Citation Nr: 18106969 Decision Date: 06/01/18 Archive Date: 05/31/18 DOCKET NO. 15-06 405A DATE: June 1, 2018 REMANDED Entitlement to special monthly compensation (SMC), based on the need for regular aid and attendance is remanded. REASONS FOR REMAND The Veteran had active service from September 1988 to April 1992. In January 2018, the Veteran and his spouse, P.G., testified at a videoconference hearing, at the Houston, Texas Regional Office, before the undersigned Veterans Law Judge. 1. Entitlement to SMC based on the need for regular aid and attendance is remanded. The Veteran contends he needs regular aid and attendance of another person due to his service-connected chronic venous stasis, vascular disease, right and left lower extremities, and the related ulcerations. The Veteran’s service-connected disabilities include posttraumatic stress disorder rated 70 percent disabling; chronic venous stasis vascular disease, right lower extremity, rated 60 percent disabling; chronic venous stasis vascular disease, left lower extremity, rated 60 percent disabling; ankle sores due to undiagnosed illness, rated as 10 percent disabling; tinnitus, rated as 10 percent disabling; and bilateral hearing loss, rated as 0 percent disabling. In November 2012, a private doctor, Dr. W., opined that the Veteran was in need of aid and attendance of another in ordinary activities of daily living. Dr. W. indicated the Veteran was not bedridden, could walk and get around unassisted, and could attend to the needs of nature unassisted, but could not undress or dress himself, could not wash and keep himself ordinarily clean and presentable, and was not able to physically protect himself from the everyday hazards of life. Dr. W.’s statement listed the Veteran’s diagnoses as chronic venous insufficiency with ulcers, assessed as severe, morbid obesity assessed as severe, and diabetes mellitus, II, assessed as good. It was also noted that the Veteran had chronic ulceration in the bilateral lower extremities. In January 2018, the Veteran testified he was not able to properly care for himself, and that he needed aid and attendance with cleaning and changing the dressings for his leg ulcers. He testified his wife cooked his meals because he was not able to get up to the stove and it was painful to stand. In some cases, he was able to put on his own clothing, but he needed assistance putting on his socks and shoes. He testified he had to stay in his wheelchair and was not able to stand. He was not able to take a shower, did not have shower rails, and had to be bathed by his wife using the sink. He also reported that he previously had a VA home health nurse for his leg ulcers, but she was not doing it right and his ulcers were getting worse so his wife started changing the dressings. He testified he received treatment from a private doctor, who was a wound care specialist, for his leg ulcers and that he had submitted these records. Although Dr. W., opined that the Veteran was in need of aid and attendance, it appears this was due to both service-connected and non- service-connected disabilities. In light of the 2012 opinion and the Veteran’s testimony in 2018, it is unclear whether he needs aid and attendance solely due to service-connected disabilities, and he should therefore be provided an opportunity to report for a VA aid and attendance examination. Additionally, review of the record does not reveal records from the private doctor (identified at the hearing) have been associated. A remand is required to allow VA to obtain authorization and request these records. The matter is REMANDED for the following actions: 1. Ask the Veteran to complete a VA Form 21-4142 for the private physician, Dr. S. (who he identified at the hearing as the wound care specialist who treated his leg ulcers). Make two requests for the authorized records from Dr. S., unless it is clear after the first request that a second request would be futile. 2. Schedule the Veteran for a VA aid and attendance examination by an appropriate clinician. The claims file must be made available to and reviewed by the examiner in conjunction with the examination. The examiner should address whether the Veteran’s service-connected disabilities (alone) have resulted in an inability to dress or undress himself, or to keep himself ordinarily clean and presentable; frequent need of adjustment of any special prosthetic or orthopedic appliances which by reason of the particular disability cannot be done without aid; inability to feed himself through loss of coordination of upper extremities or through extreme weakness; and inability to attend to the wants of nature; incapacity, physical or mental, which requires care or assistance on a regular basis to protect him from hazards or dangers incident to his daily environment. A full rationale must be provided for any opinion(s) expressed. A. ISHIZAWAR Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD D.M. Casula, Counsel