Citation Nr: 20008340 Decision Date: 01/31/20 Archive Date: 01/31/20 DOCKET NO. 19-12 400A DATE: January 31, 2020 ORDER Entitlement to special monthly compensation based on aid and attendance is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from October 1968 until his honorable discharge in September 1970. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a March 2018 rating decision by the Regional Office (RO) of the United States Department of Veterans Affairs (VA). 1. Entitlement to special monthly compensation based on aid and attendance is remanded. The Veteran alleges that special monthly compensation based on aid and attendance is warranted due to the severity of his disabilities. Specifically, he alleges that his posttraumatic stress disorder (PTSD) has caused memory issues and resulted in him getting lost and leaving the stove on. He has also stated that his wife handles his medications and that he no longer leaves the house unaccompanied. With regards to his peripheral neuropathy, the Veteran’s wife has stated that she walks behind him to ensure that he does not fall, that she helps him shave and dress because his legs are too weak and unsteady and that she helps him shower and use the toilet due to the weakness in his legs. She also stated that the Veteran falls two to three times per month due to his leg weakness. The Veteran has been submitted three examination reports, to include in May 2015, November 2017 and February 2019, as to whether he required regular aid and attendance. A May 2015 examination report found that the Veteran required assistance in bathing and other hygiene needs due to the limited use of arms and legs. A November 2017 examination report from a VA physician determined that the Veteran required assistance in bathing due to his risk of falls and that he was able to ambulate using a power scooter. A February 2019 examination report from a VA physician determined that the Veteran was unable to prepare his own meals and that he was unable to ambulate more than two blocks using a roller. However, these examination reports all considered disabilities for which service connection has not been granted. Moreover, none of the examination reports considered the Veteran’s allegations regarding the impact of his PTSD and peripheral neuropathy. Given the foregoing, the examination reports of record provide an insufficient basis upon which to adjudicate the claim, and an examination is necessary. Finally, while on remand, the Veteran should be given an opportunity to identify any records relevant to the claim on appeal that have not been obtained. Given the time that will elapse on remand, updated VA treatment records should also be obtained. Thereafter, all identified records should be obtained. Accordingly, the case is REMANDED for the following action: 1. The Veteran should be given an opportunity to identify any outstanding private or VA treatment records relevant to the claim on appeal, to include VA treatment records dated November 2019 to the present. After obtaining any necessary authorization from the Veteran, all outstanding records should be obtained. For private treatment records, make at least two (2) attempts to obtain records from any identified sources. If any such records are unavailable, inform the Veteran and afford him an opportunity to submit any copies in his possession. For federal records, all reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 2. Forward the Veteran’s claims file to an appropriate medical professional for an opinion. The record, to include a copy of this Remand, should be made available to, and be reviewed by, the examiner. The need for an additional examination of the Veteran is left to the discretion of the clinician selected to render the opinion. Following a review of all the relevant evidence, the examiner should address the following inquiries. In offering such opinions, the examiner is advised that the Veteran is service-connected for posttraumatic stress disorder (PTSD), coronary atherosclerosis and angina pectoris, diabetes mellitus type II with erectile dysfunction, a duodenal ulcer and right and left lower extremity peripheral neuropathy associated with diabetes mellitus. The examiner should respond to the following questions: (A) Is it at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran’s service-connected disabilities alone render him to be in the need of the regular aid and attendance of another person? The examiner should address the contentions of the Veteran that his poor memory associated with his PTSD has resulted in him getting lost and that he has left the stove on in his home. The examiner should also address the contention of the Veteran that his right and left lower extremity peripheral neuropathy has resulted in poor balance and falls. (B) Is it at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran’s service-connected disabilities alone result in: (1) the loss or loss of use of both lower extremities such as to preclude locomotion without the aid of braces, crutches, canes, or a wheelchair; or (2) 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 or propulsion as to preclude locomotion without the aid of braces, crutches, canes, or a wheelchair. The examiner should specifically address the impact of Veteran’s right and left lower extremity peripheral neuropathy on his ability to ambulate. (Continued on the next page)   A rationale for any opinion offered should be provided. KRISTY L. ZADORA Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board G. Deemer, 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.