Citation Nr: 18110796 Decision Date: 06/13/18 Archive Date: 06/13/18 DOCKET NO. 12-32 597 DATE: June 13, 2018 ORDER Entitlement to a TDIU from September 1, 2017, and no earlier is granted. Special monthly compensation at the housebound rate is granted, effective September 1, 2017. FINDINGS OF FACT 1. After resolving reasonable doubt in favor of the Veteran, the evidence shows that the Veteran’s service-connected left knee disability precluded him from substantial gainful employment from September 1, 2017, and no earlier, as of that date, he had significant pain with objective evidence of hardware defect, and significant limitation of range of motion. 2. Effective September 1, 2017, separate from his TDIU, the Veteran has additional service-connected disabilities independently ratable at 60 percent or more disabling. CONCLUSIONS OF LAW 1. The criteria for the assignment of a TDIU from September 1, 2017, and no earlier, have been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.16. 2. For the period from September 1, 2017, the criteria for an award of special monthly compensation at the housebound rate have been met. 38 U.S.C. §§ 1114(s) (2012); 38 C.F.R. § 3.350(i) (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active military service from April 1960 to October 1964. In an April 2017 decision, the Board adjudicated the issue of entitlement to an increased rating for left knee disability. In January 2018, the United States Court of Appeals for Veterans Claims vacated that portion of the Board’s decision that did not adjudicate entitlement to a TDIU and remanded it for further action consistent with a Joint Motion for Remand (JMR). The issue before the Board is whether the Veteran is entitled to a TDIU from May 17, 2010 based on his left knee disability under the Court’s holding in Rice v. Shinseki, 22 Vet. App. 447 (2009). Additional evidence to the record since the most recent supplemental statement of the case; however, as the evidence pertains to the time period for which the Board grants a TDIU in the decision below, a remand for RO adjudication is not necessary.   1. TDIU Legal Criteria The schedular rating criteria are designed to compensate for average impairments in earning capacity resulting from service-connected disability in civil occupations. 38 U.S.C. § 1155. “Generally, the degrees of disability specified [in the rating schedule] are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability.” 38 C.F.R. § 4.1. Where a Veteran is unemployable by reason of his or her service-connected disabilities, but they fail to meet the percentage standards set forth in § 4.16(a), TDIU claims should be submitted to the Director, C&P Service, for extraschedular consideration. 38 C.F.R. § 4.16(b). The Board is precluded from assigning a TDIU rating on an extraschedular basis in the first instance. Instead, the Board must refer any claim that meets the criteria for referral for consideration of entitlement to TDIU on an extraschedular basis to the Director, C&P Service. Bowling v. Principi, 15 Vet. App. 1 (2001). The term “unemployability,” as used in VA regulations governing total disability ratings, is synonymous with an inability to secure and follow a substantially gainful occupation. See VAOPGCPREC 75-91 (Dec. 17, 1991). The issue is whether the Veteran's service-connected disability or disabilities preclude him from engaging in substantially gainful employment (i.e., work which is more than marginal, that permits the individual to earn a "living wage"). See Moore v. Derwinski, 1 Vet. App. 356 (1991). In determining whether the Veteran is entitled to a TDIU, neither his nonservice-connected disabilities nor his age may be considered. Van Hoose v. Brown, 4 Vet. App. 361 (1993). The Court has held that the central inquiry in determining whether a Veteran is entitled to a TDIU is whether service-connected disabilities alone are of sufficient severity to produce unemployability. Hatlestad v. Brown, 5 Vet. App. 524 (1993). In the present case, the only disability which the Board has considered is the Veteran’s left knee disability because the claim is being considered under Rice v. Shinseki, 22 Vet. App. 447 (2009) as part of the Veteran’s claim for an increased rating for the left knee. The test of individual unemployability is whether the Veteran, as a result of his service-connected disability alone, is unable to secure or follow substantially gainful occupation which is consistent with his education and occupational experience. 38 C.F.R. §§ 3.321, 3.340, 3.341, 4.16. Analysis The Veteran’s left knee disability is rated as 10 percent disabling from May 17, 2010 to July 11, 2013, as 100 percent disabling from July 11, 2013 to October 1, 2015, as 60 percent disabling from October 1, 2015 to June 27, 2016, as 100 percent disabling from June 27, 2016 to September 1, 2017, and as 60 percent thereafter. Consideration of a TDIU for those time periods for which he is assigned a 100 percent rating for his left knee are moot. In McGrath v. Gober, 14 Vet. App. 28 (2000), the Court held that when evidence is created is irrelevant compared to when the Veteran was actually experiencing the symptoms. Thus, the Board will consider whether the evidence of record suggests that the severity of pertinent symptoms increased sometime prior to the date of the clinical records noting pertinent findings. The Board has also considered the history of the Veteran’s disabilities prior to the rating period on appeal to see if it supports a higher rating during the rating period on appeal Reference to the Veteran’s left knee is presented in the evidence of record beyond the most detailed pertinent evidence discussed by the Board in this decision. The additional evidence of record does not present findings concerning the Veteran’s disability that significantly expand upon, revise, or contradict the findings in the most detailed evidence discussed by the Board in this decision.   Prior to July 11, 2013 Prior to July 11, 2013, the Veteran did not meet the schedular criteria for a TDIU. The Board finds, for the reasons noted below, that the Veteran’s left knee disability did not cause him to be unable to secure or follow a substantially gainful occupation. July 2010 x-rays of the left knee show evidence of mild medial joint space narrowing at the knee joint. The visualized bony and soft tissue structures of the left knee were otherwise unremarkable in appearance without evidence of suprapatellar knee joint effusion. In September 2010, the Veteran underwent a VA (fee basis) examination primarily for an evaluation of his right knee and left ankle disabilities. The examination report, however, provided findings for the left knee. Evaluation of the left knee revealed no locking pain, genu recurvatum, crepitus or ankylosis. Range of motion testing revealed left knee flexion to 120 degrees with no additional degree of limitation even with repetitive motion. Joint function was not additionally limited by pain, fatigue, weakness, lack of endurance or incoordination after repetitive use. Left knee stability tests were within normal limits for anterior and posterior cruciate ligaments, medial and lateral collateral ligaments and the medial and lateral meniscus. There was no subluxation on the left. In his application for a TDIU (which was filed in February 2011 while his claim for a left knee disability was pending), the Veteran asserted that he could not work due to severe pain in his spine, hips, both knees, both ankles, and his lower back. Moreover, a January 28, 2015 VA clinical record reflects that the Veteran had diffuse osteoarthritis and was unable to work due to pain. Neither of these documents specifically noted that the Veteran was unable to secure or follow substantially gainful occupation based on his left knee disability alone. A May 2011 VA emergency department report notes the Veteran was seen with left knee pain. He reported he was coming into his home and felt his left knee give way. He did not fall or hit the knee. He denied any previous trauma, swelling and locking. He had a brace on his left knee and when questioned about it, he did not know why he had the brace. On physical examination, there was no edema of the left knee, passive range of motion was full at 0 to 180 degrees and active knee motion was 0 to 100 degrees. There was no joint line tenderness, no effusion, or patellar tenderness. McMurray’s, Lachman’s and drawer’s tests were negative; collateral ligaments were stable. X-rays showed mild degenerative changes with peaking of the tibial spines; suprapatellar joint effusion was present. There was no fracture or dislocation. A May 2011 VA orthopedic surgery consult report notes that the Veteran stated that following his left endarterectomy, his left leg “gave out.” During the “giving way,” his leg locked-up and he had severe pain around his knee cap. He reported that since that time, has had difficulty walking due to pain to the distal third of his quadriceps, as well as patellar pain. He denied any joint line pain, catching, popping, or locking in the knee. He had some swelling in the upper knee, but no ecchymosis. He was wearing braces on both knees, which he stated was for support. On physical examination, he appeared to be in no acute distress. The record noted that he walked with an exaggerated antalgic gait. There was a minute amount of swelling just superior to the patella. There was no noted ecchymosis. He was moving his leg very slowly due to a complaint of pain. There was no instability with valgus varus stress and he had a negative anterior and posterior drawer. He hopped around to the chair and complained of pain through the examination, which the examiner noted was “out of proportion to findings.” There was no noted deformity palpated during the examination, but the Veteran was very tender along the tendon. X-rays show some mild arthritic changes in the knee, otherwise within normal limits. An August 2011 VA pain medicine initial evaluation report, the Veteran reported he had constant chronic pain of his left knee at a level of 6/10. He reported that the pain was worse when walking, standing or climbing stairs, and interfered with activities of daily living, mood, sleep and mobility. On December 2011 VA (fee basis) knee and lower leg conditions examination, the Veteran reported symptoms of weakness, stiffness, swelling, lack of endurance, locking, fatigability, tenderness, effusion, and constant pain. At that time, he did not experience heat, redness, giving way, deformity, drainage, subluxation and/or dislocation. His left knee, in the past 12 months, had not resulted in any incapacitation. He reported that his pain level was 8/10 and at times his knee gives way; he cannot stand and/or walk very long. It was noted that his left knee disability interfered with his activities of daily living, mood, sleep, and mobility, and he wears a knee brace. He stated that flare-ups are constant pain that occur spontaneously and are alleviated with medication and a left knee brace. He noted that the functional impairment of pain, weakness, stiffness, giving way, locking, lack of endurance, and tenderness, and noted the knee hurts while he is in bed, driving a car and walking and standing for long periods. He reported that it also prevented him from working in any type of maintenance, warehouse, construction, or welding job, and may affect him driving an 18-wheeler. While the Veteran reported such impairment, the Board finds that the more probative evidence (i.e. the objective physical examination) is against such severity of impairment. On physical examination in December 2011, left knee flexion was to 140 degrees or greater and there was no objective evidence of painful motion. Left knee extension was to 0 degree or any degree of hyperextension (no limitation of extension) and there was no objective evidence of painful motion. He was able to perform repetitive use testing with 3 repetitions on the left. Left knee post-test flexion was to 140 degrees or greater. There was no limitation of extension (0 or any degree of hyperextension). There was no additional limitation in range of motion of the knee following repetitive use and there was no functional loss and/or functional impairment of the knee. There was no tenderness or pain on palpation of joint lines or soft tissue of either knee. Lachman’s, posterior drawer, and medial-lateral instability tests on the left knee were normal. His lower extremities did not have diminished function. Muscle strength for the left knee was 5/5. The examiner noted that the Veteran’s knee disability did not impact his ability to work. An April 2012 VA pain program consult report, shows the Veteran was seen for multiple pain complaints, including the left knee. He stated that pain is worse in the knee. On physical examination the left knee had mild crepitus, and negative Patrick’s and straight leg raises bilaterally; strength was 5/5. His gait was only mildly antalgic due to knee pain with right tilt. Romberg was negative and tandem, heel/toe was intact. An August 2012 VA outpatient treatment report, shows the left knee had normal color and temperature without effusion. There was no tenderness. There was full range of motion with moderate crepitation. There was normal collateral/cruciate ligament stability. X-rays of the left knee (August 2012) show mild to moderate bicompartmental knee joint space narrowing sharpening of the tibial spines and bilateral chondrocalcinosis. The patellofemoral joint demonstrated mild degenerative changes with mild buttressing. There was no evidence of fracture, dislocation, or osseous mass swelling of the pathology. There was no evidence of knee effusion; the soft tissues were unremarkable. An October 2012 VA physical therapy report notes the Veteran reported that his left knee pain was constant at level 6/10. Left knee flexion was to 125 and extension was -5. There was no edema. A November 2012 VA physical therapy report notes the Veteran’s left knee pain was a level of 2-3/10. Left knee flexion was to 125 and extension was -5. There was no edema. A December 2012 VA physical therapy report notes the Veteran’s left knee pain was 2/10. Active range of motion of the left knee was within normal limits; strength was 5/5. A January 2013 VA orthopedic surgery clinic report notes the Veteran was seen for an injection into the left knee. It was further noted that he has DJD of the left knee and wanted to be placed on the schedule for a left total knee arthroplasty (TKA). He complained of having left knee pain with ambulation and at night, and that he only gets relief from the pain for one month after the steroid injection. The pain affects his daily activities. On physical examination the left knee was tender to palpation and there was mild effusion. There was good medial/lateral stability. Range of motion was full. X-rays showed medial, lateral patellofemoral joint narrowing but no bone on bone contact. He had medial and lateral pseudogout. In a March 2013 VA primary care note, it was noted that the Veteran presented for medical clearance prior to his knee replacement, and was doing well. On examination of the extremities, there was no edema. There was no joint deformity. He was essentially cleared for knee replacement. In April 2013 the Veteran was seen at VA orthopedic surgery clinic for an injection into the left knee. He reported having pain with ambulation and pain at night. He again stated that he only has relief from pain for one month after the steroid injection, and that the pain affects his daily activities. On physical examination, there was tenderness to palpation, good medial/lateral stability, range of motion was full, and there was mild effusion. X-rays showed medial, lateral, patellofemoral joint narrowing but no bone on bone contact. He had medial and lateral pseudogout. The Board concludes that the Veteran’s left knee disability did not cause him to be unable to secure or follow a substantially gainful occupation prior to September 1, 2017. As noted above, the Veteran had range of motion to 120 degrees (September 2010), 0 to 100 degrees (May 2011), 0 to 140 degrees (December 2011), minus five degrees to 125 degrees (October 2012), and full (January, April 2013). Even though the Veteran has worn a brace on the left knee and reports his knee giving way, the preponderance of the evidence consistently shows negative findings with respect to objective testing for recurrent subluxation and lateral instability. Further, as noted above, the May 2011 orthopedic consult provider found the Veteran’s reports of pain were out of proportion to the clinical findings and that the Veteran exaggerated a gait impairment. The December 2011 examiner found no objective evidence of pain with a full range of motion, and that the Veteran’s knee disability did not impact his ability to work. The Veteran continued to have full strength of the knee as noted in April, November, and December 2012, full range of motion again noted in August 2012, and considerable range of motion with pain at a level of 2-3/10 in November 2012. In December 2012, his pain was only a 2/10 with normal range of motion. He was also able to alleviate his pain with steroid injections. The evidence reflects that the Veteran has an occupational history as a truck driver (approximately 1997 to 2000) and was that he was incarcerated from approximately 2000 to 2010. In a May 2010 state driver license application, the Veteran stated that he met the physical requirements of 49 C.F.R.391 (Qualifications of Drivers). In addition, in a May 21, 2010 Federal and State Qualifications “Yes/No” form, the Veteran stated that he did not have impairment of a leg which interferes with the ability to perform normal tasks associated with operating a motor vehicle, or the ability to perform tasks associated with operating a motor vehicle. September 2010 Central Tech correspondence reflects that the Veteran was enrolled in truck driver training from October 25, 2010 through November 23, 2010. A January 2011 statement reflects the Veteran’s opinion that he can cook, clean, get around, drive and “other stuff on my own”, and that he did not want independent living services. A September 21, 2011 Feasibility Worksheet reflects the assessment of the case manager as follows: [The Veteran] says he is too old and uninterested in longer term training, but young and healthy enough to work many types of CDL related occupations.” A September 26, 2011 VA electronic record reflects that the Veteran called and stated that Dr. Ashling said he could work in a sedentary job. The Veteran was to explore job/training. A September 2011 VA Form 28-1902b (Counseling Record – Narrative Report) reflects that the Veteran stated that “he knows how to accommodate pain while driving”; however, the Veteran stated in his VA Form 28-1902w that he is in constant pain from his left knee, right ankle, both hips, back, and neck so that he cannot stand for long periods of time, walk far, or bend over for long. A November 2011 Counseling record reflects that the Veteran had been recently hospitalized for pancreatis but that his provider stated that he is still able to work in a sedentary job that does not involve a lot of lifting/ambulation. A December 2011 Vocational Rehabilitation record reflects that there are jobs in the trucking industry for individuals who no longer drive, such as managing and coordinating log books, receipt records, and other types of reports. A March 2012 VA clinical record reflects that it “seems unlikely he could do any work other than a sedentary job”; however, this was based on the Veteran’s multiple disabilities and specifically discusses an MRI of the back. January 2013 through April 2013 records reflect that the Veteran received corticosteroid injection into the left knee which helps with pain for approximately one month. A May 22, 2013 VA clinical record reflects that the Veteran is not able to work due to osteoarthritis but the opinion is not based solely on the Veteran’s left knee. The record actually reflects right knee pain on examination and does not address the left knee. The evidence as a whole shows that the Veteran’s left knee disability alone did cause him to be unable to secure or follow a substantially gainful occupation prior to September 1, 2017. As noted above, vocational rehabilitation records show that there are sedentary jobs for individuals with a history of truck driving such as the Veteran. Moreover, there are other sedentary jobs that do not require a college degree such as those working on the telephone and/or computer. His left knee disability has not been shown by objective evidence to be so limited in range of motion, so unstable, or so painful that it causes him to be unable to secure or follow a substantially gainful occupation. To the contrary, he has maintained significant range of motion, has not a stable knee on testing, has had full strength, and a clinician has found that his knee impairment does not affect his ability to maintain employment. From October 1, 2015 to June 27, 2016 The Veteran’s left knee is rated as 60 percent disabling from October 1, 2015 to June 27, 2016 (the date of surgery for his left knee); thus, he meets the schedular criteria for a TDIU. The Board has considered whether his left knee alone prevented substantial gainful employment during that time period, and finds that it did not. An August 2015 VA clinical record reflects that the Veteran was seen due to complaining about a painful total knee replacement. It was noted that he had significant residual pain and limitations with regard to the left revision total knee replacement; however, the clinician also noted that a “lot of his pain from walking comes from radiculitis in the left lower extremity pertaining to sciatica.” X-ray and MRI showed no loose bodies and that the total knee prosthesis was in place and in good position and alignment. The impression was “painful left total knee with no identifiable reasons.” Notably, the August 2015 clinician questioned the amount of pain which the Veteran attributed to his knee. The clinician stated as follows: I showed the patient his x-rays of his left knee, and told him that structurally the surgery was done correctly and the alignment of the prosthesis looks good, and no identifiable abnormality of the placement or function of the left total knee is noted. He would not appear to be a candidate for revision at this time. There is a question how much the radicular pain in his left lower extremity aggravates the perceived left knee pain. December 2015 correspondence from Dr. F. J. of the Oklahoma VA Medical Center reflects that the Veteran is “suffering from multiple chronic conditions, including but not limited to stroke in past, chronic low back pain, knee pain. Due to these conditions he is not able to work his previous job as truck driver.” A December 2015 VA clinical record reflects that the Veteran reported that he needed a doctor to say that he cannot work and that he has been unable to work since 2010. The clinician stated that it is “highly unlikely [the Veteran] could hold a job due to bad back and other issues.” Neither opinion reflects that the Veteran’s left knee disability alone caused him to be unable to secure or follow a substantially gainful occupation nor provides evidence of functional impairment which was so great that the Board finds it alone caused him to be unable to secure or follow a substantially gainful occupation. March 2016 private records (Central States Orthopedic William Office) reflect that the Veteran was seen for a new patient visit. He complained of knee pain which he said had been present since approximately February 2011 and which had never decreased and is constant. The Veteran denied any instability of the knee. Radiographs showed no evidence of malposition, excellent alignment, on AP view, and good alignment of the patellofemoral joint. It was a stabilized knee. On physical exam, it was noted that the Veteran “actually has pretty good range of motion”. He had terminal extension, flexion to approximately 112 degrees, no warmth, no erythema, and no effusion. The clinician stated that the Veteran had “a little bit of mild flexion laxity but I do not even call it instability. There was no evidence of any varus or valgus laxity.” The clinician acknowledged that the Veteran had complaints of pain but the clinician noted “I think there is some crossover from his back and from neuropathy. He is on chronic narcotics so it is difficult to say where the pain is really coming from.” The record does not indicate that the Veteran’s disability caused such functional impairment as to preclude substantial gainful employment. May 2016 private records (Central States Orthopedic William Office) reflect that the Veteran’s biggest problem with regard to his left knee “appears to be just some instability.” He had terminal extension, and flexion to approximately 110 degrees. The examiner noted an increase in instability from when the Veteran was previously examined as he had been unable to positively identify instability earlier. On June 27, 2016 the Veteran underwent a revision left total knee arthroplasty due to instability. The prior implant did not appear to be loose, but unstable only. At the time of surgery, the clinician stated that in the clinicians’ opinion the “biggest thing he is going to have some chronic stiffness in the knee but he had instability before so it is kind of a give and take.” Based on the foregoing, the Board finds that the Veteran’s left knee disability alone did not cause him to be unable to secure or follow a substantially gainful occupation prior to September1, 2017. As noted above, there are sedentary jobs for individuals with a history of truck driving such as the Veteran. Moreover, there are other sedentary jobs that do not require a college degree such as those working on the telephone and/or computer. None of the clinical records reflect that the Veteran’s left knee disability alone precluded substantial gainful employment consistent with his employment history prior to September 1, 2017. The Veteran has been found to be a poor historian with regard to his medical history (see May 2011 report with regard to the knee, and 2016 VA examination report for spine disability). In addition, the clinicians, who based their opinions on their objective evaluations were not confident that the Veteran’s pain actually came from his knee. One examiner stated that he found no identifiable reason for the Veteran’s complaint. Even assuming that the pain was coming from his knee, the Board still finds, based on the range of motion, the integrity of the hardware, and the lack of serious/significant instability of the knee, that it did not alone cause him to be unable to secure or follow a substantially gainful occupation. From September 1, 2017 The Veteran’s left knee is rated as 60 percent disabling from September 1, 2017. In a November 2016 rating decision, the RO granted a 100 percent temporary evaluation for convalescence from his knee surgery on June 27, 2016. His convalescence was scheduled to end on September 1, 2017, and thereafter, a 60 percent evaluation was assigned. While his 100 percent rating was in effect, the Veteran had a February 2017 bone scan of the left knee performed due to complaints of pain. The impression was that the scan was “highly concerning for hardware loosening.” May 2018 VA records reflect that the Veteran had “multiple joint pain with left knee “severe” pain [status post] bilateral TKA with 2 revisions. Dr. [A.] indicated femoral component loosing on exam and review of x-rays. The records reflect that the Veteran reported that his knee had been “hurting really bad ever since [the June 2016 surgery]. Upon examination, he had very limited painful active range of motion from 20 to 50 degrees and passive range of motion from 10 to 90 degrees. Pain was reported on all range of motion and there was “clunking movement”. A new cane was given for ambulatory assistance. The Veteran reported that his pain was a 9 out of 10. The Veteran further reported that nothing makes it better and/or rest makes it better. The Board finds, in giving the benefit of the doubt to the Veteran, that a TDIU is warranted from September 1, 2017. The records noted above reflect that during the Veteran’s convalescence period he continued to note complaints, that approximately five months later, he had possible hardware loosening noted upon imaging tests, and that shortly after that he had “very limited painful motion” upon clinical examination. Taken together, the Veteran’s employment history (manual labor and/or driving a truck), and the consistency of objective findings in 2017 as to further problems with his knee prothesis (to include a much lesser range of motion than previously found), the Board finds that a TDIU is a warranted from September 1, 2017. 2. Special Monthly Compensation VA has a "well-established" duty to maximize a claimant's benefits. See Buie v. Shinseki, 24 Vet. App. 242 (2011). This duty to maximize benefits requires VA to assess all of a claimant's disabilities to determine whether any combination of disabilities establishes entitlement to SMC under 38 U.S.C. § 1114. See Bradley v. Peake, 22 Vet. App. 280, 294 (2008). SMC is payable where the Veteran has a single service-connected disability rated as 100 percent and (1) has additional service-connected disability or disabilities independently ratable at 60 percent, separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems, 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 total disability rating requirement may be met by a finding of a TDIU where that award is based on one single condition. Bradley v. Shinseki, 22 Vet. App. 280, 293 (2008). In light of the decision above, from September 1, 2017, onward, the Veteran will be in receipt of a total disability rating for his left knee specifically. The Veteran has other compensably rated service-connected disabilities, including a right knee disability (30 percent), a thoracolumbar spine disability (20 percent), a left and right ankle disability (10 percent each), and radiculopathy of the left and right lower extremity (10 percent each). The combined disability rating for the period from September 1, 2017, excluding the already totally-rated left knee, is at least 60 percent. 38 C.F.R. § 4.25. In this case, with consideration of the above, as of September 1, 2017, the Veteran is in receipt of an award of 100 percent based solely on his left knee disability and in receipt of at least an additional 60 percent rating for other service connected disabilities. As such, the criteria for SMC at the housebound rate under 38 U.S.C. § 1114 (s) have been met, effective September 1, 2017. M. C. GRAHAM Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD T. Wishard