Citation Nr: 21076437 Decision Date: 12/23/21 Archive Date: 12/23/21 DOCKET NO. 17-48 905 DATE: December 23, 2021 ORDER Entitlement to service connection for urinary incontinence, to include as secondary to service-connected disabilities, is denied. Entitlement to special monthly compensation (SMC) based on aid and attendance (AA) / housebound (HB) is denied. FINDINGS OF FACT 1. The preponderance of the evidence is against finding that the Veteran's urinary incontinence manifested in active-duty service and was otherwise attributable to active-duty service. 2. The preponderance of the evidence is against finding at the Veteran's urinary incontinence was not proximately caused by, or aggravated by, service-connected disabilities. 3. The Veteran does not have a single disability rated as 100 percent disabling and, therefore, is not eligible for SMC based on being permanently housebound. 4. The Veteran is not housebound or in need of the regular aid and attendance of another person as a result of his service-connected disabilities. CONCLUSIONS OF LAW 1. The criteria for service connection for urinary incontinence due to service or a service-connected disability are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 2. The criteria for SMC based on the need for regular AA or at the HB rate are not met at any time during the pendency of the appeal. 38 U.S.C. § 1114; 38 C.F.R. §§ 3.102, 3.326, 3.350, 3.351, 3.352. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 2007 to January 2011. The Veteran testified at a Board of Veterans' Appeals (Board) hearing before the before a different Veterans Law Judge (VLJ) in December 2019 in support of the claim on appeal, a transcript of which is of record. However, that VLJ is no longer at the Board. In correspondence dated September 2021, the Veteran was notified that the VLJ who conducted the December 2019 hearing was no longer at the Board and was given an opportunity to request another hearing before a different VLJ. See September 2021 Board Letter. The Board also notified the Veteran that if he did not respond within 30 days from date of letter, "the Board will assume that you do not want another hearing and proceed accordingly." Id. Since the 30-day period has passed since September 2021 Board letter, the Board assumes the Veteran did not want another hearing and will proceed with adjudication of this matter. This matter was previously remanded by the Board of Veterans Appeals (BVA) in February 2020 and August 2020 for additional development. It now returns for further appellate review. 1. Urinary Incontinence The Veteran seeks service connection for urinary incontinence which he contends is related to traumatic brain injury and or neurological condition due to a back disability as a result of being exposed to improvised explosive devices (IED) blast while serving in Afghanistan See October 2016 VA Form 21-4138, Statement in Support of Claim. Legal Criteria To prevail on a direct service connection claim, there must be competent evidence of (1) a current disability, (2) in-service incurrence or aggravation of a disease or injury, and (3) a nexus between the in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009); 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303 (a). Relevant Facts and Analysis Direct Service Connection 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 Veteran's VA treatment records indicate that the Veteran's medical problems include urinary incontinence. See i.e., September 2012 VA Problem List, in CAPRI February 2015. The Veteran also reported day and night incontinence on a daily basis in September 2014. See September 2014 VA Primary Care Note in CAPRI received February 2015. His active medication list also noted that he used a urinary drainage bag. Id. The Veteran is competent and credible to report the symptoms he experiences. Thus, the Veteran has a current diagnosis of urinary incontinence, and the first prong of service connection has been met. The Veteran's service treatment records (STRs) are silent for any symptoms, treatment, or complaints of urinary incontinence. However, the Veteran reported that he experienced a spinal cord injury secondary to traumatic brain injury in June or July 2010 due to an IED blast. See February 2015 VA Central Nervous System and Neuromuscular Diseases Disability Benefits Questionnaire (DBQ). The Veteran has been granted service connection for PTSD and a lumbar spine disability due to the IED blast. Additionally, the VA has acknowledged that the Veteran was involved in a TBI incident i.e., IED blast. See August 2015 Rating Decision. Thus, the second prong, an in-service occurrence, has been established. Therefore, the claim turns on whether the Veteran current urinary incontinence is related or caused by his in-service exposure to IED blast i.e., whether there is a nexus between the two. The record contains several medical opinions and evaluations which address the issue of nexus. First, a February 2015 VA examiner stated that the Veteran's back pain, bladder, and urinary incontinence along with other symptoms may be related to spinal syringomyelia but that "it is not sure if it is a sequelae of a fall status post IED blast that happened during the service." See February 2015 VA Central Nervous System and Neuromuscular Diseases Disability Benefits Questionnaire (DBQ). In other words, the examiner stated that it was unclear if the Veteran's symptoms including urinary incontinence were related to the in-service IED blast. Essentially, the examiner could not link the Veteran's urinary incontinence to the Veteran's IED blast. The Board finds that the February 2015 VA medical opinion is probative because the examiner's opinion was based on examination of the Veteran and review of claims file and the examiner provided a reasoned analysis for opinion. A March 2015 VA neurology addendum note indicated that the Veteran did not have a diagnosis of neurogenic bladder per urologist. See March 2015 VA Neurology Addendum Note, in CAPRI received August 2017. In April 2015, the Veteran was assessed by the VA spinal cord injury (SCI) clinic. Based on examination of the Veteran, the social worker noted that the VA neurologist found that the Veteran did not qualify for the SCI clinic because he had "thoracic syrinx/prominent central canal without clear evidence of related neurological compromise[] of spinal cord origin" and that there was no specific evidence of a spinal cord dysfunction. See April 2015 VA Spinal Cord Injury Social Work Psychosocial Assessment, in CAPRI received August 2017. The Veteran was referred to a VA neurologist, Dr. S.K., for symptoms related to thoracic spinal cord syrinx in April 2015. See April 2021 VA Neurologist SCI Referral, in CAPRI received August 2017. The Veteran reported that he believed his symptoms were related to an IED blast he was exposed to in 2010 while serving in Afghanistan. Id. He was walking when the IED went off and fell due to being affected by the shock waves, he was referred for treatment for PTSD/TBI. The Veteran noted that he began to experience intermittent spells of paralysis in 2014, including complete motor loss of lower extremities that lasts seconds or minutes. He also endorsed multiple falls without any incontinence, clear confusion, or serious injuries. Id. However, he stated he experiences bladder incontinence with some bowel accidents, and he noted he uses condom catheter and is bladder training. Dr. S.K. noted that the Veteran did not have a catheter on at the time of the evaluation. She reviewed the thoracic spine magnetic resonance imaging (MRI) and found that the Veteran had minimal degenerative joint disease and thoracic syrinx. Id. She noted that no abnormalities were found on thoracic dermatomes and sensory examinations. Based on her neurological examination, Dr. S.K. assessed the Veteran's as follows: Thoracic syrinx/prominent central canal without clear evidence of related neurological compromised of spinal cord origin. I found nothing specific on exam to correlate with spinal cord dysfunction. There is no evidence of hyperreflexia, Babinski sign or clonus. I noted no clear sensory level. though [sic] he has complaints of occasional incontinence, urodynamic studies did not show abnormalities. See April 2021 VA Neurologist SCI Referral, in CAPRI received August 2017. In January 2016, the Veteran was seen by a private urologist for complaints of urinary incontinence. See January 2016 Lima Urology Treatment Records. He reported that he has had urinary incontinence for the past two to three years. He also noted that he had a spinal cord injury but denied any treatment for such injury. The urologist assessed the Veteran with neurogenic bladder secondary to spinal injury which caused unstable bladder contractions. Id. The Veteran was scheduled for urodynamic study. In July 2019, the Veteran underwent a cystogram, an imaging study for bladder. See July 2019 Private Cystogram Report. The results of the study revealed an unremarkable urinary bladder and the Veteran's bladder drained satisfactorily. Id. The Board affords less probative weight to the Lima Urology medical opinion that the Veteran had neurogenic bladder secondary to spinal injury which caused unstable bladder contractions. See January 2016 Lima Urology Treatment Records. This opinion is contradicted by the medical evidence of record including the provider's own urodynamic study which found an unremarkable urinary bladder. See July 2019 Private Cystogram Report; see also March 2015 VA Neurology Addendum Note, in CAPRI received August 2017 (noting Veteran did not have a diagnosis of neurogenic bladder per urologist.) Additionally, the opinion appears to be derived solely from the Veteran's assertions and is not supported by any rationale. Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007) (A medical opinion must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two.) Pursuant to the February 2020 Board remand, the VA obtained a medical opinion in March 2020. See March 2020 VA Medical Opinion DBQ. The examiner noted review of the claims file including the April 2015 VA neurologist evaluation performed by Dr. S.K. The examiner opined that it was less likely than not that the Veteran's urinary incontinence was related by the claimed in-service injury. In his rationale, the examiner explained that Dr. S.K. "conducted a thorough neurological evaluation of the Veteran who presented with multiple complaints.... The provider found no neurological deficits and opined that the Veteran had asymptomatic syringomyelia, commonly observed with this condition." He further stated he agreed with Dr. S.K.'s findings and conclusions. He noted that the Veteran's complaints of bladder incontinence were subjective, and that VA treatment providers including Dr. S.K. "found no objective evidence of neurogenic bladder or any motor or sensory deficits." Id. VA also obtained a medical opinion in August 2020. See September 2020 VA Medical Opinion DBQ. The August 2020 VA examiner opined that the Veteran's urinary incontinence was not incurred in service because the onset of urinary incontinence happened in 2014, which postdates his active service. Id. The examiner also opined that the Veteran's urinary incontinence was less likely than not caused by or related to the in-service IED blast injury. Id. The examiner reasoned that the VA neurologist note "doubted that his urinary incontinence was related to the IED blast in service as onset of urinary incontinence occurred in 2014 which is years after the IED. Likewise, no evidence of abnormal seizure activity as [electroencephalogram] done 5/18/20 was normal." Id. The Board finds the above opinions to address the Veteran's assertion, through his representative, that his urinary incontinence was due to his spinal injury. Upon review of the medical evidence and medical opinions, the Board accords great probative weight to the March 2020 and August 2020 VA medical opinions because the opinions considered an accurate history, were definitive, and supported by a detailed rationale that considered the lay and medical evidence. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The March 2020 VA examiner provided a negative nexus opinion based on finding no objective evidence of neurogenic bladder or any motor or sensory deficits which could be linked to the IED blast. See March 2020 VA Medical Opinion DBQ. Similarly, the August 2020 VA examiner noted the onset of the Veteran's urinary incontinence was years after service and the in-service IED blast. Notably, the March 2020 VA medical opinion was consistent with the evidence of record and supported by the findings of the VA neurologist, Dr. S.K., who performed extensive neurological evaluation. Specifically, Dr. S.K. noted that she found "nothing specific on exam to correlate with spinal cord dysfunction." She further noted the Veteran occasionally complained of urinary incontinence but found that "urodynamic studies did not show abnormalities." See April 2021 VA Neurologist SCI Referral, in CAPRI received August 2017. Taken together, the March 2020 and August 2020 VA medical opinions as well as the extensive neurologic evaluation performed by Dr. S.K., found no correlation between the Veteran's IED blast and his current urinary incontinence. In other words, the VA medical opinions along with medical treatment records weigh heavily against finding a nexus between the Veteran's urinary incontinence and his active service. The Board considered the Veteran's lay statements that his urinary incontinence bothers him and that he believes it is due to his in-service injury from an IED blast. However, while the Veteran is competent to report the symptoms of his disabilities, he is not competent to opine on matters requiring medical knowledge, such as diagnosing or determining the nature and etiology of medical conditions. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Therefore, the Board places more probative weight on the objective medical evidence of record. includes the February 2015, March 2020, and August 2020 examinations discussed which the Board find to be adequate as the examiners saw the Veteran in person, reviewed his file, and offered opinions backed by explanations based on the in-person interview, the Veteran's file, and the examiner's expertise. It is important for the Veteran to understand that the medical findings provide highly probative evidence against this claim that the Board cannot, unfortunately, ignore, outweighing the Veteran's belief that his disability is the result of service or a service-connected disability, providing a highly clear basis for the opinion. The Board concludes that, while the Veteran has a current diagnosis of urinary incontinence, the preponderance of the evidence weighs against finding that the Veteran's diagnosis of the urinary incontinence began during service or is otherwise related to an in-service injury, event, or disease. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). In sum, while the Veteran's claim meets prong (1) a current disability and (2) an in-service occurrence it fails at prong (3), as there is no nexus between the Veteran's current urinary incontinence and his active service. Regarding all the above, the Board has considered the applicability of the benefit of the doubt doctrine. Because the preponderance of the evidence is against the Veteran's claim, the benefit of the doubt doctrine does not apply. See 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). Accordingly, the claim for direct service connection for urinary incontinence is denied. Secondary Service Connection Alternatively, the Veteran contends his urinary incontinence is due to his service-connected syringomyelia and/or lumbar spine disability. See December 2019 Hearing Transcript. Legal Criteria In order to prevail under a theory of secondary service connection, there must be: (1) evidence of a current disorder; (2) evidence of a service-connected disability; and (3) medical nexus evidence establishing a connection between the service-connected disability and the current disorder. See Wallin v. West, 11 Vet. App. 509, 512 (1998). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Relevant Facts and Analysis The first element of secondary service connection has been met as the Veteran has a current disability of urinary incontinence. See September 2014 VA Primary Care Note in CAPRI received February 2015 (confirming diagnosis). The Veteran was granted service connection for syringomyelia in the August 2020 Board decision. The Veteran is also service connected for a lumbosacral strain. See August 2020 Rating Decision-Codesheet. Thus, the second element of secondary service connection has been met. Regarding, the issue of nexus, the Board remanded the claim in August 2020 for a medical opinion addressing whether the Veteran's urinary incontinence was proximately due to aggravated by his service-connected syringomyelia or his lumbar spine disability. Pursuant to the August 2020 Board remand, the VA obtained a medical opinion in September 2020. See September 2020 VA Medical Opinion DBQ. The examiner opined that it was less likely than not that the Veteran's urinary incontinence was proximately due to his service-connected syringomyelia or lumbosacral strain. She reasoned that the April 2015 VA neurologist noted that the Veteran's urinary incontinence was unlikely related to the Veteran's syrinx. She also noted that the Veteran's lumbar spine VA examinations from January 2015 and December 2015 found no urinary complaints. Finally, the examiner noted that a July 2016 electromyography (EMG) found "normal pelvic floor indicating no nerve (or spine) etiology for urinary incontinence." Id. The examiner also opined that that the Veteran's urinary incontinence was less likely than not aggravated by his service-connected syringomyelia or lumbosacral strain. See September 2020 VA Medical Opinion DBQ. In her rationale, the examiner noted that the May 2019 private urology note found "no evidence of neurogenic bladder which would occur if his urinary incontinence were due to lumbar spine condition." Id. She further noted that thoracic spine MRIs from 2015 and 2016 showed stable syrinx, in concluding that the were no evidence of aggravation of his urinary incontinence by his service-connected conditions. Id. The Board finds the September 2020 opinion is entitled to probative weight as the opinion is based on a thorough review of the claims file and prior VA examinations and includes a reasoned rationale for the conclusions which is supported by the objective medical evidence. The Veteran's lay statements of record note ongoing symptoms of urinary incontinence and that this ongoing symptomology is attributed to his service connected syringomyelia and/or lumbosacral strain. While the Veteran's lay statements of record contend that his ongoing symptoms are related to his service-connected disabilities, he is not competent to provide a nexus opinion in this case. The record does not reflect that the Veteran has the requisite training or expertise to offer a medical opinion diagnosing urinary incontinence and linking his current symptoms to a service-connected disability and as such he is not competent to provide an opinion in this case. Jandreau v. Nicholson, 492 F.3d 1377. The Board observes that the February 2015 VA examiner stated that the Veteran's back pain, bladder and urinary incontinence along with other symptoms may be related to spinal syringomyelia but that "it is not sure if it is a sequelae of a fall status post IED blast that happened during the service." See February 2015 VA Central Nervous System and Neuromuscular Diseases DBQ. This opinion appears to support the Veteran's contention that the Veteran's urinary incontinence was due to his service-connected syringomyelia. However, the February 2015 VA examiner's opinion was not definitive as she noted there may be a correlation between the IED blast and various symptoms which included urinary incontinence. See Bloom v. West, 12 Vet. App. 185, 186-187 (1999) (opinion that service "could have" precipitated a disability found too speculative). Additionally, the examiner noted that additional testing including spinal angiogram was pending. The Board assigns minimal probative weight to the February 2015 VA examiner's opinion that his urinary incontinence may have been related to his syringomyelia because it was speculative and based on an incomplete medical evaluation where additional testing was pending. The Board has considered the extensive medical evidence of record and finds that the September 2020 VA medical opinion is entitled to the most probative weight. The Board finds that the medical evidence including the September 2020 VA medical opinion is more probative and more credible than the lay opinions of record. Based on the evidence of record, the most probative evidence of record does not establish that the Veteran's current urinary incontinence is proximately due to or the result of or aggravated by his service-connected syringomyelia and/or lumbosacral strain. In sum, upon careful review and weighing of the evidence, with reasoning as detailed above, the Board finds that the preponderance of the evidence is against the claim for service connection of the Veteran's urinary incontinence, as secondary to his service-connected syringomyelia and lumbosacral strain disabilities. As the weight of the evidence is against this claim, the "benefit of the doubt" rule is not for application, and the Board must deny the claim. See 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. at 49 (1990). 2. SMC for AA/HB The Veteran contends that he is entitled SMC based on the need for the regular AA of another person. See October 2014 VA Form 21-4138, Statement in Support of Claim. Legal Criteria Generally, with respect to claims of entitlement to SMC based on the need for the regular aid and attendance of another person, such claims will be granted when a veteran, due to a service-connected disability, has the anatomical loss or loss of use of both feet or 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. See 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 the following: inability of a veteran to dress or undress himself/herself or to keep himself/herself 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; inability of a veteran to feed himself/herself 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 a veteran from the hazards or dangers inherent in his/her 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 veteran remain in bed. It is not required that all of the disabling conditions listed above be found to exist before a favorable rating may be made. The particular personal functions that a veteran is unable to perform should be considered in connection with his/her condition as a whole. It is only necessary that the evidence establish that a veteran is so helpless as to need regular aid and attendance, not that there be a constant need. 38 C.F.R. § 3.352(a). In addition, special monthly compensation (SMC) is payable at a specified rate if the Veteran, as the result of service-connected disability, has a service-connected disability rated as total, and (1) has additional service-connected disability or disabilities independently ratable at 60 percent or more, or, (2) by reason of such veteran's service-connected disability or disabilities, is permanently housebound. For the purpose of this subsection, the requirement of permanently housebound will be considered to have been met when the veteran is substantially confined to such veteran's house (ward or clinical areas, if institutionalized) or immediate premises due to a service-connected disability or disabilities which it is reasonably certain will remain throughout such veteran's lifetime. 38 U.S.C. § 1114 (s); 38 C.F.R. § 3.350 (b). Relevant Facts and Analysis The Veteran is service connected for the following disabilities: posttraumatic stress disorder (PTSD) rated as 70 percent disability; headaches, rated as 50 percent disabling; syringomyelia rated as 30 percent disabling; lumbosacral strain, rated as 10 percent disabling; tinnitus, rated as 10 percent disabling; gastroesophageal reflex (GERD) rated as 10 percent disabling; left lower extremity radiculopathy, rated as 10 percent disabling; and bilateral hearing loss rated as noncompensable. See August 2020 VA Rating Decision-Codesheet. The Veteran was also granted total disability rating for individual unemployability (TDIU) effective April 14, 2014. Id. a. Loss/Loss of use of Both Feet, Loss of One Hand and One foot, and/or Visual Impairment The Veteran is not service connected for any disability that causes the anatomical loss or loss of use of both feet, one hand and one foot, or blindness in both eyes with 5/200 visual acuity. See January 2015 VA Compensation and Pension Examination for Aid Attendance or Housebound. The examiner indicated that the Veteran was not legally blind or confined to a bed. Thus, based on the foregoing evidence, the Board finds that the Veteran cannot prevail on his SMC claim under this part of the criteria at all times during the pendency of the appeal. See 38 U.S.C. § 1114 (l); 38 C.F.R. § 3.350(b). b. Bedridden As to being bedridden, the Veteran does not claim and the record, including the January 2015 VA Compensation and Pension Examination for Aid Attendance or Housebound does not show that he is in fact bedridden due to only his service-connected disabilities. Therefore, the Board finds that the Veteran cannot prevail on his SMC claim under this part of the criteria at all times during the pendency of the appeal. See 38 U.S.C. § 1114 (l); 38 C.F.R. § 3.350 (b). c. Permanently Housebound and/or Permanently Institutionalized As to being "permanently housebound" by reason of disability or disabilities, the Board finds that nothing in the record, including the findings by January 2015 VA Compensation and Pension Examination for Aid Attendance or Housebound as well as any of the VA examinations of record, suggests that the Veteran is permanently housebound or permanently institutionalized due to only his service-connected disabilities. The Veteran did not require nursing home care. See January 2015 VA Compensation and Pension Examination for Aid Attendance or Housebound. The VA examiner concluded that Veteran's lumbar spine disability did not require AA because the Veteran did not have any neurologic compromise and displayed full and intact functioning of lower extremities. Id. He further opined that the Veteran's headaches did not impede his ability to perform activities of daily living (ADLs). Id. During a May 2015 VA examination for the Veteran's lumbar spine disability, the examiner noted that there were "[n]o physiologic or organic basis for his incontinence or intermittent leg paralysis symptoms. See May 2015 VA Back Conditions DBQ. The examiner further noted that the "Veteran uses a walker for his symptoms of intermittent paralysis, however, again, there is no physiologic basis for his symptoms." Id. The April 2020 VA examiner found that the Veteran did not have any neurological deficits associated with his asymptomatic syringomyelia. See April 2020 VA Medical Opinion DBQ. In reaching this conclusion, the Board has not overlooked any lay claims from the Veteran and his wife that his service-connected disabilities so impair him that they believe he is housebound. However, the Board once again finds that providing an opinion as to whether his service-connected disabilities make him housebound requires special medical training that lay persons do not have. Therefore, the Board finds the determination is "medical in nature" and not capable of lay observation. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Accordingly, since laypersons are not capable of opining on matters requiring medical knowledge, the Board finds that any lay opinions are not competent evidence. See Jandreau, supra. The Board finds that the most probative evidence of record shows that the Veteran's service-connected disabilities neither confine him to his dwelling and the immediate premises, nor require permanent institutionalization at any time during the time frame that is the subject of the appeal. Therefore, the Board also finds that the claim for SMC based on this part of the housebound criteria are not met at all times during the pendency of claim on appeal. 38 U.S.C. § 1114 (s); 38 C.F.R. § 3.351 (d). The Board notes that the Veteran asserted he was entitled to SMC due in part to his urinary incontinence. See October 2014 VA Form 21-4138, Statement in Support of Claim. However, unfortunately the Veteran is not service connected for urinary incontinence. Consequently, the criteria for establishing entitlement to SMC based on the need for aid and attendance are not met. The Board also considered whether SMC was warranted under 38 U.S.C. § 1114(s). SMC is payable where a veteran has a single service-connected disability rated as 100 percent and 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. 38 U.S.C. § 1114; 38 C.F.R. § 3.350. Here, the Board notes that the Veteran has been granted TDIU effective April 14, 2014. See August 2020 VA Rating Decision-Codesheet. However, "[m]ultiple service-connected disorders that are defined as "one disability" under 38 C.F.R. § 4.16(a) in order to establish entitlement to a TDIU may not serve as "a service-connected disability rated as total" for the purpose of establishing eligibility for SMC under 38 U.S.C. § 1114(s). Youngblood v. Wilkie, 31 Vet. App. 412, 416 (2019). He does not otherwise have a single disability rated as 100 percent disabling. Therefore, an SMC award is not currently warranted under 38 U.S.C. § 1114 (s). In sum, the Board finds that the Veteran was not, as the result of service-connected disabilities, with such significant disabilities as to be in need of regular aid and attendance and was not, by reason of service-connected disabilities, permanently housebound. As such, the Board concludes that the criteria for SMC based on the need for aid and attendance or housebound status have not been met. 38 U.S.C. §§ 1114 (l), (s), 5121; 38 C.F.R. §§ 3.350, 3.352, 3.1000, 3.1010. Accordingly, entitlement to SMC based on the need for aid and attendance or housebound status, for accrued benefits purposes, is denied. The Board is grateful to the Veteran for his service, and regrets that it cannot render a favorable decision in this matter. Garrett Morales Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board G. Lilly, 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.