Citation Nr: 21067246 Decision Date: 11/03/21 Archive Date: 11/03/21 DOCKET NO. 16-31 009 DATE: November 3, 2021 ORDER New and material evidence has been received, and the application to reopen the service connection for a cervical spine disorder is granted. Entitlement to service connection for a cervical spine disability is denied. Entitlement to service connection for thoracolumbar spine disability to include degenerative joint disease and degenerative disc disease is denied. Entitlement to service connection for epidermal inclusion cysts on back (claimed as lumps on back) is denied. Entitlement to total disability rating based on individual unemployability is granted, subject to the laws and regulations governing the award of monetary benefits. Entitlement to a certificate of eligibility for specially adapted housing is denied. Entitlement to a certificate of eligibility for special home adaptation grant is denied. FINDINGS OF FACTS 1. The November 2000 rating decision denying the Veteran's claim of entitlement to service connection for a cervical spine disorder is final. 2. Evidence received since the November 2000 rating decision is new and material and raises a reasonable possibility of substantiating the Veteran's service connection for a cervical spine disorder. 3. The weight of the probative medical evidence of record is against finding that the Veteran's current cervical spine disability is related to his in-service injury or is otherwise caused by or related to his military service 4. The weight of the probative medical evidence of record is against finding that the Veteran's current low back disability is related to his in-service back injury or is otherwise caused by or related to his military service. 5. The weight of the probative medical evidence does not show that the Veteran's current epidermal inclusion cysts on back (claimed as lumps on back) have onset in service or were otherwise caused by service. 6. The medical and lay evidence shows that the Veteran's service-connected psychiatric disorder results in significant symptoms that preclude him from securing and following substantially gainful employment. 7. The Veteran is service connected for PTSD at 70 percent and external hemorrhoids at 10 percent. 8. The Veteran does not have service-connected amyotrophic lateral sclerosis, blindness in both eyes, disability from full thickness burns, subdermal burns or deep partial thickness burns, residuals of inhalation injury, anatomical loss or loss of use of both hands, loss of use of any upper extremity, the loss or loss of use of both lower extremities, or the loss or loss of use of one lower extremity together with residuals of organic disease or injury which so affect the functions of balance and propulsion. CONCLUSIONS OF LAW 1. The November 2000 rating decision which denied entitlement to service connection for a cervical spine disability is final. 38 U.S.C. § 7105 (c); 38 C.F.R. §§ 3.104, 20.302, 20.1103. 2. The criteria to reopen the claim for service connection for a cervical spine disability based on new and material evidence have been met. 38 U.S.C. § 5108; 38 C.F.R. § 3.156 (a). 3. The criteria for service connection for a cervical spine disability have not been met. 38 U.S.C. §§ 1101, 1110, 1131; 38 C.F.R. §§ 3.303, 3.309, 3.311. 4. The criteria for service connection for a low back disability have not been met. 38 U.S.C. §§ 1101, 1110, 1131; 38 C.F.R. §§ 3.303, 3.309, 3.311. 5. The criteria for service connection for epidermal inclusion cysts on back (claimed as lumps on back) have been met. 38 U.S.C. §§ 1110, 1112, 1113, 1154(a), 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.311. 6. The criteria for entitlement to a TDIU have been met. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.340, 3.341, 4.16. 7. The criteria for entitlement to a certificate of eligibility for specially adapted housing have not been met. 38 U.S.C. §§ 2101, 5107; 38 C.F.R. § 3.809. 8. The criteria for a certificate of eligibility for special home adaptation have not been met. 38 U.S.C. §§ 2101, 5107; 38 C.F.R. § 3.809a. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from March 1977 to March 1981. This matter is on appeal from a January 2013 rating decision and was previously remanded by the Board in June 2019. As a preliminary matter, the Board notes that the Veteran's representative, C. Pitts, withdrew his representation in his September 2019 correspondence. In an October 2019 VA 21-22 Form, the Veteran appointed the American Legion as his new representative. The Board also notes that additional evidence has been submitted to the claims file after the September 2020 Supplemental Statement of Case. However, the new evidence added is irrelevant to the issues on appeal. As such, a waiver of the AOJ consideration of the evidence is not necessary. See 38 C.F.R. § 20.1305 (c). Next, with regard to the service connection claim for a dental condition, the Board notes that the Veteran's claim for loss of teeth had been denied by a November 2000 rating decision. As the Veteran failed to timely file an appeal, that decision became final. See 38 U.S.C. § 7105. Despite his attempts to reopen the matter, the claim to reopen was finally denied by the Board in its March 2020 decision. However, it recognized that the Veteran may pursue a service connection claim for a dental condition for treatment purposes under 38 C.F.R. § 3.381. Mays v. Brown, 5 Vet. App. 302 (1993). Therefore, the adjudication of the Veteran's petition to reopen the previously denied claim for service connection for a dental condition for loss of teeth for compensation purposes must also include consideration of an original claim for entitlement to service connection for a dental condition for the purpose of establishing eligibility for outpatient dental treatment as set forth in 38 C.F.R. § 17.161. However, before the Board may obtain jurisdiction of the matter of service connection for a dental condition for treatment purposes, the AOJ must first adjudicate the claim. 38 C.F.R. § 3.381. Therefore, the issue was remanded by the Board so that the claim may be referred to VHA for appropriate consideration. During this process, the Veteran must also be notified of the factors pertinent to substantiate his claim. Subsequently, in an April 2020 Deferred Rating Decision, the AOJ found that it did not receive any evidence of a dental condition for treatment purposes from VAMC. In an April 2020 letter to the Veteran, it informed him of how to initiate his claim for dental treatment. As of date, there is no indication in the claims file that the Veteran pursued his claim for a dental condition for treatment purposes as outlined by the AOJ. Thus, the matter is not before the Board at this time. Reopening a Claim Generally, a claim that has been finally denied in an unappealed RO decision or a Board decision may not thereafter be reopened and allowed. 38 U.S.C. §§ 7104 (b), 7105(c). The exception is that if new and material evidence is presented or secured with respect to a claim which has been disallowed, VA shall reopen the claim and review the former disposition of the claim. 38 U.S.C.§ 5108. New evidence means evidence not previously submitted to agency decision-makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156 (a). Cervical Spine Disability The Veteran's claim for entitlement to service connection for a cervical spine condition was denied by a November 2000 rating decision because there was no evidence his neck condition occurred in or was caused by his service. That decision became final since the Veteran did not timely file an appeal and no additional evidence was received within 1 year of the notification of the November 2000 rating decision. Thus, for the matter to be reopened, new and material evidence is required. The Veteran filed a claim to reopen his previously denied service connection claim in July 2010. Evidence received since the November 2000 rating decision consists of new VA treatment records, newly submitted statements from the Veteran's VA physician, Dr. P.P., which offered a positive nexus opinion between his cervical spine disability and his reported in-service injury. The Board finds that the evidence added to the record since the November 2000 rating decision is new and material as it was not previously part of the record and raises a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156. As new and material evidence has been received, the Veteran's service connection claim for a cervical spine condition is reopened. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. U.S.C. §§ 1110, 1131. Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303 (a). Service connection for certain chronic diseases, such as arthritis, will be rebuttably presumed if manifest to a compensable degree within one year after separation from active service. 38 U.S.C.§§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. Moreover, for such diseases, an alternative method of establishing the second and third elements is through a demonstration of continuity of symptomatology. See 38 C.F.R. § 3.303 (b); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Degenerative joint disease and degenerative disc disease, cervical spine, claimed as a neck condition. By way of procedure, the Veteran's service connection claim for a cervical spine disability was denied by a November 2000 rating decision. After the decision became final, the Veteran filed to reopen his claim in July 2010. The matter has since been reopened and the Board will address the merits of the claim. It is the Veteran's contention that he sustained a cervical spine (neck) injury as a result of his service when he ran into a steel pole and cracked both teeth to the root. See January 2011 Third Party Correspondence. In another statement, the Veteran also contends that his neck condition may have resulted from his radiation exposure. See May 2012 VA Form 21-4138 Statement in Support of Claim. Service treatment records were silent for any complaints or treatment for a thoracolumbar spine condition. However, it does show that he fractured tooth number 8 and 9 in June 1980. In an April 2014 letter, a VA dentist conceded that the in-service injury occurred, given the injuries to his teeth. Post service, the record shows that the Veteran was involved in a serious motor vehicle accident in March 1999. Private MRI reports in June 1999 revealed anterior and posterior spurring at C4 to C5, C5 to C6, C6 to C7 with prolapse of the vertebral disc at these levels and some elevation of the longitudinal ligament. Further private treatment records in August 1999 reflected CT scans revealing a small medium left paracentral disc protrusion at C5 to C6, with tiny disc bulges at C3 to C4 and very mild posterior osteophytosis at C4 to C5. In a July 1999 report, Dr. T.Y. offered a clinical impression of acute cervical strain and cervical spondylosis. In an October 1999 private treatment report from Dr. J.W., the Veteran complained of neck pains that originated from his motor vehicle accident. It was noted that he failed to improve with numerous forms of conservative therapy over an extended period of time. In a VA physical therapy consult note in June 2000, it was noted that the Veteran specifically complained that he never had back pain prior to his motor vehicle accident in March 1999. The report further indicated that the Veteran was referred to physical therapy to address his back and neck pain. A physical examination revealed that he had a normal range of motion in his cervical spine. In a January 2008 letter from the Veteran's VA physician Dr. P.P., the physician specially indicated that the Veteran's current cervical spine degenerative joint disease resulted from the March 1999 car accident. This incident caused significant pain and limitations on his mobility and his ability to work. See January 2008 Medical Treatment Record-Government Facility. The Board notes, however, that Dr. P.P. issued a May 2014 medical opinion stating that the Veteran's cervical spine disability resulted from his injury during service. His opinion is in direct contradiction with his own conclusion issued in January 2008. Furthermore, in finding so, Dr. P.P. failed to provide any supportive rationale, nor did he cite to any service treatment records that would suggest the onset of a cervical spine condition in service. More recent VA treatment records in 2017 showed that the Veteran continued to report neck pains from his degenerative disease, which he indicated was getting worse. In reviewing the record, the Board finds that service connection for a cervical spine disability is not warranted in this case. The medical evidence clearly shows that the Veteran has a clinical diagnosis of a cervical spine disability, which was documented in 1999, several years after service. As an initial matter, the evidence does not show that the Veteran's cervical spine disability, which include degenerative arthritis, was chronic in service or manifest to a compensable degree in service within one year of separation from service. Therefore, a continuity of symptomatology has not been established. The Veteran's service treatment records were silent for any complaints, diagnosis, or treatment for any injury or symptoms related to his cervical spine. It was not until 1999 that the Veteran began complaining and demonstrating objective manifestations of a cervical spine disability after a March 1999 motor vehicle accident. In August 1999, he was ultimately diagnosed with acute cervical strain and cervical spondylosis. He later enrolled in physical therapy. Subsequently, he was treated for chronic neck pain for several years. The Board is mindful of the May 2014 medical opinion provided by Dr. P.P., which indicates that the Veteran's cervical spine disability is related to his service. However, the physician failed to provide any supportive rationale to his conclusion and failed to cite to any records that would support the positive nexus. Moreover, this positive medical opinion is in direct contradiction to his own opinion issued earlier in January 2008. Therefore, the Board affords the May 2014 medical opinion no probative weight. The Board finds the Veteran's statements regarding the origin of his cervical spine disabilities, including the length of time he has suffered neck pain, internally inconsistent and inconsistent with the medical evidence of record. In making credibility determinations, the Board may consider factors such as facial plausibility, bias, self-interest, internal inconsistency of statements, and consistency with other evidence of record. See Caluza v. Brown,7 Vet. App. 498, 511 (1995). The Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence. See Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). Rather, the Board must first establish a proper foundation for drawing inferences against a claimant from an absence of documentation. See Fountain, 27 Vet. App. at 272. In this case, the Veteran has asserted that his cervical spine disability had originated in service after he ran into a steel pole. However, as previously discussed, his service treatment records were silent for any indication of a neck injury. Moreover, by his own admission to his treating VA physician, the Veteran indicated that he had never experienced back or neck pain until his March 1999 motor vehicle accident. The Board notes that the claims file does not contain a VA examination report pertaining to the Veteran's cervical spine disability. Under the VCAA, VA must provide an examination when there is (A) competent evidence of a current disability (or persistent or recurrent symptoms thereof) that (B) may be associated with service, but (C) there is insufficient medical evidence to make a decision on the claim. 38 U.S.C. § 5103A(d). The Federal Circuit has addressed the appropriate standard to be applied in determining whether an examination is warranted under this statute. In Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010) and Colantonio v. Shinseki, 606 F.3d 1378 (Fed. Cir. 2010), the Federal Circuit held that while there must be competent evidence of a current disability, competent evidence is not required to indicate that the current disability may be associated with service. Colantonio, 606 F.3d at 1382; Waters, 601 F.3d at 1277. On the other hand, a conclusory generalized lay statement suggesting a nexus between a current disability and service would not suffice to meet the standard of subsection (B), as this would, contrary to the intent of Congress, result in medical examinations being "routinely and virtually automatically" provided to all veterans claiming service connection. Waters, 601 F.3d at 1278-1279. While he has claimed that his cervical spine condition had onset in service, the Veteran's conclusory generalized lay statement suggesting a nexus is not sufficient to meet the standard to warrant an examination, given his inconsistent statements about onset and medical evidence indicating that his current cervical spine condition had developed several years after service following a motor vehicle accident in 1999. Similarly, the Board also finds that an additional examination is not necessary to address the Veteran's claim that his cervical spine disability was caused by his possible radiation exposure in service. Service connection for conditions claimed to be due to exposure to ionizing radiation in service can be established in any of three different ways. See Davis v. Brown, 10 Vet. App. 209, 211 (1997); Rucker v. Brown, 10 Vet. App. 67, 21 (1997). First, there are diseases that are presumptively service-connected in radiation-exposed veterans under 38 U.S.C. § 1112 (c) and 38 C.F.R. § 3.309 (d). A "radiation-exposed" veteran is one who participated in a radiation-risk activity. A "radiation-risk activity" includes the onsite participation in a test involving the atmospheric detonation of a nuclear device, occupation of Hiroshima or Nagasaki during World War II, or presence at certain specified sites. 38 C.F.R. § 3.309 (d)(3). In this case, the Veteran did not participate in a radiation risk activity, and thus is not a "radiation exposed" veteran for the purposes of presumptive service connection discussed above. Secondly, other "radiogenic" diseases, such as any disease listed under 38 C.F.R. § 3.311 (b)(2) may be service connected. In the present case, the Veteran has cervical spine disability, which is not one of the diseases listed as specific to "radiation-exposed veterans" for the purpose of presumptive service connection. See 38 C.F.R. § 3.309 (d)(2)(xi). For claims involving diseases that are not listed in § 3.311(b)(2), VA will consider the claims under § 3.311 if the veteran submits competent scientific or medical evidence that the claimed condition is a radiogenic disease. However, such evidence was not submitted in this case. While service connection on a presumptive basis could not be established in this case, the Veteran may pursue a claim on a direct basis. See Combee v. Brown, 34 F.3d 104344 (Fed. Cir. 1994). In pursuing such claim, the Veteran has not provided any competent evidence suggesting that his cervical spine condition may be associated with radiation exposure. In fact, pursuant to a January 2015 letter from the Army Dosimetry Center, there were no military records that would show the Veteran's exposure to ionizing radiation during service. Therefore, the Veteran's generalized lay statements are inadequate to serve as the necessary nexus in this case. Additionally, the Board also finds that his statements would not suffice to trigger VA's duty to provide a VA examination to address the Veteran's claim that radiation exposure resulted in a cervical spine condition. Accordingly, service connection for a cervical spine disability is denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C. § 5107(b) and 38 C.F.R. § 3.102. Degenerative joint disease and degenerative disc disease, thoracolumbar spine disability, claimed as a back condition. Procedurally the Veteran initiated a service connection claim for a back condition in July 2010 by submitted a VA Form 21-526b, Veteran's Supplemental Claim for Compensation. His claim was denied by a January 2013 rating decision, to which the Veteran expressed his disagreement in March 2013. His claim was denied again by a July 2014 rating decision. He submitted another Notice of Disagreement in January 2015. It is the Veteran's contention that he sustained a chronic lumbar spine disability as a result of his service. Specifically, while on active duty, he ran into a steel pole, causing injury to his back, neck, and cracking several teeth. While his teeth were fixed, he continued to experience pain in his neck and back. See January 2011 Third Party Correspondence. The Board also notes that in his May 2012 correspondence, the Veteran has also asserted that he was exposed to radiation, which likely led to his current back disability. Service treatment records were silent for any complaints or treatment for a thoracolumbar spine condition. However, it does show that he fractured tooth number 8 and 9 in June 1980. Post service, private treatment records from Dr. T.Y. in June 1999 noted that the Veteran indicated that he was involved in a motor vehicle accident on March 23, 1999 when a hay truck hit his car. He has since experienced severe pain and discomfort. A clinical assessment of post traumatic syndrome with chronic back pain and herniated disc was offered. The Veteran was to return in 3 weeks for a follow up evaluation. Follow up notes in June and July 1999 noted that the Veteran was seen for joint aches and pains after the reported accident. The Veteran complained of back pains with degenerative changes noted in the lumbar spine. He reported chronic pain and discomfort in both his lumbar and cervical spine. A clinical assessment of post traumatic syndrome with neck and back radicular pain was provided. Private treatment records in August 1999 revealed a normal lumbar CT scan. The L1-2, L3-4, L4-5, and L5-S1 interspaces were normal. There was no evidence of acquired or congenital spinal stenosis. The nerve roots appeared unremarkable at all levels. No pars defect or spondylolisthesis was seen. There was normal preservation of the intervertebral disc spaces with no evidence of degenerative changes of significance. There were no bony destruction or other abnormalities. See February 2012 Medical Treatment Record-Non-Government Facility. However, in a September 1999 private treatment record, the Veteran's private physician noted that the Veteran had a history of degenerative disc disease, which was causing him excruciating pain. The physician noted that the Veteran was doing well until a bale of hay fell on him while on the job. He was subsequently scheduled for a back surgery. A VA physical therapy consult note in June 2000 indicated that the Veteran specifically complained that he never had back pain prior to his motor vehicle accident in March 1999. He reported that he engaged in physical therapy after the motor vehicle accident. In July 2004, a VA MRI of the lumbar spine revealed early degenerative disease at the L5 to S1 level without other significant abnormality. VA treatment records in January 2007 noted that the Veteran was seen for back pain. He reported intermittent, non-radiating, and sharp pain that is aggravated by sitting. He told his physician that he had been experiencing such symptoms for approximately 7 years. He recalled a car accident 7 years prior and stated that he had been "disabled" ever since. Upon physical examination, the VA physician noted reduced lumbar lordosis with diffused tenderness in lumbar paraspinals and flank muscles. He demonstrated signs of a lumbar degenerative disease, specifically in the L5/S1. The physician educated the Veteran on care, physical therapy, and medication uses/management. Moreover, in a January 2008 letter, the Veteran's VA physician specially indicated that the Veteran's current lumbar spine degenerative joint disease resulted from the March 1999 car accident. This incident caused significant pain and limitations on his mobility and his ability to work. See January 2008 Medical Treatment Record-Government Facility. However, the Veteran submitted a May 2014 from his VA physician Dr. P.P. who found that it was likely that his degenerative joint and disc disease of the lumbar spine were caused by the traumatic injury in service. The Board notes, however, that Dr. P.P. failed to offer any supportive rationale, nor did he cite to any service treatment records that would suggest a long-term back injury. Furthermore, the May 2014 medical opinion is in direct contradiction of the January 2008 findings. Based on his January 2020 Disability Benefits Questionnaire, the Veteran indicated that his back condition began in 1980. He stated that it was caused by physical training exercises, heavy lifting and rucking with heavy weights on his back during service. He recalled moderate back pain and tightness at the onset of his condition. He now complains of sharp pain and stiffness requiring a back brace, pain killers and cortisone injections. Upon physical evaluation, the Veteran demonstrated unlimited range of motion in flexion and extension. In conclusion, the examiner opined that the Veteran's backed disability is less likely than not related to his service. His service treatment records did not indicate any progressive, longitudinal complaints of back pain or treatment of the back during active duty. In fact, the first reported or documented back diagnosis was several years after his service. In a July 2020 medical opinion addendum, the examining physician opined that the Veteran's current lumbar spine disability is less likely than not related to his military service. The Veteran indicated that he ran into a steel pole in service, causing injury to his back and teeth. But while that in-service event is conceded, the Veteran's service treatment records only showed fractured teeth. There is no relationship of facial injury and his low back. There are no reports of progressive and longitudinal back complaints after the Veteran ran into a pole. Even immediately after his post-service MVA in 1999, there was no evidence of a spinal condition. Therefore, it is less likely that the Veteran's current back diagnosis incurred in or was caused by his in-service injury. Upon review of the record, the Board finds that service connection for a low back disability is not warranted as the probative medical evidence of record does not support a conclusion of a nexus between the Veteran's back disability and his service. The Veteran has consistently asserted that his lumbar spine disability resulted from service when he ran into a steel pole, injuring his back, along with losing some teeth. While the Board concedes the occurrence of the in-service accident in which he ran into a pole, the Veteran's service treatment records do not support an injury to his back. Post-service medical evidence did not show a chronic back condition within one year after service. In fact, the earliest documentation of back pain was made by the Veteran in 1999 after a motor vehicle accident. Private treatment records in June and July 1999 showed that the Veteran sought medical attention after the accident, with complaints of lingering severe back and neck pain. Subsequent treatment records later that year continued to show that his complaints of low back pain originated from the March 1999 motor vehicle accident. Lay evidence provided by the Veteran indicates that despite his 1999 accident in which he injured his back, he believes that his current back disability had onset in service. While the Veteran believes that his current back disability is related to his service injury, he is not competent to provide a nexus opinion on this matter. This is a medically complex question that requires medical expertise, and he is not shown to possess such expertise. Thus, his lay contentions are not competent evidence by which causation may be established. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). Therefore, the Board must rely on the most probative medical evidence of record, which remains the July 2020 DBQ. While the Veteran has submitted a positive opinion by his private physician, dating May 2014, the Board affords that opinion little probative weight. Dr. P.P. concluded that the Veteran's back disability is caused by his military service. However, he failed to offer any supportive rationale and did not explain the lack of documented back complaints during and immediately after service. In finding in favor of a nexus, he did not cite to any positive medical evidence from the claims file that would support such a nexus. In contrast, the July 2020 DBQ found that that it was less likely that the Veteran's current back disability is related to his in-service injury. While conceding the injury during service, the examining physician found no evidence of a chronic back condition in service subsequent to the injury. The Veteran clearly sought medical attention at sick bay for the injuries to his teeth. However, there was no mention of a back pain immediately after the incident, nor was there any complaint throughout his service. Moreover, the examiner noted a lengthy period of time after separation before any back complaints emerged. Almost a decade later, the Veteran was involved in a car accident to which he began complaining of back pain. But even considering the 1999 accident, the Veteran did not demonstrate degenerative changes to his back until several more years after. The Board, therefore, highlights that the lack of documentation of back complaints in service and the 1999 intervening accident several years after separation, all which suggest that it is less likely that the Veteran's back disorder had onset in or is otherwise caused by service. While service connection may be granted for diseases such as arthritis under 38 C.F.R. § 3.309 (a), the disease must have manifested within one year after separation from service. In this case, there is no evidence that indicate complaints of back pain within that year following separation from service. Thus, service connection for a low back disability, to include degenerative joint disease of the lumbar spine, is not warranted. Finally, the Board notes that the Veteran asserted that his low back disability may have resulted from his possible radiation exposure. Service connection for conditions claimed to be due to exposure to ionizing radiation in service can be established in any of three different ways. See Davis v. Brown, 10 Vet. App. 209, 211 (1997); Rucker v. Brown, 10 Vet. App. 67, 21 (1997). First, there are diseases that are presumptively service-connected in radiation-exposed veterans under 38 U.S.C. § 1112 (c) and 38 C.F.R. § 3.309 (d). A "radiation-exposed" veteran is one who participated in a radiation-risk activity. A "radiation-risk activity" includes the onsite participation in a test involving the atmospheric detonation of a nuclear device, occupation of Hiroshima or Nagasaki during World War II, or presence at certain specified sites. 38 C.F.R. § 3.309 (d)(3). In this case, the Veteran did not participate in a radiation risk activity, and thus is not a "radiation exposed" veteran for the purposes of presumptive service connection discussed above. Secondly, other "radiogenic" diseases, such as any disease listed under 38 C.F.R. § 3.311 (b)(2) may be service connected. In the present case, the Veteran has a low back disability, which is not one of the diseases listed as specific to "radiation-exposed veterans" for the purpose of presumptive service connection. See 38 C.F.R. § 3.309 (d)(2)(xi). For claims involving diseases that are not listed in § 3.311(b)(2), VA will consider the claims under § 3.311 if the veteran submits competent scientific or medical evidence that the claimed condition is a radiogenic disease. However, such evidence was not submitted in this case. While service connection on a presumptive basis could not be established in this case, the Veteran may pursue a claim on a direct basis. See Combee v. Brown, 34 F.3d 104344 (Fed. Cir. 1994). Here, the Veteran has not provided any competent evidence suggesting that his lumbar spine condition may be associated with radiation exposure. Moreover, a January 2015 letter from the Army Dosimetry Center, there were no military records that would show the Veteran's exposure to ionizing radiation during service. Therefore, the Veteran's generalized lay statements attempting to link his lumbar spine condition and radiation exposure is inadequate to service as the necessary nexus in this case or to trigger VA's duty to provide a VA examination. The weight of the probative evidence of record simply fails to demonstrate a medical link between the issue on appeal and the Veteran's period of active service, of which there is also no record of a diagnosis within one year of separation, and the Veteran's current low back disorder is not proximately due to an in-service incurrence. Therefore, the evidence in this case is not so evenly balanced as to allow application of the benefit-of-the-doubt rule as required by law and VA regulations. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. The preponderance of the evidence is against the Veteran's claim, and as such entitlement to service connection for a low back disability is denied. Epidermal inclusion cysts on back (claimed as lumps on back) The Veteran asserts that he has lumps all over his body which began in service in 1979. He underwent operation to remove the lumps from his back in September 2016. See May 2012 VA 21-4138 Statement in Support of Claim. In a September 2013 statement, he suggested that that the inclusion cysts on his back may be caused by radiation exposure. Service treatment records dating September 1980 noted that the Veteran was seen for a small lump on his left lower eye lid. He was treated with a heating pad with no subsequent complaints. He also presented with a bump on his groin in November 1980, which was assessed as folliculitis. Post service, VA treatment records in August 2010 indicated that the Veteran was seen at emergency services for an abscess to the back that had been bothering him for 3 weeks. VA dermatology reports in April 2011 noted that the Veteran had a history of cysts excision in the upper back since September 2010. He also reported having a cyst in his neck for the past 2 weeks. In an August 2012 VA examination report, the examiner noted that the Veteran is diagnosed with 'epidermal inclusion cysts status post incision and drainage in the mid-back area.' The Veteran told the physician that he had been experiencing painful masses on his neck and back two years prior. He underwent antibiotic therapy and surgical incision for several of them. He reported that he still had several lesions on his back, chest, and groin, that are asymptomatic. Upon physical examination, the physician confirmed evidence of incisions and the presence of small cysts. In conclusion, the physician opined that the Veteran's skin condition (cysts) is less likely than not incurred in or caused by his military service. The only evidence indicative of a skin condition in service are treatment records during his stay in Fort Bliss in 1980, when he was seen for an eye lump and folliculitis of the groin which are not risk factors for epidermal inclusion cysts. In support of his claim, the Veteran submitted a May 2014 statement from his VA physician Dr. P.P. which indicated that he had been treated for skin lumps. The physician indicated that upon review of the Veteran's medical records, it is likely that his skin lumps existed at the time of his military service, evidence by the notation of treatment for skin lumps. See June 2012 Third Party Correspondence. In reviewing the record, the Board finds that service connection for epidermal inclusion cysts is not warranted. First, the Board notes that the Veteran has asserted that his condition may have resulted from his exposure to radiation. Upon request for information on the Veteran's radiation exposure, the Army Dosimetry Center could not find any records to support or confirm the Veteran's exposure to ionizing radiation during service. See Military Personnel Record received January 2015. The Board notes that his MOS is 'Improved Hawk Fire Control Maintenance,' which he worked for 3 years and 3 months. Service connection for conditions claimed to be due to exposure to ionizing radiation in service can be established in any of three different ways. See Davis v. Brown, 10 Vet. App. 209, 211 (1997); Rucker v. Brown, 10 Vet. App. 67, 21 (1997). First, there are diseases that are presumptively service-connected in radiation-exposed veterans under 38 U.S.C. § 1112 (c) and 38 C.F.R. § 3.309 (d). A "radiation-exposed" veteran is one who participated in a radiation-risk activity. A "radiation-risk activity" includes the onsite participation in a test involving the atmospheric detonation of a nuclear device, occupation of Hiroshima or Nagasaki during World War II, or presence at certain specified sites. 38 C.F.R. § 3.309 (d)(3). In this case, the Veteran did not participate in a radiation risk activity, and thus is not a "radiation exposed" veteran for the purposes of presumptive service connection discussed above. Secondly, other "radiogenic" diseases, such as any disease listed under 38 C.F.R. § 3.311 (b)(2) may be service connected. In the present case, the Veteran has epidermal inclusion cysts," which is not one of the diseases listed as specific to "radiation-exposed veterans" for the purpose of presumptive service connection. See 38 C.F.R. § 3.309 (d)(2)(xi). For claims involving diseases that are not listed in § 3.311(b)(2), such as epidermal inclusion cysts, VA will consider the claims under § 3.311 if the veteran submits competent scientific or medical evidence that the claimed condition is a radiogenic disease. However, such evidence was not submitted in this case. While service connection on a presumptive basis could not be established in this case, the Veteran may pursue a claim on a direct basis. See Combee v. Brown, 34 F.3d 104344 (Fed. Cir. 1994). However, upon review, the Board also finds that the evidence of record does not support service connection for his epidermal inclusion cysts on a direct basis. While service treatment records showed that he was seen for a lump on his eyelid and on his groin, he was treated accordingly. Subsequent treatment records did not document any recurrence of the lumps. Post service, the Veteran was seen several years later in 2010 for severe and chronic abscesses. During his emergency visit, the Veteran specifically told his doctor that he had been experiencing painful cysts on his back and neck for a few weeks prior and made no mention of cysts existing during his service. Despite his reporting, the Veteran has asserted that his epidermal inclusion cysts had onset in service, evidenced by the documented lumps. While the Veteran is competent to report symptoms such as pain and lumps on his body, he is not competent to opine on its etiology. Such a complex medical question requires prerequisite knowledge and training, to which the Veteran is not shown to have. See Barr v. Nicholson, 21 Vet. App. 303, 307-08 (2007). Therefore, the Board must turn to the most probative evidence of record, namely the August 2012 VA examination report. The August 2012 VA examiner noted the Veteran's in-service complaints of lumps in his eyelid and groin area but found that such lumps were folliculitis and different from his current epidermal inclusion cysts. In contrast, the Veteran submitted a May 2014 statement from his physician Dr. P.P. who found a positive nexus between his service and his current epidermal inclusion cysts. However, the Board affords little probative weight in the May 2014 medical opinion since Dr. P.P. did not provide sufficient rationale for his opinion. Instead, Dr. P.P. merely found that the skin abnormalities in service to be the same condition as the Veteran's current condition. He made no distinction between the Veteran's current painful abscesses (diagnosed as epidermal inclusion cysts) and his in-service folliculitis, which appeared to have resolved by the time of separation. Accordingly, after a review of the evidence, the Board finds that it fails to support the Veteran's claim for service connection for epidermal cysts of the back. Therefore, the evidence in this case is not so evenly balanced as to allow application of the benefit-of-the-doubt rule as required by law and VA regulations. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. At the preponderance of the evidence is against the claim, service connection for epidermal cysts on the back is denied. TDIU It is the Veteran's contention that his service-connected disability PTSD rendered him unemployable. He indicated that he last worked in computer repair on March 20, 1999, as he became too disabled. See September 2014 VA 21-8940 Veterans Application for Increased Compensation Based on Unemployability. Total disability will be considered to exist when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340. Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when the disabled person is unable to secure or follow a substantially gainful occupation as a result of service connected disabilities, provided that, if there is only one such disability, the disability shall be ratable at 60 percent or more, and that, if there are two or more service connected disabilities, at least one must be rated at 40 percent or more and the combined rating must be 70 percent or more. 38 C.F.R. § 4.16 (a). Being unable to maintain substantially gainful employment is not the same as being 100 percent disabled. "While the term 'substantially gainful occupation' may not set a clear numerical standard for determining TDIU, it does indicate an amount less than 100 percent." Roberson v. Principi, 251 F.3d 1378 (Fed Cir. 2001). In 2019, the U.S. Court of Appeals for Veterans Claims (CAVC) held that substantially gainful employment, in the TDIU context, contains economic and noneconomic components; the economic component 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, while the noneconomic component requires consideration of a veteran's ability to secure or follow that type of employment. Ray v. Wilkie, 31 Vet. App. 58 (2019). The CAVC also provided guidance as to the meaning of a veteran's ability to secure and follow such employment, noting that attention must be given to the veteran's occupational history, education, skill and training; whether the veteran has the physical ability to perform occupational activities; and whether the veteran has the mental ability to perform occupational activities. The Veteran is service connected for PTSD at 70 percent and hemorrhoids at 10 percent. He has a combined total disability rating of 70 percent. Therefore, the Veteran meets the schedular criteria for a TDIU. See 38 C.F.R. §§ 4.16 (a), 4.25, 4.26. In support of his claim, the Veteran submitted a September 2015 letter from his physician Dr. P.P. who indicated that the Veteran has been diagnosed with several major chronic medical conditions so severe that he is 'completely and totally disabled from any and all types of employment on a permanent basis.' In another TDIU application, the Veteran specifically indicated that he had been hospitalized within the past 12 months. He detailed that his service-connected disability affects his ability to think, especially due to all the medication he is required to take. See VA 21-8940 Veterans Application for Increased Compensation Based on Unemployability received September 2014 and October 2020. Based on his February 2015 PTSD Disability Benefits Questionnaire, the Veteran endorsed symptoms of major depressive disorder with anxiousness, distress, and melancholic features. He reported alcohol use to self-medicate. The examining physician noted that the Veteran suffers from cognitive distortions and paranoia. He has exhibited a severe degree of suspiciousness towards others and has portrayed himself as a victim. Later, in his September 2019 Disability Benefits Questionnaire for his service-connected psychiatric condition, the Veteran demonstrated severe psychological symptoms that interfered with his daily living. He endorsed passive suicidal ideations and was advised to use the crisis hotline. The examining physician noted that the Veteran's psychiatric symptoms result in occupational and social impairment with reduced reliability and productivity. The Veteran's stated that he graduated from high school and went to college for computer science but did not graduate. After working at IBM and GM until 1998, he transitioned into mill work. He ultimately retired due to medical reasons. The Veteran reported concerns with his depression, anxiety, and suicidal thoughts. His symptoms are so severe he requires medication on a regular basis. In her final remarks, the examining physician noted that the Veteran's depressed mood, anxiety, sleep impairment, mild memory loss, his disturbances of mood and motivation all create difficulty in establishing and maintaining effective work and social relationships. His symptoms also result in difficulty in adapting to stressful circumstances which include a work or work like setting. The Board finds that the record indicates that the Veteran has significant difficulties due to psychiatric symptoms. During the period on appeal, the Veteran has demonstrated worsening symptoms which contribute to his functional decline. While the Veteran was able to keep his employment for a long period of time, the deterioration of his mental state and the added stress of a more stringent work environment caused him to end his employment. Given his limited education and training, the Veteran is unlikely to be able to transfer his skills to another position. Based on the evidence, both medical and lay, the Veteran's psychiatric symptoms pose significant problems in a normal work setting. His paranoia, suspiciousness, anxiety, impaired judgement, and passive suicidal ideations, all affect his ability to adapt or function in a work or worklike setting. It is clear from the record that he has impaired logical thinking, which is perpetuated by his delusions, make it difficult to function in a typical social or work setting. In light of the Veteran's occupational background and functional limitations, and giving him the benefit of the doubt, the Board finds that the Veteran's psychiatric disorder is sufficient to render him unable to obtain and maintain any form of substantially gainful employment in accordance with his occupational background and education level. Specially Adapted Housing and Special Home Adaptation The Veteran is requesting specially adapted housing or special home adaptation grant and filed his application in June 2012. He asserted that his overall disability has caused him significant limitation in mobility especially with bending, stooping, lifting, crawling, pushing, and pulling. His physical limitations prevent him from accessing his back door and requests a ramp. Another ramp or a new pavement is needed to give him access from his driveway to his front door. He also has problems getting in and out of his bathtub and requests an assistive device. See VA 21-4138 Statement in Support of Claim received December 2013. Additionally, the Veteran complained of poor balance and falling several times requiring the use of a cane and need brace. He indicated that he has permanent loss of use of both lower extremities due to arthritis. He also has difficulties in his hands when he opens and closes them due to cramping. See VA 26-4555 Veterans Application in Acquiring Specially Adapted Housing and Special Home Adaptation. A certificate of eligibility for specially adapted housing is available to a veteran who has a permanent and total service-connected 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. The certificate of eligibility 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 so affect the functions of balance and propulsion as to preclude locomotion without the aid of braces, crutches, canes or a wheelchair; 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 so affect the functions of balance or propulsion as to preclude locomotion without the aid of braces, crutches, canes, or a wheelchair. 38 U.S.C. § 2101 (a); 38 C.F.R. § 3.809 (a), (b), (d). The phrase "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 (c). The U.S. Court of Appeals for Veterans claims (Court) has found that the term "loss of use" in the context of specially adapted housing claims generally means "a deprivation of the ability to avail oneself of the anatomical region in question." Jensen v. Shulkin, 29 Vet. App. 66 (2017). The Court also identified four elements that must be satisfied to establish entitlement to specially adapted housing based on loss of use of the lower extremities: "That the individual must (1) have a permanent and total service-connected disability (2) due to a disorder that (3) involves both lower extremities and (4) causes a loss of use so severe that it precludes locomotion without the regular and constant use of assistive devices. Jensen, 29 Vet. App. 66. If entitlement to a certificate of eligibility for specially adapted housing is not established, a veteran can qualify for a grant for a certificate of eligibility for necessary special home adaptations if he or she has a service-connected disability that results in blindness in both eyes with 20/200 visual acuity or less in the better eye with the use of a standard correcting lens or a limitation in fields of vision such that the widest diameter of the visual field subtends an angle no greater than 20 degrees. Such a disability need not be permanent and total in nature. Additionally, a special home adaptation grant is available for a veteran that has a permanent and total service-connected disability which: (1) includes the anatomical loss or loss of use of both hands; (2) is due to deep partial thickness burns that have resulted in contracture(s) with limitation of motion of two or more extremities or of at least one extremity and the trunk; (3) is due to full thickness or subdermal burns that have resulted in contracture(s) of one or more extremities or the truck; or, (4) is due to residuals of an inhalation injury (including, but not limited to, pulmonary fibrosis, asthma, and chronic obstructive pulmonary disease (COPD)). 38 C.F.R. § 3.809a (b). The Board notes that the Veteran is currently service connected for a PTSD at 70 percent and hemorrhoids at 10 percent. In support of his claim, the Veteran's registered nurse indicated in a February 2016 letter, that the Veteran requires regular assistance in his daily living due to his chronic lumbar and cervical spine degenerative disease and degenerative hip and wrist joint disease, depression, and hypertension. His diseases prevent him from bending at the waist, stooping, lifting, crawling, pushing, pulling, and overhead reach. He requires assistance to get in and out of his shower, using the toilet, washing dishes, preparing meals, making a bed, vacuuming, mopping, etc. He does not have a working refrigerator, washer or dryer, or a working heater. The Veteran ambulates with a cane and has an unstable gate. Recently, he fell into an end table with a glass top. To access his front door from the driveway, he has to go down steps to an uneven rock walkway with a step down to the dirt driveway. There are no handrails along the walkway. Therefore, a ramp would be helpful and provide safety when he walks there. Additionally, his driveway is lumpy and muddy, making it more difficult to get to his car. The access area to his back door is very steep. The steps are very weathered and worn down, making it unsafe for him to walk on them. Additionally, to get into his shower, the Veteran has to lift his legs up without the help of any hand grab bars. Given that his toilet is very low, a raised toilet or raised seat would help. Despite the Veteran's contentions, the Board finds that the medical evidence does not show that his service-connected disabilities cause the loss of either lower extremity, nor the essential or functional loss or its equivalency; nor have any service-connected conditions individually or collectively caused the loss of use of one lower extremity together with residuals of organic disease or injury which so effect the functions of balance or propulsion as to preclude locomotion without the aid of braces, crutches, canes, or a wheelchair. While it is clear from the record that the Veteran's arthritis of his back and hip cause significant problems with locomotion, he is not service connected for those disabilities. His service-connected disabilities (PTSD and hemorrhoids) have not been shown to result in amyotrophic lateral sclerosis, blindness in both eyes or service-connected disability due to full thickness or subdermal burns. Similarly, his service-connected disabilities, on their own or collectively, are not shown or alleged to result in loss of use of either upper extremity that precludes use of the arms at or above the elbows. Also, his service-connected disabilities are not shown to result in loss of use of either lower extremity. Accordingly, specially adapted housing may not be awarded based on such loss of use, to include the combination of such loss with loss of use of an upper extremity or residuals of organic disease or injury. 38 C.F.R. § 3.809(b) (1, 3-4). Notably, residuals of an organic disease or injury is also not shown. Considering all pertinent criteria, the Board does not have a basis for granting entitlement to a certificate of eligibility for specially adapted housing. 38 C.F.R. § 3.809 (b) (1-6), (d). Regarding the special home adaptation claim, it is neither shown nor has it been alleged, that the Veteran has blindness in both eyes according to the controlling regulatory standard. It is also neither shown nor has it been alleged that he has the anatomical loss of use of both hands or that he has deep partial thickness burns or full thickness or subdermal burns. Additionally, he does not have any service-connected respiratory disabilities or other service-connected disability due to residuals of an inhalation injury. Accordingly, considering all pertinent criteria, the Board does not have a basis for granting entitlement to a certificate of eligibility for special home adaptation grant. 38 C.F.R. § 3.809 (b) (1-2). (Continued on the next page) The Board empathizes with the Veteran's claims for specially adapted housing and special home adaptation as it is evident that he wants to improve his quality of life by better adapting his home environment to meet his needs. However, the Board is bound to follow the controlling regulations. Because these regulations do not allow for an award of specially adapted housing or special home adaptation grant based on the disabilities for which the Veteran is service connected, the claims must be denied. Tiffany Dawson Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board N. Yeh, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.