Citation Nr: 20007435 Decision Date: 01/29/20 Archive Date: 01/29/20 DOCKET NO. 16-39 215 DATE: January 29, 2020 ORDER Service connection for a left shoulder disorder is denied. Service connection for a neck disorder is denied. Service connection for a back disorder is denied. Service connection for a bilateral hip disorder is denied. Service connection for a bilateral foot disorder is denied. Service connection for a bilateral knee disorder is denied. Service connection for an esophageal disorder, characterized as gastroesophageal reflux disease (GERD), is denied. Service connection for a bilateral ankle disorder is denied. Service connection for an acquired psychiatric disorder, characterized as posttraumatic-stress disorder (PTSD) is denied. Service connection for a heart disorder is denied. A total disability rating based on individual unemployability (TDIU) is denied. Special monthly compensation (SMC) based on a need for aid and attendance or on account of being housebound is denied. FINDINGS OF FACT 1. The Veteran’s left shoulder disorder was not shown in service or for many years thereafter, and is not otherwise related to active duty service. 2. The Veteran’s neck disorder was not shown in service or for many years thereafter, and is not otherwise related to active duty service. 3. The Veteran’s back disorder was not shown in service or for many years thereafter, and is not otherwise related to active duty service. 4. The Veteran’s bilateral hip disorder was not shown in service or for many years thereafter, and is not otherwise related to active duty service. 5. The Veteran’s bilateral foot disorder was not shown in service or for many years thereafter, and is not otherwise related to active duty service. 6. The Veteran’s bilateral knee disorder was not shown in service or for many years thereafter, and is not otherwise related to active duty service. 7. The Veteran’s esophageal disorder, characterized as GERD, was not shown in service or for many years thereafter, and is not otherwise related to active duty service. 8. The Veteran does not have a current diagnosis of a bilateral ankle disorder for VA compensation purposes during the period on appeal. 9. The Veteran does not have a current diagnosis of a psychiatric disorder, to include PTSD, for VA compensation purposes during the period on appeal. 10. The Veteran does not have a current diagnosis of a heart disorder for VA compensation purposes during the period on appeal. 11. The Veteran’s service-connected right shoulder disability does not prevent him from obtaining and retaining substantially gainful employment. 12. The evidence does not demonstrate that the Veteran is housebound or in need of aid an attendance as a result of his service-connected right shoulder disability. CONCLUSIONS OF LAW 1. The criteria for service connection for a left shoulder disorder are not met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), 3.304, 3.307, 3.309. 2. The criteria for service connection for a neck disorder are not met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), 3.304, 3.307, 3.309. 3. The criteria for service connection for a back disorder are not met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), 3.304, 3.307, 3.309. 4. The criteria for service connection for a bilateral hip disorder are not met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), 3.304, 3.307, 3.309. 5. The criteria for service connection for a bilateral foot disorder are not met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), 3.304, 3.307, 3.309. 6. The criteria for service connection for a bilateral knee disorder are not met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), 3.304, 3.307, 3.309. 7. The criteria for service connection for an esophageal disorder, characterized as GERD, are not met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), 3.304, 3.307, 3.309. 8. The criteria for service connection for a bilateral ankle disorder are not met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), 3.304, 3.307, 3.309. 9. The criteria for service connection for an acquired psychiatric disorder, claimed as PTSD, are not met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), 3.304, 3.307, 3.309. 10. The criteria for service connection for a heart disorder are not met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), 3.304, 3.307, 3.309. 11. The criteria for entitlement to TDIU have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107(b); 38 C.F.R. §§ 3.340, 3.341, 4.16. 12. The criteria for entitlement to SMC based on housebound status or the need for aid and attendance as a result of service-connected disabilities have not been met. 38 U.S.C. §§ 1155, 1521(d), (e); 38 C.F.R. §§ 3.351, 3.352. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1965 to January 1966. In March 2018, the Board remanded the claims on appeal for additional development, to include obtaining a VA examination and all outstanding medical records. To the extent the appeal is being adjudicated, the Board is now satisfied there was substantial compliance with this Remand. See Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). Specifically, all relevant and available outstanding records have been obtained. Moreover, the Veteran was provided with VA examinations in October 2019, and the report is adequate for the purpose of rendering a decision on appeal. 38 C.F.R. § 4.2; Barr v. Nicholson, 21 Vet. App. 303 (2007). Accordingly, the Board finds that the remand directives were substantially complied with and, thus, there is no Stegall violation in this case. Service Connection 1. Entitlement to service connection for a left shoulder disorder 2. Entitlement to service connection for a neck disorder 3. Entitlement to service connection for a back disorder 4. Entitlement to service connection for a bilateral hip disorder 5. Entitlement to service connection for a bilateral foot disorder 6. Entitlement to service connection for a bilateral knee disorder 7. Entitlement to service connection for an esophageal disorder, characterized as GERD 8. Entitlement to service connection for a bilateral ankle disorder 9. Entitlement to service connection for an acquired psychiatric disorder, characterized as PTSD 10. Entitlement to service connection for a heart disorder The Veteran asserts that he has disorders relating to his left shoulder, neck, back, hips, knees, esophageal, ankles, psychiatric, and heart that are related to active service. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not etiologically related to, including aggravated by, an in-service injury, event, or disease. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. §§ 3.303(a), (d), 3.304, 3.307, 3.309. As a preliminary matter, the Board concludes that the Veteran does not have a current diagnosis of a psychiatric, bilateral ankle, and heart disorder, and has not had one of these disorders at any time during the pendency of the claim or recent to the filing of the claim. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); 38 C.F.R. § 3.303(a), (d). Specifically, the Board finds that after a thorough reading of the evidence of record, including the VA treatment records from June 2019, the record does not reflect a current diagnosis related to a psychiatric disorder at any time during the period on appeal. In this case, in order to clarify whether the Veteran has a psychiatric disorder, the October 2019 VA examiner opined that while the Veteran endorsed some psychiatric symptoms, including anxiety, based on the examination and records review, the Veteran’s symptoms did not meet full diagnostic criteria for a mental disorder. In arriving at this conclusion, the Board specifically acknowledges that the Veteran’s private internist indicated in July 2015 and November 2018, that he has a diagnosis of generalized anxiety disorder and major depression. However, as an initial matter, as discussed by the October 2019 VA examiner, the Veteran’s private internist’s field of expertise is outside the realm of psychiatry. As such, greater probative value is placed on the conclusions of the VA examiner’s determination that a diagnosis for a psychiatric disorder, including anxiety and depression is not warranted. Indeed, the United States Court of Appeals for the Federal Circuit (Federal Circuit) has recognized the unique probative value of opinions provided by VA psychiatric examiners in the context of VA examinations for a number of reasons, to include the special training VA practitioners receive in conducting such examinations, the amount of quality review these examination reports receive, the ability to review the claims file, and VA programs to ensure consistency. See Nat’l Org. of Veterans’ Advocates, Inc. v. Sec. Of Veterans Affairs, 669 F.3d 1340 (Fed. Cir. 2012) (citing 75 Fed. Reg. 39,843, 39,847-48 (July 13, 2010)). With respect to a heart and bilateral ankle disorder, the VA treatment records, including from June 2019, do not reflect any complaints, signs, symptoms, and/or a diagnosis related to a heart and/or ankle disorder during the period on appeal. Further, the October 2019 VA examiners specifically opined that the Veteran did not have a current diagnosis related to a heart and bilateral ankle disorder. Additionally, to the extent the Veteran’s July 2015 and November 2018 private opinions reflect that he has a heart and bilateral ankle disorder, the Board finds these opinions to be less probative given that the opinions are not adequately supported considering that the overwhelming medial evidence does not reflect a diagnosis. The Board acknowledges the Veteran’s assertions and belief that he has a psychiatric and heart disorder. However, he is not competent to provide a diagnosis in this case. These issues are medically complex and require specialized medical education and knowledge of the interaction between multiple systems in the body, as well as the ability to interpret complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Further, to the extent the Veteran is competent to reports symptoms such as feelings of depression and anxiety, as well as heart symptoms, the medical evidence is not sufficient to demonstrate a diagnosed disability for VA purposes - especially in light of the fact that the Veteran has not received treatment for these disorders but has received treatment for other disorders. See Kahana v. Shinseki, 24 Vet. App. 428, at 439-40 (2014) (The Board may weigh silence in a medical record against lay testimony if the alleged injury, disease, or related symptoms would ordinarily have been recorded in the medical record being evaluated). Moreover, to the extent the Veteran is competent to report pain, weakness, and limitation of motion, the Board acknowledges the holding in the United States Court of Appeals for the Federal Circuit in Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018), which holds that pain under limited circumstances can constitute a “disability” under 38 U.S.C. § 1110. However, the Board observes that to the extent the Veteran is experiencing bilateral ankle pain and related symptomology, there is not sufficient evidence that these symptoms cause any functional limitation. Specifically, the October 2019 VA examination is not sufficient to demonstrate actual ankle functional limitation. As such, the preponderance of the evidence is against a finding that the Veteran has a psychiatric, bilateral ankle and/or a heart disorder at any point during the time on appeal. See 38 U.S.C. § 1110; Rabideau v. Derwinski, 2 Vet. App. 141 (1992). Regarding a left shoulder, bilateral knee, bilateral hip, bilateral foot, esophageal, back, and neck disorder, after a review of the evidence, the Board concludes that although the Veteran has a current diagnosis of these disorders, the preponderance of the evidence weighs against finding that these disorders began during service or are otherwise etiologically related to an in-service injury, event, or disease. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. §§ 3.303(a), (d), 3.304, 3.307, 3.309. Specifically, the Veteran’s service treatment records are silent for any complaints, symptoms, or a diagnosis related to these disorders. Next, while the post-service medical evidence includes the Veteran’s report of symptoms since service, the objective medical evidence does not reflect symptoms of GERD until 2004, and symptoms of a bilateral foot, left shoulder, neck, bilateral hip, bilateral knee, and back disorder until May 2015. Therefore, continuity of symptoms has not been shown based on the clinical evidence, to include the chronic disease presumption under 38 C.F.R. § 3.307(a)(3). The Board recognizes the statements from the Veteran regarding his history of symptoms since service. While the Veteran is competent to report that he experienced symptoms such as pain, limitation of motion, numbness, and weakness since service, he is not competent to provide a diagnosis in this case or determine that these symptoms were manifestations of a particular disorder. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Nevertheless, to the extent the Veteran asserts that his disorders have persisted since service, the Board determines that the Veteran’s reported history of continued symptoms while competent, is nonetheless not sufficient to establish a relationship between his complaints and active service. See Caluza v. Brown, 7 Vet. App. 498 (1995). As an initial matter, the large gap in treatment for his disorders weighs against the Veteran’s claim especially in light of the fact that the Veteran has received treatment for other disorders during service and thereafter. See Kahana v. Shinseki, 24 Vet. App. 428, at 439-40 (2014) (The Board may weigh silence in a medical record against lay testimony if the alleged injury, disease, or related symptoms would ordinarily have been recorded in the medical record being evaluated). Further, the Veteran’s statements at this February 2015 VA examination are inconsistent with his reports of continuous symptoms since service. Moreover, the Board notes that the Veteran filed a claim for other VA benefits prior to filing his claim on appeal. Therefore, the fact that the Veteran was aware of the VA benefits system and sought out a claim for other benefits, but made no reference to the disorders he now claims, weighs heavily against his credibility. Therefore, the Veteran’s statements alone regarding continuity of symptoms since service are not sufficient to establish a relationship between his complaints and his current disorders. Although the Veteran is not competent to diagnosis and provide etiological opinions related to the disorders on appeal, service connection may nonetheless be established if a relationship is otherwise demonstrated by competent evidence, including medical evidence and opinions. Here, the competent evidence fails to establish a relationship between active duty and the Veteran’s current symptoms. In this regard, the Board places significant probative value on the opinions from the October 2019 VA examiner that performed a comprehensive physical examination and detailed review of the Veteran’s service and medical treatment records. Specifically, the examiner determined that the Veteran’s neck and bilateral knee disorder were related to the natural aging process, and as such they were not related to any in-service event or injury. Next, the examiner observed that the Veteran did not have any injuries to, and/or complaints, related to his back, feet, and esophageus during service, and did not have any symptoms or complaints related thereto until several years after service. Moreover, while the Veteran did have in-service complaints of a left shoulder disorder, the evidence of record, including the Veteran’s statements, does not reflect evidence of this disorder until 2015. Thus, to the extent that the Veteran asserts that he had GERD, as well as pain in his left shoulder, back, and feet that was not reported in the medical records, the Board (for the reasons previously discussed) does not find these statements to be credible. Regarding his left shoulder disorder, the Board also notes that the March 2016 VA examiner determined that his disorder was not related to service (based on the aforementioned) and was not aggravated by his service-connected right shoulder disorder. Additionally, the Board acknowledges the Veteran’s May 2015 and November 2018 private opinions that indicate these disorders are all related to service. However, the Board finds that these opinions are purely conclusory and are not supported by an adequate rationale. Therefore, the Board places more probative value on the well-reasoned and adequately supported opinions from the February 2015 and October 2019 VA examiners. Lastly, as part of this claim, the Board recognizes the statements from the Veteran, regarding the relationship between his disorders and active service. Nevertheless, while he is competent to provide testimony regarding observable symptomatology, he is not competent to provide a nexus opinion in this case. As discussed, these issues are medically complex, as it requires knowledge of the interaction between multiple systems in the body and interpretation of complicated diagnostic medical testing. Jandreau, 492 F.3d at 1377 n.4. Therefore, the unsubstantiated statements regarding the claimed diagnosis and etiology of the Veteran’s disorders are found to lack competency. In light of the above discussion, the Board concludes that the preponderance of the evidence is against the claims for service connection, and there is no doubt to be otherwise resolved. 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Therefore, the claims are denied. TDIU The Veteran asserts that he is unable to work because of his service-connected right shoulder disability. Total disability is considered to exist when there is any impairment which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340 (a)(1). The Board must consider if the Veteran can obtain employment more than marginal income (outside of a protected environment) as determined by the U.S. Department of Commerce to be the poverty threshold for one person. See Ray v. Wilkie, 31 Vet. App. 58 (2019). Further, the Board should also consider whether given the Veteran’s history, education, skill, and training, in conjunction with the Veteran’s physical ability and mental ability, can perform the type of activities required by the occupation at issue. See Id. Moreover, the Board must evaluate whether there are circumstances in the Veteran’s case, apart from any non-service-connected conditions and advancing age, which would justify TDIU. 38 C.F.R. §§ 3.341(a), 4.19; See Van Hoose v. Brown, 4 Vet. App. 361 (1993); see also Hodges v. Brown, 5 Vet. App. 375 (1993); Blackburn v. Brown, 4 Vet. App. 395 (1993). The Veteran’s service-connected disabilities, employment history, educational and vocational attainment, and all other factors having a bearing on the issue must be addressed. 38 C.F.R. § 4.16 (b). If a Veteran fails to meet the threshold minimum percentage standards enunciated in 38 C.F.R. § 4.16(a), rating boards should refer to the Director of Compensation and Pension Service for extra-schedular consideration all cases where the Veteran is unable to secure or follow a substantially gainful occupation by reason of service-connected disability. 38 C.F.R. § 4.16(b). See also Fanning v. Brown, 4 Vet. App. 225 (1993). After a review of the evidence of record, the Board determines that TDIU is not warranted. As an initial matter, the Veteran did not meet the schedular criteria for any part of the period on appeal. Specifically, his single service-connected right shoulder disability has been assigned a 20 percent rating. Next the Board finds that referral for extraschedular consideration is not warranted as the Veteran’s service-connected right shoulder disability did not prevent him from being able to secure or follow a substantially gainful occupation. See 38 C.F.R. § 4.16(b). Specifically, at a February 2015 and October 2019 VA examination, the Veteran reported serve pain (up to 8/10) that prevented him from performing overhead activities. Nevertheless, after a detailed examination and comprehensive testing, both examiners determined that his right shoulder disability did not impact his ability to perform occupation tasks such as standing, walking, lifting, sitting, etc. As such, there was no indication that his right shoulder disability would preclude physical or sedentary employment. Moreover, the Veteran’s VA treatment records also do not reflect impairment from his service-connected disability that would prevent him from obtaining and retaining substantially gainful employment. The Board also notes that the Veteran has a high school education and worked as a chemical operator for a pharmaceutical company for 26 years and stated at his October 2019 VA psychiatric examination that he retired because the company closed down. As such, given that his right shoulder disability does not preclude employment at the physical or sedentary level, the Board finds that the Veteran is able to obtain and maintain substantial gainful activity, including his previous job duties, despite some physical limitations. In arriving at this conclusion, the Board acknowledges the evidence in support TDIU, which includes the Veteran’s statements and his May 2015 and November 2018 private opinions. However, the Board finds his statements less probative as the medical evidence, as discussed, indicates that he is able to perform his previous job duties. Further, to the extent the Veteran’s private physician opined that he is unable to work, the Board finds that these opinions are wholly conclusory and not adequately supported. Moreover, his treating physician also indicated that his unemployability was related to nonservice-connected disorders. As such, the Board assigns more probative weight to the medical evidence which indicates that the Veteran’s service-connected disability does not prevent him from obtaining and retaining substantial gainful employment. Additionally, the Board also finds that the clinical evidence is sufficient for the Board to make its own conclusions as well. Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013) (applicable regulations place responsibility for the ultimate TDIU determination on the VA, not a medical examiner). In this regard, the Board also notes that, despite the Veteran’s contentions, shoulder impairment alone does not generally preclude substantial gainful employment. Therefore, the weight of the evidence is against the Veteran’s TDIU claim. As such, the Veteran’s TDIU claim is denied. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). SMC The Veteran asserts that he is entitled to SMC based on housebound status or the need for aid and attendance. In addition to any benefits already received, a veteran may also be entitled to SMC benefits where there is an established need for regular aid and attendance. 38 U.S.C. § 1114(l); 38 C.F.R. § 3.350(b)(3). Requiring aid and attendance means that a person is helplessness or so nearly helpless as to require the regular aid and attendance of another person. A veteran will be considered to be in need of regular aid and attendance if by reason of his service-connected disabilities he (1) is blind or so nearly blind as to have corrected visual acuity of 5/200 or less in both eyes, or concentric contraction of the visual field to 5 degrees or less; (2) is a patient in a nursing home because of mental or physical incapacity; or (3) establishes a factual need for aid and attendance under 38 C.F.R. § 3.352(a). See also 38 C.F.R. § 3.351(b), (c). The criteria to be considered in establishing a factual need for aid and attendance include: • The inability of a claimant to dress or undress himself, or to keep himself ordinarily clean and presentable; • Frequent need of adjustment of any special prosthetic or orthopedic appliances which by reason of the particular disability cannot be done without aid (this will not include the adjustment of appliances which normal persons would be unable to adjust without aid, such as supports, belts, lacing at the back, etc.); • Inability of claimant to feed himself through loss of coordination of upper extremities or through extreme weakness; • Inability to attend to the wants of nature; or, • Incapacity, physical or mental, which requires care or assistance on a regular basis to protect the claimant from hazards or dangers incident to his daily environment. See 38 C.F.R. § 3.352(a). Being bedridden is a proper basis for the determination. “Bedridden” is that condition which, through its essential character, actually requires that the claimant remain in bed. The fact that a claimant has voluntarily taken to bed or that a physician has prescribed rest in bed for the greater or lesser part of the day to promote convalescence or cure will not suffice. 38 C.F.R. § 3.352(a). It is not required that all of the disabling conditions enumerated be found to exist before a favorable rating may be made. Moreover, it is only necessary that the evidence establish that the claimant is so helpless as to need regular aid and attendance, not that there be a constant need. Determinations that a claimant is so helpless, as to be in need of regular aid and attendance will not be based solely upon an opinion that the claimant’s condition is such as would require him or her to be in bed. They must be based on the actual requirement of personal assistance from others. Id. In this case, after a detailed review of the evidence, the Board determines that SMC is not warranted based on the need for aid and attendance. As an initial matter, the evidence does not indicate, and the Veteran does not assert that he was blind, or was admitted to a skilled nursing home. The evidence also does not demonstrate a factual need for aid and attendance under 38 C.F.R. § 3.352(a). Specifically, after a detailed and comprehensive review of the record, the medical evidence including the Veteran’s May 2015 and November 2018 private evaluations, as well as the February 2015 (with the corresponding March 2016 addendum) and October 2019 VA examinations reflect that although the Veteran had significant issues with his service-connected right shoulder disorder, his physical issues where predominately related to his chronic nonservice-connected disorders relating to his back, neck, ankles, hips, feet, GERD, elbows, wrists, and hearing which all caused significant muscle weakness, limitation of motion, and ambulatory impairment. As previously discussed, the February 2015 and October 2019 VA examiners opined that the Veteran’s service-connected right shoulder disability did not cause significant impairment with his activities of daily living or ability to work. In arriving at this conclusion, the Board acknowledges that the appellant submitted numerous opinions from the Veteran’s medical providers, including from May 2015 and November 2018, which indicate that the Veteran required aid and attendance due to his medical conditions. Nevertheless, as discussed, his primary functional impairments were related to nonservice-connected disabilities, and to the extent they were related to his service-connected right shoulder disability, these opinions were very general and did not separately address or discuss if he required assistance solely because of his service-connected disabilities. As such, these opinions are less probative. Although the Board acknowledges the Veteran’s statements that he experienced limitations from his service-connected right shoulder disability, the evidence does not indicate that it causes significant inference with his daily activities, such as his ability to feed, dress, and take care of his finances, which would require the need for regular aid and attendance of another person. Instead, as discussed, the medical evidence indicates that the most significant problems are a result of his nonservice-connected disorders. Moreover, the evidence also does not indicate that assistance is required to protect him from the hazards and dangers of his daily environment as a result of his service-connected disabilities. Therefore, a factual need for aid and attendance has not been established. Lastly, if not in need of regular aid and attendance, a veteran may also be entitled to special monthly compensation for housebound benefits if, in addition to having a single permanent disability rated 100 percent disabling under the VA Schedule for Rating Disabilities (not including ratings based upon unemployability under 38 C.F.R. § 4.17 of this chapter), the Veteran either: • Has an additional disability or disabilities independently ratable at 60 percent or more, separate and distinct from the permanent disability rated as 100 percent disabling and involving different anatomical segments or bodily systems; or, • Is “permanently housebound” by reason of disability or disabilities. This requirement is met when the Veteran is substantially confined to his or her dwelling and the immediate premises or, if institutionalized, to the ward or clinical area, and it is reasonably certain that the disability or disabilities and resultant confinement will continue throughout his or her lifetime. See 38 U.S.C. § 1114(s); 38 C.F.R. § 3.350(i). Although the total disability requirement must be met by a single disability, the 60 percent requirement may be met by applying the combined rating of the Veteran’s remaining disabilities. See Bradley v. Peake, 22 Vet. App. 280 (2008) (noting that combined ratings to satisfy the second requirement but not the first). Moreover, in order to be considered “permanently housebound,” the requirement that the Veteran be “substantially confined” to the home or its immediate premises is broadly construed and met when the Veteran is simply unable to leave the home to earn a living, as opposed to requiring that the Veteran be unable to leave the house at all. 38 U.S.C. § 1114(s). Based upon the evidence of record, the Board determines that the requirements for SMC based on housebound status have not been met for any period on appeal. As an initial matter, the Veteran did not meet the schedular basis. Specifically, the Veteran was only assigned a single 20 percent disability rating. Therefore, SMC on a schedular basis is not warranted. Next, the evidence does not indicate that the Veteran is “permanently housebound” as a result of his service-connected right shoulder disability on a factual basis. As discussed, his service-connected shoulder disability does not interfere with his ability to travel outside his home. Instead, the Veteran’s physical limitations and housebound status were exclusively related to his nonservice-connected disabilities. Therefore, SMC is also not warranted on this basis. The Board has also considered the statements from the Veteran, regarding the severity of his symptoms as to warrant SMC for aid and attendance or based on housebound status. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Although the Veteran is competent to report symptoms because this requires only personal knowledge as it comes to him through his senses, he is not competent to identify a specific level of disability of his service-connected disability or render an opinion as to their effect on his activities of daily living. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (“although interest may affect the credibility of testimony, it does not affect competency to testify”). (Continued on the next page)   On the other hand, such competent evidence concerning the nature and extent of the Veteran’s service-connected disability and his ability to live independently has been provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the examination reports) directly address the criteria under which these disabilities are evaluated. Therefore, the Board finds that the medical evidence, which directly address the criteria under which SMC is evaluated, more probative than the assessments from the Veteran. In conclusion, the evidence does not support the claim for SMC by reason of the need for regular aid and attendance of another person or by reason of being housebound. The Board finds that equipoise is not shown, and the benefit of the doubt rule does not apply. As the weight of the evidence is against his claim, the appeal is denied. M. Pryce Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Meyer, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.