Citation Nr: 19106949 Decision Date: 01/29/19 Archive Date: 01/29/19 DOCKET NO. 15-04 502 DATE: January 29, 2019 ORDER Entitlement to service connection for sleep apnea is granted. Entitlement to service connection for type II diabetes mellitus is denied. Entitlement to service connection for right foot neuropathy is denied. Entitlement to service connection for left foot neuropathy is denied. Entitlement to service connection for acrophobia is denied. Entitlement to an effective date earlier than March 7, 2013, for the award of a 100 percent rating for coronary artery disease (CAD) is denied. Entitlement to an effective date earlier than March 7, 2013, for the award of special monthly compensation is denied. Entitlement to automotive and adaptive equipment or for adaptive equipment only is denied. FINDINGS OF FACT 1. Sleep apnea is shown to have been manifest during active service. 2. Type II diabetes mellitus was not manifest during active service or within one year of service; and, the preponderance of the evidence fails to establish that a present disorder is etiologically related to service, including service in Southwest Asia. 3. Right foot neuropathy was not manifest during active service; and, the preponderance of the evidence fails to establish that a present disorder is etiologically related to service, including service in Southwest Asia. 4. Left foot neuropathy was not manifest during active service; and, the preponderance of the evidence fails to establish that a present disorder is etiologically related to service, including service in Southwest Asia. 5. A present acrophobia disability is not shown during the appeal period. 6. The persuasive evidence demonstrates no claim was received by VA earlier than March 7, 2013, pertinent to the award of a 100 percent rating for CAD. 7. The persuasive evidence demonstrates no claim was received by VA earlier than March 7, 2013, pertinent to the award of special monthly compensation. 8. The persuasive evidence of record demonstrates that the Veteran’s service-connected disabilities do not result in loss or permanent loss of use of one or both feet; or loss or permanent loss of use of one or both hands; or permanent impairment of vision of both eyes. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for sleep apnea have been met. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. § 3.303 (2018). 2. The criteria for entitlement to service connection for type II diabetes mellitus, to include as a result of a service-connected disability and/or service in Southwest Asia have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 1117, 1131 (2012); 38 C.F.R. §§ 3.303, 3.307(a)(3), 3.309(a), 3.317 (2018). 3. The criteria for entitlement to service connection for right foot neuropathy, to include as a result of a service-connected disability and/or service in Southwest Asia have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 1117, 1131 (2012); 38 C.F.R. §§ 3.303, 3.307(a)(3), 3.309(a), 3.317 (2018). 4. The criteria for entitlement to service connection for left foot neuropathy, to include as a result of a service-connected disability and/or service in Southwest Asia have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 1117, 1131 (2012); 38 C.F.R. §§ 3.303, 3.307(a)(3), 3.309(a) (2018). 5. The criteria for entitlement to service connection for acrophobia have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 1131 (2012); 38 C.F.R. §§ 3.303, 3.307(a)(3), 3.309(a), 3.317 (2018). 6. The criteria for entitlement to an effective date earlier than March 7, 2013, for the award of a 100 percent rating for CAD have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 3.400 (2018). 7. The criteria for entitlement to an effective date earlier than March 7, 2013, for the award of special monthly compensation have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 3.400 (2018). 8. The criteria for entitlement to a certificate of eligibility for automotive and adaptive equipment and/or for adaptive equipment only have not been met. 38 U.S.C. § 3902 (2012); 38 C.F.R. §§ 3.350, 3.808, 4.63 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The appellant is a Veteran who served on active duty from October 1974 to October 1994. Records show he had service in Southwest Asia from March 1991 to July 1991. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from rating decisions in March 2014, September 2014, and February 2015 decision by or on behalf of the Waco, Texas, Regional Office (RO) of the Department of Veterans Affairs (VA). In October 2017, the Veteran testified at a personal hearing before the undersigned Veterans Law Judge. A copy of the transcript of that hearing is of record. The issues remaining on appeal were remanded for additional development in February 2017. The Board notes that a February 2018 rating decision granted service connection for gout, hypertension, chronic kidney disease, and end stage renal disease. The appeal as to these matters are considered to have been resolved. The appeal concerning whether the Veteran’s children, J.W.B. and D.F.B., are incapable of self-support has been addressed in a separate January 2019 Board decision. Service Connection Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131 (2012). Service connection connotes many factors but basically it means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service in the Armed Forces, or if preexisting such service, was aggravated therein. 38 C.F.R. § 3.303(a) (2018). The term “disability” for VA compensation purposes refers to the functional impairment of earning capacity rather than the underlying cause of the impairment and it is noted that pain alone may be a functional impairment. See Saunders v. Wilkie, 887 F.3d 1356, 1364-68 (Fed. Cir. 2018). Generally, the evidence 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. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). The existence of a current disability is the cornerstone of a claim for VA disability compensation. See Degmetich v. Brown, 104 F.3d 1328 (1997). Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. In the absence of proof of a present disability there can be no valid claim. Brammer v. Brown, 3 Vet. App. 223 (1992). Certain chronic diseases, including arthritis and organic diseases of the nervous system, are also subject to presumptive service connection if manifest to a compensable degree within one year from separation from service even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C. §§ 1112, 1113 (2012); 38 C.F.R. §§ 3.307(a)(3), 3.309(a) (2018). Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden element is through a demonstration of continuity of symptomatology if the disability claimed qualifies as a chronic disease listed in 38 C.F.R. § 3.309(a). Diabetes mellitus and psychoses are qualifying chronic diseases. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). VA regulations also provide that compensation will be paid for disability due to undiagnosed illness and medically unexplained chronic multisymptom illnesses, including chronic fatigue syndrome, fibromyalgia, and functional gastrointestinal disorders, to a Persian Gulf War veteran who exhibits objective indications of a qualifying chronic disability if that disability became manifest either during active service in the Southwest Asia theater of operations, or to a degree of 10 percent or more not later than December 31, 2021, and by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 C.F.R. § 3.317(a)(1) (effective before and after Oct. 24, 2017). The term medically unexplained chronic multisymptom illness means a diagnosed illness without conclusive pathophysiology or etiology that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstrations of laboratory abnormalities. Chronic multisymptom illness of partially understood etiology and pathophysiology, such as diabetes and multiple sclerosis, will not be considered medically unexplained. 38 C.F.R. § 3.317(a)(2)(ii). Signs or symptoms which may be manifestations of undiagnosed illness or medically unexplained chronic multisymptom illness include, but are not limited to: (1) Fatigue, (2) Signs or symptoms involving skin, (3) Headache, (4) Muscle pain, (5) Joint pain, (6) Neurologic signs and symptoms, (7) Neuropsychological signs or symptoms, (8) Signs or symptoms involving the respiratory system (upper or lower), (9) Sleep disturbances, (10) Gastrointestinal signs or symptoms, (11) Cardiovascular signs or symptoms, (12) Abnormal weight loss, and (13) Menstrual disorders. 38 C.F.R. § 3.317(b). If signs or symptoms have been attributed to a known clinical diagnosis, service connection may not be provided under the specific provisions pertaining to Persian Gulf veterans. See VAOPGCPREC 8-98 (Aug. 3, 1998). “The very essence of an undiagnosed illness is that there is no diagnosis.” Stankevich v. Nicholson, 19 Vet. App. 470, 472 (2006). A Persian Gulf War veteran’s symptoms “cannot be related to any known clinical diagnosis for compensation to be awarded under section 1117.” Gutierrez v. Principi, 19 Vet. App. 1, 10 (2004). The Board has the authority to discount the weight and probity of evidence in light of its own inherent characteristics and its relationship to other evidence. Madden v. Gober, 125 F.3d 1477 (Fed. Cir. 1997). VA may favor one medical opinion over another, provided an adequate basis is provided. Owens v. Brown, 7 Vet. App. 429 (1995). It is the policy of VA to administer the law under a broad interpretation, consistent with the facts in each case, with all reasonable doubt to be resolved in favor of the claimant. 38 C.F.R. § 3.102 (2018). 1. Entitlement to service connection for sleep apnea. The Veteran contends that he has sleep apnea as a result of active service. He asserted that his sleep apnea developed as a result of or as a consequence of his heart, hypertension, and migraine headache disorders. Service treatment records are negative for treatment or diagnosis of sleep apnea. In his September 1994 report of medical history, however, the Veteran reported having frequent trouble sleeping and an examination report included sleep disturbance in the summary of defects and diagnoses. A March 1995 post-service service department examination report noted symptoms including occasional snoring, but that the Veteran had no history of apneic spells, restless sleep, or daytime sleepiness. The examiner found there was no obstructive sleep apnea by history. It was noted the results of a sleep study were pending. A March 1995 sleep study included a diagnosis of mild obstructive sleep apnea. The treatment plan recommended positional therapy. VA examination in February 2014 included a diagnosis of obstructive sleep apnea with a date of diagnosis in 2009. The examiner found the Veteran’s sleep apnea was in no way proximately due to or the result of his migraines, hemorrhoids, pseudofolliculitis barbae, or first-degree heart block. An April 2017 VA examination included a diagnosis of obstructive sleep apnea. It was noted the Veteran complained of insomnia and difficulty breathing during sleep which initially presented in or around 1999. An August 2010 sleep study documented the sleep disorder. The examiner found it was less likely it had its onset in service, was etiologically related to service in Southwest Asia, was secondary to a service-connected disability, or was aggravated by a service-connected disability. Despite the negative opinions of records, the Board finds the Veteran has obstructive sleep apnea and that a diagnosis provided in March 1995 is shown to have been based upon symptoms that had persisted since active service. The Veteran’s report of sleep disturbance in September 1994 and the confirmed diagnosis of obstructive sleep apnea upon sleep study soon after service in March 1995 is persuasive. The Veteran is essentially shown to have first endorsed symptoms of sleep apnea during his active service. The subsequent VA examination opinions warrant a lesser degree of probative weight as they fail to address the question of when the Veteran’s sleep apnea had its initial onset. The appeal for entitlement to sleep apnea is granted. 2. Entitlement to service connection for type II diabetes mellitus, to include as a result of a service-connected disability and/or service in Southwest Asia. 3. Entitlement to service connection for right foot neuropathy, to include as a result of a service-connected disability and/or service in Southwest Asia. 4. Entitlement to service connection for left foot neuropathy, to include as a result of a service-connected disability and/or service in Southwest Asia. 5. Entitlement to service connection for acrophobia. The Veteran contends that he has type II diabetes mellitus, foot neuropathy, and acrophobia as a result of service. He contends that he has an acrophobia disability that is separate and distinct from his service-connected posttraumatic stress disorder (PTSD). He has also asserts that he had been provided a diagnosis of diabetes mellitus in 1978 which he self-treated by diet for many years and that his diabetes mellitus developed or was aggravated as a result of his service-connected CAD, hypertension, PTSD, and migraine headache disorders. Service treatment records include diagnoses and physical profile determinations for acrophobia beginning in March 1977. A January 1984 report included an assessment of rule out diabetes mellitus. A subsequent January 1984 report noted fasting blood sugar (FBS) findings of 94, within the normal range. A September 1994 FBS finding of 102 was in the normal range. VA examination in February 2014 found the Veteran did not meet the criteria for a diagnosis of acrophobia. It was noted that his discomfort with heights was subsumed under the diagnosis of PTSD. The examiner noted that heights acted as a trigger for increased arousal and posttraumatic re-experiencing rather than being a separate anxiety disorder. A February 2014 VA diabetes mellitus examination included a diagnosis of type II diabetes mellitus. The examiner stated that the onset of the Veteran’s diabetes was unclear. Reference was made to the Veteran’s report that he was diagnosed with diabetes in 1978 and was treated with diet until 2006. It was noted that in approximately 2004 he had been hospitalized and treated with insulin and had been on insulin since 2006. A May 2014 kidney conditions disability benefits questionnaire (DBQ) provided by A.C., M.D., included a diagnosis of type II diabetes mellitus. It was noted that the Veteran had diabetes since he was in his 40’s. A June 2014 private medical statement from L.R., M.D., noted the Veteran had a long history of diabetes. In an October 2016 Dr. A.C. signed a statement with the Veteran and his spouse, a nurse, indicating a nexus between his diabetes and hypertension and chronic kidney disease. A March 2017 VA examination found the full diagnostic criteria for a specific phobia (acrophobia) were not met. It was noted the Veteran continued to experience symptoms of PTSD which was his primary diagnosis. An April 2017 VA examination included a diagnosis of type II diabetes mellitus, but found it was less likely it was incurred during active service or was caused/aggravated by a service-connected disability. The rationale for the opinion noted that service treatment records were negative for a diagnosis of diabetes during active service and that a glucose tolerance test at the time documented a normal glucose response. It was the examiner’s opinion that the normal response excluded a diagnosis of diabetes during service and that records showed the onset in 2010. The examiner further found that the Veteran’s service-connected eczema, migraines, CAD, PTSD, and hemorrhoids were not shown to have had any physiologic or causal association with the development or progression/aggravation of diabetes based on the current medical data. Nor were specific exposures during service in Southwest Asia associated with an increased risk for the development of type II diabetes mellitus. The examiner found the Veteran had diabetic peripheral neuropathy involving the lower extremities and feet, but that it too was less likely a direct, secondary, or aggravated condition as a result of service. Based upon the evidence of record, the Board finds chronic diabetes mellitus, foot neuropathy, and acrophobia disabilities were not manifest during active service. There is no indication that type II diabetes mellitus or right or left foot neuropathy were manifest within one year of the Veteran’s discharge from service and the preponderance of the evidence fails to establish that the present disorders at issue are etiologically related to service. The February 2014 and March 2017 VA medical opinions are found to be persuasive that a present diagnosis of acrophobia was not warranted. February 2014 and April 2017 VA opinions are also persuasive that the Veteran’s type II diabetes mellitus and diabetic neuropathy of the feet were not incurred during nor aggravated as a result of service, including as proximately due to a service-connected disability or service in Southwest Asia. In fact, the April 2017 examiner noted a normal glucose test response at the time of separation from service excluded a diagnosis of diabetes mellitus. The opinions are shown to have based upon a substantially correct review of the evidence of record and to have adequately considered the lay statements and reported symptom manifestations history of record. See Dalton v. Nicholson, 21 Vet. App. 23 (2007). To the extent private medical statements, including from the Veteran’s spouse, indicate a relationship between the diabetes mellitus and diabetic neuropathy disorders and service-connected disabilities, the Board finds the statements warrant a lesser degree of probative weight due to inconsistency with the other evidence of record. Statements as to a relationship rather than a more specific cause and effect nexus or as to a long history of diabetes are too vague to warrant any greater probative weight. Consideration must be given to the Veteran’s personal assertion that he has a present disability as a result of service. Lay persons are competent to provide opinions on some medical issues. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). The specific issues in this case, however, fall outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). The claimed disabilities at issues are not conditions that are readily amenable to lay diagnosis or probative comment regarding etiology. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). The Board acknowledges that the Veteran is competent to report observable symptoms, but there is no indication that he is competent to etiologically link any such symptoms to a current diagnosis. He is not shown to possess the requisite medical training, expertise, or credentials needed to render a diagnosis or a competent opinion as to medical causation. Nothing in the record demonstrates that he received any special training or acquired any medical expertise in as to such disorders. See King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012). Accordingly, the lay evidence does not constitute competent medical evidence and lacks probative value. When all the evidence is assembled VA is then responsible for determining whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a preponderance of the evidence is against the claim in which case the claim is denied. Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001). The preponderance of the evidence in this case is against the Veteran’s type II diabetes mellitus, right and left foot neuropathy, and acrophobia claims. Effective Date 6. Entitlement to an effective date earlier than March 7, 2013, for the award of a 100 percent rating for coronary artery disease. 7. Entitlement to an effective date earlier than March 7, 2013, for the award of special monthly compensation. VA regulations provide that the terms claim and application mean a formal or informal communication in writing requesting a determination of entitlement or evidencing a belief in entitlement to a benefit. 38 C.F.R. § 3.1(p) (effective prior to March 24, 2015). Generally, the date of receipt of a claim is the date on which a claim, information, or evidence is received by VA. 38 C.F.R. § 3.1(r) (2018). A sympathetic reading as to all potential claims raised by the evidence is required. Szemraj v. Principi, 357 F.3d 1370, 1373 (Fed. Cir. 2004). The Board, however, is not required to conjure up issues that were not raised by an appellant. See Brannon v. West, 12 Vet. App. 32 (1998). A VA failure of a duty to assist a veteran or even the existence of grave procedural error do not render a VA decision non-final. See Cook v. Principi, 318 F.3d 1334, 1348 (Fed. Cir. 2002). VA law provides that the effective date for an award of disability compensation for an original claim shall be the date of receipt of the claim, or the date entitlement arose, whichever is later, unless the claim is received within one year of separation from service. 38 U.S.C. § 5110(a) (2012); 38 C.F.R. § 3.400(b)(2) (2018). The Veteran contends that effective dates earlier than March 7, 2013, are warranted for the awards of a 100 percent rating for CAD and for special monthly compensation. He asserts that he had submitted an increased rating claim at a VA hospital in Detroit, Michigan, in 2000, but that it had been lost. The pertinent evidence shows service connection including for first degree atrioventricular (AV) block was established in a January 1995 rating decision. A 0 percent rating was assigned. The Veteran’s combined service-connected disability was 10 percent from November 1, 1994. In correspondence dated in January 2009, the Veteran requested an increase in his service-connected migraine headache disability. He also referred to having filed his original claim in 1994, but made no reference to having submitted an earlier increased rating claim. That matter was addressed in an unappealed April 2009 rating decision. VA records show that on March 7, 2013, the Veteran’s claims, including for an increased rating for first degree AV block, was received. A March 2014 rating decision granted an increased 100 percent rating effective for CAD including atherosclerotic cardiovascular disease, myocardial infarction, heart block, percutaneous coronary intervention, and congestive heart failure with stents (previously first-degree AV block). Special monthly compensation was awarded effective from March 7, 2013, under 38 U.S.C. 1114(s) based upon the award of a 100 percent rating and additional service-connected disability independently ratable at 60 percent or more. A February 2015 rating decision awarded special monthly compensation effective from March 7, 2013, under 38 U.S.C. 1114(l) based upon the need for regular aid and attendance. Based upon the evidence of record, the Board finds no basis for effective dates earlier than March 7, 2013, for the awards of a 100 percent rating for CAD or for special monthly compensation. There is no probative evidence that an unresolved claim was received by VA pertinent to these matters prior to March 7, 2013. Appropriate assistance was provided to obtain all sufficiently identified records. The statements of the Veteran and his spouse as to his having submitted an increased rating claim to a VA hospital in Detroit are found to be inconsistent with the overall evidence of record and with the Veteran’s own statements in correspondence received by VA in January 2009. Therefore, the appeal for earlier effective dates must be denied. 8. Entitlement to automotive and adaptive equipment or for adaptive equipment only. VA laws provide for financial assistance in the purchase of one automobile or other conveyance or entitled to necessary adaptive equipment for a Veteran with a service-connected disability that results in loss or permanent loss of use of one or both feet; loss or permanent loss of use of one or both hands; permanent impairment of vision of both eyes; severe burn injury; or amyotrophic lateral sclerosis. 38 U.S.C.A. § 3902(a) (2012); 38 C.F.R. § 3.808 (2018). For adaptive equipment eligibility only, a showing of ankylosis of one or both knees or one or both hips is sufficient. 38 C.F.R. § 3.808(b)(6). The provisions of Title 38, Chapter 39, provide that for automobiles and adaptive equipment an eligible person is a Veteran with a service-connected disability that includes one of the following: loss or permanent loss of use of one or both feet; or loss or permanent loss of use of one or both hands; permanent impairment of vision of both eyes to the required specified degree; or a severe burn injury. 38 U.S.C. § 3901(1)(A) (2012). The term “adaptive equipment” includes, but is not limited to, power steering, power brakes, power window lifts, power seats, and special equipment necessary to assist the eligible person into and out of the automobile or other conveyance. Such term also includes (A) air-conditioning equipment when such equipment is necessary to the health and safety of the veteran and to the safety of others, regardless of whether the automobile or other conveyance is to be operated by the eligible person or is to be operated for such person by another person; and (B) any modification of the size of the interior space of the automobile or other conveyance if needed because of the physical condition of such person in order for such person to enter or operate the vehicle. 38 U.S.C. § 3901(2). A loss of use of a hand or a foot will be held to exist when no effective function remains other than that which would be equally well served by an amputation stump at the site of election below knee with use of a suitable prosthetic appliance. The determination will be made on the basis of the actual remaining function, whether the acts of balance, propulsion, etc., could be accomplished equally well by an amputation stump prosthesis. 38 C.F.R. §§ 3.350 (a)(2)(i), 4.63 (2018). The Veteran contends that eligibility for automotive and/or specially adapted equipment is warranted based upon permanent loss of use of his lower extremities due to severe neuropathy. In statements and testimony provided in support of the claim the Veteran and his spouse asserted that he was unable to exert himself due to systemic problems associated with his service-connected heart disabilities. VA records show service connection is established for CAD including atherosclerotic cardiovascular disease, myocardial infarction, heart block, percutaneous coronary intervention, and congestive heart failure with stents (100 percent), chronic kidney disease to include end stage renal disease associated with hypertension (100 percent), PTSD with major depressive disorder (70 percent), pseudofolliculitis barbae (30 percent), migraine including migraine variants (30 percent), gout arthritis (20 percent), hemorrhoids/polyp (10 percent), and hypertension (0 percent). The Board also notes that service connection is established in this decision for obstructive sleep apnea. An August 2013 VA examination for housebound status or permanent need for regular aid and attendance noted diagnoses of end stage renal disease, neuropathy, hypertension, CAD, and diabetes mellitus. The examiner noted the Veteran walked with an antalgic gait, that he was not legally blind, and that bilateral feet and ankle pain limited ambulation. He was able to leave home as needed, but required an aid for locomotion less than one block. VA heart conditions examination in February 2014 included diagnoses of myocardial infarction, atherosclerotic cardiovascular disease, CAD, congestive heart failure, heart block, and percutaneous coronary intervention. It was noted the heart conditions resulted in a functional impact and that the Veteran was only capable of sedentary activity. A February 2014 kidney disorders examination included diagnoses of diabetic nephropathy, peritoneal dialysis, and end stage renal failure. The examiner found the Veteran’s kidney conditions resulted in a functional impact due to chronic fatigue and lack of energy that made it impossible for him to be gainfully employed. VA treatment records show the Veteran was provided a power scooter in March 2015. It was noted that upon review he appeared to meet VA medical criteria for power mobility secondary to musculoskeletal issues with documented degenerative joint disease to the knees and left shoulder. It was noted that he had unconfirmed significant cardiac issues. There was also documentation of diabetes with polyneuropathy to the lower extremities. VA examination in April 2017 included a diagnosis of gout and noted the Veteran reported symptom flare-ups about once per month. The examiner noted he experienced pain and tenderness to the bilateral knees, feet, and toes, but that there was no limitation of joint motion or joint deformities attributable to the condition. An April 2017 apnea examination found the Veteran’s sleep apnea had no impact on his ability to work. Based upon the available record, the persuasive evidence demonstrates that the Veteran’s service-connected disabilities do not result in loss or permanent loss of use of one or both feet; loss or permanent loss of use of one or both hands; permanent impairment of vision of both eyes; or ankylosis of one or both knees or one or both hips. The overall record does not demonstrate a permanent loss of use of a foot as a result of service-connected disability. Therefore, entitlement to automotive and/or specially adapted equipment only is not warranted. The preponderance of the evidence is against the claim. MICHAEL A. HERMAN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD T. Douglas, Counsel