R. § 3.350(a)(2). SMC(m) will be awarded for loss or loss of use of both hands. The Board finds the functioning of either of the Veteran’s hands would not be equally well-served by an amputation with use of a suitable prosthetic appliance. An October 2014 VA examiner stated the Veteran takes care of his activities of daily living, but it causes pain. The Veteran reported he could not do stained glass work or open jars due to hand pain. In January 2015 and May 2015, the Veteran reported morning stiffness with moderate pain. In September 2015, the Veteran reported significant worsening of hand arthralgias and that he could barely use them for anything. An October 2015 statement reported the Veteran had difficulty holding a walker due to hand arthritis. He stated it takes hours in the morning to get his hands loosened up. He reported he could not open medicine bottles, jars, or hold things without pain. He reported difficulty writing or typing. He reported he cannot pick up a quarter. A December 2015 private treatment visit noted the Veteran had stiffness and swelling, most marked in the hands. He stated the Veteran could not make a fist. The Veteran reported difficulty with activities of daily living, dropping items, and buttoning a shirt. A May 2016 VA treatment visit observed swelling and the noted the Veteran could not make a fist or grip. The examiner filled out a form indicating that due to the Veteran’s rheumatoid arthritis, he was able to feed himself, but required assistance for bathing and tending to his hygiene. In October 2017, the Veteran’s wife reported the Veteran was unable to feed himself due to hand arthritis. A January 2018 VA examination for aid and attendance opined the Veteran had the ability to grasp and manipulate objects with the bilateral hands with decreased muscle strength and decreased fine motor movements. The examiner opined the Veteran would not be equally well served by an amputation with the use of a suitable prosthetic appliance. In August 2018, a private physician stated the Veteran was unable to perform activities of daily living without assistance due to a combination of his widespread joint pain and dyspnea from his service-connected lung cancer. While the Board took the above medical opinions into consideration, the responsibility for determining loss of use is with the adjudicator and not an examining physician. Tucker v. West, 11 Vet. App. 369, 373 (1998). The Board gives great probative weight to the January 2018 VA examination that found the Veteran would not be equally well served by an amputation with the use of a suitable prosthetic appliance. The Board finds this opinion credible because it was made after an in-person examination. The opinion was consistent with treatment records and lay statements showing the Veteran is able to perform some activities of daily living. In May 2016 and November 2017, the Veteran’s physician stated the Veteran was able to feed himself and brush his teeth. A January 2018 VA examination for aid and attendance noted the Veteran was able self-feed and groom without assistance. While the Veteran’s wife has more recently reported she needs to help the Veteran feed due to his hand arthritis, the August 2018 private medical opinion stated the Veteran’s inability to feed himself was in large part due to his dyspnea. The Board finds the preponderance of the evidence shows the Veteran’s hand arthralgia produces significant functional limitations, but there still remains effective function. Even when considering the additional functional limitation caused by pain, the Veteran is still able to perform some activities of daily living. The Veteran would not be equally well-served by an amputation with use of a suitable prosthetic appliance. Accordingly, SMC for loss of use of the hand or hands is not warranted. 30. SMC for Aid and Attendance SMC based on the need for aid and attendance of another is payable when a veteran, due to service-connected disability, is so helpless as to be in need of regular aid and attendance. See 38 U.S.C. § 1114(l); see also 38 C.F.R. § 3.350(b). Pursuant to 38 C.F.R. § 3.352(a), the following criteria are to be considered for determining whether a claimant is in need of the regular aid and attendance of another person: (1) the inability of the claimant to dress himself or to keep himself ordinarily clean and presentable; (2) frequent need of adjustment of any special prosthetic or orthopedic appliance which, by reason of the particular disability, cannot be done without aid; (3) the inability of the claimant to feed himself through the loss of coordination of the upper extremities or through extreme weakness; (4) the inability to attend to the wants of nature; or, (5) a physical or mental incapacity that requires care and assistance on a regular basis to protect the claimant from the hazards or dangers incident to his or her daily environment. A veteran need show only one of the enumerated factors identified in 38 C.F.R. § 3.352(a) to establish entitlement to aid and attendance. Turco v. Brown, 9 Vet. App. 222, 224 (1996). Moreover, it is only necessary that the evidence establish that the veteran is so helpless as to need regular aid and attendance, not that there be a constant need. Id. The performance of the necessary aid and attendance service by a relative of the claimant or other member of his or her household will not prevent the granting of the additional allowance. 38 C.F.R. § 3.352(c). The Board finds that SMC for aid and attendance is warranted because the evidence shows that due to the Veteran’s service-connected conditions, he requires assistance to dress and keep himself ordinarily clean and presentable, attend to the wants of nature, feed himself, and protect himself from the hazards or dangers incident to his daily environment. The Veteran reported he needs assistance with dressing, bathing, and toileting. The Veteran’s wife reported she also assists him with feeding. The Veteran and his wife are competent to give testimony concerning his functional limitations, and the Board finds their reports to be credible. Layno v. Brown, 6 Vet. App. 465 (1994). An August 2018 private medical opinion found it was unquestionable that the Veteran is unable to perform activities of daily living independently due solely to his service-connected conditions. The examiner stated the Veteran is unable to dress himself, perform hygiene activities, feed himself, and perform toileting tasks, due to his marked shortness of breath and extreme joint impairments. The physician stated that failing to provide the Veteran with care would likely result in additional injury or trauma. The Board finds the examiner’s opinion highly probative as it contains clear conclusions with supporting data and a reasoned medical explanation connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The Board considered whether the Veteran was entitled to SMC at the housebound rate under 38 U.S.C. § 1114(s). The Veteran is not entitled to separate payments at the (s) and (l) rates, unless the disability or disabilities which render the Veteran eligible for SMC(l) are separate and distinct from that or those which entitle him to SMC(s). Here, there are not disabilities which render the Veteran eligible for aid and attendance that are separate and distinct from disabilities which would entitle him to SMC(s). SMC(l) at the aid and attendance rate is a greater monetary benefit than SMC(l) at the housebound rate. Thus, in light of this evidence, the Board finds SMC based on the need for regular aid and attendance is warranted. KELLI A. KORDICH Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD T. Winkler, Associate Counsel