Citation Nr: 21067064 Decision Date: 11/03/21 Archive Date: 11/03/21 DOCKET NO. 14-01 908 DATE: November 3, 2021 ORDER Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder and depressive disorder, is granted. Entitlement to an evaluation for type II diabetes mellitus in excess of 20 percent is denied. Entitlement to service connection for diabetic nephropathy as secondary to service-connected diabetes mellitus type II is granted. Entitlement to an evaluation in excess of 10 percent for peripheral neuropathy of the left upper extremity is denied. Entitlement to an evaluation in excess of 10 percent for peripheral neuropathy of the right upper extremity is denied. Entitlement to an evaluation in excess of 40 percent for left lower extremity peripheral vascular disease is denied. Entitlement to an evaluation in excess of 40 percent for right lower extremity peripheral vascular disease is denied. Entitlement to an evaluation in excess of 20 percent for peripheral neuropathy of the left lower extremity, prior to August 25, 2017, and 40 percent thereafter is denied. Entitlement to an evaluation in excess of 20 percent for peripheral neuropathy of the right lower extremity, prior to August 25, 2017, and 40 percent thereafter is denied. Prior to August 25, 2017, entitlement to a disability rating of 70 percent, but no higher, for an acquired psychiatric disorder, to include PTSD and depressive disorder is granted. Beginning August 25, 2017, entitlement to a disability rating in excess of 70 percent for an acquired psychiatric disorder, to include PTSD and depressive disorder, is denied. Entitlement to a total disability rating based on individual unemployability (TDIU) based on a single disability is granted. Entitlement to special monthly compensation based on housebound status (SMC(s)) is granted. Entitlement to special monthly compensation at the aid and attendance rate (SMC(l)) based on loss of use of the bilateral feet is granted. Entitlement to specially adapted housing (SAH) is granted. Entitlement to a special home adaptation (SHA) grant is denied. REMANDED Entitlement to service connection for hepatitis C, liver cirrhosis, or other hepatic disease, to include as secondary to diabetes mellitus type II, is remanded. REFERRED The issues of entitlement to service connection for a back condition, a right knee condition, an ankle condition, and chronic obstructive pulmonary disease (COPD) have been raised in the record, as acknowledged below in a July 2015 Deferred Rating Decision, apparently without any subsequent action taken, to date; as such, these issues are referred to the Agency of Original Jurisdiction (AOJ) for adjudication. FINDINGS OF FACT 1. The Veteran's diagnosed depressive disorder is secondary to his service-connected disabilities, to include PTSD. 2. During the period on appeal, the Veteran's diabetes mellitus type II did not require regulation of activities. 3. The Veteran has currently diagnosed diabetic nephropathy that is secondary to his service-connected diabetes mellitus type II. 4. The Veteran's left upper extremity diabetic peripheral neuropathy presents with motor and sensory examination within normal limits, and symptoms of mild intermittent pain, mild numbness, and mild tingling, with decreased sensation to light touch testing, decreased position sense vibration sensation, and decreased cold sensation with no atrophy or trophic changes best approximated as mild incomplete paralysis of the median nerve. 5. The Veteran's right upper extremity diabetic peripheral neuropathy presents with motor and sensory examination within normal limits, and symptoms of mild intermittent pain, mild numbness, and mild tingling, with decreased sensation to light touch testing, decreased position sense vibration sensation, and decreased cold sensation with no atrophy or trophic changes best approximated as mild incomplete paralysis of the median nerve. 6. The Veteran's right lower extremity PVD results in symptoms of claudication on walking between 25 and 100 yards on a level grade at 2 miles per hour, persistent coldness of the extremities, and trophic changes, bilaterally, with ABI testing of 0.86, without 7. The Veteran's left lower extremity PVD results in symptoms of claudication on walking between 25 and 100 yards on a level grade at 2 miles per hour, persistent coldness of the extremities, and trophic changes, bilaterally, with ABI testing of 1.02. 8. Prior to August 25, 2017, the Veteran's left lower extremity diabetic peripheral neuropathy disability was primarily manifest by trophic changes, sensory disturbance, slight loss of reflexes, and pain, without significant impairment of motor functions, muscle atrophy, or complete paralysis, approximated as causing moderate incomplete paralysis to the sciatic nerve; for the subsequent period, the amputation rule (38 C.F.R. § 4.68) bars any increase as the Veteran is already in receipt of right lower extremity ratings equivalent to amputation at the elective level. 9. Prior to August 25, 2017, the Veteran's right lower extremity diabetic peripheral neuropathy disability is primarily manifest by trophic changes, sensory disturbance, slight loss of reflexes, and pain, without significant impairment of motor functions, muscle atrophy, or complete paralysis, approximated as causing moderate incomplete paralysis to the sciatic nerve; for the subsequent period, the amputation rule (38 C.F.R. § 4.68) bars any increase as the Veteran is already in receipt of right lower extremity ratings equivalent to amputation at the elective level. 10. Prior to August 25, 2017, the Veteran's symptoms attributable to his acquired psychiatric disorder, to include PTSD and depressive disorder were productive of occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood; the symptoms were not productive of complete social impairment. 11. For the period on appeal after August 25, 2017, the Veteran's acquired psychiatric disorder, to include PTSD and depressive disorder, was not productive of complete social impairment. 12. The symptoms of the Veteran's service-connected psychiatric disorder, alone, are productive of unemployability (TDIU). 13. The Veteran TDIU is based on a single disability and he has additional disabilities rated at 60 percent or more; accordingly, entitlement to statutory housebound SMC(s) is established. 14. The symptoms of the service-connected bilateral lower extremity disabilities, to include PVD, diabetic peripheral neuropathy, and foot disabilities result in loss of use of the bilateral feet; accordingly special monthly compensation at the aid and attendance rate based on loss of use of the bilateral feet, SMC(l), is warranted; the grant of SMC(l) for loss of use of the bilateral feet renders the issue of whether such symptoms also create the need for aid and attendance moot; the Veteran's bilateral upper extremity diabetic peripheral neuropathy symptoms are not significant and do not render him in need of aid and attendance. 15. For the purposes of SAH, the Veteran's service-connected bilateral lower extremity PVD, diabetic peripheral neuropathy, and foot disabilities necessitate regular and constant use of a wheelchair, braces, crutches, or canes as a normal mode of locomotion although occasional locomotion by other methods may be possible. 16. A grant of SHA is precluded as a matter of law due to the grant of SAH. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder and depressive disorder, have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 2. The criteria for entitlement to an evaluation in excess of 20 percent for type II diabetes mellitus have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.119, Diagnostic Code 7913. 3. The criteria for service connection for a separate evaluation for diabetic nephropathy as secondary to service-connected diabetes mellitus type II have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310, 4.115b, Diagnostic Code 7541. 4. The criteria for entitlement to an evaluation in excess of 10 percent for peripheral neuropathy of the left upper extremity have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8516. 5. The criteria for entitlement to an evaluation in excess of 10 percent for peripheral neuropathy of the right upper extremity have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8516. 6. The criteria for entitlement to an evaluation in excess of 40 percent for left lower extremity peripheral vascular disease have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.114, Diagnostic Code 7114. 7. The criteria for entitlement to an evaluation in excess of 40 percent for right lower extremity peripheral vascular disease have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.114, Diagnostic Code 7114. 8. The criteria for entitlement to an evaluation in excess of 20 percent for peripheral neuropathy of the left lower extremity, prior to August 25, 2017, and 40 percent thereafter have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.68, 4.124a, Diagnostic Code 8520. 9. The criteria for entitlement to an evaluation in excess of 20 percent for peripheral neuropathy of the right lower extremity, prior to August 25, 2017, and 40 percent thereafter have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.68, 4.124a, Diagnostic Code 8520. 10. For the period on appeal prior to August 25, 2017, the criteria for a disability rating of 70 percent, but no higher, for an acquired psychiatric disorder, to include PTSD and depressive disorder have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411. 11. For the period on appeal after August 25, 2017, the criteria for a disability rating in excess of 70 percent for an acquired psychiatric disorder, to include PTSD and depressive disorder have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411. 12. The criteria for entitlement to a TDIU based on a single disability have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.15, 4.16. 13. The criteria for special monthly compensation based on statutory housebound status have been met. 38 U.S.C. §§ 1114, 5107; 38 C.F.R. §§ 3.350, 3.352. 14. The criteria for entitlement to special monthly compensation at the aid and attendance rate based on loss of use of the bilateral feet (SMC(l)) have been met. 38 U.S.C. §§ 1114, 5107; 38 C.F.R. §§ 3.350, 3.352. 15. The criteria for entitlement to specially adapted housing (SAH) have been met. 38 U.S.C. §§ 2101, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.809. 16. The criteria for entitlement to a special home adaptation (SHA) grant are denied as a matter of law. 38 C.F.R. § 3.809a(a). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had honorable active duty service in the United States Army from April 1970 to April 1972, and May 1972 to September 1978. The issues came to the Board of Veterans' Appeals (Board) from a September 2015 Rating Decision. In March 2018, the Veteran participated in a Video Conference hearing before the undersigned Veterans Law Judge (VLJ), a transcript of which is of record. In May 2018, the Board remanded the matter for further development. During the pendency of the appeal, service connection for hypertension was granted and is thus no longer an issue on appeal. Insofar as the increased rating claims are concerned, although there were increases granted during the pendency of the appeal, as the maximum benefit was not assigned for all periods within appellate review these issues remain before the Board. The Board has modified the issue of entitlement to an increased rating for PTSD to reflect the grant of service connection for depressive disorder; the decision below contemplates all psychiatric symptoms for all periods, as the evidence shows the symptoms attributable to each are indistinguishable. As the Veteran was granted a TDIU below on the basis of multiple disabilities, and entitlement to SMC is a question before the Board, the issue as to whether the Veteran is entitled to a TDIU based on a single disability is before the Board. Service connection 1. Entitlement to service connection for depressive disorder as secondary to service-connected disabilities is granted. The Veteran seeks service connection for a depressive disorder. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease incurred in service. 38 C.F.R. § 3.303(d). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310. In the June 2021 VA medical opinion, the examiner noted the Veteran's symptoms met the DSM-5 diagnostic criteria for Unspecified Depressive Disorder. The examiner opined that the claimed condition was at least as likely as not proximately due to or the result of the Veteran's declining health conditions which interfere with social and occupational functioning. The examiner further opined that the symptoms attributable to this condition could not be distinguished from his service-connected PTSD symptoms. The VA examiner's opinion is accepted as competent evidence as to the nature and etiology of the psychiatric conditions; accordingly, service connection for unspecified depressive disorder as secondary to service-connected disabilities is granted. It is noted that the Veteran's depressed symptoms were previously attributed to his PTSD, and the grant of service connection for an additional mental disorder does not entitle the Veteran to two mental disorder ratings. Granting separate ratings for multiple psychiatric diagnoses would result in pyramiding, contrary to the provisions of 38 C.F.R. § 4.14, as a veteran may not be compensated twice for the same symptomatology as "such a result would overcompensate the claimant for the actual impairment of his earning capacity." See Brady v. Brown, 4 Vet. App. 203, 206 (1993). Rather, this grant will result in a single rating for an acquired psychiatric disorder, to include PTSD and depressive disorder, under the General Formula for Mental Disorders, as noted below. Increased Rating Claims 2. Entitlement to an evaluation for diabetes mellitus type II in excess of 20 percent is denied. 3. Entitlement to service connection for diabetic nephropathy as secondary to service-connected diabetes mellitus type II is granted. The Veteran contends that he is entitled to a higher rating for his diabetes due to restriction of activities. At the March 2018 hearing, the Veteran testified he was restricted in his activities as well as his diet. Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. Part IV. If two evaluations are potentially applicable, 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. When reasonable doubt arises as to the degree of disability, such doubt will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. Diagnostic Code 7913 provides a structured scheme of specific, successive, cumulative criteria. Each higher rating includes the same criteria as the lower rating plus distinct new criteria. Middleton v. Shinseki, 727 F.3d 1172, 1178 (Fed. Cir. 2013). A 10 percent rating is warranted when diabetes is manageable by restricted diet only. A 20 percent rating is warranted when diabetes requires one or more daily injection of insulin and restricted diet, or an oral hypoglycemic agent and restricted diet. A 40 percent rating is warranted when it requires one or more daily injection of insulin, restricted diet, and regulation of activities. Regulation of activities is defined as avoidance of strenuous occupational and recreational activities. A 60 percent rating is warranted when diabetes requires one or more daily injection of insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if separately evaluated. A 100 percent rating is warranted when diabetes requires more than one daily injection of insulin, restricted diet, and regulation of activities, with episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider, plus either progressive loss of weight and strength or complications that would be compensable if separately evaluated. Compensable complications of diabetes are evaluated separately unless they are part of the criteria used to support a 100-percent evaluation. Noncompensable complications of diabetes are considered part of the diabetic process. 38 C.F.R. § 4.119, Diagnostic Code 7913 (Note 1). Because Diagnostic Code 7913 contains successive criteria, the criteria for the lower rating must be met before a higher disability rating may be awarded. A higher rating cannot be granted based on a finding that the Veteran's disability picture more nearly approximates the criteria for the next higher rating. However, reasonable doubt regarding the presence of a criterion may be resolved in the Veteran' favor. Johnson v. Wilkie, 30 Vet. App. 245 (2018). As the Veteran is seeking a greater than 20 percent evaluation, the question in this appeal is whether the Veteran's diabetes mellitus required regulation of activities. Regulation of activities is defined as avoidance of strenuous occupational and recreational activities. This criterion requires medical evidence. Camacho v. Nicholson, 21 Vet. App. 360, 364-65 (2007). At the time of the prior remand, the medical evidence associated with record did not establish that regulation of activities was required for the management of the Veteran's diabetes mellitus. See May 2014, August 2017, and December 2017 VA examinations. Subsequently, the February 2020, June 2020, and January 2021 VA examinations both noted the Veteran's diabetes mellitus type II required more than one injection per day but did not require regulation of activities as part of medical management of his diabetes disability. These findings are uncontradicted by competent medical evidence. The Veteran is competent to report reduction in activities. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). However, the medical evidence of record is against a finding that regulation of activities was medically required during the period on appeal. Because regulation of activities is required for any rating in excess of 20 under the rating criteria, the criteria for an increased rating in excess of 20 percent remains denied on appeal. However, a separate rating is warranted for renal involvement. The competent medical evidence shows that the Veteran has been diagnosed with diabetic nephropathy. See February 2020 VA examination. During this examination, signs of some edema, generalized poor health due to renal dysfunction, and weakness due to renal dysfunction were noted. Renal involvement in diabetes mellitus warrants a separate rating. See 38 C.F.R. § 4.115b, Diagnostic Code 7541. As such, service connection for diabetic nephropathy is accordingly granted. The Agency of Original Jurisdiction (AOJ) will assign the effective date for service connection for diabetic nephropathy and determine the appropriate rating in the first instance. The other complications attributable to diabetes mellitus noted in the record -- diabetic peripheral neuropathy and hypertension have already been assigned separate evaluations. The ratings assigned for diabetic peripheral neuropathy are discussed below; the rating assigned to hypertension is not presently on appeal. 4. Entitlement to an evaluation in excess of 10 percent for peripheral neuropathy of the left upper extremity is denied. 5. Entitlement to an evaluation in excess of 10 percent for peripheral neuropathy of the right upper extremity is denied. The Veteran contended at the March 2018 hearing that his symptoms of his bilateral upper extremity peripheral neuropathy conditions had worsened and endorsed loss of feeling in his hands. The Veteran's bilateral upper extremity peripheral neuropathy has been evaluated by analogy to in accordance with the criteria set forth in 38 C.F.R. § 4.124a, Diagnostic Code 8516 for the ulnar nerve. Under these criteria, mild incomplete paralysis is rated as 10 percent disabling for both the major and minor extremity. Moderate incomplete paralysis is rated as 30 for the major extremity and 20 for the minor extremity. Severe incomplete paralysis is rated as 40 for the major extremity and 30 for the minor extremity. Complete paralysis of the ulnar nerve includes the "griffin claw" deformity, due to flexor contraction of ring and little fingers, atrophy very marked in dorsal interspace and thenar and hypothenar eminences; loss of extension of ring and little fingers cannot spread the fingers (or reverse), cannot adduct the thumb; flexion of wrist weakened is rated at 60 percent for the major extremity and 50 percent for the minor extremity. 38 C.F.R. § 4.124a. The words "mild," "moderate," and "severe" as used in the various Diagnostic Codes are not defined in the Rating Schedule. Regulations provide that ratings for peripheral neurological disorders are to be assigned based the relative impairment of motor function, trophic changes, or sensory disturbance. 38 C.F.R. § 4.120. Consideration is also given for loss of reflexes, pain, and muscle atrophy. See 38 C.F.R. §§ 4.123, 4.124. The term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating is for the mild, or at most, the moderate degree. The disability ratings for the peripheral nerves are for unilateral involvement; when bilateral, the ratings combine with application of the bilateral factor. 38 C.F.R. § 4.124a, Note at "Diseases of the Peripheral Nerves." The Note to 38 C.F.R. § 4.124a establishes a maximum disability rating for conditions that are wholly sensory, as opposed to a minimum disability rating for conditions that are more than wholly sensory. See Miller v. Shulkin, 28 Vet. App. 376 (2017). Previously, due to the Veteran's testimony and contentions of worsening (which were noted not to be reflected in the evidence of record), a new VA examination was ordered by the Board. Subsequently, during the February 2020 VA examination, the examiner confirmed diagnoses of bilateral upper extremity diabetic peripheral neuropathy. The findings were the same, bilaterally, regarding symptoms. The examiner noted that motor and sensory examination was within normal limits. The examiner noted symptoms of mild intermittent pain, numbness, and tingling. Strength and deep tendon reflexes were normal. Light touch testing was decreased for the shoulders, forearms, hands, and fingers; position sense vibration sensation, and cold sensation were also decreased. There was no atrophy or trophic changes. The examiner approximated the conditions being equivalent to mild incomplete paralysis of the median nerve and noted that the conditions would cause difficulty with repetitive motion. The findings on the most recent examination are not contradicted by the medical evidence of record. The prior examinations of record, to include those conducted in June 2013, April 2014, and September 2017 noted no symptoms or at worst, mild symptoms, bilaterally, and did not estimate impairment at more than a mild level. The February 2020 examiner's findings regarding the severity and extent of the symptoms are accepted and adopted as factual and representative of the period on appeal. The February 2020 examiner's estimation of the degree of severity as being no more than mild and equivalent nerve group involvement is also accepted. The Board acknowledges the lay assertions of sensory disturbance. However, the Board finds the medical of evidence of record as to the degree of such to be more probative because this is a question requiring medical expertise and knowledge as to the various presentations of the conditions. The Board acknowledges the argument in the September 2021 Post-Remand Brief that the VA examination was inadequate, but as no specific explanation was advanced in support of this contention, it does not need to be further addressed. The Board has considered all other potentially applicable Diagnostic Codes; changing these ratings to Diagnostic Code 8515 for the median nerve would not warrant an increase, as mild incomplete paralysis of the median nerve is also rated at 10 percent for the major or minor arm. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's claim for a rating in excess of 10 percent for peripheral neuropathy of either upper extremity. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 6. Entitlement to an evaluation in excess of 40 percent for peripheral vascular disease of the left lower extremity is denied. 7. Entitlement to an evaluation in excess of 40 percent for peripheral vascular disease of the right lower extremity is denied. The Veteran contends he should be awarded an increased evaluation for each of his bilateral lower extremity peripheral vascular disease (PVD) ratings. Each lower extremity has been assigned a 40 percent evaluation for this condition under Diagnostic Code 7114. Under Diagnostic Code 7114, a 20 percent disability rating is assigned for claudication on walking more than 100 yards, and; diminished peripheral pulses or ankle/brachial index of 0.9 or less. A 40 percent rating is assigned for claudication on walking between 25 and 100 yards on a level grade at two miles per hour; and, trophic changes (thin skin, absence of hair, dystrophic nails) or ankle/brachial index (ABI) of 0.7 or less. A 60 percent rating is assigned for claudication on walking less than 25 yards on a level grade at two miles per hour; and, either persistent coldness of the extremity or ABI of 0.5 or less. A rating of 100 percent is assigned for ischemic limb pain at rest; and, either deep ischemic ulcers or ABI of 0.4 or less. 38 C.F.R. § 4.114, Diagnostic Code 7114. The notes associated with Diagnostic Code 7114 are as follows: (1): the ankle/brachial index is the ratio of the systolic blood pressure at the ankle (determined by Doppler study) divided by the simultaneous brachial artery systolic blood pressure (the normal index is 1.0 or greater); (2) evaluate residuals of aortic and large arterial bypass surgery or arterial graft as arteriosclerosis obliterans; and (3) these evaluations are for involvement of a single extremity; if more than one extremity is affected, evaluate each extremity separately and combine (under § 4.25) using the bilateral factor (§ 4.26), if applicable. 38 C.F.R. § 4.104, Diagnostic Code 7114. Previously, due to the Veteran's contentions of worsening, a new VA examination was ordered by the Board. During the February 2020 VA examination, the examiner confirmed a diagnosis of PVD, for which the Veteran had not underwent surgery; the Veteran reported worsening symptoms, with current symptoms of leg pain, swelling, discolored and dry scaly skin. The Veteran did not report taking any medication. The severity of the current signs and symptoms were noted to be claudication on walking between 25 and 100 yards on a level grade at 2 miles per hour, persistent coldness of the extremities, and trophic changes, bilaterally. The Veteran was noted to use a cane and scooter for the condition to assist with mobility. ABI testing for right ankle was 0.86; left ankle was 1.02. The prior August 2015 VA examination does not show symptoms of greater severity with regards to findings relevant for the rating criteria; the August 2017 VA examination contains findings that are less favorable to the Veteran, as claudication is noted on walking more than 100 yards. No VA examination found ischemic ulcers, ischemic limb pain at rest, or an ABI of 0.5 or less, nor is such shown in the other medical evidence of record. The findings of the February 2020 VA examination are comprehensive and adequate, and documented a worsening condition and are adopted as representative of the entirety of the period on appeal. Applying the February 2020 VA examination findings most favorable to the Veteran to the rating criteria, the Board finds that an increased evaluation to 60 or 100 percent is still not warranted. The competent evidence does not establish the Veteran's PVD causes claudication on walking less than 25 yards on a level grade at two miles per hour, or ischemic limb pain at rest with deep ischemic ulcers or an ABI of 0.4 or less. 38 C.F.R. § 4.114, Diagnostic Code 7114. The Board acknowledges the argument in the September 2021 Post-Remand Brief that the VA examination was inadequate, but as no specific explanation was advanced in support of this contention, it does not need to be further addressed. 8. Entitlement to an evaluation in excess of 20 percent prior to August 25, 2017, and in excess of 40 percent thereafter for peripheral neuropathy of the left lower extremity (sciatic nerve) is denied. 9. Entitlement to an evaluation in excess of 20 percent prior to August 25, 2017, and in excess of 40 percent thereafter for peripheral neuropathy of the right lower extremity (sciatic nerve) is denied. The Veteran seeks a higher evaluation for the sciatic nerve peripheral extremity ratings assigned to the bilateral lower extremities. Paralysis of the sciatic nerve is evaluated in accordance with the criteria set forth in 38 C.F.R. § 4.124a, Diagnostic Code 8520. Under these criteria, mild incomplete paralysis is rated as 10 percent disabling. Moderate incomplete paralysis is rated as 20 percent disabling. Moderately severe incomplete paralysis is rated as 40 percent disabling. Severe incomplete paralysis, with marked muscular atrophy is rated as 60 percent disabling. Complete paralysis, with the foot dangles and drops, no active movement possible of muscles below the knee, flexion of knee weakened or (very rarely) lost is rated as 80 percent disabling. 38 C.F.R. § 4.124a. The words "mild," "moderate," and "severe" as used in the various Diagnostic Codes are not defined in the Rating Schedule. Regulations provide that ratings for peripheral neurological disorders are to be assigned based the relative impairment of motor function, trophic changes, or sensory disturbance. 38 C.F.R. § 4.120. Consideration is also given for loss of reflexes, pain, and muscle atrophy. See 38 C.F.R. §§ 4.123, 4.124. The term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating is for the mild, or at most, the moderate degree. The disability ratings for the peripheral nerves are for unilateral involvement; when bilateral, the ratings combine with application of the bilateral factor. 38 C.F.R. § 4.124a, Note at "Diseases of the Peripheral Nerves." The Note to 38 C.F.R. § 4.124a establishes a maximum disability rating for conditions that are wholly sensory, as opposed to a minimum disability rating for conditions that are more than wholly sensory. See Miller v. Shulkin, 28 Vet. App. 376 (2017). During the initial period on appeal, there are several relevant records for this claim. In a July 2007 sensory nerve conduction study, numbness in the feet was noted as the reason for the study. The studies were noted to be compatible with a mild early sensorimotor peripheral neuropathy affecting the lower extremities. During the June 2013 VA examination, the Veteran was noted to have severe constant pain related to diabetic peripheral neuropathy of the bilateral lower extremities. He had severe paresthesias and/or dysesthesias, and severe numbness. Strength was noted to be decreased for knee flexion and ankle dorsiflexion. Deep tendon reflexes were absent for the knees and decreased for the ankles. Light touch/monofilament testing showed decreased sensation in the feet and toes. Vibration sensation was decreased; cold sensation was absent. No atrophy was noted, but trophic changes of loss of hair growth and smooth shiny skin were noted. The examiner estimated such as causing moderate incomplete paralysis to the sciatic nerve, bilaterally. During the April 2014 VA examination, the Veteran reported numbness in his toes and the bottom of his feet. He reported neuropathy having an onset prior to developing diabetes mellitus and reported taking gabapentin for the condition. The examiner noted mild constant pain affecting the bilateral lower extremities, mild paresthesias and/or dysesthesias, and mild numbness. Muscle strength was normal with the exception of ankle plantar flexion and dorsiflexion, which were evaluated as less than normal strength, bilaterally. Deep tendon reflexes were normal with the exception of the bilateral ankles, noted to be decreased, bilaterally. Light tough/monofilament testing showed normal results at the knees and thighs, but decreased at the ankles, lower legs, feet, and toes. Position sense was normal; vibration sensation was decreased; cold sensation was decreased. There was no atrophy or trophic changes. The condition was noted to cause pain with walking and standing. During the August 25, 2017 VA examination, the Veteran reported continuing to have sharp, shooting pain in his feet and legs requiring the use of gabapentin. The Veteran was noted to have severe constant pain affecting the bilateral extremities, moderate paresthesias and/or dysesthesias, and severe numbness. The Veteran's muscle strength testing results were all normal; deep tendon reflexes were decreased for the knee and ankle. Light touch/monofilament testing was decreased for the for the knee and thigh; and absent for the ankle, lower leg, feet, and toes. Position sense and vibration sensation were normal. No atrophy was noted; the Veteran had trophic changes of smooth shiny hairless skin on the lower legs. The clinician estimated the severity of the conditions as being moderately severe incomplete paralysis of the sciatic nerve, bilaterally, and severe incomplete paralysis of the femoral nerve, bilaterally. It was noted that 2007 EMG studies showed mild sensorimotor peripheral neuropathy. The Veteran's dexterity was noted to be impaired as well as his ability to ambulate. The examiner specifically noted there was a worsening of the symptoms. On review, the most favorable findings in the June 2013 VA examination are adopted as representative for the period on review. The April 2014 VA examination is not adopted as being as reliable, as trophic changes were not noted. However, the severity estimates in the August 2017 VA examination are not adopted for any prior period, as the examiner noted a worsening in the condition. The findings of the June 2013 VA examination are not contradicted by any relevant medical evidence of record for this period. Based on the above, the Board finds that for the period on review prior to August 25, 2017, the Veteran's bilateral lower extremity diabetic peripheral neuropathy disability is primarily manifest by trophic changes, sensory disturbance, slight loss of reflexes, and pain. The Board also finds that the most probative evidence of record is against a finding that the disability is manifest by significant impairment of motor functions, muscle atrophy, or complete paralysis. Given the multiple disabilities affecting the lower extremities, the approximation of such as causing moderate incomplete paralysis to the sciatic nerve is accepted. During this initial period, the Board has considered all other potentially applicable Diagnostic Codes, but there is no evidence showing the Veteran has neurological impairment associated with any other peripheral nerves for this period. Therefore, a separate or higher rating under a different Diagnostic Code is not warranted. The Board acknowledges that the Veteran used an assistive device due for this period of time for a number of issues. To the extent that such was attributable to the bilateral lower extremity diabetic peripheral neuropathy, 38 C.F.R. § 4.120 "contemplates any impairment of motor or sensory function that would require the use of an assistive 38 C.F.R. § device such as a cane or walker." Spellers v. Wilkie, 30 Vet. App. 211, 218 (2018). The Board acknowledges the argument in the September 2021 Post-Remand Brief that the VA examination was inadequate, but as no specific explanation was advanced in support of this contention, it does not need to be further addressed. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's claim in excess of 20 percent prior to August 25, 2017 for peripheral neuropathy of the lower extremity. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. The requested increase for the subsequent period must also be denied as any increase for the period after August 25, 2017 would violate the "amputation rule." Per 38 C.F.R. § 4.68, the "amputation rule," "the combined rating for disabilities of an extremity shall not exceed the rating for the amputation at the elective level, were amputation to be performed." In considering what the level of amputation would encompass the conditions at hand, 38 C.F.R. § 4.71A, Diagnostic Code 5161 provides that an amputation at the upper third of the thigh, one-third of the distance from perineum to knee joint, measured from perineum warrants an 80 percent evaluation. A higher 90 percent evaluation for amputation is applicable only when there is amputation of the thigh with disarticulation and loss of extrinsic pelvic girdle muscles, under 38 C.F.R. § 4.71A, Diagnostic Code 5160. For the period on appeal beginning August 25, 2017, the Veteran was assigned bilateral 40 percent evaluations under Diagnostic Code 7114 for lower extremity peripheral vascular disease, bilateral 40 percent evaluations under Diagnostic Code 8520 for diabetic peripheral neuropathy affecting the sciatic nerve, bilateral 30 percent evaluations under Diagnostic Code 8526 for diabetic peripheral neuropathy affecting the femoral nerve, and bilateral 30 percent evaluations under Diagnostic Code 5010-5284 for foot disabilities. As such, the Veteran has been assigned total evaluations for each lower extremity in excess of 80 percent for this period. Because there is no contention or evidence of record that the conditions on appeal caused loss or symptomatology to the extrinsic pelvic girdle muscles, the maximum elective level of amputation would be above one-third of the distance from perineum to knee joint, measured from perineum. As such warrants 80 percent, and the Veteran is already assigned ratings in excess of 80 percent for each lower extremity, per the "amputation rule" further increases may not be awarded. Accordingly, the requests for increases after August 25, 2017 as to these bilateral lower extremity disabilities are denied as a matter of law. 10. Entitlement to an increased evaluation of 70 percent, but no higher for an acquired psychiatric disorder, to include PTSD and depressive disorder, prior to August 25, 2017 is granted. 11. Entitlement to an evaluation in excess of 70 percent for an acquired psychiatric disorder, to include PTSD and depressive disorder, for the period after August 25, 2017 is denied. The Veteran seeks an increased rating for his service-connected psychiatric disorder. The Veteran was evaluated at 30 percent prior to August 25, 2017, and 70 percent thereafter. Under the General Formula for Mental Disorders (General Formula), the Board must conduct a "holistic analysis" that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages. Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-118 (Fed. Cir. 2013). The issue in this appeal is whether the Veteran's associated symptoms caused the level of impairment required for a disability rating of 100 percent. The Board concludes that the Veteran's symptoms did not cause the level of impairment required for a disability rating of 100 percent. The Veteran's symptoms more closely approximated the symptoms associated with a 70 percent rating and resulted in a level of impairment that most closely approximated the level of impairment associated with a 70 percent rating. A 30 percent rating is assigned when symptoms such as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, or recent events), cause occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and normal conversation). A 50 percent rating is assigned when symptoms such as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; or difficulty in establishing and maintaining effective work and social relationships cause occupational and social impairment with reduced reliability and productivity. A 70 percent rating is assigned when symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); or inability to establish and maintain effective relationships cause occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; or memory loss for names of close relatives, own occupation, or own name. Regarding the initial period on review, after review of the various treatment records, the Board finds that an increase is warranted. The VA and private treatment records, the findings in the various VA examinations, and the Veteran's lay statements show that the Veteran's psychiatric disorder was manifested by symptoms associated with a 70 percent rating. Specifically, the Veteran was noted during examinations to have irritable behavior and angry outbursts; hypervigilance; exaggerated startle response; problems with concentration; circumstantial, circumlocutory, or stereotyped speech; obsessional rituals which interfere with routine activities; a depressed mood; anxiety; chronic sleep impairment; mild memory loss; and disturbances of motivation and mood. The Veteran also, during various points in the record, endorsed suicidal ideation, which was concerning enough to remove the firearms in his house. See June 2013 VA examination. He also endorsed hallucinations and reported near-continuous depression during the period on appeal. These symptoms appear to have affected the Veteran's ability to function independently, appropriately, and effectively. Although the Veteran was not working during the period, the evidence contains sufficient evidence to conclude these symptoms would cause occupational and social impairment with deficiencies in most areas. Accordingly, a 70 percent evaluation is warranted for the initial period on review. A higher 100 percent evaluation is not warranted for any period on appeal. The Veteran's symptoms are not shown to be sufficient to cause total social impairment. The Veteran appears, from the record, to adequately maintain some relationships, including that with his daughter, who is noted to provide care for the Veteran at various points in the record, as well as his nephew. The Board finds the severity, frequency, and duration of the Veteran's unlisted symptoms most closely approximate the symptoms contemplated by a 70 percent rating. See 38 C.F.R. § 4.126. A higher 100 percent evaluation is not warranted as total social impairment is not established. 12. Entitlement to a TDIU based on a single disability is granted. The Veteran has been deemed unemployable and granted a TDIU below based on multiple disabilities (bilateral foot disabilities). However, it must be ascertained whether a TDIU can be granted based on a single disability, as this is a threshold question for other benefits on appeal. A TDIU may be assigned, where the schedular rating is less than total, where a veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. 38 C.F.R. § 4.16(a). To qualify for schedular consideration of a TDIU, if there is only one such disability, this disability shall be ratable at 60 percent or more, and, if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more and sufficient additional disability to bring the combined rating to 70 percent or more. Id. An award of TDIU is an individualized determination, specific to a veteran's particular circumstances, e.g., their history, education, skills, and training. See Todd v. McDonald, 27 Vet. App. 79, 85 (2014). It does not require a showing of 100 percent unemployability. Roberson v. Principi, 251 F.3d 1378, 1385 (Fed. Cir. 2001). The ultimate question is whether they are capable of performing the physical and mental acts required by employment, not whether they can find employment. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). The Veteran has been awarded a 70 percent evaluation for his service-connected psychiatric disability, and thus could be awarded TDIU on a schedular basis. 38 C.F.R. § 4.16(a). In the June 2021 VA examination Individual Unemployability Statement, the clinician noted that due to the service-connected psychiatric disability the Veteran would have difficulty attending to (or is easily distracted from) the task at hand, and that he was so sleep disrupted that he would be fatigued at work, making concentration and focus difficult. Given that the Veteran's psychiatric disability appears to have been static during the period on appeal, as reflected in the rating assigned supra, these findings are considered to apply to the entire period on appeal. The Board finds that these factors would preclude gainful employment. Accordingly, a TDIU based on a single disability is warranted. 13. Entitlement to SMC(s) for statutory housebound status is granted. Special monthly compensation (SMC) benefits by reason of being housebound are payable if the Veteran has a single permanent disability rated 100 percent disabling and has either (1) additional service-connected disability or disabilities independently ratable at 60 percent or more ("statutory housebound"), or (2) is permanently housebound by reason of service-connected disability or disabilities ("housebound in fact"). 38 U.S.C. § 1114(s); 38 C.F.R. § 3.350(i). The disabilities independently ratable at 60 percent or more must be separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems. 38 C.F.R. § 3.350(i)(1). As noted in Bradley v. Peake, 22 Vet. App. 280 (2008) a total disability rating based on individual unemployability (TDIU) based on a single disability qualifies as "100 percent" for SMC statutory housebound purposes. However, several separately rated disabilities cannot be combined to achieve a single total (100 percent) rating in order to qualify for SMC (even based on a single disease entity/process, to include, for example, multiple sclerosis. VAOPGCPREC 66-91 (Aug. 15, 1991). In this case, as noted above, the Veteran qualifies for the grant of a TDIU for a single disability. He has additional disabilities independently rated at more than 60 percent. Accordingly, the Veteran qualifies for an SMC(s) statutory housebound award and such is granted on appeal, subject to laws and regulations applicable to payment of VA monetary benefits 14. Entitlement to special monthly compensation at the aid and attendance rate based on loss of use of the bilateral feet (SMC(l)) is granted. SMC(l) is payable at the aid and attendance rate 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 renders the Veteran permanently bedridden or with such significant disabilities as to be in need of regular aid and attendance. 38 U.S.C. § 1114(l); 38 C.F.R. § 3.350(b). Loss of use of a hand or a foot will be held to exist when no effective function remains other than that which would be equally well served by an amputation stump at the site of election below elbow or knee with use of a suitable prosthetic appliance. The determination will be made on the basis of the actual remaining function, whether the acts of grasping, manipulation, etc., in the case of the hand, or of balance, propulsion, etc., in the case of the foot, could be accomplished equally well by an amputation stump with prosthesis. 38 C.F.R. § 3.350(a). The Board does not find the Veteran's bilateral upper extremity radiculopathy symptoms to be sufficiently significant to warrant the need for aid and attendance. While noting his testimony of needing assistance with dressing due to such, the examinations have consistently categorized the symptoms as mild, and the Veteran's contention is rejected. See June 2013, April 2014, September 2017, and February 2020 VA examinations of the peripheral nerves. However, the record shows that the Veteran has loss of use of the bilateral lower extremities due to his service-connected bilateral PVD, diabetic peripheral neuropathy, and foot disorders. As noted above, the Veteran is in receipt of a combined maximum rating that can be assigned the bilateral lower extremities, short of amputation above the thigh with disarticulation and loss of extrinsic pelvic girdle muscles. Review of the relevant VA examinations shows pain on movement, significant pain after use, numbness of the feet, and significant limitations on duration and distance for standing and walking for each of these conditions are documented in the relevant VA examinations. See August 2015, August 2017, and February 2020 VA examinations. Notably, the February 2020 VA examination for PVD identified the Veteran as being limited to 100 feet due to PVD. Moreover, the Veteran has serious service-connected bilateral foot conditions that he reported caused his separation from employment in 2007. See July 2009 VA examination of the feet. The record is unambiguous in that the Veteran requires the use of a wheelchair and a cane for all but brief episodes of walking. Although the record identifies various non- service-connected conditions also limiting mobility (see November 2011, June 2013, February 2020, and May 2021 VA 21-2680 submissions), a holistic review of the evidence shows the Veteran is limited in walking distance to approximately 100 feet due to service-connected conditions alone. Considering the advances in prosthetics, the Board notes that an amputation of the feet would likely reflect equal (if not greater) mobility and function as presented by the Veteran's service-connected bilateral lower extremity disabilities. As such, this claim appears to meet the relevant legal criteria for SMC(l) to be awarded based on limitations related to loss of use of the bilateral feet. Accordingly, the Veteran is considered to have established qualified loss of use of the bilateral lower extremities, and SMC(l) for loss of use of the bilateral lower extremities is granted. The award of SMC(l) on the basis of loss of use of the feet moots the question of entitlement to SMC(l) due to the need of regular aid and attendance due to the bilateral lower extremity symptoms, as multiple SMC(l) awards may not be granted on the basis of the same symptomatology. 38 U.S.C. § 1114(o); 38 C.F.R. § 3.350(e)(1)(ii); Breniser v. Shinseki, 25 Vet. App. 64, 75 (2011). 15. Entitlement to specially adapted housing (SAH) is granted. 16. Entitlement to a special home adaptation (SHA) grant is denied. The July 2021 Supplemental Statement of the Case (SSOC) classified the issue on appeal as being a request for specially adapted housing as well as a special home adaptation grant; accordingly, both issues are considered now on appeal. Previously, the Veteran had testified at the March 2018 Board hearing that he had received the requested modifications, insofar as a ramp and shower modifications were concerned. The record shows a H.I.S.A. grant was issued, according to a June 2013 Notification Letter, which is a different program than the issues on appeal. See 38 U.S.C. §§ 1710(a), 1717(a)(2); 38 C.F.R. § 17.3100. At the hearing, the Veteran testified he still wished to have assistance with mowing his lawn. The benefits in question are not payable for lawn maintenance, but the Board will analyze whether there is any other basis to award the requested benefits. Specially adapted housing is available to a veteran who is entitled to compensation for permanent and total disability due to: (1) amyotrophic lateral sclerosis rated as 100 percent disabling under 38 C.F.R. § 4.124a, Diagnostic Code 8017; (2) blindness in both eyes, having only light perception, plus the anatomical loss or loss of use of one lower extremity; (3) full thickness or subdermal burns that have resulted in contractures with limitation of motion of two or more extremities or of at least one extremity and the trunk; or (4) the loss or loss of use of both upper extremities such as to preclude use of the arms at or above the elbows. Specially adapted housing is also available to a veteran with a permanent and total disability that precludes locomotion without the aids of braces, crutches, canes, or a wheelchair due to: (5) the loss, or loss of use, of both lower extremities; (6) the loss or loss of use of one lower extremity, together with residuals of organic disease or injury which affect the functions of balance and propulsion; or, (7) the loss or loss of use of one lower extremity together with the loss or loss of use of one upper extremity which affect the functions of balance or propulsion. 38 U.S.C. § 2101(a); 38 C.F.R. § 3.809(a), (b), (d). The term "preclude locomotion" is defined as the necessity for regular and constant use of a wheelchair, braces, crutches, or canes as a normal mode of locomotion although occasional locomotion by other methods may be possible. 38 C.F.R. § 3.809(d). The Court of Appeals for Veterans Claims found that a "loss of use" exists when there is "deprivation of the ability to avail oneself" of that extremity, and functional impairment caused by pain, weakness, or incoordination should be taken into account when making that determination. See Jensen v. Shulkin, 29 Vet. App. 66, 78-79 (2017). The Veteran is service connected for a variety of disabilities and has a total evaluation far in excess of 100 percent. The record shows that the Veteran has loss of use of the bilateral lower extremities due to his service-connected bilateral PVD, diabetic peripheral neuropathy, and foot disorders. The pain on movement, numbness, and significant limitations in duration and distance for standing and walking are documented in the relevant VA examinations. As discussed above, the Veteran is noted in the record to use a wheelchair and a cane for all but brief episodes of walking. The Board finds that the evidence demonstrates that the Veteran's service-connected bilateral lower extremity PVD, diabetic peripheral neuropathy, and foot disabilities do necessitate regular and constant use of a wheelchair, braces, crutches, or canes as a normal mode of locomotion although occasional locomotion by other methods may be possible, and eligibility for a SAH is accordingly warranted. If entitlement to specially adapted housing (SAH) is not established, a veteran can qualify for a grant for necessary special home adaptations (SHA) under 38 C.F.R. § 3.809a, a lesser benefit. However, under 38 C.F.R. § 3.809a(a), SHA is only available when the Veteran does not qualify for the greater benefit of SAH. As such, SHA must be denied. The decision reached on these issues represents a grant of the maximum benefit scenario for the Veteran. REASONS FOR REMAND 1. Entitlement to service connection for hepatitis C, liver cirrhosis, or other hepatic disease, to include as secondary to diabetes mellitus type II is remanded. At his hearing the Veteran contended that he developed hepatitis C due to his being exposed to human waste products when assigned to waste detail in service. As noted previously, there is no medical opinion presented to support this theory which the Veteran testified to have conceived apparently on his own. Such lay theorizing does not constitute evidence to support the claim, as the Veteran has not been shown to possess the requisite expertise or knowledge to address these questions. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see Kahana v. Shinseki, 24 Vet. App. 428, 438 (2011). Also, the Veteran reported that his physician had stated that his cirrhosis of the liver may have resulted from his hepatitis C or from his diabetes mellitus, and the examiner did not know which. The Veteran also testified to having received treatment to cure his hepatitis, but that his liver was already significantly damaged with cirrhosis, and the cirrhosis was not cured by the treatment. Hence, the claim appears to be one for liver cirrhosis, hepatitis C, or other hepatic disease, including secondary to diabetes mellitus type II. After the Board remand, a February 2020 VA examination was conducted that confirmed diagnoses of hepatitis C and cirrhosis of the liver. The examiner noted the conditions were diagnosed in 1975; the examiner indicated that a baseline level of severity could not be determined. The VA examination needs to be clarified. The findings raise additional questions, to include when the condition was initially diagnosed. It is unclear whether the examiner intended to provide a retrospective diagnosis to 1975 for the claimed conditions, and if so, what the basis for such was. Further, the examiner should clearly answer the question as to whether any diagnosed hepatitis C, liver cirrhosis, or hepatic disease is secondary to diabetes mellitus type II, and not simply indicate whether there was a baseline. Accordingly, this claim is remanded for a new VA examination that clearly identifies the date that the condition was initially diagnosed and the basis for the finding, and adequately addresses the question of whether the Veteran's hepatitis C, liver cirrhosis, or other hepatic disease, had an onset during active service or is otherwise secondary to diabetes mellitus type II. The matter is REMANDED for the following actions: 1. Obtain an addendum opinion from an appropriate clinician regarding the etiology of any current liver disorder. Determine the date that hepatitis C, liver cirrhosis, or other hepatic disease condition was initially diagnosed and provide the basis for the finding. Determine whether the Veteran's hepatitis C, liver cirrhosis, or other hepatic disease at least as likely as not (50 percent probability or greater) (a) had an onset during active service, or (b) is proximately due to or aggravated by diabetes mellitus type II. Aggravation under 38 C.F.R. § 3.310 (b) does not require that there be "permanent" worsening of the nonservice connected disability. The examiner must provide separate findings and rationales relating to causation and aggravation A complete rationale must be provided for all opinions rendered. 2. Thereafter, readjudicate; if the benefit sought remains denied, issue a Supplemental Statement of the Case (SSOC). L. CHU Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. C. KING 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.