Citation Nr: 21072658 Decision Date: 12/03/21 Archive Date: 12/03/21 DOCKET NO. 17-02 578 DATE: December 3, 2021 ORDER Entitlement to service connection for a lumbar spine disability is denied. Entitlement to service connection for diabetes mellitus, type II is denied. Entitlement to service connection for an eye disability is denied. Entitlement to service connection for a psychiatric disability, manifested by depression, is granted. Entitlement to a compensable rating for status post osteotomy, bilateral feet, is denied. Entitlement to a rating in excess of 30 percent prior to October 13, 2020 for bilateral pes planus and in excess of 50 percent therefrom is denied. Entitlement to an effective date of February 6, 2013, but no earlier, for the assignment of a 30 percent disability rating for bilateral pes planus is granted. Entitlement to special monthly compensation (SMC) based on need for the regular aid and attendance or by reason of being housebound is denied. REMANDED Entitlement to service connection for hypertension is remanded. FINDINGS OF FACT 1. The probative evidence does not establish that the Veteran's lumbar spine disability is at least as likely as not related to an in-service injury, disease, or event. 2. The probative evidence does not establish that the Veteran's diabetes mellitus, type II is at least as likely as not related to an in-service injury, disease, or event. 3. The probative evidence does not establish that the Veteran's eye disability is at least as likely as not related to an in-service injury, disease, or event. 4. Affording the Veteran, the benefit of the doubt, his unspecified depressive disorder is etiologically related to his bilateral pes planus. 5. The preponderance of the evidence is against finding that the bilateral foot (toes) scars are unstable or painful. 6. Prior to October 13, 2020, the Veteran's bilateral pes planus was not productive of pronounced bilateral acquired flatfoot, with marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of the Achilles tendon on manipulation, not improved by orthopedic shoes or appliances. 7. Since October 13, 2020, the Veteran is in receipt of the maximum schedular evaluation for bilateral pes planus; loss of use of either foot has not been shown. 8. It is factually ascertainable that the Veteran's bilateral pes planus symptoms increased in severity based on a February 6, 2013, medical record. 9. The Veteran's service-connected disabilities have not rendered him unable to care for his daily personal needs without assistance from others, or unable to protect himself from the hazards and dangers of daily living on a regular basis, nor is he substantially confined to his dwelling, the immediate premises, a ward, or clinical area of an institution due to a service-connected condition; he does not have a single disability that is rated 100 percent. CONCLUSIONS OF LAW 1. The criteria for service connection for lumbar spine disability have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303. 2. The criteria for service connection for diabetes mellitus, type II have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309. 3. The criteria for service connection for an eye disability have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303. 4. The criteria for service connection for a psychiatric disability, manifested as depression have been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310. 5. The criteria for a compensable rating for status post osteotomy, bilateral feet, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.10, 4.118, Diagnostic Code (Code) 7805. 6. The criteria for a rating higher than 30 percent prior to October 13, 2020, for bilateral pes planus and higher than 50 percent from such date have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Code 5276. 7. The criteria for an effective date of February 6, 2013, but no earlier, for the assignment of a 30 percent disability rating for bilateral pes planus have been met. 38 U.S.C. §§ 5110, 5107; 38 C.F.R. §§ 3.105 (a), 3.155, 3.400; 38 C.F.R. § 3.157 (2013). 8. The criteria for SMC based on need for the regular aid and attendance or by reason of being housebound have not been met. 38 U.S.C. §§ 1114(l), 1114(s), 5107; 38 C.F.R. §§ 3.350(b), 3.352. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The appellant is a Veteran who served on active duty from September 1975 to August 1988. These matters are before the Board of Veterans' Appeals (Board) on appeal from rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO). In February 2019, these matters were remanded for further development. Service Connection Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated in active military service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a). For purposes of establishing service connection, every Appellant shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. See 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b). According to 38 C.F.R. § 3.304(b), the term "noted" denotes only such conditions that are recorded in examination reports. A history of pre-service existence of conditions recorded at the time of examination does not constitute a notation of such conditions but will be considered together with all other material evidence in determinations as to inception. 38 C.F.R. § 3.304(b)(1); Crowe v. Brown, 7 Vet. App. 238 (1994). Service connection requires competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). In the absence of proof of a present disability there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Additionally, for Veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, including hypertension and diabetes mellitus, type II, are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. Alternatively, when a disease at 38 C.F.R. § 3.309(a) is not shown to be chronic during service or the one-year presumptive period, service connection may also be established by showing continuity of symptomatology after service. See 38 C.F.R. § 3.303(b). The use of continuity of symptoms to establish service connection is limited only to those diseases listed at 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). A disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310. Additionally, where symptoms are capable of lay observation, a lay witness is competent to testify to a lack of symptoms prior to service, continuity of symptoms after in-service injury or disease, and receipt of medical treatment for such symptoms. Charles v. Principi, 16 Vet. App. 370, 374 (2002). When considering whether lay evidence is competent, the Board must determine, on a case-by-case basis, whether the Veteran's disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011). VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 1. Entitlement to service connection for lumbar spine disability The Veteran is seeking service connection for a lumbar spine disability. Neither the Veteran nor his experienced counsel has offered to specific contentions indicating why he believes service connection is warranted. The Veteran is diagnosed with a current lumbar spine condition. Although records reflect a current diagnosis of disc degeneration, there is no probative evidence indicating a relationship between the Veteran's lumbar spine disability and his service, to include any in-service event. Post-service treatment records reflect a lumbar spine injury in 1995. He subsequently underwent surgery for a herniated disc in 1996 and 1997. According to a February 2013 VA primary care medical record, the Veteran attributed his current complaints to the back injury in the "late 1990's." The Veteran's service treatment records (STRs) do not reflect a lumbar spine injury or any complaints involving the lumbar spine in service. At service separation, the Veteran signed a form certifying to the truth of his statement that he did not have recurrent back pain; bone, joint or other deformity; or any other illness or injury other than those specifically noted. He routinely sought treatment throughout service for multiple other injuries and complaints, so the absence of complaints involving the low back further indicates that such did not occur. Overall, the STRs, including the Veteran's certification, are highly probative evidence that he did not have a back injury or symptoms in service. To the extent that the Veteran himself has opined there is a relationship, the Veteran in this case is not competent to provide a nexus opinion regarding this issue. The issue is medically complex, as it requires knowledge of the lumbar spine, the risk factors for lumbar spine diagnoses, and the relationship between the two. It is outside the competence of the Veteran in this case because the record does not show that he has the medical training or credentials to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). The Board notes that the Veteran has not been afforded a VA examination with respect to his claim but finds that one is not required as the only indication that the lumbar spine disability is related to service is the Veteran's own conclusory, generalized lay statement in the form of his claim. Waters v. Shinseki, 601 F.3d 1274, 1278 (Fed. Cir. 2010); Euzebio v. Wilkie, 31 Vet. App. 394 (2019); cf Colantonio v. Shinseki, 606 F.3d 1378, 1381-82 (Fed. Cir. 2010). As the evidence is not in equipoise, the claim is denied. 2. Entitlement to service connection for diabetes mellitus, type II The Veteran is seeking service connection for a diabetes mellitus, type II, (herein after "diabetes"). Neither the Veteran nor his experienced counsel has offered to specific contentions indicating why he believes service connection is warranted. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that although the Veteran has a current diagnosis of diabetes, the preponderance of the evidence weighs against finding that diabetes began during service or is otherwise related to an in-service injury or disease. The STRs show no complaints or treatment of diabetes mellitus, type II. On service separation examination, laboratory testing including urinalysis negative for sugar. Direct service connection cannot be established where there is no evidence indicating a nexus between a current disability and an in-service injury or disease. Post-service treatment records, to include Social Security disability records, indicate the Veteran has been on disability since 2012 in part due to diabetes. There is no indication that his current diabetes is related to any event in service. Service connection on a presumptive basis is also not warranted. Here, the Veteran does not provide any information as to when his condition began, and the earliest notation in the available medical records shows a diagnosis of diabetes mellitus, type II decades after service separation in 1988. As diabetes mellitus, type II was not seen until several years following the Veteran's separation from service, service connection on a presumptive basis is also not warranted. No VA examination is required as there is no evidence of an in-service event, injury, or disease related to his now-diagnosed diabetes mellitus, type II, and no indication of a nexus to service. As the evidence is not in equipoise, the claim is denied. 3. Entitlement to service connection for an eye disability The Veteran asserts that his eye disability is due to his service or secondary to diabetes. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that although the Veteran has a current diagnosis of mild diabetic retinopathy and age-related cataracts, the preponderance of the evidence weighs against finding that an eye disability began during service or is otherwise related to an in-service injury or disease. The STRs include a June 1980 record that documents the Veteran was seen for an incident where diesel fuel spilled into his eyes. He was referred to the Eye Clinic, and his eyes were irrigated with water. There was no damage seen. On the May 1988 separation examination, the Veteran denied any vision loss, and eye examination was normal. Although the event in service occurred, the evidence weighs against a nexus. The evidence does not show an onset proximate in time to service. Post-service treatment records include an August 2017 VA treatment record that shows the Veteran's eye condition included mild diabetic retinopathy as well as age-related cataracts. A nexus to service is not otherwise shown. During September 2017 VA examination, the examiner diagnosed an additional eye disability of suspect glaucoma. The VA examiner indicated that the Veteran's current eye disabilities were not due to the diesel fuel that spilled in his eyes during active duty. The examiner indicated that retinopathy and glaucoma were due to the diabetes mellitus, type II, and the cataracts are age-related. The examiner's opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The VA examiner indicates the diagnoses are related to the Veteran's non-service-connected diabetes mellitus, type II, as well as his age. There is no competent medical evidence to the contrary. Although the Veteran is competent to describe his history of eye disabilities, he is not competent to render such am opinion regarding etiology of such complex eye conditions. As such, the question of etiology in this case may not be competently addressed by lay evidence. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). In sum, the preponderance of the evidence is against these service connection claims. See 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 55. 4. Entitlement to service connection for a psychiatric disability, claimed as depression The Veteran asserts that his depression was due to service or to his service-connected bilateral pes planus. See February 2021 and May 2021 attachments from his attorney. The Board is required to consider all theories of entitlement reasonably raised by the record. See Robinson v. Shinseki, 557 F.3d 1355, 1361 (Fed. Cir. 2009) (the Board is required to weigh all theories of entitlement raised either by the claimant or by the evidence). At service entrance, the Veteran endorsed a history of depression or excess worry a and nervous trouble of any sort. The examiner noted depression and nervousness (economic and family). Because a condition was noted at service entrance, the presumption of soundness does not apply. 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b). If a condition is noted at the time of service entrance, a veteran is not entitled to the presumption of soundness. 38 U.S.C. § 1111; Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). Under such circumstances, service connection is warranted if the preexisting disorder was aggravated by a veteran's active service. A preexisting injury or disease will be presumed to have been aggravated by active service where there is an increase in disability during such service, unless there is a specific finding that the increase in disability was due to the natural progress of the disease. 38 U.S.C. § 1153; 38 C.F.R. § 3.306(a). It is the veteran who must show that there was an increase in disability during service to trigger the presumption of aggravation. See Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). The presumption of aggravation only requires evidence of an actual worsening of a preexisting condition during service; it does not require direct evidence of nexus, that is, that the worsening was caused by service. Smith v. Shinseki, 24 Vet. App. 40, 47-48 (2010). Under § 1153, once a veteran establishes worsening, "the burden shifts to the Secretary to show by clear and unmistakable evidence that the worsening of the condition was due to the natural progress of the disease." Horn v. Shinseki, 25 Vet. App. 231, 235 n.6 (2012) (citing Wagner, 370 F.3d at 1096). Here, aggravation is not indicated. The Veteran again reported intermittent depression and anxiety on his separation examination. The examiner noted intermittent depression depending on the circumstances, and nervousness in he morning, decreased with eating. There is no indication that this represented a worsening of the condition. To the contrary, the notation indicates symptoms materially the same as those reported at service entrance. At an October 2020 VA examination, the Veteran reported depression in service, but also stated that he was not depressed in 1988 when he got out, but rather "was pretty happy then until everything started going bad" after service in the 1990s. He indicated that he was only depressed in relation to service because he did not have a sense of purpose any further after service. His statement to the examiner is further evidence indicating that no aggravation occurred. Since that time, various statements submitted by the Veteran's friends and family indicated he was quiet and withdrawn during service. Indeed, a March 2016 statement from E.T. describes the Veteran was outgoing, had lots of friends, was involved in school activities, played sports, was in the marching band prior to. He indicated that the Veteran's mood started to change around 1980. He indicates that the Veteran's demeanor became different, he was withdrawn and reported experiencing depression. The Board does not find this evidence to indicate aggravation during service. It is clearly contradicted by the affirmative evidence of preexisting symptomatology. In February 2021, a private psychologist, Dr. H.H-G, diagnosed the Veteran with an unspecified depressive disorder. In February 2021, Dr. H.H-G interviewed the Veteran and offered an opinion on service connection, citing objective and subjective evidence and medical literature, that it was more likely than not that the unspecified depressive disorder "began in military service, continues uninterrupted to the present and is aggravated by his bilateral pes planus." The Board finds that this opinion is of limited probative value as to the direct theory as it did not address the clearly preexisting depression and nervousness. The STRs, which show preexisting symptoms, contradict the private opinion indicating that his condition began during service. On October 2020 VA examination, the examiner diagnosed depression, and opined that the depression is not due to the Veteran's service; or secondary to any service-connected disabilities. The examiner repeatedly cited the Veteran's report that his symptoms were due to due to being alone, including the loss of his family. The Board does not find this opinion particularly probative as it does not address the STRs nor does it appear to have given more than a very superficial consideration of the case. The Board ultimately finds that there is a causal relationship between the Veteran's bilateral pes planus and unspecified depressive disorder warranting secondary service connection. The February 2021 opinion of the Dr. H.H-G provided medical evidence and opinion of a medical connection between the Veteran's bilateral pes planus symptoms and the unspecified depressive disorder symptoms noted on the February 2021 private examination. Indeed, Dr. H.H-G opined that the Veteran's unspecified depressive disorder symptoms began in-service. As this is also when the associated bilateral pes planus symptoms began, the Board finds that, affording the Veteran the benefit of the doubt, the unspecified depressive disorder developed during service and as secondary to the bilateral pes planus. Therefore, entitlement to service connection for an unspecified depressive disorder secondary to bilateral pes planus is warranted. Increased Rating Disability ratings are determined by the application of VA's Schedule for Rating Disabilities (Schedule), which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Pertinent regulations do not require that all cases show all findings specified by the Schedule, but that findings sufficient to identify the disease and the resulting disability and, above all, coordination of the rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21; Mauerhan v. Principi, 16 Vet. App. 436. When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where there is a question as to which of two ratings shall be applied, the higher rating 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. 5. Entitlement to a compensable rating for status post osteotomy, bilateral feet The Veteran's scars to his feet/toes are currently rated under Code 7805. He asserts that compensable ratings are warranted. Scars are rated under 38 C.F.R. § 4.118, Codes 7800-7805. Importantly, the regulations pertaining to scars were revised, effective August 13, 2018. These new regulations apply to claims that were pending on August 13, 2018 (such as here), if the new regulations are more favorable to the veteran's case. As an initial matter, neither the old nor new versions of Codes 7800-7802 are for application to this appeal, as based upon the nature of the four scars at issue. See, e.g., May 2014 VA examination. Rather, the Veteran argues that compensable ratings are warranted under Code 7804 for scars that are unstable or painful. In this respect, Codes 7804 and 7805 were unaffected by the 2018 revisions. As noted, the scars are currently evaluated as noncompensable under Code 7805. This Code applies to limitation of function of the affected part and provides: "Evaluate any disabling effect(s) not considered in a rating provided under diagnostic codes 7800-04 under an appropriate diagnostic code." See 38 C.F.R. § 4.118. Thus, the Board will consider whether compensable ratings are warranted under Code 7804, which establishes a 10 percent rating upon evidence of one or two scars that are unstable or painful. Any disabling effects not considered by the Codes pertaining to scars should be rated under an appropriate Code. Private treatment records do not show any complaints or treatment of osteotomy scars of both feet. VA treatment records do not show any complaints or treatment of osteotomy scars of both feet. Social Security disability records do not contain any scarring as part of their determination. During May 2014 VA examination to determine the current severity of the Veteran's service-connected pes planus, the examiner noted the Veteran had scars on his feet associated with in-service osteotomies. The scars were located on two toes of each foot all measuring 5 cm by 0.1 cm each. The scars were not painful or tender and were not unstable or resulting in any orthopedic impairment. As the Veteran's bilateral feet/toe scars do not affect the head, face, or neck, are not associated with underlying soft tissue damage, do not measure at least 144 square inches, are not unstable or painful, and do not produce any disabling effect, there is no basis for a separate compensable rating under any diagnostic code for scars or otherwise. Separate compensable ratings must be denied. As the weight of the evidence is against assignment of higher ratings, the claim is denied. 6. Entitlement to a rating higher than 30 percent for bilateral pes planus prior to October 13, 2020 and higher than 50 percent from such date The Veteran asserts that his bilateral pes planus disability warrants ratings higher than what is currently assigned. The Veteran's bilateral pes planus is currently rated at 30 percent under Code 5276 effective from March 25, 2013. and a 50 percent rating effective from October 13, 2020. Code 5276 provides for a 10 percent rating for moderate; weight-bearing line over or medial to great toe, inward bowing of the Tendo-Achillis, pain on manipulation and use of the feet, bilateral or unilateral. A 30 percent rating is afforded for severe bilateral acquired flatfoot, with objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated an indication of swelling on use, and characteristic callosities. A 50 percent evaluation is assigned for pronounced bilateral acquired flatfoot, with marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of the Achilles tendon on manipulation, not improved by orthopedic shoes or appliances. Effective February 7, 2021, VA amended the rating schedule for the feet by adding DC 5269 for plantar fasciitis. The intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint, even in the absence of arthritis, to include in situations where the disability at issue is not evaluated based on range of motion measurements. 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1, 5 (2011); Southall-Norman v. McDonald, 28 Vet. App. 346 (2016). A February 2013 VA treatment record documents the Veteran's complaint of increased foot pain. He was subsequently referred for a VA podiatry consultation. A VA podiatry consultation dated March 25, 2013, documents the Veteran's pes planus manifests as bilateral involvement, characteristic callouses and objective pain. A May 2014 VA examination report noted hallux valgus, callouses, and hammer toes on both feet as a result of the Veteran's pes planus. There was no evidence of decreased longitudinal arch height, objective evidence of marked deformity or marked pronation. There was no evidence of any lower extremity deformity other than pes planus. There was no evidence of inward bowing or marked inward displacement. It was noted that the Veteran uses arch support or custom orthotic inserts to help alleviate pain. During October 2020 VA examination, the Veteran reported his current symptoms included constant pain that was dull, tender, can be stabbing at times. He reports the pain worsened in the last 18 months and was currently a 9 out of 10 on the pain scale. There is pain in both feet with manipulation. No Morton's neuroma or metatarsalgia. The Veteran reported that he constantly uses orthotic inserts with orthopedic shoes. The examiner noted that the Veteran's bilateral foot disability impacts his ability to perform any type of occupational tasks, because the disability effects the Veteran's ability to run and also limits the amount of time he can stand on his feet. Concerning the Veteran's bilateral pes planus, the Board finds that prior to October 13, 2020, the condition most nearly approximates a 30 percent rating. Relevant factors include weakness, fatigability, restricted or excess movement of the joint, or pain on movement. See 38 C.F.R. § 4.45. Indeed, the medical evidence shows that the Veteran had bilateral foot pain, with occasional pain on with manipulation of both feet and pain accentuated on use. He exhibited decreased longitudinal arch height on weight bearing. Moreover, he had difficulty with prolonged walking and standing. A rating in excess of 30 percent is not warranted since there is no evidence in record prior to October 13, 2020, of pronounced bilateral acquired flatfoot, with marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of the Achilles tendon on manipulation, not improved by orthopedic shoes or appliances. Therefore, a higher rating is not warranted for bilateral pes planus, prior to October 13, 2020. 38 C.F.R. § 4.71a, Code 5276. As of October 13, 2020, the Veteran's bilateral pes planus is rated as 50 percent disabling, which is the maximum schedular disability rating under Code 5276. 38 C.F.R. § 4.71a. Therefore, a higher schedular disability rating is warranted only for loss of use of the feet. See 38 C.F.R. § 4.71a, Code 5167. The evidence does not show, and the Veteran does not assert, that his bilateral pes planus is of such severity that it resulted in loss of use of either foot at any time during the period on appeal. In conclusion, the Board finds that the preponderance of the evidence is against increased staged ratings. 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. Therefore, a higher disability rating is not warranted, and to this extent, the claim is denied. 7. Entitlement to an earlier effective date for the assignment of a 30 percent rating for bilateral pes planus Relevant to an effective date earlier than March 25, 2013, for the assignment of a 30 percent rating for the Veteran's bilateral pes planus, the assignment of effective dates of awards is generally governed by 38 U.S.C. § 5110 and 38 C.F.R. § 3.400. Unless specifically provided otherwise, the effective date of an award based on an original claim, a claim reopened after final disallowance, or a claim for increase "shall be fixed in accordance with the facts found but shall not be earlier than the date of receipt of application therefor." 38 U.S.C. § 5110(a). The implementing regulation clarifies this to mean that the effective date of an evaluation and award of compensation based on an original claim, a claim reopened after final disallowance, or a claim for increase will be the "[d]ate of receipt of claim or date entitlement arose, whichever is the later." 38 C.F.R. § 3.400. The "date of the claim" means the date of the application based upon which benefits are awarded, not the original claim for service connection. Sears v. Principi, 16 Vet. App. 244, 246-47 (2002), aff'd, 349 F.3d 1326 (Fed. Cir. 2003). In this context, it should be noted that the provisions of 38 U.S.C. § 5110 also refer to the date an application is received. While the term "application" is not defined in the statute, the regulations use the terms "claim" and "application" interchangeably, and they are defined broadly to include "a formal or informal communication in writing requesting a determination of entitlement, or evidencing a belief in entitlement, to a benefit." 38 C.F.R. §§ 3.1(p), 3.155; Servello v. Derwinski, 3 Vet. App. 196, 198 (1992). The Board notes that VA amended its adjudication regulations on March 24, 2015, to require that all claims governed by VA's adjudication regulations be filed on standard forms prescribed by the Secretary, regardless of the type of claim or posture in which the claim arises. See 79 Fed. Reg. 57660 (Sept. 25, 2014). The amendments, however, are only effective for claims and appeals filed on or after March 24, 2015. As the underlying claim and appeal in this case was filed prior to that date, the amendments are not applicable in this instance and the regulations in effect prior to March 24, 2015 will be applied. A December 1990 rating decision continued a 10 percent rating for the Veteran's bilateral pes planus. The Veteran did not disagree with that rating decision. The Veteran submitted a claim for an increased rating on May 22, 2013. Included with his claim were treatment records to include a March 25, 2013, VA podiatry examination report. Notably, the Veteran was also seen on February 6, 2013, for a VA primary care visit. The Veteran reported an increase in constant pain in his feet. The examiner evaluated his disabilities to include his feet. The examiner determined that the evaluation was abnormal and referred the Veteran for a VA podiatry consultation. As noted, the Veteran was subsequently seen on March 25, 2013, for evaluation of his feet. The February 6, 2013 treatment entry is an informal claim for an increase. See 38 C.F.R. § 3.157(b). The February 6, 2013 treatment entry makes it factually ascertainable that a worsening of the Veteran's bilateral foot disability had occurred. Such worsening found during treatment rendered at a VA hospital satisfies the requirements of 38 C.F.R. § 3.157(b)(1). See Massie v. Shinseki, 25 Vet. App. 123, 134 (2011). It follows then that the February 6, 2013, treatment entry is an informal claim for increased benefits as a result of his increase in symptomology. See 38 C.F.R. § 3.157(b) (2013). The date of the February 6, 2013 VA primary care examination has been accepted as the date of receipt of a claim. Id. § 3.157(b)(1). The evidentiary record is silent for any complaints of or treatment for bilateral pes planus prior to February 6, 2013. Therefore, there is no basis in which the Board can grant an earlier effective date prior to February 6, 2013. Accordingly, the Board finds the criteria for an effective date of February 6, 2013, but no earlier, for the assignment of a 30 percent disability rating for bilateral pes planus is granted. See Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990); 38 C.F.R. § 3.102. 8. Entitlement to SMC based on need for the regular aid and attendance or by reason of being housebound If a veteran has a single service-connected disability rated as 100 percent disabling, he is entitled to compensation benefits at the "housebound" rate if he: (1) has additional service-connected disability or disabilities independently ratable at 60 percent, separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems; or (2) is "permanently housebound" by reason of service-connected disability or disabilities. 38 U.S.C. § 1114(s); 38 C.F.R. § 3.350(i). The "permanently housebound" requirement is met when the veteran is substantially confined, as a direct result of service-connected disabilities, to his dwelling and the immediate premises or, if institutionalized, to the ward or clinical areas, and it is reasonably certain that the disability or disabilities and resultant confinement will continue throughout his lifetime. Leaving one's house for medical purposes cannot, by itself, serve as the basis for finding that one is not substantially confined for purposes of housebound benefits. Howell v. Nicholson, 19 Vet. App. 535, 540 (2006). A higher level of compensation is payable to eligible veterans who, by reason of service-connected disability, require the regular aid and attendance of another person. SMC at the aid and attendance rate is warranted if the Veteran, as a result of service-connected disability, has suffered the anatomical loss or loss of use of both feet, or of one hand and one foot, or is blind in both eyes, or is permanently bedridden or so helpless as to be in need of regular aid and attendance. 38 U.S.C. § 1114(l); 38 C.F.R. § 3.350(b). Determinations as to the need for aid and attendance must be based on actual requirements of personal assistance from others. In making such determinations, consideration is given to: inability of a claimant to dress or undress himself; to keep himself ordinarily clean and presentable; frequent need of adjustment of any special prosthetic or orthopedic appliance which by reasons of the particular disability cannot be done without aid; inability to feed himself through the loss of coordination of upper extremities or through extreme weakness; inability to tend to the wants of nature; or incapacity, physical or mental, that requires care and assistance on a regular basis to protect claimant from the hazards or dangers incident to his daily environment. "Bedridden" will be a proper basis for the determination and is defined as that condition which, through its essential character, actually requires that the claimant remain in bed. The fact that the claimant has voluntarily taken to bed or that a physician has prescribed rest in bed for the greater or lesser part of the day to promote convalescence or cure will not suffice. It is not required that all the disabling conditions enumerated above be found to exist before a favorable rating may be made. The particular personal functions that the claimant is unable to perform should be considered in connection with his condition as a whole. It is only necessary that the evidence establishes that the claimant is so helpless as to need regular aid and attendance, not that there is a constant need. 38 C.F.R. § 3.352(a); see also Turco v. Brown, 9 Vet. App. 222, 224 (1996) (holding that at least one factor listed in section 3.352(a) must be present for a grant of SMC based on need for aid and attendance). The evidence does not show, and the Veteran does not suggest, that he is "permanently housebound" due to his service-connected disabilities. Indeed, he has also reported during the appeal period that he attended church occasionally and got out and walked daily as well as rides his bike daily for a minimum of 3 miles. See March 2013 and July 2018 VA treatment reports. Initially, the Board notes that nothing of record suggests, nor does the Veteran allege, that he is bedridden due to service-connected disability. Furthermore, nothing of record indicates that he is unable to feed, dress, or groom himself. The evidence seems fairly consistent in showing that, although not without difficulty, he is independent in his daily activities. The Board acknowledges VA examination reports documenting limited mobility due to his service-connected foot disability. There has been no evidence submitted in support of a conclusion that he needs the aid or attendance of someone else in the ordinary activities of daily living, or that he is housebound (i.e., confined to his house or immediate premises). In summary, although the evidence shows that the Veteran does have impairment of certain functions, the preponderance of the evidence is against a finding that he is housebound or so helpless that he requires regular aid and attendance, due solely to his service-connected disabilities. Therefore, the benefit of the doubt rule is not for consideration, and the appeal in this matter must be denied. REASON FOR REMAND Entitlement to service connection for hypertension is remanded. The Veteran asserts that his hypertension is due to his service. The STRs show no complaints or treatment of hypertension. On May 1988 service separation examination, the Veteran indicated that he did not know whether or not he has had an issue with his blood pressure. As STRs do not indicate a diagnosis of hypertension but do show a possibility of high blood pressure during active duty, the Veteran should be afforded a VA examination or opinion. See McClendon v. Nicholson, 20 Vet. App. 79 (2006). The matter is REMANDED for the following action: Obtain a VA opinion addressing the etiology of the Veteran's hypertension. The Board leaves it to the discretion of the clinician to determine whether the Veteran needs to be examined in-person. (Continued on the next page) The clinician is asked to address the following: Is it at least as likely as not that the Veteran's hypertension had its onset during service or is otherwise related to service? Consider that the Veteran indicated on the May 1988 service separation examination that he was unsure if he had a history of high blood pressure. Corey Bosely Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. McPhaull, 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.