Citation Nr: 21077037 Decision Date: 12/28/21 Archive Date: 12/28/21 DOCKET NO. 09-10 630 DATE: December 28, 2021 REMANDED Entitlement to special monthly pension (SMP) benefits based on the need for regular aid and attendance or by reason of being housebound is remanded. REASONS FOR REMAND The Veteran served on active duty from February 1972 to June 1972. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2008 rating decision in which a Department of Veterans Affairs (VA) Regional Office (RO) denied entitlement to SMP. The Board remanded the current matter on appeal to the Agency of Original Jurisdiction for further development in June 2012, March 2017, and February 2021. Entitlement to SMP The Board is cognizant of the fact that the current appeal has been the subject of multiple prior remands. Notably, however, the Board observes that the record with respect to this appeal is incomplete and that further development is otherwise necessary to ensure that the Veteran is allowed every possible consideration. At the outset, the Board observes that the most recent VA clinical treatment records associated with the claims file include an April 2018 VA primary care treatment report which notes that the Veteran underwent physical therapy for his shoulder and neck. These records are particularly relevant to this matter where the Veteran reported during prior examination in April 2017 that his shoulder disability was one of the conditions that most interfered with his daily living activities. The Board further notes that the physical therapy treatment records may provide further insight into his limitations resulting from his shoulder disability. Accordingly, remand is required to obtain the Veteran's right shoulder physical therapy records. 38 C.F.R. § 3.159. Given the nature of the Veteran's SMP claim and indication in the record that he has continued to receive treatment for his claimed conditions, on remand, the AOJ should also obtain all outstanding VA treatment records, including clinical treatment records dated since May 2018. Id. The Veteran's need for physical therapy for his right shoulder provides indication that his disabilities may have worsened since prior examination in April 2017. Further, at a December 2014 VA examination, the examiner indicated that the Veteran's best corrected vision was 5/200 or worse bilaterally. While the subsequent examination in April 2017 indicated that his corrected vision was better than 5/200, clarification should be obtained from the new examiner on remand. Thus, the Board finds that, to afford the Veteran every possible consideration, a new examination is warranted to consider the current severity of his nonservice-connected disabilities. Cf. VAOPGCPREC 11-95 (April 7, 1995); Snuffer v. Gober, 10 Vet. App. 400 (1997). Accordingly, this matter is hereby REMANDED for the following action: 1. Obtain the Veteran's outstanding VA clinical treatment records, to include specifically all physical therapy treatment records for his shoulder and neck dated sometime proximate to April 2018, and all clinical treatment records dated since May 2018. Follow the procedures set forth in 38 C.F.R. § 3.159(c) regarding requesting records from Federal facilities. All records and/or responses received should be associated with the claims file. 2. Then, arrange for the Veteran to undergo new VA examination by an appropriate examiner to ascertain the current severity of his nonservice-connected disabilities and to determine whether he meets the criteria for aid and attendance or housebound status. The claims file and a copy of this REMAND must be made available to, and reviewed by, the examiner. Any and all indicated studies and tests deemed necessary by the examiner should be accomplished. If an opinion or examination is needed by a specialist(s), that too should be undertaken. After review of the file and examination(s), the examiner should specifically address the current symptomatology associated with each of the Veteran's various disabilities, as identified extensively in the record, and the severity of those symptoms. Specifically, the examiner must address the following: (a.) Whether the Veteran 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. (b.) Whether the Veteran is a patient in a nursing home on account of mental or physical incapacity. (c.) Whether the Veteran is so helpless or so nearly helpless as to require the regular aid and attendance of another person. In making this determination, the examiner should specifically comment on whether the Veteran is unable to dress or undress himself, or to keep himself ordinarily clean and presentable; requires the frequent adjustment of any special prosthetic or orthopedic appliances which by reason of the particular disability cannot be done without such aid; is unable to feed himself because of the loss of coordination of upper extremities or because of extreme weakness; is unable to attend to the wants of nature; or has an incapacity, physical or mental, that requires care of assistance on a regular basis to protect him from the hazards or dangers incident to his daily environment; or is bedridden. (d.) For housebound purposes, whether the Veteran is substantially confined to his 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 lifetime. In addressing the above, the examiner must consider and discuss all pertinent medical evidence, to include the December 2014 VA examination finding that the Veteran's best corrected vision was 5/200 or worse in both eyes, and lay evidence of record, to include the Veteran's prior assertion that his depressive disorder and shoulder disability impact his ability to complete his daily living activities the most, and all assertions as to the historical and current severity of his multiple disabilities. A clear rationale for all opinions is required, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. No action is required of the Veteran until he is notified by VA. However, he is advised of his obligation to cooperate in ensuring that the duty to assist is satisfied. Kowalski v. Nicholson, 19 Vet. App. 171 (2005). His failure to report for any VA medical examination scheduled in association with his appeal may impact the determination made. 38 C.F.R. § 3.655. The Veteran also is advised that he has the right to submit additional evidence and argument with respect to this matter. Kutscherousky v. West, 12 Vet. App. 369 (1999). This appeal must be afforded prompt treatment. THERESA M. CATINO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Michael Wilson, 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.