Citation Nr: 18132129 Decision Date: 09/05/18 Archive Date: 09/05/18 DOCKET NO. 14-44 431 DATE: September 5, 2018 ORDER Service connection for a cervical syrinx is granted. Service connection for bilateral carpal tunnel syndrome is granted. Service connection for loss of use of the upper extremities as a residual of syringomyelia is denied. Service connection for loss of use of the lower extremities as a residual of syringomyelia is denied. Service connection for impotence as a residual of syringomyelia is denied. Special monthly compensation (SMC) for specially adapted housing or a special home adaptation grant is denied. Eligibility for financial assistance for automobile or other conveyance and adaptive equipment, or for adaptive equipment only, is denied. A rating decision dated August 20, 2009, contained clear and unmistakable error (CUE) in assigning the effective date for the grant of service connection for schizoaffective disorder, bipolar disorder, aggravated by posttraumatic stress disorder (PTSD); on that basis an effective date of July 23, 1992, for the grant of service connection for such psychiatric disability is granted. FINDINGS OF FACT 1. The Veteran’s cervical syrinx at C6 was incurred in service. 2. The Veteran’s bilateral carpal tunnel syndrome was incurred in service. 3. No disability manifested by loss of use of the upper or lower extremities, or impotence, was incurred in service or is caused or aggravated by the Veteran’s cervical syrinx or any other service-connected disability. 4. The Veteran’s service-connected disabilities of schizoaffective disorder, bipolar disorder, aggravated by PTSD, left ulnar neuropathy of the minor arm, left knee chondromalacia, a cervical syrinx, and bilateral carpal tunnel syndrome have not resulted in loss of use of both upper extremities, loss of use of one or both hands, or ankylosis or loss of use of the lower extremity or foot. 5. The Veteran’s service-connected disabilities do not result in loss or loss of use of a hand or foot, permanent impairment of both eyes, severe burn injury, amyotrophic lateral sclerosis, or ankylosis of a knee or hip. 6. In the August 20, 2009, rating decision granting service connection for schizophrenia, bipolar disorder aggravated by PTSD, the existing law was not correctly applied in determining the appropriate effective date; the error was undebatable; and, but for the error, an effective date of July 23, 1992, would have been awarded for the grant of his September 1992 claim for service connection benefits. CONCLUSIONS OF LAW 1. The criteria for service connection for a cervical syrinx have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309. 2. The criteria for service connection for bilateral carpal tunnel syndrome have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309. 3. The criteria for service connection for loss of use of the upper extremities as a residual of syringomyelia have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310. 4. The criteria for service connection for loss of use of the lower extremities as a residual of syringomyelia have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310. 5. The criteria for service connection for impotence as a residual of syringomyelia have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310. 6. The criteria for SMC for specially adapted housing or a special home adaptation grant have not been met. 38 U.S.C. §§ 2101, 5107; 38 C.F.R. §§ 3.809, 3.809a. 7. The criteria for eligibility for financial assistance for automobile or other conveyance and adaptive equipment, or for adaptive equipment only, have not been met. 38 U.S.C. § 3901, 3902, 5107; 38 C.F.R. § 3.808, 3.350(a)(2). 8. The August 20, 2009, decision contained CUE, and an effective date of July 23, 1992, for the grant of service connection for schizophrenia, bipolar disorder aggravated by PTSD, must be granted. 38 U.S.C. § 5110(a); 38 C.F.R. §§ 3.105(a), 3.156(c), 3.400. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1980 to July 1992. This appeal is before the Board of Veterans’ Appeals (Board) from July 2013, July 2014, October 2014, and November 2014 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection requires: (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. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498 (1995). In addition, for certain chronic diseases, such as arthritis and organic diseases of the nervous system, a presumption of service connection arises if the disease is manifested to a degree of 10 percent within one year following discharge from service. 38 C.F.R. §§ 3.307, 3.309(a). When a chronic disease is not shown within one year after service, under 38 C.F.R. § 3.303(b) for the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. When the fact of chronicity in service is not adequately supported, a showing of continuity after discharge is required to support a claim for such diseases; however, such continuity of symptomatology may only support a claim for those chronic diseases listed under 38 C.F.R. § 3.309(a). 38 C.F.R. § 3.303(b); see Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may also be established on a secondary basis for a disability that is shown to be proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. Id.; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). 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. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant. As reflected in his November 2012 claim and reiterated in September 2014 argument from his attorney, the Veteran asserts that he has total loss of use of his extremities and impotence, and that such conditions are residual disabilities of syringomyelia incurred in service. For the reasons set forth below, the Board finds that service connection for a cervical syrinx and bilateral carpal tunnel syndrome is warranted; but that service connection for further disability manifested by loss of use of the upper or lower extremities and impotence claimed as secondary to syringomyelia, is not warranted. Service treatment records reflect treatment for tension headaches in February 1984, muscle strain of the left calf in October 1984, back pain in October 1984, and elbow pain in November 1988. An August 1991 radiologic report of the cervical spine revealed normal vertebral body heights and intervertebral space heights, and minimal marginal spur formation at C7 disk space seen; otherwise, the rest of the bones appeared normal, with the contralateral intervertebral foramen appearing to be normally patent and Atlanto-Odontoid relationship appearing to be normal. The impression was “Minimal disk space marginal spur formation at C7 level noted otherwise the study appear unremarkable.” In October 1991, it was noted that lumbosacral spine X-rays had been negative. In November 1991, the Veteran reported having one week of sudden tingling and pain in the fingers and toes, and the impression was very sensitive nerves with paresthesias, cramps, and muscle fibrillations. It was noted that X-ray of the cervical spine had shown spur at C7 of no clinical significance. In June 1992, the Veteran reported a history of bilateral knee pains and bilateral hand numbness. Following service, the Veteran filed service connection claims in September 1992 for several disabilities. On January 1993 VA examination in connection with his claims, he reported left elbow pain and weakness, and occasional numbness the palm side of the fourth and fifth fingers if the left hand, and to a lesser extent on the right hand. Following examination, he was diagnosed with left ulnar neuropathy, for which he was granted service connection in a May 1993 rating decision. Private rheumatology and neurology treatment notes reflect that in November 1993, the Veteran was noted to complain of pain and stiffness in his hands, elbows, and shoulders. Physical examination showed no wrist swelling, good range of motion of both wrists, and that the elbows, shoulders, cervical spine, hips, knees, ankles and feet were normal. X-rays of both hands showed no evidence of inflammatory or degenerative disease. In January 1994, the Veteran again reported numbness and tingling in both hands, and also some sexual impotence as of late. January 1994 magnetic resonance imaging (MRI) revealed a 5-millimeter (mm.) cystic lesion in the spinal cord at C6 level, possibly post-traumatic sequalae, and small central focal disc bulge at C7-T1 and C5-6. January 1994 electromyography (EMG)/nerve conduction study (NCS) revealed abnormal EMG and NCS consistent with mild to moderate bilateral carpal tunnel syndrome without active denervation. MRI of the thoracic spine was normal. A January 1994 follow-up note reflects that the Veteran had a cystic lesion within his spinal cord at the C6 level and a small bulging disc at C7-T1 and C5-6, but that these did not appear to cause problems with his spinal cord or roots. It was noted that the lesion in his spinal cord could be a tumor or related to old neck trauma; if it were the latter, it should not change at that time. It was also noted that electrical testing had revealed bilateral carpal tunnel. A March 1994 follow-up note from the Veteran’s neurologist reflects that the Veteran returned, having had a repeat MRI scan that showed no change within the cystic lesion measuring about 5 mm. at the C5-6 level of the spinal cord. It was noted that the Veteran had headaches that ran from his suboccipital region up to the scalp in front and the hairline, but that the neurologist did not believe that these were related to this tiny cyst within the spinal cord. The actual etiology of the cyst was unclear. It was also noted that the Veteran’s other problem was basically hand paresthesias, but these had responded to splinting and his electrical testing had revealed carpal tunnel. It was further noted that the last problem was that just recently he had been impotent in a sexual attempt and loss of sexual desire. The neurologist was uncertain that this was necessarily related to his small cyst, or was more on an emotional basis. The Veteran’s hand and finger numbness and tingling were thus noted in service and on January 1993 VA examination and in January 1994, leading to his January 1994 diagnosis of bilateral carpal tunnel syndrome following EMG/NCS. The Veteran, furthermore, has a current diagnosis of bilateral carpal tunnel syndrome, as reflected during May 2015 VA treatment and on June 2015 VA examination. In view of the above and the nature of the Veteran’s service connection claim for loss of use of the upper extremities, and resolving reasonable doubt in his favor, the Board finds that bilateral carpal tunnel syndrome was incurred in service. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). Accordingly, service connection for bilateral carpal tunnel syndrome is warranted. Regarding the Veteran’s cervical syrinx—for which he also has current diagnoses—while the Veteran had in-service cervical spine X-rays, his first cervical MRI of record was in January 1994, approximately one and a half years after his almost 12-year period of service; the MRI revealed his cervical syrinx at C6. There is no indication in the record that any event took place in the one and a half years since service that might have resulted in his syrinx. Thus, resolving reasonable doubt in the Veteran’s favor, the Board finds that his cervical syrinx was incurred in service, and service connection for a cervical syrinx is warranted. However, as explained below, the weight of the probative evidence reflects that such syrinx is, and has been, asymptomatic with no residuals, including those claimed by the Veteran. Subsequent VA treatment records reflect that the Veteran was noted to walk with no limp, squat fully, and walk on toes, heels, and inside and outside of his feet on December 1996 VA joints examination; strength and motion were full in the upper and lower extremities, and sensation to pinprick was intact and equal bilaterally in the lower extremities, and in the upper extremities was decreased at the ulnar side of both hands and at the fourth and fifth fingers bilaterally. He reported that pain and tingling in the hands was getting worse on February 1999 VA examination, which was noted to be related to his carpal tunnel syndrome. In January 2000, he had a normal gait and full range of knee motion, and in March 2001 he was noted to have had recently diagnosed diabetes mellitus (in 2000). In October 2012, cervical spine MRI revealed multilevel degenerative change, and again syrinx at the C6 level. In November 2012, the Veteran was evaluated by a VA physician’s assistant who noted his cervical syrinx and stated that it was the physician assistant’s belief that the syrinx was causing most of the Veteran’s physical symptoms, including problems with his extremities, even though the 5-mm. syrinx had not increased in size. Further, November 2012 notes from a VA registered nurse reflect an assessment of syringomyelia with worsening neurological function, impaired ability to care for self, and mobility and performance of activities of daily living impaired significantly. It was noted that the Veteran would be going for neurosurgery consult regarding his syringomyelia. On February 2013 VA neurosurgery consult, the examining physician noted that the Veteran did have findings of a syrinx at the C6 level, and also had complaints of all over body pain and weakness, including his joints and muscles. The physician noted personally interviewing and examining the Veteran, and stated that he did not believe that the Veteran’s symptoms were related to the syrinx nor saw any evidence that the syrinx was clearly symptomatic (e.g., by virtue of myelopathy). June 2013 treatment records from another VA physician note the finding of C6 syrinx that was shown to be stable, January 2008 to January 2013; the physician did not think the stable syrinx was the cause of his current symptoms. A July 2013 note reflects that the Veteran had chronic pain syndrome and history of syrinx at C6 that neurosurgery did not feel was causing any symptoms, and he presented to the emergency room with left-sided numbness and slight weakness onset over about one hour and lasted all day-but now improving. The assessment was possible transient ischemic attack (TIA) with left sided numbness, resolving; chronic pain syndrome; and diabetes type II. A July 2013 record from a VA neurologist notes that the Veteran was known to have a long-standing history of cervical syrinx at the C5-C6 area, which had been stable over many, many, years, and that he was complaining of additional symptoms in the last 9 to 12 months. It was noted that past medical history was significant for cervical syrinx, as well as diabetes with neuropathy and other disorders. On examination, motor system showed the Veteran to have good strength with reflexes being suppressed, with no drift; sensory system showed a slight decrease in pinprick in a stocking distribution; and coordination was normal. The impression was recent TIA with left hemiparesis. It was noted that the Veteran also had a history of long-standing cervical syrinx, as well as diabetes and other conditions. The examining neurologist stated, “I doubt his current symptoms are related to the syrinx and I would be more suspicious of a neurogenic cause for it.” In July 2013, a VA physician reviewed the record and noted that an asymptomatic syrinx is a common incidental finding on neuroimaging in spinal cord injury patients, usually has a benign prognosis, and likely represents focal area of liquification necrosis of cord tissue. In June 2015 the Veteran was given a VA neurological disorders examination. The impression included poorly controlled diabetes; carpal tunnel; syringomyelia (self-diagnosed per patient) vs. asymptomatic syrinx (per neurology consult 3/26/2015); and diabetic neuropathy. The examining physician explained that the Veteran’s diagnosis of syringomyelia referred to presence of a syrinx, which is a small fluid-filled cavity in the cervical spinal cord at the C6 level. It had been identified on cervical spine MRI but not identified to be causing any neurological abnormalities, as documented on numerous occasions throughout the record, including by his VA neurologist in February and July 2013, and in March 2015, where the VA neurologist assessed peripheral neuropathy secondary to poorly-controlled diabetes mellitus, and syringomyelia, small, nonsurgical, asymptomatic. The examiner determined that there was no indication that the cervical syrinx had ever been symptomatic or caused any disability, or any indication in the Veteran’s neurology evaluations that the he ever had any symptomatic manifestations of the small C6 level cervical cord syrinx, even if MRI showed the cervical syrinx just 18 months after service. The VA examiner furthermore provided the opinion that etiology of the Veteran’s erectile dysfunction was unknown, but that he had several risk factors for it. These included: diabetes mellitus type II; hypertension; previous diagnosis of TIA with left hemiparesis; his history as a smoker; and his history of diagnosed psychosexual dysfunction with inhibited sexual excitement. It was also noted that the Veteran felt that the medication he took for hypertension and pain might contribute to his erectile dysfunction. Further VA treatment records reflect that, on April 2016 VA neurology consultation, the Veteran reported gradual onset of gait instability that had been progressively worsening over the past 15 years. It was noted that he had been found to have a posterior fossa arachnoid cyst and syrinx at the level of C6. It was also noted that he had a history significant for poorly-controlled diabetes melitis, and that he reported a brief episode of numbness of the left side and face. The impression was left-side numbness, concerning for TIA vs stroke, and stroke work-up was planned; and gait instability, probably secondary to neuropathy from prolonged history of diabetes mellitus that was poorly-controlled. On neurology note the next day, physical exam was normal and the Veteran presented asymptomatic. A later April 2016 note reflects an assessment of gait imbalance secondary to neuropathy, probably from diabetes mellitus. In this case, the Board finds that the overwhelming weight of the competent and probative evidence suggests that the Veteran’s cervical syrinx is, and has always been, asymptomatic, with no residual disability resulting from it. Such evidence includes the medical opinions of the Veteran’s own private neurologist who initially diagnosed the cervical syrinx in 1994, but determined that such condition did not appear to cause problem with his spinal cord and roots. That neurologist also determined that the Veteran’s reported symptoms were unlikely to be related to his cervical syrinx, and that his bilateral hand symptoms were due to carpal tunnel syndrome. In October and November 2012, a VA physician’s assistant and nurse indicated a belief that the Veteran’s cervical syrinx was causing physical problems. However, the physicians, including neurologists, to whom the physician’s assistant and nurse referred the Veteran for evaluation, after further neurological examination and work-up, repeatedly and consistently opined that his syrinx was asymptomatic and not responsible for any symptomatology; this includes the February, June, and July 2013 VA physicians. This opinion was repeated by the June 2015 VA neurological disorders examiner. These physicians based this assessment on the nature of the Veteran’s cervical syrinx itself, including its small size and stability and lack of progression over many, many years. They also based it on the nature of the Veteran’s reported symptomatology, including his asserted upper and lower extremity symptoms, determining that it was likely due to another medical condition or conditions; these have included carpal tunnel syndrome, diabetic neuropathy (repeatedly noted to be the likely cause of his gait instability), and a TIA. Similarly, the June 2015 VA examiner noted numerous risk factors and possible etiologies of the Veteran’s erectile dysfunction, discussed above. The Board notes arguments put forth by the Veteran’s attorney in September 2014, as well as a “Syringomyelia Fact Sheet” submitted by the attorney. Initially, the Veteran’s attorney makes arguments regarding the adequacy of a July 2013 opinion from a VA physician. However, as described above, the Board is not relying on any such opinion in this case, and only acknowledges the physician’s note that that an asymptomatic syrinx is a common incidental finding on neuroimaging in spinal cord injury patients, usually has a benign prognosis, and likely represents focal area of liquification necrosis of cord tissue. This notation is not challenged by the Veteran’s attorney and is not contradicted by the “Syringomyelia Fact Sheet,” which notes that, “[i]n the absence of symptoms, syringomyelia is usually not treated.” The Veteran’s attorney further pointed to telephone notes from a staff physician in VA’s neurology department in January and February 2008, Dr. S.B., in which Dr. S.B. noted the Veteran’s cervical syrinx. In January 2008, Dr. S.B. stated that there “could be numbness and pain related to syringomyelia.” In February 2008, he stated: “Also ulnar nerve problem. I suspect connected through the spinal cord condition, from injury in the service so making service connected.” However, Dr. D.B.’s January 2008 impression that there “could be numbness and pain related to syringomyelia” is, at best, equivocal. Also, his statement regarding the ulnar nerve is unclear. As noted above, the Veteran was service-connected for left ulnar neuropathy in 1993, unrelated to any spinal cord problem; it is unclear whether Dr. S.B. was speculating as to why the Veteran was service-connected for the left ulnar nerve, or whether he was opining that the left ulnar nerve problem, specifically, was related to the Veteran’ s spine condition—an opinion that is not explained. Regardless, even considering these notes from Dr. D.B., the Board still finds, for the reasons above, that the overwhelming weight of the competent and probative evidence suggests that the Veteran’s cervical syrinx is, and has always been, asymptomatic, with no residual disability resulting from it. Again, such persuasive evidence has been provided by the VA physicians, neurologists, and June 2015 examiner mentioned above, as well as the Veteran’s own private neurologist in 1994. The Veteran’s attorney also notes the July 2013 VA treating neurologist’s assessment that it was doubtful that the Veteran’s current symptoms were related to the syrinx. His attorney asserts that the neurologist did not address favorable medical nexus evidence in the record, provide a rationale for the opinion, or opine as to the etiology of the Veteran’s pain and weakness. Initially, the Board notes that the VA neurologist was providing an assessment for treatment purposes, and was not providing any medical opinion regarding the Veteran’s service connection claim requested by VA. Furthermore, the July 2013 VA neurologist’s opinion is, again, consistent with the overwhelming medical evidence of record suggesting that the Veteran’s cervical syrinx is asymptomatic. These opinions, including the July 2013 neurologist’s, were based on the nature of the Veteran’s cervical syrinx, including its small size and stability and lack of progression over many, many years. This is consistent with the “Syringomyelia Fact Sheet” provided by the Veteran’s attorney, which indicates that a syrinx becomes symptomatic as it “expands and elongates over time, destroying a portion of the spinal cord from its center and expanding outward. As a syrinx widens it compresses and injures nerve fibers that carry information from the brain to the extremities.” Again, they were also based it on the nature of the Veteran’s reported symptomatology, including his asserted upper and lower extremity symptoms, determining that it was likely due to another medical condition or conditions; these have included carpal tunnel syndrome, diabetic neuropathy and a TIA. The July 2013 VA neurologist noted that past medical history was significant for diabetes with neuropathy, diagnosed TIA with left hemiparesis, and suggested that there was a different neurogenic cause for the Veteran’s symptoms. Also, the Board notes that the June 2015 VA examiner specifically noted review of neurology notes from Dr. D.B. and other evidence submitted by the Veteran’s attorney in making his opinion. Finally, while the submitted “Syringomyelia Fact Sheet” provides general information regarding syringomyelia, does not speak to the Veteran’s specific case of cervical syrinx or the particular circumstances of the Veteran’s medical condition. It is therefore of very little to no probative value on the question of what disability or symptoms, if any, have resulted from such cervical syrinx. Therefore, a preponderance of the evidence is against a finding that any disability manifested by loss of use of the upper or lower extremities, or impotence, was incurred in service or is caused or aggravated by the Veteran’s cervical syrinx or any other service-connected disability. Accordingly, service connection for loss of use of the upper and lower extremities and impotence must be denied. Specially Adapted Housing/Special Home Adaptation, and Automobile/Adaptive Equipment Specially adapted housing is available to a veteran who has a permanent and total service-connected disability due to: (1) amyotrophic lateral sclerosis rated as 100 percent disabling under 38 C.F.R. § 4.124a, Diagnostic Code 8017; (2) blindness in both eyes, having only light perception, plus the anatomical loss or loss of use of one lower extremity; (3) full thickness or subdermal 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 (4) the loss or loss of use of both upper extremities such as to preclude use of the arms at or above the elbows. Specially adapted housing is also available to a veteran with a permanent and total 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 phrase “preclude locomotion” is defined as the necessity for regular and constant use of a wheelchair, braces, crutches or canes as a normal mode of locomotion, although occasional locomotion by other methods may be possible. 38 C.F.R. § 3.809(c). If entitlement to specially adapted housing is not established, a veteran can qualify for a grant for necessary special home adaptations if he/she has a service-connected disability that results in blindness in both eyes with 20/200 visual acuity or less in the better eye with the use of a standard correcting lens or a limitation in fields of vision such that the widest diameter of the visual field subtends an angle no greater than 20 degrees; such a disability need not be permanent and total in nature. Additionally, a special home adaptation grant is available for a veteran that has a permanent and total disability which: (1) includes the anatomical loss or loss of use of both hands; (2) 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; (3) is due to full thickness or subdermal burns that have resulted in contracture(s) of one or more extremities or the truck; or, (4) is due to residuals of an inhalation injury (including, but not limited to, pulmonary fibrosis, asthma, and chronic obstructive pulmonary disease (COPD)). 38 C.F.R. § 3.809a(b). Financial assistance may be provided to an “eligible person” in acquiring an automobile or other conveyance and adaptive equipment, or adaptive equipment only. 38 U.S.C. § 3902(a)(b). Eligibility for assistance to purchase a vehicle and adaptive equipment is warranted where one of the following exists as the result of injury or disease incurred or aggravated during active 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, meaning 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; (4) severe burn injury precluding effective operation of an automobile; (5) amyotrophic lateral sclerosis; or, (6) for adaptive equipment only, ankylosis of one or both knees or one or both hips. 38 U.S.C. § 3901; 38 C.F.R. § 3.808. The term “loss of use of a hand or foot” is defined as existing when “no effective function remains other than that which would be equally well served by an amputation stump at the site of election below the elbow or knee with the use of a suitable prosthetic appliance.” 38 C.F.R. § 3.350(a)(2). The Veteran’s service-connected disabilities are: schizoaffective disorder, bipolar disorder, aggravated by PTSD, rated 100 percent; left ulnar neuropathy of the minor arm, rated 10 percent; left knee chondromalacia, rated 10 percent; a cervical syrinx; and bilateral carpal tunnel syndrome. In this case, SMC for specially adapted housing or a special home adaptation grant, and eligibility for financial assistance for automobile or other conveyance and adaptive equipment, or for adaptive equipment only, are not warranted. Initially, the Veteran does not have any permanent and total service-connected disability that is due to or includes any of the conditions listed in 38 C.F.R. §§ 3.809 and 3.809(a). The Veteran is being granted service connection for bilateral carpal tunnel in this decision, and such disability has not yet been rated in the first instance by the agency of original jurisdiction (AOJ). However, nothing in the record suggests that such carpal tunnel syndrome has resulted in anything close to either loss of use of both upper extremities such as to preclude use of the arms at or above the elbows, or loss of use of one or both hands; on June 2015 VA examination, while there was some weakened movement on wrist extension, muscle strength testing in the hands and upper extremities was full and normal. Likewise, while the Veteran is service connected for left knee chondromalacia, such disability is rated 10 percent, and not total. Also, there is no indication of either ankylosis or loss of use of the left lower extremity or foot; an October 2012 VA examination confirmed that neither condition is present. In short, none of the above criteria for either SMC under 38 U.S.C. § 2101 or financial assistance under 38 U.S.C. §§ 3901 or 3902 have been shown to be met. Accordingly, SMC for specially adapted housing or a special home adaptation grant, and eligibility for financial assistance for automobile or other conveyance and adaptive equipment, or for adaptive equipment only, must be denied. CUE Based on Assigned Effective Date of Service Connection In an August 20, 2009, rating decision, the AOJ granted service connection for “schizoaffective disorder, bipolar disorder aggravated by PTSD,” with an assigned effective date of September 12, 2005. The Veteran alleged that the decision contained CUE in assigning that effective date on the basis that it failed to appropriately apply the provisions of 38 C.F.R. § 3.156(c). The AOJ granted an earlier effective date of April 5, 2004, in a November 2014 rating decision, on the basis that CUE had existed in the August 2009 decision’s assignment of an effective date, as the Veteran had filed a claim to reopen a previously denied claim for a mental disorder (which he identified as PTSD) on that earlier date. However, the Veteran asserts that an effective date of July 23, 1992—the first date after his separation from service—is warranted, and has continued his appeal. Previous determinations which are final and binding, including decisions of service connection, degree of disability, age, marriage, relationship, service, dependency, line of duty, and other issues, will be accepted as correct in the absence of clear and unmistakable error. Where evidence establishes such error, the prior decision will be reversed or amended. For the purpose of authorizing benefits, the rating or other adjudicative decision which constitutes a reversal of a prior decision on the grounds of clear and unmistakable error has the same effect as if the corrected decision had been made on the date of the reversed decision. 38 C.F.R. § 3.105(a). To revise a prior final VA decision: (1) either the correct facts known at the time of the decision were not before the adjudicator, or the law as it existed at the time of the decision was incorrectly applied—the claimant, in short, must assert more than a disagreement as to how the facts were weighed or evaluated; (2) based on the record and law that existed at the time, the error was undebatable, so that it can be said that reasonable minds could only conclude that the original decision was fatally flawed at the time it was made; and (3) but for the error, the outcome would have been manifestly different. Cook v. Principi, 318 F.3d 1334, 1344 (Fed. Cir. 2002) (en banc); Bustos v. West, 179 F.3d 1378, 1380 (Fed. Cir. 1999). Only evidence that was in the claims file at the time of the challenged decision may be considered. Pierce v. Principi, 240 F.3d 1348 (Fed. Cir. 2001) (holding that “evidence” in 38 U.S.C. § 5109A(a) is limited to evidence that was of record at the time of the challenged RO decision). 38 C.F.R. § 3.156(c)(1) provides that, notwithstanding any other section of 38 C.F.R. Part 3, at any time after VA issues a decision on a claim, if VA receives or associates with the claims file relevant official service department records that existed and had not been associated with the claims file when VA first decided the claim, VA will reconsider the claim, notwithstanding 38 C.F.R. § 3.156(a) (concerning the requirement to reopen a previously finally denied claim with new and material evidence). This includes (i) service records that are related to a claimed in-service event, injury, or disease, regardless of whether such records mention the Veteran by name, as long as the other requirements of 38 C.F.R. § 3.156(c) are met; (ii) additional service records forwarded by the Department of Defense or the service department any time after VA’s original requires for service records; and (iii) declassified records that could not have been obtained when the records were classified when VA decided the claim. 38 C.F.R. § 3.156(c)(2) provides that such records do not include records that VA could not have obtained when it decided the claim because the records did not exist when VA decided the claim, or because the claimant failed to provide sufficient information for VA to identify and obtain the records from the respective service department, the Joint Services Records and Research Center, or from any other official source. 38 C.F.R. § 3.156(c)(3) provides that “[a]n award made based all or in part on the records identified by paragraph (c)(1) of this section is effective on the date entitlement arose or the date VA received the previously decided claim, whichever is later, or such other date as may be authorized by the previously decided claim.” In this case, the Veteran filed a claim for service connection for depression and PTSD in September 1992. In response to a request for information from the AOJ, the Veteran submitted a statement in November 1992 that, while serving on the Kennedy in July 1981, he witnessed an accident on the flight deck whereby 2 fatalities occurred and 2 serious injuries of lost limbs; he stated that he did not know the people, but that afterword he began to have flashbacks about the incident. In January 1993, the Veteran underwent VA examinations regarding several of his claimed disabilities, including a general medical examination that touched on mental health. However, no psychiatric examination was conducted by a mental health professional concerning his claim for psychiatric disabilities. In a March 1993 rating decision, the AOJ denied service connection for depression and PTSD, on the basis that “[t]here is no evidence at all of the veteran having ever been treated or manifesting any symptoms suggestive of PTSD,” and that “[b]ecause of family problems and apparently financial problems considered a possible contributing factor to the veteran’s weight problems, a diagnosis of depression was entertained while the veteran was on active duty,” but that, “[h]owever, no actual depressive neurosis is shown and no depression was noted on the VA examination.” From the date of the March 1993 denial to April 5, 2004, the Veteran attempted to reopen his claim for psychiatric disability, as various asserted diagnoses, on several occasions, but his claim was denied each time. June 2009 emails indicate that the Division Head, Aviation Mishap Investigations, was called by a VA Veterans Service Representative (VSR) and requested information to assist the Veteran regarding a mishap that supposedly occurred on the USS Kennedy circa 1981/82; he needed validation that the mishap actually occurred, supposedly involving at least two deaths, and possibly aircraft. In a follow-up message, the VSR stated that he had discovered a reference to an accident on the USS John F. Kennedy on December 3, 1981, when an arresting wire broke during the landing of an A-7 Corsair aircraft killing two men and injuring three others, and requested verification of this incident from an official source. A July 2009 memorandum from the VSR—also a VA Military Records Specialist—regarding research on the Veteran’s stressor states the following: verification of the death of two crew members and injuries of other crew members as a result of airplane accident that occurred on the USS Carrier Kennedy had been requested. The Veteran’s Navy personnel records indicate that he was assigned to the USS John F Kennedy (CV67) on April 6, 1981 until May 8, 1984. The Veteran provided information received by the VA on June 16, 2008, concerning, an accident on the USS Kennedy on December 3, 1981. An arresting wire breaks during the landing of an A-7 Corsair aircraft, killing two men and injuring three others. An email response from the U.S. Naval Safety Center confirms a Class A mishap that an incident occurred on December 3, 1981, on board the USS Kennedy. Her response indicated that there were nine flight deck injuries with two fatalities. The Veteran was subsequently given a VA initial evaluation for PTSD in August 2009. He was diagnosed as having schizoaffective disorder, bipolar type, aggravated by PTSD, and chronic PTSD, which, in the examiner’s opinion, was the result of his exposure to the stressor of the aircraft accident in service. The August 20, 2009, rating decision granting service connection for schizoaffective disorder, bipolar disorder aggravated by PTSD, states the following: “You are noted to have been aboard the USS Carrier Kennedy on December 3, 1981 in there were two fatalities and nine flight deck injuries when an arresting wire broking during the landing of a A-4 Corsair aircraft. Exposure to a stressor is conceded.” The decision noted several instances of mental health treatment in service for depression, anxiety, nightmares, and related symptomology. It also noted a private mental health opinion that the Veteran’s psychiatric illness was without any significant remission since his discharge in 1992, and the August 2009 VA examiner’s opinion that, in addition to PTSD, the Veteran “developed symptoms of schizoaffective disorder and bipolar type while in the military and have since evidenced that your symptoms are chronic in nature.” The Veteran essentially asserts that the AOJ committed CUE in its August 20, 2009, decision, not cured in its November 2014 decision, by failing to reconsider his claim under 3.156(c)(1) following the official service department verification of his stressor originally described in November 1992, and assign a rating in accordance with 3.156(c)(3), as appropriate. Initially, in a September 2015 statement of the case, the AOJ declined to make a determination as to whether, the email correspondence from the Naval Safety Center would be considered a service department record under 38 C.F.R. 3.156(c), as “the issue is not material to the outcome of the claim in the absence of a diagnosis of PTSD prior to the 2004 reopened claim.” However, while the official service documentation of the December 1981 accident has not been associated with the claims file, the file contains the July 2009 memorandum from the VA Military Records Specialist concluding that the Veteran’s claimed stressor had been verified, including through confirmation by the U.S. Naval Safety Center, has been. The Board finds that such received confirmation from a service department is sufficient evidence that VA has received official service department records for purposes of 38 C.F.R. § 3.156(c)(1). See, e.g., Mayhue v. Shinseki, 24 Vet. App. 273, 275-80, (2011). Also, as reflected in the June 2009 emails regarding the Veteran’s asserted in-service stressor, there is no indication that the Veteran failed to provide sufficient information for VA to identify and obtain such records verifying his in-service stressor from the service department or official source when he originally reported it in November 1992. Thus, the provisions of 3.156(c)(2) would not apply in this case. Furthermore, despite the fact that the Veteran’s original claim was denied in March 1993 on the basis that a post-service psychiatric diagnosis had not been shown, the service department records verifying the Veteran’s stressor were clearly “relevant”; they were “noncumulative and pertinent to the matter at issue in the case.” See Kisnor v. Shulkin, 869 F.3d 1360, 1368-69 (Fed. Cir. 2017). The August 2009 rating decision specifically cites the verification of the Veteran’s claimed stressor as relevant to establishing the Veteran’s service connection claim. Moreover, such verification appears to have led to VA’s scheduling of the August 2009 VA initial evaluation for PTSD—during which the Veteran’s exposure to the aircraft accident in service was noted to lead to his PTSD diagnosis—on which the grant of service connection in August 2009 for the Veteran’s psychiatric disability was primarily based. Thus, as VA had received official service department records relevant to the Veteran’s September 1992 service connection claim for depression and PTSD, that existed and had not been associated with the claims file when VA first decided the claim in March 1993, the AOJ should have reconsidered the Veteran’s claim; if it did not reconsider the September 1992 claim in the decision granting service connection for the Veteran’s psychiatric disability and assigning an effective date, that decision would contain CUE. See George v. Shulkin, 29 Vet. App. 199 (2018). In its September 2015 statement of the case, the AOJ determined the following: A review of your VA records does not show a diagnosis of PTSD until several years after the claim of August 2004 was filed. Although some primary care records show PTSD as a notation in the primary history, there is no evidence that a licensed mental health psychologist or psychiatrist had diagnosed PTSD. It is determined that a clear and unmistakable error can exist if the VA fails to apply appropriate regulations, however, in this case, the alleged error in the failure to apply this regulation is not material to the outcome of the claim as the veteran was not diagnosed with posttraumatic stress disorder until years after the reopened claim was filed 2004. Because service connection cannot be granted without a diagnosis, a clear and unmistakable error does not exist… It is not entirely clear whether the AOJ determined that, because PTSD had not been diagnosed at the time the Veteran’s original claim had been filed, that it was not required to reconsider the claim under 38 C.F.R. § 3.156 (c)(1); or whether it had reconsidered the Veteran’s claim, but found that an earlier effective date was not warranted under 38 C.F.R. § 3.156(c)(3) because PTSD was not diagnosed until after 2004. The Board notes that, in reconsidering a service connection claim for PTSD under 38 C.F.R. § 3.156(c), the grant of an effective date years after claim for such has been filed, where there is a finding that PTSD did not exist until that later time as shown by medical evidence, is not necessarily CUE. Id. However, this is not the case here. The AOJ in this case did not reconsider the Veteran’s September 1992 claim and determine an effective date based on a finding that PTSD did not exist—and, hence, entitlement to service connection benefits did not arise—until a later date than that of the claim. It clearly, and explicitly, based the April 5, 2004, effective date on a finding that the Veteran had filed a claim to reopen his previously denied service connection claim for psychiatric disability on that date. Moreover, reconsideration of the Veteran’s September 1992 service connection claim did—or would have—resulted in the grant of service connection for schizophrenia, bipolar disorder aggravated by PTSD. The medical nexus basis for such grant, as explicitly stated in the August 20, 2009, rating decision granting such, was a private mental health opinion that the Veteran’s psychiatric illness was without any significant remission since his discharge in 1992, and the August 2009 VA examiner’s opinion that, in addition to PTSD, the Veteran “developed symptoms of schizoaffective disorder and bipolar type while in the military and have since evidenced that [his] symptoms are chronic in nature.” There is thus, based on the AOJ’s decision, no reasonable basis for determining that entitlement to service connection for psychiatric disability—specifically, the existence of the disability itself—had not arisen by the time of his September 1992 claim for service connection benefits. In light of the above, the Board finds that, in the August 20, 2009, rating decision granting service connection for schizophrenia, bipolar disorder aggravated by PTSD, the provisions of 38 C.F.R. § 3.156(c) were not correctly applied in determining the appropriate effective date; that the error was undebatable; and that, but for the error, an effective date of July 23, 1992—the day following the Veteran’s separation from service—would have been awarded for the grant of his September 1992 claim for service connection benefits. See 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400. Accordingly, the August 20, 2009, decision contained CUE that has not been corrected by any subsequent VA action, and an effective date of July 23, 1992, for the grant of service connection for schizophrenia, bipolar disorder aggravated by PTSD, must be granted. JONATHAN B. KRAMER Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Andrew Mack, Counsel