Citation Nr: 21063756 Decision Date: 10/15/21 Archive Date: 10/15/21 DOCKET NO. 17-17 167 DATE: October 15, 2021 ORDER 1. Entitlement to compensation under 38 U.S.C. § 1151 for methicillin-resistant staphylococcus aureus (MRSA) infection as a result of hip surgery at the Washington D.C. VA Medical Center (Washington VAMC) is denied. 2. Entitlement to service connection for a collapsed vein condition, to include as secondary to a MRSA infection as a result of hip surgery at the Washington VAMC, is denied. 3. Entitlement to service connection for immune system dysfunction, to include as secondary to a MRSA infection as a result of hip surgery at the Washington VAMC, is denied. 4. Entitlement to service connection for an acquired psychiatric disorder, to include as secondary to a MRSA infection as a result of hip surgery at the Washington VAMC, is denied. 5. Entitlement to service connection for diabetes is denied. 6. Entitlement to service connection for bilateral upper extremity diabetic neuropathy is denied. 7. Entitlement to service connection for erectile dysfunction is denied. 8. Entitlement to service connection for a lumbar spine disorder is denied. 9. Entitlement to service connection for a bilateral upper extremity disorder, other than the Veteran's service-connected bilateral shoulder disabilities, is denied. 10. Entitlement to service connection for a cervical spine disorder is denied. 11. Entitlement to service connection for a bilateral hand disorder is denied. 12. Entitlement to service connection for a right hip disorder is denied. 13. Entitlement to service connection for a left hip disorder is denied. 14. Entitlement to service connection for a left hip scar, to include as secondary to a left hip disorder, is denied. 15. Entitlement to a rating in excess of 20 percent for a right shoulder disability is denied. 16. Special monthly compensation based on the need for aid and attendance or based on being housebound (SMC) is denied. 17. From December 16, 2013, a total disability rating based on individual unemployability as a result of service-connected disabilities (TDIU) is granted. FINDINGS OF FACT 1. The preponderance of the evidence is against a finding that the Veteran's pre-existing MRSA infection was caused or became worse due to VA treatment or that an additional disability resulted from carelessness, negligence, lack of skill, or similar incidence of fault on the part of the attending VA personnel. 2. The preponderance of the evidence is against a finding that any collapsed vein condition, immune system dysfunction, or acquired psychiatric disorder is due to or the result of the Veteran's active service or was caused or aggravated by a service-connected disability. 3. The preponderance of the evidence is against a finding that diabetes, bilateral upper extremity diabetic neuropathy, erectile dysfunction, a lumbar spine disorder, a bilateral upper extremity disorder (other than the Veteran's service-connected bilateral shoulder disabilities), a cervical spine disorder, a bilateral hand disorder, or a bilateral hip disorder is etiologically related to the Veteran's active service. 4. The preponderance of the evidence is against a finding that any left hip scar is due to or the result of the Veteran's active service or was caused or aggravated by a service-connected disability. 5. The Veteran's right (minor) shoulder disability is manifested by painful and limited motion, but is not shown to have been manifested by motion limited to 25 degrees from the side, ankylosis, a humerus impairment, or a clavicle or scapula impairment. 6. The Veteran's service-connected disabilities have not caused the anatomical loss or loss of use of both feet or one hand and one foot, caused the Veteran to be blind in both eyes, or rendered him permanently bedridden or so helpless as to be in need of regular aid and attendance. 7. On December 16, 2013, the Veteran's increased rating claim was received, and his service-connected disabilities are shown to preclude him from obtaining or maintaining substantially gainful employment as of that date. CONCLUSIONS OF LAW 1. The criteria for establishing entitlement to compensation under 38 U.S.C. § 1151 for a MRSA infection as a result of VA surgical treatment at the Washington VAMC have not been met. 38 U.S.C. §§ 1151, 5107; 38 C.F.R. §§ 3.102, 3.361, 17.32. 2. Service connection for a collapsed vein condition is not warranted. 38 U.S.C. § 1131; 38 C.F.R. §§ 3.303, 3.304, 3.310. 3. Service connection for immune system dysfunction is not warranted. 38 U.S.C. § 1131; 38 C.F.R. §§ 3.303, 3.304, 3.310. 4. Service connection for an acquired psychiatric disorder is not warranted. 38 U.S.C. § 1131; 38 C.F.R. §§ 3.303, 3.304, 3.310. 5. Service connection for diabetes is not warranted. 38 U.S.C. § 1131; 38 C.F.R. §§ 3.303, 3.304. 6. Service connection for bilateral upper extremity diabetic neuropathy is not warranted. 38 U.S.C. § 1131; 38 C.F.R. §§ 3.303, 3.304. 7. Service connection for erectile dysfunction is not warranted. 38 U.S.C. § 1131; 38 C.F.R. §§ 3.303, 3.304. 8. Service connection for a lumbar spine disorder is not warranted. 38 U.S.C. § 1131; 38 C.F.R. §§ 3.303, 3.304. 9. Service connection for a bilateral upper extremity disorder (other than the Veteran's service-connected bilateral shoulder disabilities) is not warranted. 38 U.S.C. § 1131; 38 C.F.R. §§ 3.303, 3.304. 10. Service connection for a cervical spine disorder is not warranted. 38 U.S.C. § 1131; 38 C.F.R. §§ 3.303, 3.304. 11. Service connection for a bilateral hand disorder is not warranted. 38 U.S.C. § 1131; 38 C.F.R. §§ 3.303, 3.304. 12. Service connection for a right hip disorder is not warranted. 38 U.S.C. § 1131; 38 C.F.R. §§ 3.303, 3.304. 13. Service connection for a left hip disorder is not warranted. 38 U.S.C. § 1131; 38 C.F.R. §§ 3.303, 3.304. 14. Service connection for a left hip scar is not warranted. 38 U.S.C. § 1131; 38 C.F.R. §§ 3.303, 3.304, 3.310. 15. A rating in excess of 20 percent for a right shoulder disability is not warranted. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.71a, Diagnostic Codes (Code) 5003, 5010, 5200-03. 16. The criteria for SMC have not been met. 38 U.S.C. §§ 1114, 5107; 38 C.F.R. §§ 3.350, 3.352. 17. From December 16, 2013, the criteria for a TDIU have been met. 38 U.S.C. §§ 5101, 5110; 38 C.F.R. §§ 3.340, 3.341, 3.400, 4.15, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The appellant is a Veteran who had active service from February 1984 to November 1986. This case is before the Board of Veterans' Appeals (Board) on appeal from multiple Department of Veterans Affairs (VA) rating decisions. A March 2013 rating decision denied service connection for a bilateral hip disorder, a bilateral hand disorder, a cervical spine disorder, a bilateral upper extremity disorder, and a lumbar spine disorder. An October 2015 rating decision denied the 1151 claim, denied service connection for a collapsed vein condition, an immune system disorder, an acquired psychiatric disorder, a left hip scar, diabetes, bilateral upper extremity neuropathy, and erectile dysfunction, denied an increased rating for a right shoulder disability, and denied SMC. A February 2018 rating decision denied an increased rating for a right shoulder disability and denied a TDIU. A January 2020 rating decision granted a TDIU effective September 1, 2017. In February 2020 the matters were remanded for additional development. 1151 Eligibility The Veteran asserted that VA was negligent in performing hip surgery at the Washington VAMC. He reported that he was infected with MRSA between August 2006 and October 2006 when he was admitted for hip surgery and placed on a floor with other patients that had MRSA. He also reported that around June 2008 he was again placed in a room with a patient with MRSA. Under 38 U.S.C. § 1151, compensation shall be awarded for a qualifying additional disability or a qualifying death of a veteran in the same manner as if such additional disability were service connected. A disability or death is a qualifying additional disability or qualifying death if the disability or death was not the result of the veteran's willful misconduct, the disability or death was caused by hospital care, medical or surgical treatment, or examination furnished to the veteran under any law administered by the Secretary, either by a Department employee or in a Department facility, and the proximate cause of the disability or death was either carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of the Department in furnishing the hospital care, medical or surgical treatment, or examination; or an event not reasonably foreseeable. See 38 U.S.C. § 1151. In determining whether a veteran has an additional disability, VA compares the veteran's condition immediately before the beginning of the hospital care or medical or surgical treatment upon which the claim is based to the veteran's condition after care or treatment is rendered. 38 C.F.R. § 3.361(b). To establish causation, the evidence must show that the hospital care or medical or surgical treatment resulted in the veteran's additional disability. Merely showing that a veteran received care or treatment and that the veteran has an additional disability does not establish causation. 38 C.F.R. § 3.361(c)(1). Hospital care or medical or surgical treatment cannot cause the continuance or natural progress of a disease of injury for which the care or treatment was furnished unless VA's failure to timely diagnose and properly treat the disease or injury proximately caused the continuance or natural progress. 38 C.F.R. § 3.361(c)(2). The record shows that in May 2005, prior to any hip surgery, the Veteran tested MRSA positive. He again was found to be MRSA positive in August 2005, March 2006, and November 2009. The Veteran underwent left hip surgery (according to records referencing the surgery) approximately in February 2010 as a left hip x-ray showed good position and alignment. In April 2010, his MRSA infection had resolved. However, in October 2010, there were concerns for an infection, and he was diagnosed with a MRSA infection. The next note regarding the MRSA infection is dated May 2011, when the Veteran was admitted for treatment of his hip infection. In September 2012, he once again tested negative for MRSA. In September 2014, the Veteran underwent additional hip surgery. In August 2015, a VA examiner reviewed the Veteran's claims file. The examiner opined that the Veteran's MRSA infection was at least as likely as not due to left hip surgeries in August 2006, October 2006, and June 2008. The examiner reported that the Veteran was placed on floors with patients with MRSA resulting in his MRSA infection due to proximity. In September 2015, a second VA examiner reviewed the Veteran's claims file. The examiner reported that the August 2015 VA examiner's opinion appeared to be based on the Veteran's statements and not on actual medical evidence. The examiner reported that the Veteran was first diagnosed with a MRSA infection in 2005. The examiner reported that common medical knowledge established that individuals colonized with MRSA remained with MRSA as a skin contaminant. The examiner reported that the Veteran was schedule to undergo a hip surgery in 2009, but there was no medical evidence of record to support a MRSA infection of the surgical site during his hospitalization. The examiner reported that there was no medical evidence of record to support the Veteran's assertion that he was placed in proximity to MRSA infected patients during the course of his hip surgery or convalescent period. The examiner concluded that the Veteran was colonized with MRSA well before any surgical intervention by the Washington VAMC. The examiner reported that there was no medical evidence of any surgical site infection during the surgery or convalescent period at the Washington VAMC. The examiner opined that the Veteran's MRSA infection was less likely than not caused or became worse due to VA treatment. The examiner opined it was less likely than not that an additional disability resulted from carelessness, negligence, lack of skill, or similar incidence of fault on the part of the attending VA personnel. In summary, the September 2015 VA examiner determined that the Veteran's MRSA pre-existed his first hip surgery at the Washington VAMC. The examiner determined that the Veteran was first diagnosed with MRSA in 2005, which is at least four years prior to any hip surgery, and reported that individuals colonized with MRSA remained with MRSA as a skin contaminant. The examiner opined that the Veteran's MRSA infection was less likely than not caused or became worse due to VA treatment or that an additional disability resulted from carelessness, negligence, lack of skill, or similar incidence of fault on the part of the attending VA personnel. The Board accords great probative weight to the September 2015 VA examiner's opinion, which is the only competent opinion of record, as it is based on a thorough review of the record, which includes medical records concerning the treatment in question and the Veteran's statements. Additionally, the opinion considered all of the pertinent evidence of record and provided a complete rationale, relying on and citing to the medical evidence of record. Moreover, the examiner offered a clear conclusion with supporting data. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Conversely, the opinion of the August 2015 VA examiner is given no probative weight. This examiner apparently based his opinion on the Veteran's own statements. While this examiner reported that the Veteran underwent hip surgeries in August 2006, October 2006, and June 2008, the first evidence of any hip surgery is not until 2009 or 2010. This examiner also did not discuss the Veteran's diagnosis of MRSE in 2005, which was prior to his first hip surgery. In addition, the September 2015 VA examiner reported that the opinion of the August 2015 VA examiner appeared to be based on the Veteran's statements and not on actual medical evidence. As such, the Board finds that the August 2015 VA examiner's opinion is based on the Veteran's own statements and not on any objective medical evidence. Any medical evidence or opinions based on a veteran's inaccurate reports are not probative. Reonal v. Brown, 5 Vet. App. 458, 460-61 (1993); see also LeShore v. Brown, 8 Vet. App. 406, 409 (1995). As such, the opinion of the August 2015 VA examiner is given no probative value as it is not consistent with, nor based on, the medical evidence of record. In summary, the preponderance of the competent (and thus probative) evidence in this matter is against the Veteran's claim. The evidence of record shows that the Veteran was diagnosed with MRSA prior to his first hip surgery at the Washington VAMC and fails to establish that the Veteran's MRSA became worse due to VA treatment. The criteria for establishing entitlement to compensation under 38 U.S.C. § 1151 have not been met. Accordingly, the appeal in the matter must be denied. Service Connection Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303. Service connection requires competent evidence showing: (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). Service connection may also be established under 38 C.F.R. § 3.303(b), where a condition in service is noted but is not, in fact, chronic, or where a diagnosis of chronicity may be legitimately questioned. The continuity of symptomatology provision of 38 C.F.R. § 3.303(b) has been interpreted as an alternative to service connection only for the specific chronic diseases listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 718 F.3d 1331 (Fed. Cir. 2013). Service connection may also be established with certain chronic diseases based upon a legal presumption by showing that the disorder manifested itself to a degree of 10 percent disabling or more within one year from the date of separation from service. Such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309(a). While the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. Service connection may be established on a secondary basis for a disability which is proximately due to, or the result of, a service-connected disability. 38 C.F.R. § 3.310(a). Secondary service connection may also be established for a disability which is aggravated by a service-connected disability. To substantiate a claim of secondary service connection, the record must show (1) a current disability (for which secondary service connection is sought); (2) an already service-connected disability; and (3) that the already service-connected disability caused or aggravated the disability for which service connection is sought. Wallin v. West, 11 Vet. App. 509 (1998). Collapsed Vein Condition, Immune System Dysfunction, and Acquired Psychiatric Disorder The Veteran asserted that he experienced a collapsed vein condition, immune system dysfunction, and an acquired psychiatric disorder due to a MRSA infection as a result of hip surgery at the Washington VAMC. The Veteran's service treatment records (STRs) show no complaints, treatment, or diagnosis for a collapsed vein condition, immune system dysfunction, or an acquired psychiatric disorder during his active service. The Veteran has not submitted any competent medical opinion of record suggesting that a collapsed vein condition, immune system dysfunction, or an acquired psychiatric disorder might be related to his active service. As such, service connection on a direct basis is not warranted for a collapsed vein condition, immune system dysfunction, or an acquired psychiatric disorder. The Veteran was diagnosed with substance abuse disorder in 1999. He was later diagnosed with psychotic disorder in 2004. The August 2015 VA examiner (as discussed above) opined that the Veteran's collapsed vein condition, immune system dysfunction, and acquired psychiatric disorder were at least as likely as not due to the MRSA infection due to hip surgeries. However, this opinion is afforded no probative value as it was based on the Veteran's own statements and not on any objective medical evidence. In September 2015, a VA examiner reviewed the Veteran's claims file, including the opinion of the August 2015 VA examiner. The examiner reported that the Veteran had a long history of mental health treatment that predated his MRSA diagnosis. The examiner reported that the Veteran's mental health treatment began in 1999, and he was later hospitalized five times for substance abuse disorder and/or psychotic disorders prior to his diagnosis of MRSA. In October 2015, the Veteran was found to have no venous abnormalities. As the Veteran's MRSA infection is not service connected, service connection on a secondary basis is not warranted. Therefore, the preponderance of the evidence is against these claims. Accordingly, the appeals in these matters must be denied. Diabetes, Bilateral Upper Extremity Diabetic Neuropathy, Erectile Dysfunction, Lumbar Spine Disorder, and Bilateral Upper Extremity Disorder The Veteran asserted that his diabetes, bilateral upper extremity diabetic neuropathy, erectile dysfunction, lumbar spine disorder, and bilateral upper extremity disorder were due to his active service. The Veteran's STRs do not show any complaints, treatment, or diagnoses for diabetes, bilateral upper extremity diabetic neuropathy, erectile dysfunction, a lumbar spine disorder, or a bilateral upper extremity disorder, other than the Veteran's service-connected bilateral shoulder disabilities, during his active service. At his February 1984 entrance physical, he had a normal clinical evaluation but for asymptomatic pes planus. While he was treated for shoulder complaints, his STRs do not show treatment for a bilateral upper extremity disorder. At his October 1986 separation physical, he continued to have a normal clinical evaluation. In addition, he specifically denied having any sugar in his urine, recurrent back pain, arthritis, or other significant medical history on an accompanying medical questionnaire. Postservice medical records show that the Veteran was first diagnosed with borderline diabetes in August 2006 and with diabetes in August 2012. The earliest notation of erectile dysfunction was in March 2006. The first objective evidence of a lumbar spine disorder is a June 2004 lumbar spine MRI that showed mild spinal stenosis. In August 2006, he reported pain that radiated from his shoulders to his hands. As such, the first evidence of any of these conditions is almost two decades after his separation from active service. The Veteran has not submitted any competent (medical opinion or treatise) evidence suggesting that his diabetes, bilateral upper extremity diabetic neuropathy, erectile dysfunction, lumbar spine disorder, or bilateral upper extremity disorder may be related to activities during his active duty service. His STRs do not document any treatment or diagnosis for diabetes, bilateral upper extremity diabetic neuropathy, erectile dysfunction, a lumbar spine disorder, or a bilateral upper extremity disorder during his active service or any injury or complaints in service to which these conditions could be related. Under such circumstances, VA examinations are not necessary. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Veteran's own assertions that any diabetes, bilateral upper extremity diabetic neuropathy, erectile dysfunction, lumbar spine disorder, or bilateral upper extremity disorder is due to his active service is not probative. The diagnosis of these conditions is a medical question. He is a layperson, and has not submitted any medical (opinion, test, or treatise) evidence in support of these claims. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Finally, as the record does not show a diagnosis of lumbar spine arthritis until June 2004, almost two decades after the Veteran's separation from active service, the chronic disease presumptive provisions of 38 U.S.C. § 1112 have no applicability in the matter. Therefore, the preponderance of the evidence is against these claims. Accordingly, the appeals in these matters must be denied. Cervical Spine Disorder, Bilateral Hand Disorder, and Bilateral Hip Disorder The Veteran asserted that his cervical spine disorder, bilateral hand disorder, and bilateral hip disorder were due to his active service. The Veteran's STRs do not show any complaints, treatment, or diagnoses for a chronic cervical spine disorder, a chronic bilateral hand disorder, or a chronic bilateral hip disorder during his active service. At his February 1984 entrance physical, he had a normal clinical evaluation but for asymptomatic pes planus. In February 1985, he treated for hand pain and was diagnosed with chilblains versus frostbite. In September 1986, he treated for a swollen left finger and was diagnosed with an abrasion. At his October 1986 separation physical, he continued to have a normal clinical evaluation. In addition, he specifically denied having any arthritis or other significant medical history on an accompanying medical questionnaire. Postservice medical records regarding the Veteran's cervical spine disorder show that a September 1990 cervical spine x-ray was normal. A January 2006 cervical spine x-ray and MRI showed some degenerative changes. Postservice medical records regarding the Veteran's bilateral hand disorder show that an October 1990 right hand x-ray was normal. In August 1991, he reported he injured his left finger in service. In April 2006, he reported his hands hurt while riding his scooter. Postservice medical records regarding the Veteran's bilateral hip disorder show that in March 2005, he reported having right hip pain for the previous one and a half years after a fall. He underwent multiple left hip surgeries (as discussed more fully above). A May 2018 right hip x-ray showed mild degenerative changes. On December 2012 VA hand examination, the Veteran reported that he had frost bite in 1985 and had been unable to do heavy work with his hands since then. He also reported a four-year history of decreased grip strength and numbness. On review of the claims file and interview and examination of the Veteran, the examiner diagnosed the Veteran with resolved frost bite. The examiner opined that the Veteran's bilateral hand disorder was less likely than not due to or the result of the Veteran's active service. The examiner reported that the Veteran had frost bite in service. The examiner reported that the Veteran's current hand symptoms began four years previously. The examiner reported that there was no documentation of a current hand condition. On December 2012 VA hip examination, the Veteran reported fracturing his left hip in 2009. On review of the claims file and interview and examination of the Veteran, the examiner diagnosed the Veteran with left hip arthropathy with total hip replacement. The examiner opined that any hip disorder was less likely than not incurred in or caused by the Veteran's active service. The examiner reported that the Veteran fractured his hip in 2009. On February 2013 VA cervical spine examination, the Veteran reported that he had cervical spine pain that radiated into his arms that started five to six years previously. On review of the claims file and interview and examination of the Veteran, the examiner diagnosed the Veteran with cervical spine strain as of 2007. Cervical spine x-rays showed some degenerative changes. The examiner opined that the Veteran's cervical spine disorder was less likely than not incurred in or caused by his active service. The examiner reported that the Veteran separated from active service more than 25 years previously and now had mild to moderate degenerative joint disease, which was not more than anticipated at this stage of his life. The examiner reported that there was no clinical or imaging evidence of cervical spine radiculopathy. A chronic cervical spine disorder, a chronic bilateral hand disorder, and a chronic bilateral hip disorder were not manifested in service. While the record shows he reported hand complaints during his active service, his STRs do not show any chronic hand diagnosis. In addition, he had a normal separation evaluation and did not report having any neck, hand, or hip symptoms. Therefore, his hand complaints during his active service are shown to have been acute, and not reflecting an underlying chronic hand disability. The Veteran has not submitted any competent (medical opinion) evidence to the contrary. There is also no evidence in the record that arthritis of the cervical spine, hand, or hip was manifested in the first postservice year. Consequently, service connection for a cervical spine disorder, a bilateral hand disorder, or a bilateral hip disorder on the basis that such disability was shown as chronic in service, for arthritis on a chronic disease presumptive basis, or based on continuity is not warranted. Whether a current cervical spine disorder, a bilateral hand disorder, or a bilateral hip disorder is etiologically related to active service or acute injuries in service rather than to postservice etiological factors (such as a fall or aging) is a medical question which requires medical expertise. See Jandreau, 492 F.3d 1372. The Veteran is a layperson. He has not presented any competent (medical opinion or treatise) evidence in support of his theory of entitlement. His own lay opinion has no probative value in these matters. The only competent (medical) evidence in the record that directly addresses the matter of a nexus between the Veteran's cervical spine disorder, bilateral hand disorder, and bilateral hip disorder and the Veteran's active service are in the findings and opinions of the December 2012 and February 2013 VA examiners. Noting that the Veteran reported that he had a five to six year history of cervical spine symptoms, a four year history of hand symptoms, and fractured his left hip in 2009, the examiners concluded that the Veteran's cervical spine disorder, bilateral hand disorder, and bilateral hip disorder were less likely than not due to the Veteran's active service. The opinions (against the Veteran's claims) reflect familiarity with the entire record, including the Veteran's accounts, and include rationale that cites to supporting clinical and factual data. The Board finds the December 2012 and February 2013 VA medical opinions probative evidence in this matter. As there is no competent evidence to the contrary, the Board finds the medical opinions persuasive. Therefore, the preponderance of the evidence is against these claims. Accordingly, the appeals in these matters must be denied. Left Hip Scar The Veteran asserted that his left hip scar was secondary to his left hip replacement surgery. The Veteran's STRs show no complaints, treatment, or diagnosis for a left hip scar during his active service. The Veteran has not submitted any competent medical opinion of record suggesting that any left hip scar might be related to his active service. As such, service connection on a direct basis is not warranted for a left hip scar. Regarding secondary connection, as discussed more fully above, as the Veteran's left hip disorder is not service connected, service connection on a secondary basis is not warranted. Therefore, the preponderance of the evidence is against the claim. Accordingly, the appeal in the matter must be denied. Increased Rating Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the appellant working or seeking work. 38 C.F.R. § 4.2. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. Reasonable doubt regarding degree of disability is to be resolved in favor of the claimant. 38 C.F.R. § 4.3. The Veteran's increased rating claim was received in December 2013. October 2015, March 2016, and March 2018 rating decisions continued the assigned 20 percent rating for his right shoulder disability. The Veteran asserted that he was entitled to a higher rating. The criteria for rating shoulder disabilities are in 38 C.F.R. Part 4, Codes 5200 through 5203. As the Veteran is left-handed, his right shoulder is considered his minor extremity. The Veteran's right shoulder disability is rated 20 percent under Code 5003-5201 (for arthritis due to trauma based on limitation of motion of the shoulder). Code 5200 pertains to ratings for ankylosis of the shoulder; Code 5202 pertains to rating for impairment of the humerus (to include malunion, fibrous union, and non-union, as well as dislocation of the scapulohumeral joint); and Code 5203 pertains to impairment of the clavicle or scapula (dislocation, malunion or nonunion). As the record does not show such pathology or impairment, those Codes have no applicability in this matter. Code 5201 pertains to ratings for limitation of shoulder motion. For the minor upper extremity, a 20 percent rating is assigned for limitation at the shoulder level or for limitation at midway between the side and shoulder level. A 30 percent rating, the maximum rating, is assigned for limitation to 25 degrees from the side. The Board notes that, effective February 7, 2021, the criteria for evaluating musculoskeletal disorders were amended, including Code 5201. Under the new criteria for the minor extremity, a 20 percent rating is assigned for limitation of motion limited to 90 degrees or limited to 45 degrees, and a 30 percent rating is assigned for limitation of motion limited to 25 degrees from side. As relevant to this decision, the amended rating criteria for an increased 30 percent rating under Code 5201 requires the same criteria under either version of the Code. Normal ranges of motion of the shoulder are flexion (forward elevation) from 0 degrees to 180 degrees, abduction from 0 to 180 degrees, external rotation from 0 to 90 degrees, and internal rotation from 0 to 90 degrees. 38 C.F.R. § 4.71, Plate I. In determining the degree of limitation of motion, the provisions of 38 U.S.C. §§ 4.10, 4.40, and 4.45 are for consideration. See DeLuca v. Brown, 8 Vet. App. 202 (1995). The basis of disability evaluation is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45. The Veteran's treatment records show treatment for right shoulder symptoms, but do not show findings warranting a 30 percent rating under Code 5201. On March 2015 VA examination, the Veteran reported problems with pain. He reported having flare-ups when he used his right arm to roll his wheelchair, laying on his right side, or lifting. On examination, right shoulder flexion was to 90 degrees and abduction was to 90 degrees. The examiner indicated that pain was noted on examination but did not result in or cause functional loss, and that the Veteran's range of motion did not contribute to a functional loss. There was no evidence of pain with weight bearing. The examiner reported that repetitive use testing did not result in additional functional loss or range of motion. The examiner indicated that pain, weakness, fatigability, or incoordination did not significantly limit functional ability with repeated use over a period of time. The examiner indicated that there were no additional contributing factors of disability. The Veteran retained normal (5/5) right shoulder strength. There was no muscle atrophy, ankylosis, shoulder instability, dislocation, or labral pathology, a clavicle, scapula, acromioclavicular (AC) joint or sternoclavicular joint condition, or humerus impairment. The examiner indicated that the Veteran's right shoulder disability did not impact his ability to perform any type of occupational tasks. On October 2017 VA examination, right shoulder flexion was to 170 degrees and abduction was to 170 degrees. The examiner indicated that pain was noted on examination and caused functional loss. There was evidence of pain with weight bearing but not with non-weight bearing. The examiner reported that the Veteran was unable to perform repetitive use testing due to pain. The examiner indicated that the Veteran had less movement than normal. The Veteran retained normal (5/5) right shoulder strength. There was no muscle atrophy, ankylosis, shoulder instability, dislocation, or labral pathology, a clavicle, scapula, AC joint or sternoclavicular joint condition, or humerus impairment. The examiner noted that the Veteran's right shoulder disability impacted his ability to perform occupational tasks in that he had limitations with heavy lifting, heavy carrying, and overhead lifting. On January 2018 VA examination, the Veteran reported right shoulder pain that was worse with movements. He reported having flare-ups that prevented him from lifting his hand above his head due to pain. On examination, right shoulder flexion was to 170 degrees and abduction was to 170 degrees. The examiner indicated that pain was noted on examination that did not result in functional loss. There was no evidence of pain with weight bearing. The examiner reported that repetitive use testing did not result in additional loss of function or range of motion. The Veteran retained normal (5/5) right shoulder strength. There was no muscle atrophy, ankylosis, shoulder instability, dislocation, or labral pathology, a clavicle, scapula, AC joint or sternoclavicular joint condition, or humerus impairment. The examiner found that the Veteran's right shoulder disability did not impact his ability to perform occupational tasks. On January 2020 VA examination, the Veteran reported dull right shoulder pain. He reported having flare-ups and functional loss that included pain with prolonged sitting, sleep disturbances, being unable to raise his shoulder overhead, and pain with cross-body movements. On examination, right shoulder flexion was to 70 degrees and abduction was to 45 degrees. The examiner indicated that pain was noted on examination that caused functional loss. There was evidence of pain with weight bearing. The examiner reported that repetitive use testing did not result in additional loss of function or range of motion. The examiner indicated that pain, fatigue, and weakness significantly limited functional ability with repeated use over a period of time and during flare-ups further limiting flexion to 65 degrees and abduction to 40 degrees. The Veteran retained reduced (4/5) right shoulder strength. There was no muscle atrophy, ankylosis, shoulder instability, dislocation, or labral pathology, a clavicle, scapula, AC joint or sternoclavicular joint condition, or humerus impairment. The examiner found that the Veteran's right shoulder disability impacted his ability to perform occupational tasks due to prolonged sitting causing shoulder pain. The current 20 percent rating under Code 5003-5201 is assigned for left shoulder arthritis with limitation of motion, and reflects limitation of motion at midway between the side and shoulder (45 degrees), at most. A higher 30 percent rating requires limitation of minor shoulder motion to 25 degrees from the side. Such limitation (to include as due to pain) is not shown. No record provides a basis for finding that the limitation was at 25 degrees from the side. The criteria for a 30 percent rating are not shown to be met or approximated. See 38 C.F.R. § 4.7. No examination found, and no treatment record shows, ankylosis, humerus impairment, or clavicle or scapula impairment with malunion, nonunion, or dislocation; consequently, rating the disability under alternate criteria based on such manifestations and functional impairment is not for consideration. The Board has considered whether a higher disability evaluation may be warranted on the basis of functional loss due to weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. §§ 4.40 and 4.45. See also DeLuca, 8 Vet. App. 202. While the January 2020 VA examiner indicated that pain, fatigue, and lack of endurance resulted in additional limitation of motion, the resultant limitation of motion was not equivalent to a 30 percent rating. Accordingly, a higher rating is not warranted for functional loss due to pain. While the Veteran reported experiencing left shoulder pain, pain alone is not sufficient to warrant a higher rating, unless it results in additional loss of function. Mitchell v. Shinseki, 25 Vet. App. 32, 36-38 (2011). The Board has no reason to question that the Veteran's right shoulder disability results in functional limitations. Such limitations are contemplated by the criteria for the 20 percent rating that is assigned. The Board finds that the Veteran's right shoulder symptoms do not include any that are not adequately addressed by the schedular rating criteria. The disability picture presented is not shown to be exceptional, nor is it asserted to be, so as to suggest referral for consideration of an extraschedular rating under 38 C.F.R. § 3.321 may be warranted. Therefore, the preponderance of the evidence is against the claim. Accordingly, the appeal in the matter must be denied. SMC Compensation at the aid and attendance rate is payable when a veteran's service connected disability or disabilities cause the anatomical loss or loss of use of both feet or one hand and one foot, cause the veteran to be blind in both eyes, or render him permanently bedridden or so helpless as to be in need of regular aid and attendance. 38 U.S.C. § 1114(l); 38 C.F.R. § 3.350(b). Determinations as to the need for regular aid and attendance are factual and must be based upon the actual requirements for personal assistance from others. In making such determinations, consideration is given to such conditions as: the inability of the 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 assistance; the inability of the claimant to feed himself through loss of coordination of upper extremities or through extreme weakness; the inability to attend to the wants of nature; or incapacity, either physical or mental, which requires care or assistance on a regular basis to protect a claimant from hazards or dangers incident to one's daily environment. It is not required that all of the disabling conditions enumerated be present before a favorable rating is made. The particular personal functions that the claimant is unable to perform should be considered in connection with his condition as a whole. It is only necessary that the claimant be so helpless as to need regular aid and attendance, not that there is a constant need. "Bedridden" constitutes a condition which, through its essential character, actually requires that an individual remain in bed. The fact that a claimant has voluntarily taken to bed, or that a physician has prescribed bed rest for a lesser or greater portion of the day, will not suffice. 38 C.F.R. § 3.352(a). In Turco v. Brown, 9 Vet. App. 222, 224 (1996), the Court held that eligibility for SMC by reason of regular need for aid and attendance requires that at least one of the factors set forth in VA regulation is met. In addition, determinations that the 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. See Turco, 9 Vet. App. at 224. The evidence must show that the claimant is so helpless as to need regular aid and attendance; constant need for aid and attendance is not required. 38 C.F.R. § 3.352(a). In December 2013, the Veteran filed a claim for SMC. Review of the record shows that since December 2013, the Veteran has been service connected for a left shoulder disability rated at 40 percent and a right shoulder disability rated at 20 percent. His combined disability rating since December 2013 has been 60 percent. On March 2015 VA shoulder examination, the examiner indicated that the Veteran's shoulder disabilities did not impact his ability to perform any type of occupational tasks. In May 2015, the Veteran's wife reported that she was the caretaker for the Veteran when his nurse was not scheduled. She reported that she helped the Veteran with bathing and dressing, prepared meals, managed the finances, reminded him to take his medications, and accompanied him outside the house. On May 2015 Examination for Housebound Status or Permanent Need for Regular Aid and Attendance, the examiner reported that the Veteran's diagnoses were osteoarthritis and schizoaffective disorder. The examiner indicated that the Veteran was able to feed himself, was not legally blind, and did not require nursing home care. The examiner reported that the Veteran had a decreased ability to ambulate due to osteoarthritis pain (although it is unclear how the Veteran's service-connected shoulder disabilities affected his ability to ambulate). The examiner reported that the Veteran was unable to prepare his own meals and needed assistance in dressing. The Veteran reported that he was also diagnosed with a left hip total replacement, dyspepsia, chronic pain syndrome, depression, MRSA, cervical spine arthritis, pelvic and hip pain, hypertension, polyneuropathy, and diabetes (however, these conditions are not service connected and are not considered in determining entitlement to SMC). On October 2017 VA shoulder examination, the examiner noted that the Veteran's right shoulder disability impacted his ability to perform occupational tasks in that he had limitations with heavy lifting, heavy carrying, and overhead lifting. On January 2018 VA examination, the examiner found that the Veteran's shoulder disabilities did not impact his ability to perform occupational tasks. In July 2019 and September 2019, the Veteran's physician indicated he was capable of increased independence in activities of daily living. On January 2020 VA examination, the examiner found that the Veteran's shoulder disabilities did impact his ability to perform occupational tasks due to prolonged sitting causing shoulder pain. In January 2020, the Veteran's physician indicated he was independent in activities of daily living. As such, the evidence shows that the Veteran's service-connected shoulder disabilities do not preclude him from caring for his daily personal needs such as feeding himself or otherwise protecting himself from the hazards and dangers incident due to his daily environment without the regular assistance of another person. The medical evidence does not establish that the Veteran's service-connected disabilities have caused the anatomical loss or loss of use of both feet or one hand and one foot, caused the Veteran to be blind in both eyes, or rendered him permanently bedridden or so helpless as to be in need of regular aid and attendance. There is no medical opinion, private or VA, in support of the Veteran's SMC claim. Therefore, the preponderance of the evidence is against the claim. Accordingly, the appeal in the matter must be denied. TDIU prior to September 1, 2017 Total disability will be considered to exist when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340. Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when the disabled person is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that, if there is only one such disability, the disability shall be ratable at 60 percent or more, and that, if there are two or more service-connected disabilities, at least one must be rated at 40 percent or more and the combined rating must be 70 percent or more. 38 C.F.R. § 4.16(a). In December 2013, the Veteran filed his increased rating claim for a right shoulder disability. In September 2016, the Veteran asserted entitlement to a TDIU due to his service-connected disabilities. Pursuant to Rice v. Shinseki, 22 Vet. App. 447 (2009), a claim for a TDIU either expressly raised by the Veteran or reasonably raised by the record involves an attempt to obtain an appropriate rating for a disability and is part of the claim for an increased rating. As the Veteran's right shoulder disability is due to his left shoulder disability, the AOJ considered these a single disability for TDIU purposes as they shared a common etiology. See 38 C.F.R. § 4.16 (a). These disabilities combine for a 60 percent disability rating. 38 C.F.R. § 4.25. As such, the Veteran met the schedular criteria for a TDIU from December 12, 2013, as he had a single disability ratable at 60 percent. In a September 2017 VA Form 21-8940 (Veteran's Application for Increased Compensation Based on Unemployability), the Veteran reported that his bilateral shoulder disabilities prevented him from securing or following any substantially gainful employment. He indicated that he last worked full time in 1990. He indicated that he left his employment due to his disabilities. He indicated that he had a high school education. A January 2020 rating decision granted the Veteran a TDIU from September 1, 2017. However, the Veteran has not expressed a desire to abandon the claim regarding whether a TDIU is warranted prior to September 2, 2017. As such, the appeal for a TDIU continues. Harper v. Wilkie, 30 Vet. App. 356 (2018). In October 2017, a private vocational expert reviewed the Veteran's claims file. The vocational expert concluded that the Veteran's service-connected bilateral shoulder disabilities prevented the Veteran from securing and following any substantial gainful occupation since at least 2003. The January 2020 rating decision granted a TDIU based on the opinion of the vocational expert as of the date the Veteran's VA Form 21-8940 was received. However, as discussed above, the Veteran is entitled to a TDIU as of the date of his claim for an increased rating in December 2013. As the AOJ granted a TDIU based on the opinion of the October 2017 private vocational expert, the evidence of record establishes that the Veteran's service-connected disabilities prevented him from sustaining substantial gainful employment effective the date he filed his increased rating claim. The Veteran's former representative asserted that the Veteran filed a claim for a TDIU in June 2010 that had not been adjudicated. However, correspondence from the Veteran in June 2010 shows that while he reported that he looked for a job and was not hired, he never asserted he was unable to work due to his service-connected disabilities. The first claim for a TDIU in the claims file is not until the September 2016 notice of disagreement with the March 2016 rating decision that denied an increased rating for the Veteran's right shoulder disability. Accordingly, the earliest date for the award of a TDIU is December 12, 2013, the date he asserted he was entitled to an increased rating and subsequently met the schedular requirement for a TDIU. As such, the Board concludes that the evidence for and against a TDIU is at least in relative equipoise, and given this conclusion, the Board will resolve any reasonable doubt in the Veteran's behalf, and hold that TDIU is warranted as of the date the Veteran filed an increased rating claim and subsequently met the schedular requirements for a TDIU on December 12, 2013. David Gratz Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Berryman, 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.