Citation Nr: 21073671 Decision Date: 12/09/21 Archive Date: 12/09/21 DOCKET NO. 18-28 222 DATE: December 9, 2021 ORDER Entitlement to service connection for an adjustment disorder unspecified (claimed as psychiatric impairment), as secondary to service-connected bilateral hearing loss, is granted. Entitlement to service connection for arteriosclerotic heart disease is denied. Entitlement to service connection for atrial fibrillation is denied. Entitlement to service connection for chronic obstructive pulmonary disease (COPD) is denied. Entitlement to service connection for diabetes mellitus, type II, is denied. Entitlement to service connection for emphysema is denied. Entitlement to service connection for peripheral vascular disease is denied. Entitlement to an initial 30 percent disability rating prior to November 14, 2013 for service-connected bilateral hearing loss is granted Entitlement to a disability rating in excess of 40 percent from November 14, 2013 to October 16, 2017, and in excess of 50 percent thereafter, for service-connected bilateral hearing loss is denied. Entitlement to earlier effective dates for the awards of increased 40 and 50 percent disability ratings for service-connected bilateral hearing loss is denied. Entitlement to a certificate of eligibility for specially adapted housing or a special home adaptation grant is denied. Entitlement to special monthly compensation (SMC) based on the need for aid and attendance or housebound status is denied. REMANDED Service connection for lower extremity cellulitis is remanded. FINDINGS OF FACT 1. The evidence is in relative equipoise as to whether the Veteran's service-connected bilateral hearing loss aggravated his acquired adjustment disorder. 2. The preponderance of the evidence is against finding that the Veteran's arteriosclerotic heart disease began during active service, or is otherwise related to an in-service event, injury, or disease. 3. The preponderance of the evidence is against finding that the Veteran's atrial fibrillation began during active service, or is otherwise related to an in-service event, injury, or disease. 4. The preponderance of the evidence is against finding that the Veteran's COPD began during active service, or is otherwise related to an in-service event, injury, or disease. 5. The preponderance of the evidence is against finding that the Veteran's diabetes mellitus began during active service, or is otherwise related to an in-service event, injury, or disease. 6. The preponderance of the evidence is against finding that the Veteran's emphysema began during active service, or is otherwise related to an in-service event, injury, or disease. 7. The preponderance of the evidence is against finding that the Veteran's peripheral vascular disease began during active service, or is otherwise related to an in-service event, injury, or disease. 8. Prior to November 14, 2013, the Veteran's bilateral hearing loss manifested no more than a Level VI hearing impairment in both ears. 9. From November 14, 2013 to October 17, 2017, the Veteran's bilateral hearing loss manifested no more than a Level VIII hearing impairment in his right ear and a Level VII hearing impairment in his left ear. 10. From October 17, 2017, the Veteran's bilateral hearing loss manifested no more than a Level VII hearing impairment in his right ear and a Level IX hearing impairment in his left ear. 11. It was not factually ascertainable that an increase in severity occurred at any point prior to November 14, 2013 or October 17, 2017 in regard to the Veteran's 40 and 50 percent ratings, respectively, for bilateral hearing loss. 12. The Veteran's service-connected disabilities did not result in the loss of use of one lower extremity together with residuals of organic disease or injury which so affect the functions of balance or propulsion as to preclude locomotion without the aid of braces, a cane, and wheelchair. 13. The Veteran did not have a permanent and total disability that includes the anatomical loss or loss of use of both hands, blindness in both eyes, deep partial thickness, full thickness, or subdermal burns that resulted in contractures with limitation of motion of two or more extremities or of at least one extremity and the trunk, or residuals of an inhalation injury. 14. The Veteran was not helpless or so nearly helpless, due to service-connected disabilities, as to require the regular need for aid and attendance of another person. CONCLUSIONS OF LAW 1. The criteria for establishing service connection for acquired adjustment disorder, unspecified, as secondary to service-connected bilateral hearing loss, have been satisfied. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 2. The criteria for service connection for arteriosclerotic heart disease have not been satisfied. 38 U.S.C. §§ 1110, 1112, 1116, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 3. The criteria for service connection for atrial fibrillation have not been satisfied. 38 U.S.C. §§ 1110, 1112, 1116, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 4. The criteria for service connection for COPD have not been satisfied. 38 U.S.C. §§ 1110, 1112, 1116, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 5. The criteria for service connection for diabetes mellitus have not been satisfied. 38 U.S.C. §§ 1110, 1112, 1116, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 6. The criteria for service connection for emphysema have not been satisfied. 38 U.S.C. §§ 1110, 1112, 1116, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 7. The criteria for service connection for peripheral vascular disease have not been satisfied. 38 U.S.C. §§ 1110, 1112, 1116, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 8. The criteria for an initial 30 percent disability rating prior to November 14, 2013 for service-connected bilateral hearing loss have been satisfied. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.85, 4.86, Diagnostic Code 6100 9. The criteria for a disability rating in excess of 10 percent prior to November 14, 2013, in excess of 40 percent from November 14, 2013 to October 16, 2017, and in excess of 50 percent from October 17, 2017, for service-connected bilateral hearing loss have not been satisfied. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.85, 4.86, Diagnostic Code 6100. 10. The criteria for earlier effective dates for the awards of increased 40 and 50 percent disability ratings for service-connected bilateral hearing loss have not been satisfied. 38 U.S.C. § 5110; 38 C.F.R. § 3.400. 11. The criteria for entitlement to a certificate of eligibility for financial assistance in acquiring specially adapted housing or a special home adaptation grant have not been satisfied. 38 U.S.C. § 2101, 2101a; 38 C.F.R. §§ 3.809, 3.809a. 12. The criteria for entitlement to SMC based upon the need of aid and attendance/housebound status have not been satisfied. 38 U.S.C. § 1114; 38 C.F.R. §§ 3.350, 3.352. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1964 to January 1967. The Veteran died in August 2019, and his surviving spouse has been substituted as the Appellant. This matter comes before the Board of Veterans' Appeals (Board) from rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). The Appellant was scheduled for a hearing before the Board in in September 2021. The record indicates that she cancelled the hearing. Thus, the hearing request is considered withdrawn. 38 C.F.R. § 20.704(e). Service Connection Generally, to establish service connection, a claimant must show: (1) a present disability; (2) an 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, the so-called "nexus" requirement. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303; see also Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). A disability that is proximately due to, the result of, or aggravated by a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310. VA has also established certain rules and presumptions for chronic diseases. See 38 C.F.R. §§ 3.303(b), 3.307, 3.309(a); Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). With chronic diseases shown as such in service so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless attributable to intercurrent causes. 38 C.F.R. § 3.303(b). If chronicity in service is not established, a showing of continuity of symptoms after discharge may support the claim. 38 C.F.R. § 3.303(b). In addition, for veterans who have served 90 days or more of active service during a war period or after December 31, 1946, chronic diseases are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 C.F.R. §§ 3.307(a)(3), 3.309(a). 1. Service connection for acquired adjustment disorder. Prior to his death, the Veteran asserted that his acquired adjustment disorder, diagnosed upon VA examination in January 2017, was caused or aggravated by his bilateral hearing loss on a secondary basis. Upon VA examination, however, the January 2017 VA examiner opined that it was less likely than not that his adjustment disorder was caused or aggravated by his hearing loss. The examiner explained that, while his disability is related to a number of health difficulties, including adjustment to heart surgery, sleep issues, and smoking cessation, as well as situational factors, according to the medical record his hearing loss was not one of those disabilities. The Board notes, however, that the examiner did not address whether his hearing loss aggravated his adjustment disorder in any way. The legal standard for secondary service connection based on aggravation does not require permanent aggravation. Rather, the evidence must show that there was an increase in the claimed disability beyond a medically established baseline proximately due to or the result of a service-connected disability. See 38 C.F.R. § 3.310(b). In contrast, the record reflects a November 2019 opinion from the Veteran's long-time physician, Dr. A.P., who opined that it was at least as likely as not that the Veteran's diagnosed acquired psychiatric disorder "was secondary to his hearing loss." Dr. A.P. stated that, "[a]s a result of his problems with hearing, [the Veteran] developed significant paranoia. As [the Veteran] often could not hear what people were saying he developed paranoia, thinking that people were talking badly about him." Dr. A.P. also provided a copy of a medical treatise that found that people with hearing loss are often prone to mental health impairment, including depression, anxiety, and paranoia. There are no other medical opinions in the claims file that are in significant conflict with the above opinions. Based on the foregoing, the Board finds the evidence is at least in relative equipoise as to whether the Veteran's acquired psychiatric disorder was at least as likely as not aggravated by his bilateral hearing loss, which the Board notes was fairly severe. As such, after resolving all doubt in the Appellant's favor, the claim for service connection for an acquired adjustment disorder, on an aggravation basis, and for accrued benefits purposes, is granted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 2. Service connection for arteriosclerotic heart disease. 3. Service connection for atrial fibrillation. 4. Service connection for COPD. 5. Service connection for emphysema. 6. Service connection for diabetes mellitus. 7. Service connection for peripheral vascular disease. As to the remaining service connection claims (with the exception of the cellulitis claim addressed in the Reasons for Remand section below), and while the record confirms a history of these disabilities prior to his death, the claims for service connection for arteriosclerotic heart disease, atrial fibrillation, COPD, emphysema, diabetes mellitus, and peripheral vascular disease must be denied. The Veteran's service treatment records (STRs) show no complaints, diagnosis, or treatment related to these claimed disabilities. As the Veteran reported other ailments during service, and as such problems are the type that a reasonable person would report while in the military with access to healthcare, if the Veteran was experiencing problems indicative of his claimed disabilities during service the Board would expect that he would have reported these problems to medical professionals. During his November 1966 separation examination, evaluation of all systems was normal, and the veteran specifically denied having had any concerns, past or present, in a contemporaneous report of medical history. The Veteran's claimed disabilities are not shown by medical evidence until many years, if not decades, after his separation from service. As a chronic disability is not shown to have been present during service or in the first year after separation of service, and continuity of symptomatology leading to a diagnosis of such is not shown, in-service incurrence of his claimed disabilities cannot be presumed. See 38 C.F.R. §§ 3.307, 3.309(a). To the extent the Veteran asserts a continuity of symptomatology beginning during service, the Board finds these statements to lack credibility as they are in direct conflict with the Veteran's report of medical history at separation from service where he denied any medical concerns. The Board finds the report of medical history at separation from service to be more reliable than more recent assertions as it was done contemporaneous to service and for the purpose of identifying disability at that time. Additionally, the Appellant has offered no actual theory as to why she believes the Veteran's disabilities should be service-connected, nor did the Veteran in any statement prior to his death. While the Board acknowledges her statement in September 2021 that one of the Veteran's doctors told him "everything was likely related to service," no further information was provided, and the record contains no etiological opinion from any of the Veteran's private physicians as to these disabilities. The Board also acknowledges that no VA examination was afforded to the Veteran prior to his death pertaining to these disabilities, nor has any VA examiner's opinion been obtained. Generally, a VA medical examination or opinion is necessary when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, (2) evidence establishing that an event, injury, or disease occurred in service, or establishing certain diseases manifesting during an applicable presumptive period for which the veteran qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the Veteran's service or with another service-connected disability, but (4) there is insufficient competent medical evidence on file for VA to make a decision on the claim. 38 U.S.C. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4)(i); see also McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). As outlined above, the second and third McLendon criteria are not met. As such, remand for a medical opinion is not warranted. The Board has considered the Appellant's statements, as well as the Veteran's statements of record prior to his death, to include his assertions that his claimed disabilities are related to service. As the Veteran and the Appellant are not shown to have medical education or experience, they are lay persons and are competent to report (1) symptoms that are observable to a layperson, (2) symptoms at the time supporting a later diagnosis by a medical professional; or (3) a contemporaneous medical diagnosis. See Davidson v. Shinseki, 581 F.3d 1313 (2009). They are not, however, competent to independently render a medical diagnosis or opine as to the specific etiology of a condition as these are medically complex issues. Thus, his lay assertions do not constitute evidence upon which service connection can be granted. In any event, the Board ultimately assigns greater probative weight to the medical evidence of record, to include the opinion rendered by a trained medical professional based on appropriate diagnostic testing and reasonably drawn conclusions with supportive rationale. For the above reasons, the preponderance of the evidence is against the claims and service connection for arteriosclerotic heart disease, atrial fibrillation, COPD, emphysema, diabetes mellitus, and peripheral vascular disease must be denied. In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claims, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Increased Ratings for Bilateral Hearing Loss Prior to his death, the Veteran was awarded service connection for bilateral hearing loss in December 2013 and was assigned 10 percent rating from October 14, 2009 and a 40 percent rating from November 14, 2013. During the course of the appeal, his disability rating was increased to 50 percent effective October 17, 2017. Prior to his death, the Veteran asserted that higher ratings were warranted. Disability ratings are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Different ratings may be assigned for different periods of time for the same disorder if the facts show distinct time periods with different levels of disability. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). If two ratings are potentially applicable, the higher rating will be assigned if the disability more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. See 38 C.F.R. § 4.3. Ratings of defective hearing are based on organic impairment of hearing acuity as measured by the results of controlled speech discrimination testing together with the average hearing threshold level as measured by pure tone audiometry tests in the frequencies 1000, 2000, 3000 and 4000 Hertz. 38 C.F.R. § 4.85. Under 38 C.F.R. § 4.85, Table VI, Numeric Designation of Hearing Impairment Based on Puretone Threshold Average and Speech Discrimination, is used to determine a Roman numeral designation (I through XI) for hearing impairment based on a combination of the percent of speech discrimination and the pure tone threshold average. The Roman numeral designation is located at the point where the percentage of speech discrimination and pure tone average intersect. 38 C.F.R. § 4.85(b). The pure tone threshold average is the sum of the pure tone thresholds at 1000, 2000, 3000, and 4000 Hertz, divided by 4. Table VII, Percentage Evaluation for Hearing Impairment, is used to determine the rating by combining the Roman numeral designations for hearing impairment of each ear. The horizontal rows represent the ear having the better hearing and the vertical columns the ear having the poor hearing. The disability rating is located at the point where the rows and column intersect. 38 C.F.R. § 4.85(e). When the pure tone threshold at each of the four specified frequencies of 1000, 2000, 3000 and 4000 Hertz is 55 decibels or more, the Roman numeral designation for hearing impairment will be determined from either Table VI or Table VIA, whichever results in the higher numeral. When the pure tone threshold is 30 decibels or less at 1000 Hertz, and 70 decibels or more at 2000 Hertz, the Roman numeral designation for hearing impairment will be determined from either Table VI or Table VIA, whichever results in the higher numeral. That numeral will then be elevated to the next higher Roman numeral. Each ear will be evaluated separately. 38 C.F.R. § 4.86. Table VIA can also be used when the examiner certifies that use of the speech discrimination test is not appropriate. 38 C.F.R. § 4.85(c). Turning to the evidence, the Veteran was afforded a VA audiological examination for his initial service connection claim in December 2009. The results of the examination, as measured by a pure tone audiometry test, were as follows: HERTZ 1000 2000 3000 4000 Average RIGHT 55 60 60 70 61 LEFT 60 65 65 75 66 In addition, speech recognition was 96 percent in the right ear and 88 percent in the left ear, as measured by the Maryland CNC test. Applying these values to both Table VI and Table VIA, the right ear is assigned a Level IV Roman numeral designation and the left ear is assigned a Level V Roman numeral designation, both under Table VIA due to an exceptional pattern of hearing impairment. See 38 C.F.R. § 4.86(a). Pursuant to Table VII, this corresponds with the currently assigned initial 10 rating during this appeal period. The Board notes, however, that a private audiogram is of record from October 2009. The results of the examination, as measured by a pure tone audiometry test, were as follows: HERTZ 1000 2000 3000 4000 Average RIGHT 55 60 70 80 66 LEFT 55 75 75 75 70 Speech recognition testing seems to reflect 72 percent in the right ear and 68 percent in the left ear. Applying these values to both Table VI and Table VIA, both ears are assigned a Level VI Roman numeral designation, with Table VI resulting in the higher numeral bilaterally. Pursuant to Table VII, this corresponds with a 30 percent disability rating. Based on the above, the Board resolves reasonable doubt in the Appellant's favor in finding that the Veteran's hearing loss disability warrants an initial 30 percent rating. Higher ratings for the period thereafter, however, are not warranted. In that regard, the Veteran was afforded an additional VA audiological examination in November 2013. During the examination, the Veteran reported increased difficulty hearing other people in conversation. The results of the examination, as measured by a pure tone audiometry test, were as follows: HERTZ 1000 2000 3000 4000 Average RIGHT 85 85 95 100 90 LEFT 70 80 80 90 80 Speech recognition was 80 percent in the right ear and 60 percent in the left ear, as measured by the Maryland CNC test. Applying these values to Table VI and Table VIA, his right ear is assigned a Level VIII Roman numeral designation, and his left ear is assigned a Level VII Roman numeral designation, both under Table VIA. See 38 C.F.R. § 4.86(a). Pursuant to Table VII, this also corresponds with the current 40 percent disability rating effective the date of the examination. The Veteran was also afforded an additional VA audiological examination for his increased rating claim in November 2017. During the examination, the Veteran again reported increased difficulty hearing conversation. The results of the examination, as measured by a pure tone audiometry test, were as follows: HERTZ 1000 2000 3000 4000 Average RIGHT 65 80 85 95 81 LEFT 70 80 85 90 81 Speech recognition was 72 percent in the right ear and 48 percent in the left ear, as measured by the Maryland CNC test. Applying these values to Table VI and Table VIA, his right ear is assigned a Level VII Roman numeral designation under Table VIA and his left ear is assigned a Level IX Roman numeral designation under Table VI. See 38 C.F.R. § 4.86(a). Pursuant to Table VII, this also corresponds with the current 50 percent disability rating effective the date of the examination. The Veteran's remaining treatment records during the appeal are not in significant conflict with the above findings. Based upon the foregoing, at no point during the period on appeal beginning November 14, 2013 does the Veteran's hearing loss disability warrant rating higher than the 40 and 50 percent ratings that are currently assigned. The Board sympathizes with the Veteran's complaints prior to his death, as well as the Appellant's, regarding the functional impact of his hearing loss on his daily life. The symptoms reported are contemplated by the rating schedule. Martinak v. Nicholson, 21 Vet. App. 447, 455 (2007). The assignment of disability ratings for hearing impairment is derived from a mechanical formula based on levels of pure tone threshold average and speech discrimination. See Lendenmann v. Principi, 3 Vet. App. 345 (1992). In sum, an initial 30 percent rating is warranted for the period prior to November 13, 2014, and to that extent, the claim is granted. As the evidence is against a finding that the Veteran's hearing loss more nearly approximated the criteria for ratings in excess of 40 percent from November 13, 2014 and 50 percent from October 31, 2017, entitlement to increased ratings for bilateral hearing loss during those periods must be denied. 38 C.F.R. §§ 4.3, 4.7, 4.85, 4.86. Earlier Effective Dates for Increased Ratings for Hearing Loss In the Veteran's May 2018 VA Form 9, his representative asserted that an effective date earlier than October 17, 2017 was warranted for the award of a 40 percent rating for bilateral hearing loss. The Board notes that the Veteran's 40 percent rating for hearing loss was actually effective November 14, 2013, which was awarded in the December 2013 rating decision that initially granted service connection for hearing loss. While a 10 percent rating was awarded effective the date of his original service connection claim on October 14, 2009, as the Board has determined above, an initial 30 percent rating is instead warranted effective October 14, 2009. The Veteran's representative also asserted in the May 2018 Form 9 that an earlier effective date should be warranted for the Veteran's 50 percent disability rating as well, currently effective October 17, 2017. Essentially, the Appellant's representative asserts that the Veteran's higher 40 and 50 percent ratings should date back to his original 2009 service connection claim. Generally, the effective date for a grant of service connection will be the day following separation from active service or the date entitlement arose if the claim is received within one year after discharge from service. Otherwise, for an award based on an original claim, claim reopened after a final disallowance, or claim for an increased rating, the effective date is the date of receipt of the claim, or the date entitlement arose, whichever is the later. 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400. The effective date of a grant of increased disability compensation is either the date of receipt of the claim for increase or the earliest date within a year prior to the receipt of the claim as of which it is factually ascertainable that an increase in disability had occurred. 38 C.F.R. § 3.400(o). In this case, there was no actual claim for an increase. As the Appellant's representative noted in the May 2018 VA From 9, the RO erroneously stated in an August 2018 Statement of the Case (SOC) that the Veteran did not appeal the original grant of service connection in December 2013, to include any rating assigned and their effective dates. The record does indeed reflect a timely Notice of Disagreement (NOD) submitted in April 2014 challenging the "[e]valuation of 40 percent for bilateral hearing loss to include the effective date awarded." Thus, the rating decision on appeal did not become final. Regardless, as noted above, the effective date of the Veteran's 40 percent rating is based on the date when it was factually ascertainable that an increase in his hearing loss had occurred. As the Board has determined above, it is the date of his November 2013 VA examination. Moreover, in assigning the Veteran an increased 50 percent rating in a December 2017, rating decision the RO applied an effective date of October 17, 2017, the date of a VA 21-526EZ, Fully Developed Claim. While this date may be erroneous, as the Veteran's increased rating claim was still on appeal due to the timely filing of the April 2014 NOD, the effective date of the 50 percent rating afforded the Veteran a better benefit, as the true date of his 50 percent rating based on the effective date rules above should have been the date of his November 28, 2017 VA examination. The Board, however, will not disturb the effective date of the 50 percent rating. Based on the foregoing, there is no basis for assigning earlier effective dates for the Veteran's 40 and 50 percent ratings for hearing loss, and the claim is denied. Specially-Adapted Housing/Special Home Adaptation Grant Under the version of 38 C.F.R. § 3.809 which became effective on October 25, 2010, eligibility for assistance in acquiring specially adapted housing may be granted if a Veteran is entitled to VA compensation for permanent and total disability due to: (1) The loss or loss of use of both lower extremities such as to preclude locomotion without the aid of braces, crutches, canes, or a wheelchair; or (2) blindness in both eyes, having only light perception, plus the anatomical loss or loss of use of one lower extremity; or (3) 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 or propulsion as to preclude locomotion without the aid of braces, crutches, canes, or a wheelchair; or (4) 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; or (5) the loss or loss of use of both upper extremities such as to preclude use of the arms at or above the elbow; or (6) 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. 38 C.F.R. § 3.809 (as of October 25, 2010). Under revised criteria effective on December 3, 2013, eligibility for assistance in acquiring specially adapted housing may also be granted if the Veteran has service-connected ALS rated 100 percent disabling under 38 C.F.R. § 4.124a, Diagnostic Code 8017. 38 C.F.R. § 3.809(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). As an initial matter, the Board finds that the Veteran is not service-connected for an eye disability, a disability of the upper extremities, a severe burn injury, or ALS. At the time of his death, the Veteran was service-connected for bilateral hearing loss and tinnitus, and the Board is granting the Veteran's claim for service connection for an acquired psychiatric disorder. Instead, the crux of this case concerns whether the Veteran, due to service-connected disabilities, had the loss or loss of use of one lower extremity together with residuals of organic disease or injury that so affect the functions of balance or propulsion as to preclude locomotion without the aid of braces, crutches, canes, or a wheelchair. Here, however, the record reflects that, while the Veteran's various disabilities prior to his death may have required the need for regular aid or attendance, or housebound status, it would have been due to disabilities for which service connection was not in effect. Of note, two VA aid and attendance or housebound examinations are of record, completed in March 2018 and October 2018. Both physicians indicated that it was the combined effects of his COPD/emphysema, heart problems, and diabetes mellitus that resulted in the Veteran's inability to walk and stand for prolonged periods, prepare his own meals, bathe, and manage his medication and financial affairs. Neither examiner indicated that the Veteran's hearing loss, tinnitus, or any acquired psychiatric disorder affected the functions of balance or propulsion as to preclude locomotion without the aid of braces, crutches, canes, or a wheelchair. While the Board acknowledges that the Veteran's cellulitis claim is being remanded by the Board below, neither VA aid and attendance or housebound examination suggests that any skin disability affected the Veteran's balance or propulsion, nor does any other evidence of record. Upon review, the Board finds that the Veteran does not meet the requirements for specially adapted housing, and the award of a certificate of eligibility for specially adapted housing is not warranted. Nevertheless, if entitlement to specially adapted housing is not established, a veteran can qualify for a grant for necessary special home adaptations if he is entitled to compensation for (1) permanent and total service-connected disability which (i) includes the anatomical loss or loss of use of both hands, (ii) 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, (iii) is due to full thickness or subdermal burns that have resulted in contracture(s) with limitation of motion of one or more extremities or the trunk, or (iv) is due to residuals of an inhalation injury (including, but not limited to, pulmonary fibrosis, asthma, and chronic obstructive pulmonary disease); or (2) a service-connected disability (which need not be rated as permanently and totally disabling) which is due to blindness in both eyes, having central visual acuity of 20/200 or less in the better eye with the use of a standard correcting lens. 38 U.S.C. § 2101 (b); 38 C.F.R. § 3.809a(b) (2017). Here, however, the record does not show, nor has the Veteran or Appellant asserted, that he has blindness, anatomical loss or loss of use of both hands, a disability from burns, or residuals of an inhalation injury. Accordingly, the Board finds that the Veteran has not met the criteria of 38 C.F.R. § 3.809a and the award of a certificate of eligibility for a special home adaptation grant is also not warranted as a matter of law. See Sabonis v. Brown, 6 Vet. App. 426 (1994). SMC Based on Need of Regular Aid and Attendance/Housebound Special monthly compensation can be awarded when a Veteran is in need of aid and attendance or when the Veteran has a single service-connected disability rated at 100 percent and is permanently housebound by reason of service-connected disability or disabilities. 38 C.F.R. § 3.350(b)(3), (i). The requirement of being permanently housebound is met when (1) the Veteran has a single permanent disability rating of 100 percent, and (2) has an additional service-connected disability or disabilities, separate and distinct from the 100 percent disability, rated at 60 percent, or (3) is "permanently housebound" by reason of service-connected disability or disabilities. Permanently housebound is met when the veteran is substantially confined to his or her dwelling and the immediate premises or, if institutionalized, to the ward or clinical area, and it is reasonably certain that the disability or disabilities and resultant confinement will continue throughout his or her lifetime. See 38 U.S.C. § 1114(s); 38 C.F.R. § 3.350(i). For the relevant period on appeal, the Veteran was not rated at 100 percent for a service-connected disability, nor was there an additional service-connected disability independently rated at least 60 percent at any point during the appeal prior to his death. Further, and as noted above, examinations specifically to determine housebound status or a permanent need for regular aid and attendance were afforded in March and October 2018. While noting the Veteran used a wheelchair and scooter due to several disabilities, the examinations do not indicate that he was permanently housebound, as the Veteran was noted to be able to leave his home for appointments. Thus, SMC cannot be awarded on the basis of housebound status. As for the need for aid and attendance, the Veteran must be helpless or so nearly helpless as to require the regular aid and attendance of another person due to service-connected disabilities. A person will be considered in need of regular aid and attendance if he: (1) is blind or so nearly blind as to have corrected visual acuity of 5/200 or less, in both eyes, or concentric contraction of the visual field to 5 degrees or less; or (2) is a patient in a nursing home because of mental or physical incapacity; or (3) establishes a factual need for aid and attendance under the criteria set forth in 38 C.F.R. § 3.352(a). 38 C.F.R. § 3.351(c). The following will be accorded consideration in determining the need for regular aid and attendance: inability of claimant to dress or undress himself, or to keep himself ordinarily clean and presentable; frequent need of adjustment of any special prosthetic or orthopedic appliances which by reason of the particular disability cannot be done without aid (this will not include the adjustment of appliances which normal persons would be unable to adjust without aid, such as supports, belts, lacing at the back, etc.); inability of claimant to feed himself through loss of coordination of upper extremities or through extreme weakness; inability to attend to the wants of nature; or incapacity, physical or mental, which requires care or assistance on a regular basis to protect the claimant from hazards or dangers incident to his or her daily environment. 38 C.F.R. § 3.352(a). It is not required that all of the disabling conditions enumerated in 38 C.F.R. § 3.352(a) be found to exist before a favorable rating may be made. The particular personal functions which the veteran was unable to perform should be considered in connection with his former condition as a whole. It is only necessary that the evidence establish that the veteran was so helpless as to need regular aid and attendance, not that there was a constant need for aid and attendance. 38 C.F.R. § 3.352(a); see Turco v. Brown, 9 Vet. App. 222, 224 (1996) (holding that at least one factor listed in § 3.352(a) must be present to grant special monthly compensation based on the need for aid and attendance). Aid and attendance can also be awarded if a veteran is bedridden, which means a condition which, through its essential character, actually requires that the claimant remain in bed. The fact that 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. 38 C.F.R. § 3.352(a). Here, no examination has determined, nor has the Veteran or Appellant asserted, that he was blind or so nearly blind as to have corrected visual acuity of 5/200 or less, in both eyes, or concentric contraction of the visual field to 5 degrees or less, or that he was a patient in a nursing home because of mental or physical incapacity. Further, the record is negative for any indication that his service-connected disabilities, by themselves, have resulted in the Veteran being bedridden or requiring the regular aid and attendance of another person. While he did require assistance in feeding himself, bathing, and with medication management during the relevant period, his examinations suggest that the impairments related to his various nonservice-connected diabetes, respiratory, and cardiac disabilities substantially contributed to the level of aid and attendance that he required. Therefore, the Board finds that the Veteran, prior to his death, was not entitled to SMC on account of the need for aid and attendance of another person or house bound status, and the claim for SMC must also be denied. REASONS FOR REMAND The Veteran sought service connection for lower extremity cellulitis, which his medical treatment records note was diagnosed and being treated during the appeal. Records also note a history of "contact dermatitis or other eczema." The Veteran's STRs do note treatment for cellulitis of the right foot in October 1964. However, no VA examination was afforded to the Veteran prior to his death to address whether any skin disability diagnosed during the appeal is related to his in-service cellulitis. Generally, a VA medical examination or opinion is necessary when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, (2) evidence establishing that an event, injury, or disease occurred in service, or establishing certain diseases manifesting during an applicable presumptive period for which the veteran qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the Veteran's service or with another service-connected disability, but (4) there is insufficient competent medical evidence on file for VA to make a decision on the claim. 38 U.S.C. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4)(i); see also McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). As such, the claim must be remanded for a medical opinion. The matter is therefore REMANDED for the following actions: 1. Ask the Appellant to identify all outstanding treatment records relevant to the claim for service connection for cellulitis. All identified VA records should be added to the claims file. All other properly identified records should be obtained if the necessary authorization to obtain the records is provided. If any records are not available, or the Appellant identifies sources of treatment but does not provide authorization to obtain records, appropriate action should be taken (see 38 C.F.R. § 3.159(c)-(e)), to include notifying the Appellant of the unavailability of any records. 2. After records development is completed, the claims file should be sent to an appropriate examiner to offer an opinion as to whether it is at least as likely as not (50 percent probability or greater) that any skin condition of the Veteran's lower extremities, diagnosed during the appeal and prior to his death, onset during service or was otherwise related to an in-service injury, event, or disease, to include his in-service treatment for cellulitis. The need for an examination is left to the discretion of the examiner. A rationale for all opinions offered is requested as adjudicators are precluded from making any medical findings. LLOYD MASON CRAMP Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. Scarduzio, 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.