Citation Nr: 18159844 Decision Date: 12/20/18 Archive Date: 12/20/18 DOCKET NO. 16-12 530 DATE: December 20, 2018 ORDER Entitlement to service connection for chronic kidney disease is denied. Entitlement to a rating evaluation in excess of 10 percent for chronic, inactive left tibia osteomyelitis, with repeated episodes, is denied. Entitlement to a rating evaluation in excess of 30 percent for the residuals of left tibia and fibula fractures, with marked knee disability, is denied. Entitlement to a rating evaluation in excess of 20 percent for service-connected left ankle degenerative arthritis, which manifests as limited motion, is denied. Entitlement to a compensable evaluation for left lower tibia scar is denied. REMANDED Entitlement to service connection for a below-knee amputation of the right leg is remanded. The appeal of the denial to special monthly compensation based on need for aid and attendance is remanded. Entitlement to special monthly compensation based on housebound criteria is remanded. Entitlement to automobile or other conveyance and adaptive equipment, or for adaptive equipment only, is remanded. Entitlement to specially adapted housing is remanded. Entitlement to a special home adaptation grant is remanded. FINDINGS OF FACT 1. The preponderance of the evidence is against a finding that the Veteran’s chronic kidney disease was incurred in or aggravated by active duty service in the United Sates Air Force. 2. At no time during the applicable claim period, September 12, 2012 to the time of the Veteran’s death, did he demonstrate active osteomyelitis of the left leg and/or tibia. 3. At no time during the applicable claim period, September 12, 2012 to the time of the Veteran’s death, did he demonstrate nonunion of the tibia and fibula, with loose motion, requiring a brace. 4. At no time during the applicable claim period, September 12, 20102 to the time of the Veteran’s death, did he demonstrate left ankle ankylosis. 5. At no time during the applicable claim period, September 12, 2012 to the time of the Veteran’s death, did he demonstrate a left lower tibia scar that was deep and nonlinear, superficial and nonlinear, unstable or painful, and/or otherwise disabling. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for chronic kidney disease have not been satisfied. 38 U.S.C. §§ 1101, 1131, 1133, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2017). 2. The criteria for a disability rating in excess of 10 percent for the Veteran’s inactive left tibia osteomyelitis, with repeated episodes, have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.10, 4.21, 4.40, 4.45, 4.46, 4.59, 4.71a, DC 5000 (2017). 3. The criteria for a disability rating in excess of 30 percent for the Veteran’s residuals of left tibia and fibula fractures, with marked knee disability, have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.10, 4.21, 4.40, 4.45, 4.46, 4.59, 4.71a, DC 5262 (2017). 4. The criteria for a disability rating in excess of 20 percent for the Veteran’s left ankle degenerative arthritis, which manifests as limited motion, have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.10, 4.21, 4.40, 4.45, 4.46, 4.59, 4.71a, DCs 5270 & 5271 (2017). 5. The criteria for a compensable evaluation for a left lower tibia scar have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.10, 4.21, 4.40, 4.45, 4.46, 4.59, 4.71a, DCs 7800-7805 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served honorably in the United States Air Force from September 1949 to January 1954. The Veteran passed away on November 11, 2016. The agency of original jurisdiction (AOJ) granted the Appellant’s motion to substitute for her deceased spouse on June 6, 2017. The Board has thoroughly reviewed all the evidence in the Veteran’s claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, all of the evidence submitted by the Veteran or on his behalf. See Gonzalez v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claims. The Appellant must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran/Appellant). SERVICE CONNECTION In general, a service connection claim may be granted for a disability resulting from a disease or injury incurred in, or aggravated by, active service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303 (a). “To establish a right to compensation for a present disability, a Veteran must show: ‘(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service-the so-called ‘nexus’ requirement.” Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). In each case where service connection for any disability is sought, due consideration shall be given to the places, types, and circumstances of such Veteran’s service as shown by such Veteran’s service record, the official history of each organization in which such Veteran served, such Veteran’s medical records, and all pertinent medical and lay evidence. 38 U.S.C. § 1154 (a). Additionally, for Veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, such as kidney disease, are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C. §§ 1101, 1112, 1137; 38 C.F.R. §§ 3.307, 3.309. Alternatively, when a disease at 38 C.F.R. § 3.309 (a) is not shown to be chronic during service or the one-year presumptive period, service connection may also be established by showing continuity of symptomatology after service. See 38 C.F.R. § 3.303 (b). However, the use of continuity of symptoms to establish service connection is limited only to those diseases listed at 38 C.F.R. § 3.309 (a) and does not apply to other disabilities which might be considered chronic from a medical standpoint. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the Veteran. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). 1. Entitlement to service connection for chronic kidney disease is denied. In December 2013, the Veteran submitted his VA Form 21-526b. Therein, the Veteran initiated his entitlement claim for service connection for chronic kidney disease. As noted above, there are three requisite elements that must be satisfied to warrant service connection: a current disability, an in-service incurrence or aggravation, and a “nexus” between the first and second elements. See Holton, 557 F.3d at 1366 (quoting Shedden, 381 F.3d at 1167). In October 2010, Dr. SB reported that the Veteran endured chronic kidney disease, with a creatine baseline of 1.4 - 1.7. Consequently, the Board finds that the Veteran maintained a current diagnosis and, therefore, the first requisite element of a service-connection claim is satisfied. Id. The Veteran’s service treatment records (STRs) have been associated with his claims file since May 1954. Deliberate and careful Board review of the Veteran’s STRs does not reveal any evidence that would support an in-service incurrence of chronic kidney disease. The Board has also deliberately and carefully reviewed the Veteran’s extensive post-service VA treatment records. Therein, on September 7, 2006, Dr. IPK noted the Veteran’s high creatine levels within a primary care physician note. This notation from Dr. IPK represents the earliest evidence of kidney disease within the Veteran’s claim file. The Board observes that this first indication of kidney disease was added more than five decades after the Veteran’s separation from the Air Force; consequently, the Board cannot award service connection based on continuity of symptomology after active duty service. See 38 C.F.R. § 3.309 (b). Ultimately, the Board finds that the preponderance of the evidence stands counter to the Appellant’s entitlement claim for service connection for chronic kidney disease. Since the preponderance of the evidence is against service-connection claim, the provisions of 38 U.S.C. § 5107(b), regarding reasonable doubt, are not applicable. The Appellant’s claim for entitlement to service connection for chronic kidney disease must be denied, because the preponderance of the evidence weighs against her claim. INCREASED RATINGS Disability ratings are determined by applying the criteria set forth in VA’s Schedule for Rating Disabilities (Rating Schedule), which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.1 (2017). The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. If there is a question as to which evaluation to apply to the Veteran’s disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When reasonable doubt arises as to the degree of disability, such doubt will be resolved in the Veteran’s favor. 38 C.F.R. § 4.3. In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of any disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the veteran’s medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999). The Board must also assess the competence and credibility of lay statements and testimony. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). In increased rating claims, a Veteran’s lay statements alone, absent a negative credibility determination, may constitute competent evidence of worsening, at least with respect to observable symptoms. See Vazquez-Flores v. Shinseki, 24 Vet. App. 94, 102 (2010), rev’d on other grounds by Vazquez-Flores v. Shinseki, 580 F.3d 1270, 1277 (Fed. Cir. 2009). The Veteran was uniquely suited to describe the severity, frequency, and the duration of the symptoms that accompanied his four service-connected disabilities addressed below. See Falzone v. Brown, 8 Vet. App. 398 (1995); Heuer v. Brown, 7 Vet. App. 379 (1995). The Veteran filed his increased rating claims on September 12, 2013. As noted above, the Veteran’s entire history is reviewed when assigning a disability evaluation. 38 C.F.R. § 4.1. However, where service connection has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). In determining the present level of a disability for any increased evaluation claim, the Board must consider the application of staged ratings. See Hart v. Mansfield, 21 Vet. App. 505, 509-510 (2007); Fenderson v. West, 12 Vet. App. 119, 126 (1999). The Board must consider whether there have been times when his disabilities on appeal have been more severe than at others, and rate them accordingly. “The relevant temporal focus for adjudicating an increased-rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim.” Hart, 21 Vet. App. at 509. Therefore, in the present case, the Board will place a specific focus on evidence of record back to September 12, 2012. 2. Entitlement to an evaluation in excess of 10 percent for chronic, inactive left tibia osteomyelitis, with repeated episodes, is denied. In September 2013, the Veteran submitted his VA Form 21-4138. Therein, the Veteran initiated his entitlement claim for a disability rating in excess of 10 percent for left tibia osteomyelitis. The Veteran’s left tibia osteomyelitis is rated under 38 C.F.R. § 4.71a, Diagnostic Code (DC) 5000. Under the umbrella of DC 5000, for osteomyelitis, acute, subacute, or chronic, a 10 percent evaluation is assigned for inactive osteomyelitis following repeated episodes without evidence of active infection in the past 5 years. A 20 percent evaluation is assigned for osteomyelitis with discharging sinus or other evidence of active infection within the past 5 years. A 30 percent evaluation is assigned for osteomyelitis with definite involucrum or sequestrum, with or without discharging sinus. A 60 percent evaluation is assigned for frequent episodes of osteomyelitis with constitutional symptoms. A 100 percent evaluation is assigned for osteomyelitis of the pelvis, vertebrae, or extending into major joints, or with multiple localizations or with long history of intractability and debility, anemia, amyloid liver changes or other continuous constitutional symptoms. 38 C.F.R. § 4.71a. Note (2) to Diagnostic Code 5000 provides that the 20 percent rating on the basis of activity within the past 5 years is not assignable following the initial infection of active osteomyelitis with no subsequent reactivation. The prerequisite for this historical rating is an established recurrent osteomyelitis. To qualify for the 10 percent rating, two or more episodes following the initial infection are required. This 20 percent rating or the 10 percent rating, when applicable, will be assigned once only to cover disability at all sites of previously active infection with a future ending date in the case of the 20 percent rating. The Board observes that the Veteran was afforded a VA examination for osteomyelitis in April 2003. At time Dr. RWP diagnosed “(c)hronic osteomyelitis of the left tibia, inactive, without evidence of flaring up of the infection since coverage was done here in the years soon after the patient’s exit from the service. Within his impression, Dr. RWP noted that, “there is an old midshaft fracture of the tibia with much old periosteal new bone formation consistent with a history of chronic osteomyelitis. There is no evidence of active appearing periosteal elevation at this time. The soft tissues are distorted with tapering distally toward the ankle and some calcification medially. Also, the fascial plane appears distorted and there may be some edema and soft tissue swelling.” At various times within the applicable claim period, September 12, 2012 to present, the Veteran’s medical treatment notations were associated with his claims file. For instance, in June 2014, the Veteran’s treatment records from the Dallas VA medical center (VAMC) were associated with the claims file. The Report of a November 2014 examination reveals that the Veteran reported that his last treatment for osteomyelitis was in the 1950s. He had no surgical treatment for his osteomyelitis. There were no additional episodes or recurring infections following his initial infestation and had no signs or findings attributable to osteomyelitis or treatment for osteomyelitis. There was no amputation due to osteomyelitis. In December 2014, the Veteran’s notations from the North Texas HCS were associated with the claims file. After thorough and deliberate Board review of all the evidence during the relevant claim period, there was no notation generated by the competent medical community that indicated the Veteran’s osteomyelitis of the left tibia was active. In August 2016, a wound care consult was generated at the Dallas VAMC. Therein, the VA provider observed that, “(p)atient presents with several small wounds to his left medial leg and one small wound to his left foot that are all beginning to epithelize nicely.” The VA provider identified the type of wound as “(p)atrial to full thickness.” Important to this Board analysis, the VA provider specifically noted that he did not suspect any “infectious process.” Again, under 38 C.F.R. § 4.71a, DC 5000, a 20 percent evaluation is assigned for osteomyelitis with discharging sinus or other evidence of active infection within the past 5 years. After deliberate review of the Veteran’s claims file, the Board finds that at no time during the applicable claim period, September 12, 2012 to time of his death, did the Veteran demonstrate active osteomyelitis of the left tibia. Ultimately, the Board finds that the preponderance of the evidence stands counter to the Appellant’s entitlement claim for a disability rating in excess of 10 percent for the Veteran’s osteomyelitis of the left leg. Since the preponderance of the evidence is against increased disability rating claim, the provisions of 38 U.S.C. § 5107(b), regarding reasonable doubt, are not applicable. The Appellant’s claim of entitlement to an increased disability rating for osteomyelitis of the left leg must be denied, because the preponderance of the evidence weighs against her claim. The Board notes that the Appellant and her representative have not raised any other issues, nor have any other issues been reasonably raised by the record. See Yancy v. McDonald, 27 Vet. App. 484, 495 (2016); Doucette v. Shulkin, 38 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). 3. Entitlement to a rating evaluation in excess of 30 percent for the residuals of left tibia and fibula fractures, with marked knee disability, is denied. In September 2013, the Veteran submitted his VA Form 21-4138. Therein, the Veteran initiated his entitlement claim for a disability rating in excess of 30 percent for his service-connected residuals of left tibia and fibula fractures. The diagnostic criteria applicable to the residuals of tibia and fibula fractures are found at 38 C.F.R. § 4.71a, DC 5262. Under DC 5262, a 20 percent evaluation is warranted when malunion of the tibia and fibula is productive of moderate knee or ankle disability, and a 30 percent evaluation is warranted when such disability is marked. A 40 percent evaluation is warranted for nonunion of the tibia and fibula, with loose motion, requiring a brace. 38 C.F.R. § 4.71a, DC 5262. Words such as “slight,” “moderate,” and “marked” are not defined in the Rating Schedule. Rather than applying a mechanical formula, VA must evaluate all evidence, to the end that decisions will be equitable and just. 38 C.F.R. § 4.6. Although the use of similar terminology by medical professionals should be considered, is not dispositive of an issue. Instead, all evidence must be evaluated in arriving at a decision regarding a request for an increased rating. 38 U.S.C. § 7104; 38 C.F.R. §§ 4.2, 4.6. The Board observes that the Veteran was afforded a VA examination for the residuals of a left tibia fracture in January 2007. At that time, Dr. RWP noted that, “x-rays of the left tibia and fibula in April 2003 show an old, healed fracture proximal shaft of fibula and old mid-shaft fracture of the tibia with a lot of old periosteal new bone formation consistent with osteomyelitis, otherwise normal.” Concerning the Veteran’s left knee, Dr. RWP noted that, “he has left knee pain that started approximately 1-1/2 years ago . . .. The pain is sharp, especially with walking one block. The pain averages 7/10 . . .. He uses no braces or supports. He does use a cane and a wheelchair . . .. ” Important to this Board analysis, Dr. RWP did not note nonunion of the tibia and/or fibula at any point during his examination and/or the resultant notation. At various times within the applicable claim period, September 12, 2012 to present, the Veteran’s medical treatment notations were associated with his claims file. For instance, in June 2014, the Veteran’s treatment records from the Dallas VA medical center (VAMC) were associated with the claims file. In November 2014, the Veteran was afforded an examination of his left leg. He reported flare-ups of pain occurring 2 times a month lasting a day. During this time, he reported that he could not move his leg. It was noted that the Veteran was wheelchair bound. The Veteran was observed to have range of flexion to 90 degrees (normal endpoint was noted to be 140 degrees) with no objective evidence of painful motion and no limitation of extension. Repetitive motion reduced flexion to 80 degrees. In December 2014, the Veteran’s notations from the North Texas HCS were associated with the claims file. In February and December 2016, additional treatment notations from the Dallas VAMC were associated with the claims file. After thorough and deliberate review of all the evidence during the relevant claim period, the Board did not identify a single medical notation that indicated that the Veteran demonstrated nonunion of the tibia and fibula, with loose motion, requiring a brace. The Veteran was noted to have less movement than normal and weakened movement following repetitive use testing. There was no tenderness or pain to palpation for the joint line or soft tissues of either knee. Muscle strength testing was 4/5 with both flexion and extension. Joint stability testing was normal and there was no evidence or history of recurrent subluxation or dislocation. The Veteran did not have any meniscal conditions or surgical procedures for a meniscal condition. The Veteran’s left leg disability did not result in functional impairment of an extremity such that no effective function remains other than that which would be equally well served by an amputation with prosthesis. Again, under 38 C.F.R. § 4.71a, DC 5262, a 40 percent evaluation is warranted for nonunion of the tibia and fibula, with loose motion, requiring a brace. After deliberate review of all the evidence within the Veteran’s claims file, the Board finds that at no time during the applicable claim period, September 12, 2012 to time of his death, did the Veteran demonstrate nonunion of the tibia and fibula, with loose motion, requiring a brace. Ultimately, the Board finds that the preponderance of the evidence stands counter to the Appellant’s entitlement claim for a disability rating in excess of 30 percent for the Veteran’s residuals of left tibia and fibula fractures, with marked knee disability. Since the preponderance of the evidence is against this increased rating claim, the provisions of 38 U.S.C. § 5107(b), regarding reasonable doubt, are not applicable. The Appellant’s claim of entitlement to an increased disability rating for the residuals of left tibia and fibula fractures, with marked knee disability must be denied, because the preponderance of the evidence weighs against her claim. The Board notes that the Appellant and her representative have not raised any other issues, nor have any other issues been reasonably raised by the record. See Yancy v. McDonald, 27 Vet. App. 484, 495 (2016); Doucette v. Shulkin, 38 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). 4. Entitlement to an evaluation in excess of 20 percent for degenerative arthritis of the left ankle, which manifests as limited motion, is denied. In September 2013, the Veteran submitted his VA Form 21-4138. Therein, the Veteran initiated his entitlement claim for an increased disability rating for service-connected degenerative left ankle arthritis. After a thorough review of the record, the Board finds that the evidence does not support entitlement to a rating in excess of 20 percent for the Veteran’s left ankle at any time during the pertinent appellate period. The Board will consider not only the criteria of the currently assigned diagnostic code, but also the criteria of other potentially applicable diagnostic codes. The assignment of a particular Diagnostic Code is “completely dependent on the facts of a particular case.” See Butts v. Brown, 5 Vet. App. 532, 538 (1993). If there is a question as to which evaluation to apply to the Veteran’s disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Veteran is rated under Diagnostic Codes (DCs) 5010-5271 for his left ankle disability. The Board notes that hyphenated codes are used when a rating under one diagnostic code requires use of an additional code to identify the basis for the evaluation assigned. 38 C.F.R. § 4.27. Under DC 5003, degenerative arthritis, established by X-ray findings, will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. The rating criteria for limited motion of the ankle are listed in DC 5271. Diagnostic Code 5271 authorizes a 10 percent rating for moderate limited motion of the ankle, and a 20 percent rating for marked limited motion of the ankle. 38 C.F.R. § 4.71a. This diagnostic code does not provide for a rating in excess of 20 percent. The Board notes that the Veteran is currently assigned the maximum 20 percent rating under DC 5271. While the rating schedule itself does not provide any additional guidance as to what constitutes “moderate” or “marked” limitation of ankle motion, guidance can be found in VBA's M21-1 Adjudication Procedures Manual. Specifically, the M21-1 states that moderate limitation of ankle motion is present when there is less than 15 degrees dorsiflexion or less than 30 degrees plantar flexion, while marked limitation of motion is demonstrated when there is less than 5 degrees dorsiflexion or less than 10 degrees plantar flexion. See VBA Manual M21-1, III.iv.4.A.3.k. Normal ankle motion is dorsiflexion to 20 degrees, and plantar flexion to 45 degrees. 38 C.F.R. § 4.71a, Plate II. Diagnostic Code 5270 authorizes a 30 percent rating for ankylosis of the ankle when plantar flexion is between 30 and 40 degrees, or for ankylosis of the ankle when dorsiflexion is between 0 and 10 degrees. A 40 percent rating is warranted when there is ankylosis in plantar flexion at greater than 40 degrees, or in dorsiflexion at more than 10 degrees or with abduction, adduction, inversion or eversion deformity. 38 C.F.R. § 4.71a. Other diagnostic codes pertinent to the ankle include the following: DC 5272 (ankylosis of the subastragular or tarsal joint), DC 5273 (malunion of the os calcis or astragalus), and DC 5274 (astragalectomy). In his September 2013 VA Form 21-4138, the Veteran contended that his service-connected left ankle disability warrants a higher percentage, beyond the current 20 percent rating. For this increased rating contention, the Board concludes that the preponderance of the evidence does not support the Appellant’s claim. The Board observes that the Veteran was last afforded a VA examination that addressed the severity of the Veteran’s left ankle in January 2007. At that time, the Veteran reported that, “(h)e has left ankle pain every day that is constant. The pain is a sticking type pain. The pain average about 6/10 and it is difficult for him to walk on his left leg. He can only walk approximately one block before his pain gets worse. He uses a cane and wheelchair to get around most of the time.” Upon examination of the Veteran’s left ankle, Dr. RWP did not observe deformities, swelling or palpable tenderness. At that time, the Veteran demonstrated the following range of motion: “He had dorsiflexion of 0 to 10 degrees with pain medially and laterally at 10 degrees minus 10 degrees secondary to pain. Plantar flexion is 0 to 30 degrees with pain medially and laterally at 30 degrees minus 15 degrees secondary to pain. Active range of motion did not produce any weakness fatigue or incoordination. There was no additional loss with range of motion or repetitive movements.” Important to this Board analysis, Dr. RWP did not observe and/or note ankylosis of the Veteran’s left ankle. At various times within the applicable claim period, September 12, 2012 to present, the Veteran’s medical treatment notations were associated with his claims file. For instance, in June 2014, the Veteran’s treatment records from the Dallas VA medical center (VAMC) were associated with the claims file. In November 2014, the Veteran was afforded a VA examination of his left ankle. Range of plantar flexion was to 40 degrees while range of dorsiflexion was to 20 degrees. Following repetitive use testing, range of plantar flexion was reduced to 35 degrees while range of dorsiflexion was limited to 25 degrees. The examination report notes that normal endpoint of plantar flexion is 45 degrees and normal endpoint of dorsiflexion is 20 degrees. Range of motion testing was painful on active, passive, and/or repetitive use testing. There was no pain when the left ankle joint was used in weight bearing or nonweight bearing and no localized tenderness or pain on palpation of the joints or soft tissue. The examiner estimated that range of motion due to pain and/or functional loss during flare-ups or when the joint was used repeatedly over a period of time would result in plantar flexion to 5 degrees and dorsiflexion to 0 degrees. There was no ankle instability or dislocation suspected. In December 2014, the Veteran’s notations from the North Texas HCS were associated with the claims file. In February and December 2016, additional treatment notations from the Dallas VAMC were associated with the claims file. After thorough and deliberate review of all the evidence during the relevant claim period, the Board did not identify a single medical notation that indicated that the Veteran demonstrated left ankle ankylosis. While the Veteran experiences marked limitation of motion, under the above-referenced applicable DCs to the Veteran’s service-connected left ankle disability, an increased rating would necessitate ankylosis of plantar or dorsiflexion. While the Veteran’s experienced significant limitation of motion during flare-ups or after using the ankle for periods of time as noted by the November 2014 examination, review of the Veteran’s medical treatment records for the relevant appeal period does not show that the Veteran had left ankle ankylosis. On the contrary, the November 2014 examiner specifically noted that the left ankle did not have ankylosis. Ultimately, the Board concludes that the preponderance of the evidence is against the Appellant’s entitlement claim for an increased rating for the late Veteran’s service-connected left ankle disability. Accordingly, this increased rating claim must be denied. In reaching this determination, the Board again acknowledges that VA is statutorily required to resolve the benefit of the doubt in favor of the Appellant when there is an approximate balance of positive and negative evidence regarding the merits of an outstanding issue. This doctrine of reasonable doubt, however, is inapplicable in this case because the preponderance of the evidence is against the Appellant’s claim. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990); 38 U.S.C. § 5107 (b). The Board notes that the Appellant and her representative have not raised any other issues, nor have any other issues been reasonably raised by the record. See Yancy v. McDonald, 27 Vet. App. 484, 495 (2016); Doucette v. Shulkin, 38 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). 5. Entitlement to a compensable evaluation for left lower tibia scar is denied. In September 2013, VA received correspondence from the Veteran’s representative. Thereby, the Veteran initiated his entitlement claim for an increased disability rating for the service-connected “residuals of left leg compound fracture of the tibia.” The Veteran’s left lower tibia scar is rated under Diagnostic Code 7805. 38 C.F.R. § 4.118. In general, the rating criteria for scars are provided under DCs 7800, 7801, 7802 and 7804. In addition, Diagnostic Code 7805 provides that any disabling effect(s) not considered in a rating provided under DCs 7800-7804 should be evaluated under an appropriate Diagnostic Code. Id. Under Diagnostic Code 7801, scars not of the head, face or neck that are deep and nonlinear and cover an area or areas of at least six square inches (39 square cm) but less than 12 square inches (77 square cm) warrant a 10 percent rating. Higher ratings are warranted for scars covering larger areas. Id. Under Diagnostic Code 7802, scars not of the head, face or neck that are superficial and nonlinear and cover an area or areas of 144 square inches (929 square cm) or greater warrant a 10 percent rating. Id. Under DC 7804, the presence of one or two scars that are unstable or painful warrants a 10 percent disability rating. Three or four scars that are unstable or painful warrant a 20 percent rating. The presence of five or more scars that are unstable or painful warrant a 30 percent rating. Note (1) explains that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Under Note (2), if one or more scars are both unstable and painful, 10 percent is to be added to the rating that is based on the total number of unstable or painful scars. Id. The Board observes that the Veteran was afforded a VA examination for the residuals of a left tibia fracture in January 2007. At that time, Dr. RWP noted a scar measuring “4-inch x 3-inch skin graft at the left shin area that is well healed. The scar is nontender, good texture, good adherence, no keloid formation, no elevation or depression, no hernias, no ulcerations, no limitation of function of the scar, no functional impairment.” At various times within the applicable claim period, September 12, 2012 to present, the Veteran’s medical treatment notations were associated with his claims file. For instance, in June 2014, the Veteran’s treatment records from the Dallas VA medical center (VAMC) were associated with the claims file. In December 2014, the Veteran’s notations from the North Texas HCS were associated with the claims file. In February and December 2016, additional treatment notations from the Dallas VAMC were associated with the claims file. After thorough and deliberate review of all the evidence during the relevant claim period, the Board did not identify a single medical notation indicating indicated that the Veteran’s left tibia scar was deep and nonlinear, superficial and nonlinear, unstable or painful, and/or otherwise disabling. Ultimately, the Board concludes that the preponderance of the evidence is against the Appellant’s entitlement claim for an increased rating for the late Veteran’s service-connected left lower tibia scar. Accordingly, this increased rating claim must be denied. In reaching this determination, the Board again acknowledges that VA is statutorily required to resolve the benefit of the doubt in favor of the Appellant when there is an approximate balance of positive and negative evidence regarding the merits of an outstanding issue. This doctrine of reasonable doubt, however, is inapplicable in this case because the preponderance of the evidence is against the Appellant’s claim. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990); 38 U.S.C. § 5107 (b). The Board notes that the Appellant and her representative have not raised any other issues, nor have any other issues been reasonably raised by the record. See Yancy v. McDonald, 27 Vet. App. 484, 495 (2016); Doucette v. Shulkin, 38 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). REASONS FOR REMAND Upon review of the record, the Board concludes that further evidentiary development is necessary. Although the Board sincerely regrets this delay, a remand is necessary to ensure VA provides the Appellant with appropriate assistance in developing her claims prior to final adjudication. 6. Entitlement to service connection for a below-knee amputation of the right leg is remanded. In December 2013, the Veteran submitted his VA Form 21-526b. Therein, the Veteran initiated his entitlement claim for service connection for “loss of right leg, above the knee . . ..” Again, in order to establish service connection for the claimed disorder on a direct basis, generally there must be probative evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). Service connection may also be granted for a disability that is proximately due to, or the result of, a service-connected disability. See 38 C.F.R. § 3.310 (a). When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. See id; Harder v. Brown, 5 Vet. App. 183, 187 (1993). To prevail on the issue of secondary service connection, the record must show (1) evidence of a current disability, (2) evidence of a service-connected disability, and (3) medical nexus evidence establishing a connection between the current disability and the service-connected disability. Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-17 (1995). Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease or injury, will be service-connected. However, VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. 38 C.F.R. § 3.310 (b); see also Allen v. Brown, 7 Vet. App. 439, 448 (1995). (This standard of assessing aggravation of disability under 38 C.F.R. § 3.310 was established in 2006. See 71 Fed. Reg. 52744-47 (Sept. 7, 2006) (codified at 38 C.F.R. § 3.310)). Although VA indicated that the purpose of the regulation was merely to apply the Court’s 1995 ruling in Allen, it was made clear in the comments to the regulation that the 2006 changes were intended to place the burden on the claimant to establish a pre-aggravation baseline level of disability for the nonservice-connected disability before an award of service connection based on aggravation may be made. This had not been VA’s practice, which strongly suggests that the revision amounted to a substantive change in the regulation. Because the Veteran’s claim was received after the regulatory change, his claim will be adjudicated under the current version of the regulation. The VA is responsible for determining whether the evidence supports the claim or is in relative equipoise (with the Veteran prevailing in either event) or whether a preponderance of the evidence is against the claim (in which case the claim is denied). Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. §5107 (b). In June 2014, the Veteran’s treatment notations from the North Texas Health Care System (HCS) were associated with his claims file. Therein, on October 15, 2013, Dr. SL observed that the Veteran underwent a formalization procedure for a below-knee amputation of the right leg, which occurred five days earlier. The Board observes that this treatment notation clearly demonstrates that the Veteran satisfied the first requisite element for direct and/or secondary service-connection claims, from October 2013 onward. However, after careful and deliberate review of the Veteran’s claims file, the Board did not identify any evidence to substantiate the second and third elements of a direct service-connection claim for the Veteran’s below-knee amputation of the right leg. The Board has identified evidence that supports a need for further development for a secondary service-connection claim. Specifically, on October 9, 2013, the Veteran’s treatment notations from the North Texas HCS reflected that, “(Veteran) at St. Pauls with apparent osteomyelitis of foot, WBC 35K; surgical consultation there recommending probable amputation.” An hour later, it was noted that, “Veteran transfer from St. Pauls hospital for foot pain/diabetic foot.” On October 10, 2013, a notation indicated that, “impaired tissue integrity related to mechanical destruction of tissue secondary to pressure, shear or friction., right foot osteomyelitis.” On October 15, 2013, Dr. RJB generated the following post-operative bone pathology notation: “RT foot (right below the knee amputation): --gangrene with ulceration. --underlying bone with acute osteomyelitis.” The Board observes that the Veteran had been service connected for chronic osteomyelitis of the left tibia since September 1960. The Board also observes that Veteran’s post-operative pathology report found acute osteomyelitis in the Veteran’s right leg. As a result, the Board concludes that the AOJ must obtain a competent medical provider’s opinion, regarding whether the Veteran’s below-knee amputation of the right leg is at least as likely as not the result of service-connected osteomyelitis of the left tibia.   7. Entitlement to special monthly compensation (SMC) based on the need for aid and attendance is remanded. On September 10, 2013, the Veteran initiated his claim for SMC based on the need for aid and attendance. In April 2014, the Veteran submitted a VA Form 21-4138. At that time, the Veteran stated, “please pull or review all medical VAMC Dallas from 2005-2014 for my claim for special monthly compensation. My situation has changed dramatically since the amputation of my right leg below the knee at the VAMC Dallas in October 2013.” A Veteran may receive SMC either by reason of being housebound or based on the need for regular aid and attendance, but in most cases may not receive both simultaneously. That is, regular aid and attendance is the greater monetary award. Compare 38 U.S.C. § 1114 (l) with 38 U.S.C. §1114 (s). The Board notes that the Veteran maintained an overall combined 60 percent disability rating when this entitlement claim for SMC was initiated. In any event, there is no statutory or regulatory threshold requirement for a total 100 percent rating to be eligible for entitlement to SMC based on the need for regular aid and attendance. See 38 U.S.C. § 1114 (l); 38 C.F.R. §§ 3.350 (b), 3.351(b), 3.352(a). Special monthly compensation on a higher level under 38 U.S.C. § 1114 (l) and 38 C.F.R. § 3.350 (b) is payable as the result of service-connected disability if the Veteran has an anatomical loss or loss of use of both feet, or of one hand and one foot; has blindness in both eyes with visual acuity of 5/200 or less (or concentric contraction of the field of vision beyond 5 degrees in both eyes); is permanently bedridden; or is so helpless as to be in need of regular aid and attendance of another person. Based on the above regulatory criteria, the Board recognizes that the Appellant’s entitlement claim for SMC based on the need for regular aid and attendance is inextricably intertwined with the claim for entitlement to service connection for a below-knee amputation of the right leg. Harris v. Derwinski, 1 Vet. App. 180 (1991) (two issues are “inextricably intertwined” when they are so closely tied together that a final Board decision on one issue cannot be rendered until the other issue has been considered). Because the Appellant’s two claims are inextricably intertwined, the AOJ and Board cannot resolve one claim without consideration of the other. As such, the Board must also remand the Appellant’s claim for SMC based on the need for regular aid and attendance to the AOJ for adjudication. 8. Entitlement to special monthly compensation (SMC) based on housebound criteria is remanded. On September 10, 2013, the Veteran initiated his claim for SMC based on the need for housebound benefits. In April 2014, the Veteran submitted a VA Form 21-4138. At that time, the Veteran stated, “please pull or review all medical VAMC Dallas from 2005-2014 for my claim for special monthly compensation. My situation has changed dramatically since the amputation of my right leg below the knee at the VAMC Dallas in October 2013.” Special monthly compensation benefits by reason of being housebound are payable if the Veteran has a single permanent disability rated 100 percent disabling, and has either (1) additional service-connected disability or disabilities independently ratable at 60 percent or more, or (2) is “permanently housebound” by reason of service-connected disability or disabilities. 38 U.S.C. § 1114 (s); 38 C.F.R. § 3.350(i). The disabilities independently ratable at 60 percent or more must be separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems. 38 C.F.R. § 3.350 (i)(1). Again, based on the above regulatory criteria, the Board recognizes that the Appellant’s entitlement claim for SMC based on housebound criteria is inextricably intertwined with the claim for entitlement to service connection for a below-knee amputation of the right leg. Harris, 1 Vet. App. 180 (two issues are “inextricably intertwined” when they are so closely tied together that a final Board decision on one issue cannot be rendered until the other issue has been considered). Because the Appellant’s two claims are inextricably intertwined, the AOJ and Board cannot resolve one claim without consideration of the other. As such, the Board must also remand the Appellant’s claim for SMC based on housebound criteria to the AOJ for adjudication. 9. Entitlement to automobile or other conveyance and adaptive equipment, or for adaptive equipment only, is remanded. In December 2013, the Veteran submitted his VA Form 21-4502. Thereby, the Veteran submitted his application for automobile or other conveyance and adaptive equipment. VA regulations provide that a certification of eligibility for financial assistance in the purchase of one automobile and of basic entitlement to necessary adaptive equipment will be made where the claimant meets the requirements of paragraphs (a), (b) and (c) of 38 C.F.R. § 3.808. The claimant must have had active military, naval or air service. 38 C.F.R. § 3.808 (a). Further, one of the following must exist and be the result of a disease or injury incurred in or aggravated during active military, naval or air service: (1) loss or permanent loss of use of one or both feet; (2) loss or permanent loss of use of one or both hands; (3) permanent impairment of vision of both eyes: central visual acuity of 20/200 or less in the better eye, with corrective glasses, or central visual acuity of more than 20/200 if there is a field defect in which the peripheral field has contracted to such an extent that the widest diameter of visual field subtends an angular distance no greater than 20 degrees in the better eye; and, (4) for adaptive equipment eligibility only, ankylosis of one or both knees or one or both hips. 38 C.F.R. § 3.808 (b). The Board observes that the late Veteran’s eligibility for entitlement to an automobile or other conveyance and adaptive equipment is dependent upon whether he is secondarily service connected for a below-knee amputation of right leg. As the service-connection claim and the claim for automobile and adaptive equipment are intertwined, the claim for automobile and adaptive equipment must be remanded as well. Tyrues v. Shinseki, 23 Vet. App. 166, 177 (2009) (en banc) (explaining that claims are inextricably intertwined where the adjudication of one claim could have a significant impact on the adjudication of another claim). 10. Entitlement to specially adapted housing is remanded. In January 2014, the Veteran submitted his VA Form 26-4555. Thereby, the Veteran initiated his entitlement claim for specially adapted housing. Specially adapted housing is available to a veteran with a permanent and total (P&T) disability that precludes locomotion without the aids of braces, crutches, canes, or a wheelchair due to: (5) the loss, or loss of use, of both lower extremities; (6) the loss or loss of use of one lower extremity, together with residuals of organic disease or injury which so affect the functions of balance and propulsion; or, (7) the loss or loss of use of one lower extremity together with the loss or loss of use of one upper extremity which so affect the functions of balance or propulsion. 38 U.S.C. § 2101 (a); 38 C.F.R. § 3.809 (a), (b), (d). The Board observes that the late Veteran’s eligibility for entitlement to specially adapted housing is dependent upon whether he is secondarily service connected for a below-knee amputation of right leg. As the service-connection claim and the entitlement claim for adaptive housing are intertwined, the claim for entitlement to adaptive housing must be remanded as well. Tyrues v. Shinseki, 23 Vet. App. 166, 177 (2009) (en banc) (explaining that claims are inextricably intertwined where the adjudication of one claim could have a significant impact on the adjudication of another claim). 11. Entitlement to a special home adaption grant is remanded. In January 2014, the Veteran submitted his VA Form 26-4555. Thereby, the Veteran initiated his entitlement claim for a special home adaption grant. Under the version of 38 C.F.R. § 3.809a which became effective on October 25, 2010, if entitlement to specially adapted housing is not established, a veteran can qualify for a grant for necessary special home adaptations if he is entitled to compensation for a permanent and total service-connected disability which must (1) include the anatomical loss or loss of use of both hands; or (2) be due to (i) blindness in both eyes with 5/200 visual acuity or less, or (ii) deep partial thickness burns that have resulted in contractures with limitation of motion of two or more extremities or of at least one extremity and the trunk, or (iii) full thickness or subdermal burns that have resulted in contracture(s) with limitation of motion of one or more extremities or the trunk, or (iv) residuals of an inhalation injury (including, but not limited to, pulmonary fibrosis, asthma, and COPD). 38 U.S.C. § 2101 (b); 38 C.F.R. § 3.809a (b) (2011). Under the version of 38 C.F.R. § 3.809a which became effective on September 12, 2014, if entitlement to specially adapted housing is not established, a veteran can qualify for a grant for necessary special home adaptations if he is service connected for a disability that (1) VA has rated as permanently and totally disabling, and which (i) includes the anatomical loss or loss of use of both hands; (ii) is due to deep partial thickness burns that have resulted in contracture(s) with limitation of motion of two or more extremities or of at least one extremity and the trunk; (iii) is due to full thickness or subdermal burns that have resulted in contracture(s) with limitation of motion of one or more extremities or the trunk; or (iv) is due to residuals of an inhalation injury (including, but not limited to, pulmonary fibrosis, asthma, and chronic obstructive pulmonary disease). Additionally, a Veteran can qualify for a grant for necessary special home adaptations if he is entitled to compensation for a service-connected disability, which need not be rated as permanently and totally disabling, which is due to blindness in both eyes, having central visual acuity of 20/200 or less in the better eye with the use of a standard correcting lens. 38 U.S.C. § 2101 (b); 38 C.F.R. § 3.809a (b) (2017). The Board notes that none of the Veteran’s seven service-connected disabilities meet the criteria for a special home adaption grant, regardless of regulation version. The Veteran was service connected for the residuals of a left tibia fracture, left ankle arthritis, left tibia osteomyelitis, right hip arthritis, a forehead scar, a right thigh skin graft, and a left tibia scar. However, the Appellant’s entitlement to a special home adaption grant is dependent on the outcome of the entitlement claim for service connection for a below-knee amputation of the right leg. Additionally, the claim for a special home adaptation grant is inextricably intertwined with the issue of entitlement to especially adaptive housing. The claim for a special home adaptation grant under 38 U.S.C. § 2101 (b) is available only if a Veteran is not entitled to the more substantial benefit of specially adapted housing under 38 U.S.C. § 2101 (a). As such, the adjudication of the issue of entitlement to a special home adaption grant must be deferred. See Harris v. Derwinski, 1 Vet. App. 80 (1991). Consequently, these matters are REMANDED to the AOJ for the following action: 1. The AOJ should contact the Appellant and, with her assistance, identify any additional outstanding records of pertinent medical treatment from VA or private health care providers for the Veteran’s below-knee amputation of the right leg. Specifically, all pertinent treatment records from St. Paul’s hospital should be obtained and associated with the claims file. In obtaining these records, the AOJ is instructed to follow the procedures for obtaining the records set forth by 38 C.F.R. § 3.159 (c). 2. After any additional records are associated with the claims file, the AOJ should enlist the services of an appropriate VA medical provider. Based upon a review of the entirety of the claims file, the VA provider is requested to provide an opinion as to the following question: Is it at least as likely as not (i.e. a 50 percent probability or greater) that the Veteran’s below-knee amputation of the right leg was caused or aggravated by any of the Veteran’s service-connected disabilities? The VA provider is specifically asked to address the Veteran’s service-connected left tibia osteomyelitis and the post-amputation pathology report that identifies right leg osteomyelitis. Governing regulations provide that service connection is permissible on a secondary basis if a claimed disability is proximately due, the result of, or aggravated by a service-connected disability. See 38 C.F.R. § 3.310 . The term aggravation is defined as a chronic and permanent worsening of the underlying condition beyond its natural progression versus just a temporary or intermittent flare-up of symptoms. If the examiner determines there has been aggravation, he or she should try and quantify the amount of additional disability the Veteran had, above and beyond that he had prior to the aggravation. Explanations for all opinions must be provided. In providing the requested rationale, the examiner is asked to cite to the pertinent evidence of record, including clinical records and the Veteran’s statements. 2. After completing the above development, the AOJ should review the claims file and ensure that all of the foregoing development actions have been conducted and completed in full. See Stegall v. West, 11 Vet. App. 268, 271 (1998). 3. After the above development, and any additionally indicated development, has been completed, readjudicate the issues on appeal, including the inextricably intertwined issues of entitlement to special monthly compensation based on Aid and Attendance/Housebound; entitlement to automobile and adaptive equipment or for adaptive equipment only; entitlement to specially adaptive housing; and, entitlement to a special home adaptation grant. If the benefits sought are not granted, send the Appellant and her representative a Supplemental Statement of the Case   and provide an opportunity to respond. If necessary, return the case to the Board for further appellate review. DAVID L. WIGHT Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD RLBJ, Associate Counsel