Citation Nr: 21064572 Decision Date: 10/20/21 Archive Date: 10/20/21 DOCKET NO. 17-29 964 DATE: October 20, 2021 ORDER Service connection for diabetes mellitus type II is denied. Service connection for atherosclerotic heart disease, to include coronary bypass surgery, ventricular tachycardia, and myocardial infarction, is denied. Service connection for bilateral loss of vision is denied. Service connection for a bilateral leg disability is denied. Service connection for neuropathy of the back is denied. Service connection for a right shoulder disability is denied. Service connection for an abdominal aneurysm is denied. Service connection for kidney disease is denied. Service connection for a psychiatric disability, to include posttraumatic stress disorder (PTSD) generalized anxiety disorder, and major depression is denied. Service connection for cause of death is denied. Entitlement to a rating in excess of 20 percent, for the Veteran's left shoulder rotator cuff tear is denied. Entitlement to special monthly compensation (SMC) based on the need for aid and attendance or on housebound status is denied. Entitlement to a total disability rating based on individual unemployability (TDIU) is denied. FINDINGS OF FACT 1. The preponderance of the evidence is against finding that diabetes mellitus type II began during active service, or is otherwise related to an in-service injury or disease. 2. The preponderance of the evidence is against finding that atherosclerotic heart disease, to include coronary bypass surgery, ventricular tachycardia, and myocardial infarction began during active service, or is otherwise related to an in-service injury or disease. 3. The preponderance of the evidence is against finding that bilateral loss of vision began during active service, or is otherwise related to an in-service injury or disease. 4. The preponderance of the evidence is against finding that a bilateral leg disability began during active service, or is otherwise related to an in-service injury or disease. 5. The preponderance of the evidence is against finding that neuropathy of the back began during active service, or is otherwise related to an in-service injury or disease. 6. The preponderance of the evidence is against finding that a right shoulder disability began during active service, or is otherwise related to an in-service injury or disease. 7. The preponderance of the evidence is against finding that an abdominal aneurysm began during active service, or is otherwise related to an in-service injury or disease. 8. The preponderance of the evidence is against finding that kidney disease began during active service, or is otherwise related to an in-service injury or disease. 9. The preponderance of the evidence is against finding that a psychiatric disability began during active service, or is otherwise related to an in-service injury or disease. 10. The Veteran died in August 2014. His death certificate listed coronary artery disease as the primary cause of death. His death was not caused, or contributed substantially or materially to, by a service-connected disability. 11. The Veteran's service-connected left rotator cuff tear was manifested by limitation of his minor (non-dominant) arm to greater than 25 degrees from his side, and without ankylosis or other impairment of the humerus. 12. The Veteran's service-connected disability did not cause him to be in need of regular aid and attendance or housebound. He did not have a disability rated as permanent and total. 13. The Veteran's service-connected disabilities did not preclude substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for service connection for diabetes mellitus type II are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for atherosclerotic heart disease, to include coronary bypass surgery, ventricular tachycardia, and myocardial infarction are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for service connection for bilateral loss of vision are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 4. The criteria for service connection for a bilateral leg disability are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 5. The criteria for service connection for neuropathy of the back are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 6. The criteria for service connection for a right shoulder disability are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 7. The criteria for service connection for an abdominal aneurysm are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 8. The criteria for service connection for kidney disease are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 9. The criteria for service connection for a psychiatric disability are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 10. The criteria for service connection for the cause of the Veteran's death have not been met. 38 U.S.C. §§ 1110, 1310, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.312. 11. The criteria for an initial disability evaluation in excess of 20 percent for left shoulder rotator cuff tear have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.7, 4.71a, Diagnostic Code 5201. 12. The criteria for SMC based on the need for aid and attendance or on housebound status have not been met. 38 U.S.C. §§ 1114, 5107; 38 C.F.R. §§ 3.102, 3.350, 3.351, 3.352. 13. The criteria for entitlement to a total disability rating due to service-connected disabilities have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.15, 4.16, 4.18, 4.25. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1963 to July 1965 with additional National Guard service August 1980 to September 1999. He died on August [REDACTED], 2014. The Appellant is his surviving spouse. This matter comes to the Board of Veterans' Appeals (Board) on appeal from rating decisions dated November 2013, January 2015, and June 2019 by a Regional Office (RO) of the Department of Veterans Affairs (VA). This matter was remanded in July 2019 for further development, which has been completed. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Service connection for diabetes mellitus type II, atherosclerotic heart disease, bilateral loss of vision, a bilateral leg disability, and neuropathy of the back is denied. In a January 2013 correspondence, the Veteran contended that he developed diabetes mellitus while he was a member of the Puerto Rican National Guard, and that his diabetes caused numerous complications such as heart disease, blindness, and neuropathy of both legs. National Guard duty is distinguishable from other Reserve service in that a member of the National Guard may be called to duty by the governor of their state. "[M]embers of the National Guard only serve the federal military when they are formally called into the military service of the United States; at all other times, National Guard members serve solely as members of the State militia under the command of a state governor." Allen v. Nicholson, 21 Vet. App. 54, 57 (2007). Therefore, to have basic eligibility for Veteran's benefits based on a period of duty as a member of a state National Guard, a member of the National Guard must have been ordered into Federal service by the President of the United States, 10 U.S.C. § 12401, or must have performed "full-time duty" under the provisions of 32 U.S.C. §§ 316, 502, 503, 504, or 505. Id. ACDUTRA is full time duty for training purposes performed by Reservists and members of the National Guard pursuant to 38 U.S.C. §§ 316, 502, 503, 504, or 505. 38 U.S.C. § 101 (22); 38 C.F.R. § 3.6 (c). INACDUTRA includes duty, other than full-time duty, performed for training purposes by Reservists and members of the National Guard pursuant to 38 U.S.C. §§ 316, 502, 503, 504, or 505. 38 U.S.C. § 101 (23); 38 C.F.R. § 3.6 (d). In a November 2012 correspondence, the Veteran stated that diabetes mellitus was discovered in 1984. He stated that in August 1988, he had an acute myocardial infarct. He underwent surgery, which went well until 1994. A May 1994 correspondence from Dr. L.A.R. reflects that the Veteran suffered a heart attack on August 25, 1988, and that he underwent open heart surgery in September 1988. He stated that the Veteran's recovery has been incomplete and that he continued to have shortness of breath. Military personnel records reflect active duty or ACDUTRA from June 23, 1984 July 7, 1984; and from August 24-27, 1984. There are no Line of Duty reports reflecting that diabetes or any of its subsequent complications are duty to active duty or ACDUTRA service. Similarly, none of the subsequent treatment records attribute the Veteran's diabetes or subsequent complications to duty to active duty or ACDUTRA service. The Board recognizes that the Veteran had medical training and would have been competent to render a medical opinion. However, in this case, the Veteran never rendered an opinion linking his diabetes to active duty or ACDUTRA service. He merely noted that diabetes was "discovered" in 1984, while he was a member of the Puerto Rican National Guard. The Veteran submitted a December 2013 medical opinion in which Dr. C.E.M.Q. stated that the Veteran presented with "severe cardiovascular disease, endocrine and psychiatric diseases which are more probably than not secondary to his performance during military service." The examiner provided no rationale to support this opinion. There was no explanation as to whether these disabilities were due to active duty service (July 1963 July 1965) or some incident during National Guard service. He simply noted that "During military service, [the Veteran] suffered many highly stressful circumstances." The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez, 22 Vet. App. at 304; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). The RO obtained a medical opinion in July 2020 regarding the Veteran's coronary artery disease. The examiner found that it was less likely than not that the Veteran's coronary artery disease was incurred in or cause by service. The examiner explained that the Veteran was diagnosed with coronary artery disease in 1988, and there are no service treatment records that would support the proposition that it was caused by service. In the absence of any findings in the service treatment records, or a competent medical opinion linking the Veteran's diabetes and subsequent complications to active duty or ACDUTRA service, the preponderance of the evidence weighs against the claims. As the preponderance of the evidence is against finding that diabetes mellitus type II, atherosclerotic heart disease, bilateral loss of vision, a bilateral leg disability, and neuropathy of the back began during active duty service or ACDUTRA service; the benefit of the doubt doctrine does not apply. Consequently, the claims must be denied. Service connection for a right shoulder disability is denied. In a November 2012 correspondence, the Veteran stated that he injured his right shoulder when he fell on August 28, 1990. He stated that he failed to notify the military even when he was on weekend training. He stated that ever since the injury, he has been able to raise his arm to only 45 degrees forwards and 60 degrees backwards. In an October 2013 correspondence, he stated that he injured his right shoulder while undertaking weekend training at Salinas Training Camp. He stated that he treated himself, and that no Line of Duty (LOD) report was done. The Veteran underwent a VA examination in June 1992. There was no right shoulder disability identified. Likewise, a January 1995 examination yielded normal findings. The Veteran completed a Report of Medical History in conjunction with the each of these examinations. Both times, he denied ever having any bone, joint, or other deformity; any painful or "trick" shoulder; broken bones; or arthritis, rheumatism, or bursitis. In both reports, he described his health as "excellent." A May 2013 sonogram of the right shoulder revealed a massive rotator cuff tear. Military personnel records fail to reflect that the Veteran was on active duty or ACDUTRA on August 28, 1990. Moreover, even if he had been on ACDUTRA on that date, his contention that he has had continuous symptoms are belied by the June 1992 and January 1995 examinations and his own failure to report the disability on his Reports of Medical History. The evidence fails to reflect a right shoulder injury during a period of active duty service or ACDUTRA. Moreover, even had such an injury been shown, the evidence fails to reflect that it resulted in a chronic disability (as evidenced by subsequent normal examinations and Reports of Medical History). In the absence of sufficient evidence to establish that a right shoulder injury occurred while the Veteran was on active duty or ACDUTRA, the preponderance of the evidence weighs against the claim. As the preponderance of the evidence is against finding that a right shoulder disability began during active duty service or ACDUTRA service; the benefit of the doubt doctrine does not apply. Consequently, the claim must be denied. Service connection for abdominal aneurysm and kidney disease is denied. In a November 2012 correspondence, the Veteran stated that he incurred severe abdominal pain while on military duty the weekend of August 28, 1990. He stated that no records were kept, but that same week, at the Episcopal Hospital, an abdominal aneurysm was revealed. He stated that nothing was done, but at a later date (apparently unknown to the Veteran, who stated "on __________") the aneurysm bled. On another unknown date, he underwent an operation to repair it. Six days later, he had another aneurysm, and he went into renal failure. He stated that his recovery was slow and after he was discharged, he was unable to walk. After 6 months of physical therapy, he was able to ambulate with the assistance of a walker. He stated that the renal incapacity has persisted such that he cannot work. A May 2012 CT scan revealed status post abdominal aortic aneurysm repair. There were also bilateral renal cortical cysts noted. The Veteran submitted a December 2013 correspondence in which Dr. C.E.M.Q. stated that in 2009, the Veteran presented aortic abdominal aneurysm, and after surgical procedure, developed pulmonary embolism, acute renal failure and deep vein thrombophlebitis for which revascularization was performed. Military personnel records fail to reflect that the Veteran was on active duty or ACDUTRA the weekend of August 28, 1990. The only period of active duty shown in 1990 is dated June 23, 1990 July 7, 1990. The Veteran underwent a VA examination in June 1992. There was no kidney or abdominal disability identified. Likewise, a January 1995 examination yielded normal findings. The Veteran completed a Report of Medical History in conjunction with the each of these examinations. Both times, he denied ever having any stomach, liver, or intestinal trouble; tumor, growth, or cyst; a rupture/hernia; kidney stone or blood in urine; or lameness. In both reports, he described his health as "excellent." The evidence fails to reflect an abdominal injury or renal disability during a period of active duty service or ACDUTRA. Moreover, even had such an injury been shown, the evidence fails to reflect that it resulted in a chronic disability (as evidenced by subsequent normal examinations and Reports of Medical History). In the absence of sufficient evidence to establish that an abdominal aneurysm or kidney disease occurred while the Veteran was on active duty or ACDUTRA, the preponderance of the evidence weighs against the claim. As the preponderance of the evidence is against finding that an abdominal aneurysm or kidney disease began during active duty service or ACDUTRA service; the benefit of the doubt doctrine does not apply. Consequently, the claims must be denied. Service connection for a psychiatric disability, to include PTSD, generalized anxiety disorder, and major depression is denied. The basis for the Veteran's psychiatric claim is entirely unclear. He submitted a December 2013 medical report in which Dr. C.E.M.Q. stated that during military service, the Veteran "suffered many highly stressful circumstances." The nature of the stressful circumstances is not made clear. Moreover, it is not clear whether these were stressors from the Veteran's active duty service (July 1963 July 1965) or from his service in the National Guard. Dr. C.E.M.Q. nonetheless concluded that the Veteran had "severe cardiovascular disease, endocrine and psychiatric diseases which are more probably than not secondary to his performance during military service." The examiner provided no rationale to support this opinion. In November 2015, the RO contacted the appellant to discern the nature of the stressors. In a December 2015 Statement in Support of the Claim, she stated that she was not going to submit the PTSD Questionnaire because her husband had already died. An August 2016 memorandum reflects a formal finding that there was insufficient information needed to corroborate any psychiatric stressors. Establishing service connection for PTSD requires (1) medical evidence diagnosing PTSD; (2) credible supporting evidence that the claimed in-service stressor actually occurred; and (3) medical evidence of a link between current symptomatology and the claimed in-service stressor. 38 C.F.R. § 3.304(f); see also Cohen v. Brown, 10 Vet. App. 128 (1997). A diagnosis of PTSD must be established in accordance with 38 C.F.R. § 4.125(a), which simply mandates that, for VA purposes, all mental disorder diagnoses must conform to the fourth edition of the American Psychiatric Association's Diagnostic and Statistical Manual for Mental Disorders (DSM-V). See 38 C.F.R. § 3.304(f). If the evidence establishes that the Veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the Veteran's service, the Veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. 38 C.F.R. § 3.304(f)(1). See also 38 U.S.C. § 1154(b). The ordinary meaning of the phrase "engaged in combat with the enemy," as used in 38 U.S.C. § 1154(b), requires that a Veteran have participated in events constituting an actual fight or encounter with a military foe or hostile unit or instrumentality. The issue of whether any particular set of circumstances constitutes engagement in combat with the enemy for purposes of section 1154(b) must be resolved on a case-by-case basis. See VAOPGCPREC 12-99 (October 18, 1999). The Veteran's DD 214 does not reflect any evidence that he was involved in combat, nor has there been any such assertion by either the Veteran or appellant. In order to grant service connection for PTSD to a non-combat Veteran, there must be credible evidence to support the Veteran's assertion that the stressful event occurred. Cohen v. Brown, 10 Vet. App. 128, 142 (1997); Moreau v. Brown, 9 Vet. App. 389, 395396 (1996). If the evidence establishes that the Veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the Veteran's service, the Veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. 38 C.F.R. § 3.304 (f). Subsection 3.304(f)(3) states that, "'fear of hostile military or terrorist activity' means that a Veteran experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the Veteran or others, such as from an actual or potential improvised explosive device; vehicle-imbedded explosive device; incoming artillery, rocket, or mortar fire; grenade; [and] small arms fire." 38 C.F.R. § 3.304 (f). In this case, there have not been any specific stressful events identified, either by the Veteran or the appellant, nor has there been any diagnosis of PTSD that conforms to the DSM-V criteria. The Veteran was screened for PTSD in November 2012. The screening was negative for PTSD. Service treatment records reflect that the Veteran underwent a VA examination in June 1992. There was no psychiatric disability identified. Likewise, a January 1995 examination yielded normal findings. The Veteran completed a Report of Medical History in conjunction with the each of these examinations. Both times, he denied ever having any frequent trouble sleeping, depression or excessive worry, or nervous trouble of any sort. In both reports, he described his health as "excellent." A May 2014 Social Work Assessment reflects that the Veteran exhibited depressive symptoms due to frustration stemming from his physical limitations. A July 2014 Mental Health Diagnostic Study reflects that the Veteran scored a 7 on the PHQ-9 Depression Scale. The examiner noted that the information contained in the note was based on the Veteran's self-report, and was not sufficient for diagnostic purposes. It is not clear that the Veteran was ever diagnosed with any psychiatric disability (at least no diagnosis that would conform to the DSM-V criteria), and no specific stressors have been identified. Dr. C.E.M.Q. listed generalized anxiety disorder, major depressive disease, PTSD, and a sleep disorder among the Veteran's current diagnoses; but he did not explain how he came to diagnose these disabilities. Once again, DSM-V criteria were not used in assessing the Veteran as having these psychiatric disabilities. Moreover, the opinion of Dr. C.E.M.Q., in which he opined that the Veteran's psychiatric diseases are more probably than not secondary to his performance during military service, is not supported by any rationale. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez, 22 Vet. App. at 304; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). In the absence of any identified stressors (or confirmation of those alleged stressors), the absence of any diagnosis, and in the absence of a competent medical opinion linking the Veteran's alleged symptoms to service, the preponderance of the evidence weighs against the claim. As the preponderance of the evidence is against finding that a psychiatric disability disease began during active duty service or ACDUTRA service; the benefit of the doubt doctrine does not apply. Consequently, the claim must be denied. Service connection for the cause of the Veteran's death is denied. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Service connection for the cause of a Veteran's death is warranted if a service-connected disability either caused or contributed substantially or materially to the cause of death. 38 C.F.R. § 3.312. The death of a Veteran will be considered as having been due to a service-connected disability when the evidence establishes that disability was either the principal or a contributory cause of death. 38 C.F.R. § 3.312 (a). A service-connected disability will be considered as the principal, or primary, cause of death when that disability, singly or jointly with some other condition, was the immediate or underlying cause of death or was etiologically related thereto. 38 C.F.R. § 3.312 (b). For a service-connected disability to be the principal cause of death it must singly or with some other condition be the immediate or underlying cause of to be etiologically related. 38 C.F.R. § 3.312 (b). For a service-connected disability to be a contributory cause of death, it must be shown that it contributed substantially or materially; it is not sufficient to show that it casually shared in producing death, rather there must be a causal connection. 38 C.F.R. § 3.312 (c). The Veteran died on August [REDACTED], 2014. The death certificate lists the cause of death as coronary artery disease. In this case, the Veteran's only service-connected disability was his left shoulder rotator cuff tear. The RO obtained a medical opinion in July 2020. The examiner reviewed the claims file, noted that the Veteran's cause of death was coronary artery disease, and found that the Veteran's left shoulder rotator cuff tear could not have caused or contributed substantially to the Veteran's cause of death. The examiner noted that there is no medical linkage between a left shoulder rotator cuff tear and death by coronary artery disease. The weight of the evidence is against a nexus between the Veteran's left shoulder rotator cuff tear and his coronary artery disease. The evidence is not in equipoise and there is no reasonable doubt to be resolved. As the evidence does not show the Veteran's coronary artery disease was incurred in, or is otherwise associated with, active service, a nexus has not been established. As service connection for this disease has not been established, service connection for the cause of the Veteran's death is not warranted either. Increased Ratings Disability evaluations are determined by the application of the Schedule For Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Where, as in the instant case, the appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. See Fenderson v. West, 12 Vet. App. 119 (1999). The RO granted service connection for left shoulder rotator cuff tear in a November 2013 rating decision. An initial 20 percent rating was assigned effective August 13, 2012 under the provisions of 38 C.F.R. 4.71a, Diagnostic Code 5201. Under this regulatory provision, a rating of 20 percent is warrant for minor (non-dominant) arm limited to shoulder level. A 20 percent rating is also warranted for minor (non-dominant) limitation of motion to midway between the side and shoulder level. A 30 percent rating is warranted for minor (non-dominant) arm limitation of motion to 25 degrees from the side. The applicable rating criteria for musculoskeletal disorders, in particular shoulder disabilities, under 38 C.F.R. § 4.71a were amended, effective February 7, 2021. However, the amendments are not applicable in this case because the Veteran died in 2014. When evaluating disabilities of the musculoskeletal system, 38 C.F.R. § 4.40 allows for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements. DeLuca v. Brown, 8 Vet. App. 202 (1995). Further, 38 C.F.R. § 4.45 provides that consideration also be given to weakened movement, excess fatigability and incoordination. The Veteran underwent a VA examination in August 2013. He was identified as right-hand dominant. Consequently, the left shoulder represents that Veteran's minor (or non-dominant) arm. He reported that he experienced flare-ups that impact the functionality of the shoulder when performing overhead activities. Upon examination, the Veteran achieved 100 degrees of forward flexion, with objective evidence of pain at 5 degrees. He achieved 80 degrees of abduction, with objective evidence of pain at 5 degrees. Following three repetitions of motion, there was no change in the range of motion. The examiner noted functional impairment was due to weakened movement, excess fatigability, and pain on movement. He had guarding of the left shoulder. He also had reduced muscle strength (4/5) on flexion and abduction. There was no history of recurrent dislocation (subluxation). The examiner opined that the disability would not impact his ability to work. A higher 30 percent disability rating is not warranted in this case. Such a rating would be warranted when the actual, or functional equivalent of, limitation of shoulder motion is no greater than midway between side and shoulder level. Deluca, 8 Vet. App. at 204-207. While the Veteran reported the presence of pain beginning at 5 degrees, the pain did not functionally limit motion to midway between the side and shoulder level or less. Furthermore, pain is contemplated in the assigned 20 percent evaluation. Therefore, although the Veteran reported functional loss as limitations in reaching overhead during flare-ups, and the examiner noted increased pain, this does not establish limitation of function to midway between the side and shoulder level or less. Furthermore, there was no weakness, fatigue, or decreased range of motion following repetitive motion testing. Moreover, although the examiner addressed the Veteran's flare-ups of his shoulder disability, but failed to estimate a specific range of motion during a flare-up, a remand for another examination for the sole purpose of formal consideration of the holding in Sharp, supra, is inappropriate. The Veteran unfortunately passed away in August 2014. Finally, the Veteran's left shoulder disability did not manifest with ankylosis (Diagnostic Code 5200), subluxation, or fibrous union of the humerus (Diagnostic Code 5202). Consequently, a rating in excess of 20 percent is not warranted. Entitlement to special monthly compensation (SMC) based on the need for aid and attendance or on housebound status is denied. The appellant seeks compensation based on need of the regular aid and attendance of another or housebound status. For the reasons that follow, the Board finds that SMC based on aid and attendance or housebound status is not warranted. 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 be in need of 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 and attendance; constant need for aid and attendance is not required. 38 C.F.R. § 3.352 (a). SMC is also payable at the housebound rate where the Veteran has a single service-connected disability rated as 100 percent and, in addition: (1) has a service-connected disability or disabilities independently ratable at 60 percent, separate and distinct from the 100 percent service-connected disability, and involving different anatomical segments or bodily systems, or (2) is permanently housebound by reason of service-connected disability or disabilities. 38 U.S.C. § 1114 (s); 38 C.F.R. § 3.350 (i). The requirement of "permanently housebound" status will be considered to have been met when the Veteran is substantially confined to his house (or ward or clinical areas, if institutionalized) or immediate premises due to disability or disabilities which it is reasonably certain will remain throughout his lifetime. See 38 U.S.C. § 1502 (c); 38 C.F.R. § 3.351 (d)(2). The Veteran was service-connected for a left rotator cuff tear, rated as 20 percent disabling. In support of this claim, the Veteran submitted a December 2013 medical report from Dr. C.E.M.Q., who found that the Veteran was 100 percent disabled and unable to work. He found that the Veteran needed 24/7 aid and attendance for his primary care and daily duties. Dr. C.E.M.Q. diagnosed the Veteran with hypertensive cardiovascular disease; coronary artery disease status post coronary artery bypass graft; myocardial infarction; angina pectoris; cardiac arrhythmia; left eye central artery thrombosis with blindness; diabetes mellitus type II; diabetic neuropathy; diabetic neuropathy of both lower limbs; bilateral lymphedema of the lower limbs; left eye blindness; abdominal aortic aneurysm; chronic myositis of the cervical/thoracic spines; degenerative joint disease of both shoulders; intermittent claudication of both lower limbs; generalized anxiety disorder; major depressive disease; PTSD; and a sleep disorder. He noted that the Veteran was a diabetic patient who complained of lower limb numbness, tingling, cramps, weakness, sensorial loss, and severe pain. He stated that he used a walker. He also stated that the Veteran had pain and weakness in both shoulders. He also had weakness and decreased range of motion in his neck and upper back, with numbness, tingling, cramps, and pain. He also had anxiety, irritability, mild sadness, intense feelings of guilt, worthlessness, hopelessness, loss of interest, with diminished involvement in work and recreation, inability to concentrate and lack of decisiveness, insomnia, and nightmares. The evidence supports the contention that the Veteran was in need of aid and attendance. However, the evidence fails to reflect that the Veteran was in need of aid and attendance due to service-connected disabilities. There is no evidence that suggests that the Veteran was in need of aid and attendance, or that he was housebound due solely to his service connected left shoulder rotator cuff tear. Upon review of the evidence, the Board finds that the Veteran does not qualify for SMC based on the need for aid and attendance or housebound status. The record does not contain any competent medical evidence that the Veteran's service-connected disability, alone, rendered him physically helpless in the performance of the activities of daily living or in protecting himself from the everyday hazards and dangers incident to his environment. As it pertains to housebound status, the Veteran did not have a single service-connected disability rated as total (i.e. 100 percent) with additional service-connected disabilities independently ratable at 60 percent. 38 U.S.C. § 1114(s); 38 C.F.R. § 3.350 (i)(1). The Veteran's only service-connected disability is rated as 30 percent disabling. Thus, he is not entitled to SMC at the housebound rate. Additionally, the evidence does not show that the Veteran was substantially confined to his dwelling or home due to his service-connected disability. 38 C.F.R. § 3.350 (i)(2). The Board acknowledges the Veteran was competent to report those symptoms which are capable of lay observation and describe his physical limitations. See Kahana v. Shinseki, 24 Vet. App. 428, 438 (2011). The Board acknowledges that the Veteran's various health conditions and disabilities impacted his life and limited his ability to do all of the things he would like to do. However, the treatment records fail to show that symptoms from his service-connected left shoulder rotator cuff tear resulted in the need for aid and attendance of another person or render him housebound. The evidence does not show that the Veteran's service-connected disability resulted in his inability to perform activities of daily living or to protect himself in his daily environment. 38 C.F.R. § 3.352 (a). As the most probative evidence shows that the Veteran's service-connected disability did not result in the need of aid and attendance, nor was he housebound as a result of it, the preponderance of the evidence is against the claim. The benefit of the doubt doctrine is not for application and the claim must be denied. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Entitlement to a TDIU is denied. In order to establish service connection for a total rating based upon individual unemployability due to service-connected disability, there must be an impairment so severe that it is impossible to follow a substantially gainful occupation. See 38 U.S.C. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16. In reaching such a determination, the central inquiry is "whether the Veteran's service connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). For VA purposes, the term "unemployability" is synonymous with an inability to secure and follow a substantially gainful occupation. VAOPGPREC 75-91; 57 Fed. Reg. 2317 (1992). Consideration may be given to the Veteran's level of education, special training, and previous work experience in arriving at a conclusion, but not to his age or to the impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19. The phrase "unable to secure and follow a substantially gainful occupation" contains both economic and noneconomic components. Ray v. Wilkie, 31 Vet. App. 58, 73 (2019). The economic component simply means an occupation earning more than marginal income (outside of a protected environment) as determined by the U.S. Department of commerce as the poverty threshold for one person. Id. The noneconomic component requires a determination as to a Veteran's ability to secure and follow such employment. Id. Attention should be given to the Veteran's history, education, skills, and training; whether the Veteran has the physical ability (both exertional and non-exertional) to perform the types of activities required by the occupation at issue (e.g., lifting, bending, sitting, standing, walking, climbing, as well as auditory and visual limitations); and whether the Veteran has the mental ability to perform the activities required by the occupation at issue (e.g., memory, concentration, ability to adapt to change, handle work place stress, get along with coworkers, and demonstrate reliability and productivity). Id. VA regulations establish objective and subjective standards for an award of total rating based on unemployability. When the Veteran's schedular rating is less than total (for a single or combination of disabilities), a total rating may nonetheless be assigned provided that if there is only one service-connected disability, this disability shall be rated at 60 percent or more. When there are two or more disabilities, at least one disability must be ratable at 40 percent or more, and any additional disabilities must result in a combined rating of 70 percent or more, and the disabled person must be unable to secure or follow a substantially gainful occupation. See 38 C.F.R. § 4.16(a). A total disability rating may also be assigned on an extra-schedular basis, pursuant to the procedures set forth in 38 C.F.R. § 4.16(b), for Veterans who are unemployable by reason of service-connected disabilities, but who fail to meet the percentage standards set forth in section 4.16(a). Thus, the Board must evaluate whether there are circumstances, apart from any non-service-connected conditions and advancing age, which would justify a total rating based on unemployability. A TDIU claim is an alternate way to obtain a total disability rating without recourse to a 100 percent evaluation under the rating schedule. See Parker v. Brown, 7 Vet. App. 116, 118 (1994). Consequently, the Board must determine whether the Veteran's service-connected disabilities preclude him from engaging in substantially gainful employment (work that is more than marginal, which permits the individual to earn a "living wage"). Moore v. Derwinski, 1 Vet. App. 356 (1991). The fact that a Veteran may be unemployed or has difficulty obtaining employment is not determinative. The ultimate question is whether the Veteran, because of service-connected disability, is incapable of performing the physical and mental acts required by employment, not whether he can find employment. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). An inability to work due to advancing age may not be considered. 38 C.F.R. §§ 3.341 (a), 4.19. In making its determination, VA considers such factors as the extent of the service-connected disability, and employment and educational background. See 38 C.F.R. §§ 3.340, 3.341, 4.16(b), 4.19. The Veteran was service-connected for a left shoulder rotator cuff tear, evaluated as 20 percent disabling. His combined rating therefore was 30 percent. See 38 C.F.R. § 4.25. Thus, the Veteran did not meet the schedular requirements for a total disability rating based on individual unemployability due to service-connected disabilities under 38 C.F.R. § 4.16(a). However, the Board must still determine whether the Veteran's service-connected disabilities resulted in impairment so severe that it was impossible to follow a substantially gainful occupation. The Board emphasizes that a total rating based on individual unemployability is limited to consideration of service-connected disabilities. Following a full and thorough review of the evidence of record, the Board concludes that the preponderance of the evidence is against the Veteran's claim of entitlement to a TDIU. The evidence does not demonstrate that the Veteran was unable to secure or follow a substantially gainful occupation solely by reason of his service-connected disability. The evidence consists of treatment reports reflecting that the Veteran was being treated for a large number of disabilities, only one of which was service-connected. As noted above, the Veteran submitted a December 2013 medical report from Dr. C.E.M.Q. in which he found that the Veteran was 100 percent disabled and unable to work. However, C.E.M.Q. found that the Veteran was unable to work as a result of his numerous disabilities. He did not render an opinion regarding whether the Veteran would be unable to work due solely to his service-connected left shoulder rotator cuff tear. Consequently, there is no persuasive evidence of record demonstrating or suggesting that the Veteran was unemployable as a result of his service-connected disabilities. In sum, there is no persuasive evidence of record demonstrating that the Veteran's service-connected left shoulder rotator cuff tear, alone, rendered him unable to obtain and retain substantially gainful employment, nor is the evidence in a state of equipoise on that question. As such, entitlement to a TDIU is denied. D. JOHNSON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Prem, 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.