Citation Nr: 21063870 Decision Date: 10/18/21 Archive Date: 10/18/21 DOCKET NO. 17-40 849 DATE: October 18, 2021 REMANDED Entitlement to special monthly compensation (SMC) based on the need for regular aid and attendance of another person or by reason of being housebound is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1984 to April 1984. This case is on appeal to the Board of Veterans' Appeals from a June 2015 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) which, inter alia, denied entitlement to SMC based on aid and attendance/housebound. The Veteran timely filed a notice of disagreement (NOD) in February 2016 for her SMC claim. In July 2017, she filed a substantive appeal. In March 2019, the Board remanded the claim for further development. Entitlement to special monthly compensation based on the need for regular aid and attendance of another person or by reason of being housebound. The Veteran contends that she should be in receipt of SMC benefits based on regular aid and attendance and by reason of being housebound due to her service-connected left knee and lumbar spine disabilities. The Veteran is in receipt of a total disability based on individual unemployability (TDIU) from November 17, 2015. Her service-connected disabilities include: total left knee replacement with residual surgical scar rated as 60 percent from March 1, 2016; residuals of compression fracture, L3 with post-traumatic degenerative joint disease (DJD) and lumbosacral strain rated as 10 percent disabling from June 20, 1995; and duodenal ulcer rated as 10 percent from June 20, 1995. Private treatment records from January 2020 reflect that a magnetic resonance imaging (MRI) report revealed an impression of stable severe degenerative changes at the presumed discitis osteomyelitis level of L2-L3. There were no significant changes in the loss of vertebral body height at L3. There was severe posterior and right-sided foraminal osteophytes and narrowing. There was possible compromise of the traversing right L3 and exiting right L3 nerve roots. There was no evidence of paraspinal abscess. There were stable severe degenerative changes at the presumed discitis osteomyelitis level of L2-L3. There was no significant change in the loss of vertebral body height at L3. There was severe posterior and right-sided foraminal osteophytes and narrowing. There was possible compromise of the traversing right L3 and exiting right L3 nerve roots. There was no evidence of paraspinal abscess. The Veteran was diagnosed with discitis with osteomyelitis. A February 2020 VA aid and attendance or housebound examination reflects that the Veteran's diagnoses were residuals of compression fracture, L3 post-traumatic DJD and lumbosacral spine; discitis with osteomyelitis L3; total left knee replacement with residual surgical scar; and duodenal ulcer. The clinician reported that the Veteran requires regular aid and attendance of another person for dressing and undressing, bathing, and grooming due to her service-connected back condition and left knee condition. She required assistance with putting on and taking off her shoes due to her service-connected back and knee and she sometimes required assistance getting in and out of the bathtub safely due to her service-connected back and knee. The clinician reported that she was substantially confined to her dwelling in the immediate premises. She was unable to drive currently due to her service-connected back and knee disabilities. It is possible that her back disability will improve with the planned surgery. The clinician reported that the Veteran's need for aid and attendance of another person due to her service-connected disabilities alone will likely resolve after her back surgery and the postoperative recovery period for this surgery depending on her response to this treatment. The coinciding VA examination for the Veteran's knee reflects that the Veteran reported that she continued to have left knee pain despite her revision total left knee replacement in January 2015. She reported that the anterior portion of her knee is where the pain was. She reported that her left knee swells with prolonged activity. She reported that she did not have flare-ups in the left knee. There was no evidence of pain with weight bearing. She had intermediate degrees of residual weakness, pain or limitation of motion following her total knee joint replacement. The examiner was unable to test range of motion due to her recent cervical spine fusion surgery. The February 2020 VA examination for the Veteran's lumbar spine report reflects that the Veteran reported that she has pain in her lower back bilaterally that radiates into both legs right worse than left. She reported that she is using a walker and back brace for her back condition. She stated that she requires at least standby assistance and sometimes physical assistance to get in and out of the tub for two days. She reported that she is having her food cooked by either her daughter or her sister and she just warms it up. She reported that she is unable to stand long enough to cook a meal. The Veteran reported that she is able to dress herself including putting on her back brace. She reported she has daily flare ups of her back pain at this time. She reported that it can take several hours every morning to be able to move without excruciating pain. She reported that she was told by her orthopedic surgeon that she has an unstable lumbar spine, and this is why she needs surgery. She reported that she was currently having a flare up. She reported that the range of motion of her back does not necessarily change during her flare ups. While it is clear that the Veteran has significant limitations due to her lumbar spine, it is not clear whether her limitations are due to her service-connected residuals of compression fracture L3, with posttraumatic DJD and lumbosacral strain or whether it is due to her recently diagnosed discitis with osteomyelitis. The February 2020 VA examiner did not clarify what symptoms are attributable to each diagnosis and whether the discitis with osteomyelitis is related in any way to her residuals of compression fracture L3. Notably, the discitis with osteomyelitis developed at the level of L2-L3. A remand is required for an addendum to clarify whether the Veteran's discitis with osteomyelitis is related to her service-connected residuals of compression fracture L3, with post traumatic DJD and lumbosacral strain. If not, an addendum medical opinion is required to determine whether her aid and attendance is necessary due to her service-connected residuals of compression fracture L3, with post traumatic DJD and lumbosacral strain or discitis with osteomyelitis. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). The matters are REMANDED for the following action: Arrange to obtain from an appropriate clinician an opinion addressing the Veteran's service-connected residuals of compression fracture L3, with post traumatic DJD and lumbosacral strain and discitis with osteomyelitis. Only arrange for the Veteran to undergo an examination if one is deemed necessary in the judgment of the clinician designated to provide the opinion. The clinician should address whether the Veteran's discitis with osteomyelitis was caused by or has any relation to the Veteran's service-connected residuals of compression fracture L3, with post traumatic DJD and lumbosacral strain, noting that the January 2020 MRI report revealed that discitis with osteomyelitis developed where the Veteran previously fractured her lumbar spine. The clinician should clarify whether the symptoms of each disability overlap. If the clinician does not find that the discitis with osteomyelitis was caused by or has any relation the Veteran's service-connected lumbar disability, the clinician should clarify whether the Veteran's service-connected residuals of compression fracture L3, with post traumatic DJD and lumbosacral strain, alone or in conjunction with the total left knee replacement with residual surgical scar, result in disability (physical or mental) requiring the regular aid and attendance of another person to assist with activities of daily living such as dressing and undressing, keeping herself ordinarily clean and presentable; feeding; attending to the wants of nature; frequently adjusting of any special prosthetic or orthopedic appliances which by reason of the particular disability cannot be done without aid; or protecting her from hazards or dangers incident to her daily environment. For housebound purposes, the examiner should indicate whether the Veteran is substantially confined to her dwelling and the immediate premises. L. B. CRYAN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Laroche, N. 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.