Citation Nr: 21077138 Decision Date: 12/28/21 Archive Date: 12/28/21 DOCKET NO. 17-48 306 DATE: December 28, 2021 ORDER The severance of service connection for Parkinson's Disease with balance impairment was proper and the appeal is denied. The severance of service connection for tremor and bradykinesia of the left upper extremity was proper and the appeal is denied. The severance of service connection for tremor and bradykinesia of the right upper extremity was proper and the appeal is denied. The severance of service connection for loss of automatic facial movements was proper and the appeal is denied. The severance of service connection for partial loss of sense of smell was proper and the appeal is denied. The discontinuance of Special Monthly Compensation (SMC) based on housebound status was proper and the appeal is denied. SMC based on the need of regular aid and attendance of another is denied. FINDINGS OF FACT 1. The Veteran does not have Parkinson's Disease. 2. There is no possible basis for finding that tremor and bradykinesia of the left upper extremity was a result of service or a service-connected disability. The grant of service connection for tremor and bradykinesia of the left upper extremity pursuant to a December 2013 rating decision was clearly and unmistakably erroneous. 3. There is no possible basis for finding that tremor and bradykinesia of the right upper extremity was a result of service or a service-connected disability. The grant of service connection for tremor and bradykinesia of the right upper extremity pursuant to a December 2013 rating decision was clearly and unmistakably erroneous. 4. There is no possible basis for finding that loss of automatic facial movements was a result of service or a service-connected disability. The grant of service connection for loss of automatic facial movements pursuant to a December 2013 rating decision was clearly and unmistakably erroneous. 5. There is no possible basis for finding that partial loss of sense of smell was a result of service or a service-connected disability. The grant of service connection for partial loss of sense of smell pursuant to a December 2013 rating decision was clearly and unmistakably erroneous. 6. The Veteran has a single service-connected disability rated as 100 percent but does not have additional service-connected disability/disabilities independently ratable at 60 percent, separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems. 7. The Veteran's service-connected disabilities do not cause the need for regular aid and attendance of another person. CONCLUSIONS OF LAW 1. The grant of service connection for Parkinson's Disease with balance impairment pursuant to a December 2013 rating decision was clearly and unmistakably erroneous. 2. Service connection for Parkinson's Disease with balance impairment was properly severed, and the criteria for restoration of service connection for Parkinson's Disease with balance impairment have not been met. 38 U.S.C. §§ 1110, 1131, 1155, 5109A (2012); 38 C.F.R. §§ 3.103, 3.105, 3.303, 3.307, 3.309. 3. Service connection for tremor and bradykinesia of the left upper extremity was properly severed, and the criteria for restoration of service connection for tremor and bradykinesia of the left upper extremity have not been met. 38 U.S.C. §§ 1110, 1131, 1155, 5109A (2012); 38 C.F.R. §§ 3.103, 3.105, 3.310. 4. Service connection for tremor and bradykinesia of the right upper extremity was properly severed, and the criteria for restoration of service connection for tremor and bradykinesia of the right upper extremity have not been met. 38 U.S.C. §§ 1110, 1131, 1155, 5109A (2012); 38 C.F.R. §§ 3.103, 3.105, 3.310. 5. Service connection for loss of automatic facial movements was properly severed, and the criteria for restoration of service connection loss of automatic facial movements have not been met. 38 U.S.C. §§ 1110, 1131, 1155, 5109A (2012); 38 C.F.R. §§ 3.103, 3.105, 3.310. 6. Service connection for partial loss of sense of smell was properly severed, and the criteria for restoration of service connection for partial loss of sense of smell have not been met. 38 U.S.C. §§ 1110, 1131, 1155, 5109A (2012); 38 C.F.R. §§ 3.103, 3.105, 3.310. 7. Discontinuance of SMC was proper, and the criteria for restoration of SMC based on housebound status have not been met. 38 U.S.C. §§ 1114, 5112 (2012); 38 C.F.R. §§ 3.105, 3.350. 8. The criteria for entitlement to SMC based on the need of regular aid and attendance of another have not been met. 38 U.S.C. §§ 1114 (l), 5107 (2012); 38 C.F.R. §§ 3.102, 3.350, 3.352(a). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1967 to June 1970. These matters come before the Board of Veterans' Appeals (Board) on appeal from November 2015 and January 2018 rating decisions issued by the Regional Office (RO). Severance of Service Connection Service connection will be severed only where evidence establishes that it is clearly and unmistakably erroneous (CUE) (the burden of proof being on the Government). 38 C.F.R. § 3.105(d). When severance of service connection is considered warranted, a rating proposing severance will be prepared setting forth all material facts and reasons. The claimant will be notified at his or her latest address of record of the contemplated action and furnished detailed reasons therefor and will be given 60 days for the presentation of additional evidence to show that service connection should be maintained. Unless otherwise provided in paragraph (i) of this section, if additional evidence is not received within that period, final rating action will be taken, and the award will be reduced or discontinued, if in order, effective the last day of the month in which a 60-day period from the date of notice to the beneficiary of the final rating action expires. 38 C.F.R. § 3.105(d). A change in diagnosis may be accepted as a basis for severance action if the examining physician or physicians or other proper medical authority certifies that, in the light of all accumulated evidence, the diagnosis on which service connection was predicated is clearly erroneous. This certification must be accompanied by a summary of the facts, findings, and reasons supporting the conclusion. 38 C.F.R. § 3.105(d). To establish that a grant of service connection was the product of CUE, VA must show that (1) either the correct facts as they were known at the time were not before the adjudicator, the adjudicator made an erroneous factual finding, or the statutory or regulatory provisions were incorrectly applied; (2) the alleged error was undebatable, not merely a disagreement as to how the facts were weighed or evaluated; and (3) the error manifestly changed the outcome of the prior decision. See Allen v. Nicholson, 21 Vet. App. 54, 58-59 (2007); Stallworth v. Nicholson, 20 Vet. App. 482, 487-88 (2006); cf. Bustos v. West, 179 F.3d 1378, 1380-81 (Fed. Cir. 1999); Damrel v. Brown, 6 Vet. App. 242, 245 (1994); Russell v. Principi, 3 Vet. App. 310, 313-14, 319 (1992) (en banc). A clear and unmistakable error is one about which reasonable minds could not differ. See, e.g., 38 C.F.R. § 20.1403(a). In most respects, the CUE standard for severing service connection under § 3.105(d) is equivalent to the CUE standard for reversing or revising a prior final decision under 38 C.F.R. § 3.105 (a). See Baughman v. Derwinski, 1 Vet. App. 563, 566 (1991). Section 3.105(d) places at least as high a burden of proof on the VA when it seeks to sever service connection as § 3.105(a) places upon an appellant seeking to have an unfavorable previous determination overturned. However, the determination is not limited to the law and the record that existed at the time of the original decision. VA may consider medical evidence and diagnoses that postdate the original award of service connection to demonstrate that the diagnosis on which service connection was predicated is clearly erroneous. Stallworth, 20 Vet. App. at 488. The Secretary's burden is not to prove clear and unmistakable error in the original decision in the same manner a claimant would show CUE under sections 5109A or 7111. A decision that is reversed or amended based on CUE is revised to conform to the state of the facts or the law that existed at the time of the original adjudication. Allen, 21 Vet. App. at 62. The initial question for the Board is whether the RO followed the due process requirements of 38 C.F.R. § 3.105(d) for severing service connection. The RO originally granted service connection for Parkinson's Disease with balance impairment, tremor and bradykinesia of the left and right upper extremities, loss of automatic facial movements, and partial loss of sense of smell and awarded SMC based on housebound status in a December 2013 rating decision. Service connection for Parkinson's Disease with balance impairment was established on a presumptive basis. See 38 C.F.R. §§ 3.307, 3.309 (e). Service connection for tremor and bradykinesia of the left and right upper extremities, loss of automatic facial movements, and partial loss of sense of smell was established as related to the service-connected Parkinson's Disease with balance impairment. See 38 C.F.R. § 3.310. In a July 2017 rating decision, the RO proposed to sever service connection for these disabilities and to discontinue SMC. The RO noted that the decision to grant service connection for Parkinson's Disease with balance impairment was clearly and unmistakably erroneous because the Veteran had no pathology or diagnosis of Parkinson's Disease and had never been diagnosed with Parkinson's Disease. Rather, he had been diagnosed with a Parkinson's plus syndrome which was not a disability for which the presumptive provisions apply. The decisions to grant service connection for tremor and bradykinesia of the left and right upper extremities, loss of automatic facial movements, and partial loss of sense of smell were clearly and unmistakably erroneous because the evidence showed that the Veteran did not have Parkinson's Disease that the tremor and bradykinesia of the left and right upper extremities, loss of automatic facial movements, and partial loss of sense of smell could be related to. As it was proposed to sever service connection for Parkinson's Disease with balance impairment, tremor and bradykinesia of the left and right upper extremities, loss of automatic facial movements, and partial loss of sense of smell, entitlement to SMC based on housebound status was not warranted. The RO noted the June 2017 VA neurologist's opinion finding that the Veteran did not then have or ever had pathology or diagnosis of Parkinson's Disease. The examiner observed that "at no time in this prolonged process has the Veteran ever actually been diagnosed with Parkinson's Disease and since parkinsonian symptoms developed, he was discussed as likely having a Parkinson's plus syndrome." The Veteran's clinical picture was determined to be most consistent with the diagnosis of multiple systems atrophy (MSA), a Parkinson's plus syndrome. In the January 2018 rating decision, the RO severed service connection for Parkinson's Disease with balance impairment, tremor and bradykinesia of the left and right upper extremities, loss of automatic facial movements, and partial loss of sense of smell and discontinued SMC. The RO followed the proper due process steps for severing service connection. The RO issued the proposed rating in June 2017, and the Veteran was notified at his latest address of record of this contemplated action and furnished detailed reasons therefor and was given 60 days for the presentation of additional evidence to show that service connection should be maintained in July 2017 notice letters. The notice letter also informed the Veteran that he had the opportunity for a hearing if such a request for a hearing was received by VA within 30 days from the date of the notice. See 38 C.F.R. § 3.105(i). The Veteran requested and testified in a hearing in August 2017. The RO issued the January 2018 rating decision, which severed service connection prospectively effective April 1, 2018. Notice of this rating decision, plus his appeal rights, was sent to the Veteran in January 2018. The April 1, 2018, date was greater than the last day of the month in which a 60-day period from the date of the January 2018 notice expired. Thus, all due process requirements were met in the severance of service connection for Parkinson's Disease with balance impairment, tremor and bradykinesia of the left and right upper extremities, loss of automatic facial movements, and partial loss of sense of smell and discontinuance of SMC based on housebound status. See 38 C.F.R. § 3.105(d). 1. Whether the severance of service connection for Parkinson's Disease with balance impairment was proper Having met the due process requirements, the remaining question before the Board in this case is whether the grant of service connection for Parkinson's Disease with balance impairment was clearly and unmistakably erroneous. The Board concludes that the severance of service connection was proper because the record provides clear and unmistakable evidence that the Veteran does not have Parkinson's Disease. At the time of the December 2013 rating decision, a March 2011 VA neurology consult report reflects the Veteran received treatment for an acute onset of altered mental status (AMS). The staff neurologist reported that the Veteran had been followed by neurology for tremor (essential versus medication induced) since 2007. The Veteran reported that he experienced tremors in both hands with both resting and action. For the past 2 years, he had experienced gait disturbance and had trouble arising from bed/chair without assistance. He reported that his symptoms were progressively worsening, and he now used a cane for ambulation and was experiencing a gradual decline in his activities of daily living (ADLs). He had difficulty walking; had slower speech and drifted off topic; demonstrated increased mistakes in handling the family finances; and demonstrated a noticeable decline in executive functioning over the past two to three weeks. He appeared confused and was disoriented to the day of the week. On examination, the neurologist concluded that the Veteran's presentation was likely to be a manifestation of Parkinsonism or a Parkinson's plus syndrome with rapid decline of cognitive function. The neurologist stated that the etiology or diagnosis could be broad, including Parkinson's Disease, cortical basal degeneration, Lewy body dementia with Parkinsonism, and medication induced Parkinsonism (given that the Veteran was taking lithium). A February 2013 VA neurology note reflects the Veteran's report that his tremors were much improved with the Sinemet. He was informed the results of his DAT scan which showed findings suggestive of Parkinson's or a Parkinson's plus syndrome. On examination, the neurologist concluded that Parkinson's or a Parkinson's plus syndrome were on the differential, but the Veteran's presentation was by no means classic. An August 2013 Parkinson's Disease Disability Benefits Questionnaire (DBQ) documents that the Veteran had Parkinson's Disease that was diagnosed February 8, 2013. Motor manifestations of the Parkinson's included moderate balance impairment, mild bradykinesia or slowed motion, mild loss of automatic movements, and mild tremor of the right and left upper extremities. Mental manifestations of the Parkinson's included mild depression and mild cognitive impairment or dementia. Additional manifestations of the Parkinson's included moderate, partial loss of sense of smell. However, as noted, a change in diagnosis may be accepted as a basis for severance action if the examining physician or physicians or other proper medical authority certifies that, in the light of all accumulated evidence, the diagnosis on which service connection was predicated is clearly erroneous. This certification must be accompanied by a summary of the facts, findings, and reasons supporting the conclusion. 38 C.F.R. § 3.105(d). August and November 2015 examinations for housebound status or permanent need for regular aid and attendance reflect that the Veteran had Parkinson's Disease and Atypical Parkinsonism. A July 2015 VA occupational therapy note reflects the Veteran was referred for treatment for diagnosed neurodegenerative condition (not specified) but within Parkinsonism group. On examination, the occupational therapist concluded that the Veteran had a new diagnosis of a neurodegenerative condition (not specified) with worsening level of function which impacted his ADLs. The April 2017 examination for housebound status or permanent need for regular aid and attendance reflects that the Veteran has probable MSA and peripheral neuropathy. The May 2017 VA neurology note reflects that the Veteran received follow up treatment for probable MSA. He reported a decline in his physical health and that he was experiencing more difficulty with his ADLs. On examination, a neurology fellow assessed probable MSA, peripheral neuropathy and essential tremor. The neurology fellow noted that the Veteran's MSA diagnosis was based on his autonomic symptoms and abnormal DAT scan. The neurology fellow reported that the MSA was atypical in that the course was very slowly progressive and the Veteran did not demonstrate much rigidity or classic bradykinesia on examination. The neurology fellow concluded that the Veteran's current level of disability was likely from a combination of probable MSA, peripheral neuropathy and essential tremor. The neurology fellow noted that the Veteran had significant disability on examination that impaired his daily function and that he would probably benefit from additional service at home. The June 2017 VA Parkinson's Disease examination report documents the neurologist's assessment that the Veteran did not currently have or had ever been diagnosed with Parkinson's Disease. The neurologist documented his extensive review of the claims file and stated there was no pathology or diagnosis of Parkinson's Disease and there never had been. The neurologist determined that there was neither a chronic nor a disabling condition of Parkinson's Disease. The neurologist noted that the Veteran first received treatment for tremor in 2007. Over time, other symptoms became manifest and given the neurologically complicated nature of his symptoms, a long differential diagnosis was formulated with possibilities being extensively worked up over time. The neurologist explained that at no time in this prolonged process had the Veteran ever actually been diagnosed with Parkinson's Disease, and since parkinsonian symptoms developed, he was discussed as likely having a Parkinson's-plus syndrome. The neurologist explained that the Veteran's clinical picture was determined to be most consistent with the diagnosis of multiple systems atrophy (MSA), which was a Parkinson's-plus syndrome. The neurologist noted that the Parkinson's Disease had been service connected as due to Agent Orange exposure because a neurology fellow completed a Parkinson's Disease DBQ in August 2013 on the same day that the Veteran received treatment in the neurology clinic and determined that the Veteran had a diagnosis of parkinsonism versus Parkinson's-plus syndrome. However, the neurologist reiterated that Parkinson's Disease was not considered as a possible diagnosis at the time of completion of the form. The neurologist explained that the physician completed the Parkinson's Disease DBQ form, knowingly stating that the Veteran had a diagnosis that was not even under consideration at the time. The neurologist reported that the change in diagnosis to MSA from Parkinson's Disease with numerous residuals was based on his specialty training in neurology, which included the diagnosis and management of Parkinson's Disease and the Parkinson's-plus syndromes; thorough review of the claims file, which did not previously occur (although the neurologist acknowledged that one could suppose that the examiner did review CPRS); and, an ethical integrity that did not allow him to misdiagnose a condition just for purposes of disability compensation. The neurologist concluded that the diagnosis of and service connection for Parkinson's Disease was made in error. The neurologist noted there was no presumption for service connection for the Parkinson's-plus syndromes as being due to Agent Orange exposure. The June 2017 VA Cranial Nerve Conditions examination report documents the neurologist's assessment that the Veteran did not currently have or had ever been diagnosed with a cranial nerve condition. The June 2017 VA peripheral nerves conditions examination report documents the neurologist's assessment that the Veteran did not have a peripheral nerve condition or peripheral neuropathy. The neurologist determined that there was no pathology or diagnosis of a cranial or peripheral nerve condition and there was neither a chronic nor a disabling condition at that time. In an August 2017 VA addendum medical opinion, the physician noted that a thorough review of the claims file had been performed and opined that it was less likely as not that the Veteran was diagnosed with Parkinson's Disease as initially documented in 2013. The physician opined that it was as likely as not that the Veteran had diagnosis of MSA. The physician explained that the Veteran's available records were objectively silent for his being diagnosed with Parkinson's Disease. The physician concluded, based on the weight of the available evidence, that service connection for the diagnosis of Parkinson's Disease was made in error. The physician explained that it was very common for MSA, which is one of the Parkinson's-plus syndromes, to be mistaken for atypical Parkinson's Disease when initially evaluated (as occurred in this case). The physician noted that MSA, considered one of the Parkinson's-plus neurodegenerative disorders, can manifest signs/symptoms of Parkinsonism (clinical manifestations like Parkinson's Disease but was not Parkinson's Disease). Significantly, the physician noted that the neurologist in the June 2017 examination explained in layman's terms why the Veteran did not have Parkinson's Disease and instead was diagnosed with MSA, an unrelated neurodegenerative disorder that may share some similar clinical characteristics. Here, the Board finds that there is clear and unmistakable evidence that the Veteran does not have Parkinson's Disease. As documented above, the June 2017 VA Parkinson's Disease examination report and August 2017 VA addendum medical opinion confirm that the Veteran does not have and has never actually been diagnosed with Parkinson's Disease. Accordingly, presumptive service connection for Parkinson's Disease was not warranted. In addition, MSA, a Parkinson's-plus syndrome, is not a covered disease for which the presumptive provisions apply. See 38 C.F.R. §§ 3.307, 3.309 (e). To the extent that the physician's remark (it was possible that the Veteran's condition could be due to remote environmental exposures during military service) documented in the August 2017 Central Nervous System and neuromuscular disease DBQ represents evidence in favor of a claim for service connection, the Board notes that restoration of service connection for Parkinson's Disease is not the proper remedy. The Veteran may file a claim for service connection for any other disability that he asserts onset due to injury or disease incurred in service. However, in this case, because there is clear and unmistakable evidence that the Veteran does not have Parkinson's Disease, the grant of service connection for Parkinson's Disease with balance impairment on a presumptive basis, pursuant to the December 2013 rating decision, was clearly and unmistakably erroneous. The severance of service connection was therefore proper, and the appeal is denied. 2. Whether the severance of service connection for tremor and bradykinesia of the left upper extremity was proper 3. Whether the severance of service connection for tremor and bradykinesia of the right upper extremity was proper 4. Whether the severance of service connection for loss of automatic facial movements was proper 5. Whether the severance of service connection for partial loss of sense of smell was proper The RO granted service connection for tremor and bradykinesia of the left and right upper extremities, loss of automatic facial movements, and partial loss of sense of smell as secondary to the Parkinson's Disease with balance impairment. Service connection may be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. See 38 C.F.R. § 3.310. Here, service connection for the primary disability, Parkinson's Disease, has been severed. Therefore, as a matter of law, service connection for the secondary disabilities, tremor and bradykinesia of the left and right upper extremities, loss of automatic facial movements, and partial loss of sense of smell, is not warranted. See 38 C.F.R. § 3.310; DeLisio v. Shinseki, 25 Vet. App. 45, 59 (2011). There is no indication that service connection for tremor and bradykinesia of the left and right upper extremities, loss of automatic facial movements, and partial loss of sense of smell could be granted on any other basis. Accordingly, the severance of service connection for tremor and bradykinesia of the left and right upper extremities, loss of automatic facial movements, and partial loss of sense of smell, as secondary to Parkinson's Disease, was proper, and the appeals are denied. 6. Whether discontinuance of SMC based on housebound status was proper SMC based on housebound status was granted because the Veteran was found unemployable due to service-connected posttraumatic stress disorder (PTSD) (i.e., single disability rated as 100 percent) and had additional service-connected disabilities, Parkinson's Disease with balance impairment and tremor and bradykinesia of the left and right upper extremities, independently ratable at 60 percent and separate and distinct from the service-connected PTSD. SMC is warranted on this basis where a veteran has a single service-connected disability rated as 100 percent and has additional service-connected disability/disabilities independently ratable at 60 percent, separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems. Here, the Veteran's Parkinson's Disease with balance impairment and tremor and bradykinesia of the left and right upper extremities are no longer service-connected disabilities. As such, he no longer has additional service-connected disabilities, independently ratable at 60 percent that are separate and distinct from the service-connected PTSD and is no longer entitled to SMC based on housebound status. Therefore, the discontinuance of this benefit was proper. See 38 C.F.R. § 3.105 (e). Consequently, the appeal is denied. 7. Entitlement to SMC based on the need of regular aid and attendance of another The Veteran is in receipt of a total rating based on individual unemployability due to his service-connected PTSD with bipolar disorder. His service-connected pilonidal cyst with abscess formation and draining sinus is evaluated as 10 percent disabling and his postoperative residuals of the left index finger ganglion is evaluated as non-compensable. He has no other current service-connected disorders. The Board notes that service connection for Parkinson's Disease with balance impairment, tremor and bradykinesia of the left and right upper extremities, loss of automatic facial movements, and partial loss of sense of smell was severed in a January 2018 rating decision and as determined above, the Board finds severance was proper. The Veteran asserts that his service-connected disabilities cause him to need the regular aid and attendance of another person, entitling him to SMC under 38 U.S.C. § 1114 (l) (2012), which may be established based on the need for aid and attendance. See also 38 C.F.R. §§ 3.350(b), 3.352(2). Such a need means that the Veteran is helpless or so nearly helpless, as to require the regular aid and attendance of another person. A veteran will be considered to be in need of regular aid and attendance if he or she is blind or is 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; if the veteran is a patient in a nursing home because of mental or physical incapacity; or if the evidence establishes a factual need for aid and attendance or "permanently bedridden" status under the criteria set forth in 38 C.F.R. § 3.352(a). 38 U.S.C. § 1114 (l); 38 C.F.R. § 3.351(b). The following factors are considered in determining the need for regular aid and attendance: Inability of a 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; Inability of a 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, either physical or mental, which requires care or assistance on a regular basis to protect the claimant from hazards or dangers incident to his daily environment. 38 C.F.R. § 3.352(a). The above are only factors for consideration, and it is left to the Board to determine whether a veteran is factually in need of regular aid and attendance. The particular personal functions that a veteran is unable to perform are also considered in connection with their 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, however the need must be caused solely by service-connected disabilities. Id. Further, there is no schedular threshold for the award of SMC when granted based on a need for regular aid and attendance. An August 2015 examination for housebound status or permanent need for regular aid and attendance reflects that the Veteran had Parkinson's Disease, tremors, hyper-reflexia, incontinence, peripheral neuropathy, bipolar I, PTSD, depression, anemia, gout, restless leg syndrome, and hypothyroidism. The physician indicated the Veteran's Parkinson's Disease, tremors, and hyper-reflexia restricted his activities and functions. He was confined to his bed for 12 hours for the period from 9pm to 9am and confined to his bed for 4 hours for the period from 9am to 9pm. The Veteran was able to feed himself but unable to prepare his own meals. The physician indicated that the Veteran needed assistance in bathing and tending to other hygiene needs, reporting that the Veteran was incontinent and due to tremors and hyper-reflexia, the Veteran requires assistance with bathing, toileting, and other hygiene needs. He was not legally blind and did not require nursing home care. He did require medication management due to cognitive changes and dementia. He had the ability to manage his own financial affairs. The Veteran was well-groomed, pleasant, alert, and conversant with the appropriate affect. He exhibited slight postural tremor. He was able to dress himself but experienced incontinence of stool at times. His fine motor capabilities were in the 10th percentile. He exhibited difficulty rising from a chair and had an apraxic gait and history of falls. He had mild cognitive impairment and loss of bowel control at times. He had difficulty with getting up from chairs; with prolonged ambulation; and, with preparing meals. He left his home for medical appointments and grocery shopping. He needed aids (canes, braces, crutches) or the assistance of another person for locomotion greater than 5 or 6 blocks. A November 2015 examination for housebound status or permanent need for regular aid and attendance reflects that the Veteran had Atypical Parkinsonism. The Veteran was able to feed himself but unable to prepare his own meals (he needed assistance with meal preparation). The physician indicated that the Veteran needed assistance in bathing and tending to other hygiene needs, reporting that the Veteran had poor balance and difficulty ambulating. He was not legally blind and did not require nursing home care. He did require medication management due to poor short-term memory and executive function. He had the ability to manage his own financial affairs. The Veteran had stooped posture, poor balance, difficulty ambulating due to shuffling steps and freezing gait, and frequent falls. He exhibited poor manual dexterity and fine motor coordination due to Parkinsonism, making it difficult to dress, write and prepare meals. In addition, he had poor balance and difficulty ambulating due to Parkinsonism and was a significant fall risk. In general, he exhibited rigidity of the body due to Parkinsonism. The Veteran demonstrated loss of bowel and bladder function requiring the use of diapers and exhibited autonomic dysfunction leading to frequent falls. He could leave his home with assistance and did not need aids (canes, braces, crutches) or the assistance of another person for locomotion. An April 2017 examination for housebound status or permanent need for regular aid and attendance reflects that the Veteran had probable MSA and peripheral neuropathy. The Veteran was able to feed himself but had trouble due to severe bilateral tremor. He was unable to prepare his own meals. The physician indicated that the Veteran needed assistance in bathing and tending to other hygiene needs, reporting that the Veteran was at risk to fall due to his poor balance. He was not legally blind and did not require nursing home care. He did require medication management and was unable to manage his own financial affairs. The Veteran was well nourished, well groomed, and appropriate. He stood in a stooped posture and ambulated with a cane. His significant tremors limited his ability for ADLs and fine motor activity. He lost his balance easily and tended to fall. He experienced bowel and bladder disturbance and balance trouble. He left his home for doctor's appointments but otherwise needed aid and he needed aids (canes, braces, crutches) or the assistance of another person for locomotion greater than 5 or 6 blocks. A September 2019 examination for housebound status or permanent need for regular aid and attendance reflects that the Veteran had essential tremor, cognitive impairment, incontinence, and recurrent falls. The physician indicated the Veteran's tremors and cognitive impairment restricted his activities and functions. The Veteran was able to feed himself but unable to prepare his own meals because he was unable to hold onto anything because of his tremors. The physician indicated that the Veteran needed assistance in bathing and tending to other hygiene needs, reporting that the Veteran does not have strength to get out of chairs without assistance and lacked mobility in his arms and legs to put on his pants and shirt. He was not legally blind and did not require nursing home care. He did require medication management due to his cognitive impairment. He was unable to manage his own financial affairs. The Veteran had bilateral arm/hand tremor with activity and holding objects. On occasion he was unable to feed himself, clothe himself, button his shirt, shave, or attend to needs of nature depending on the severity of his tremors. He could not walk without a walker or cane and fell frequently. He experienced chronic daily bowel and bladder incontinence and required incontinence briefs. He fell frequently due to his poor balance and weakness in his legs. He had difficulty with getting out of chairs and experienced memory issues and could not remember to take his medication without help. He left his home for medical appointments and to go to the store but needed the assistance of his family or caregiver. He used a walker and needed the assistance of his caregiver and walker for locomotion up to a mile. Here, the record does not contain any competent evidence that his service-connected PTSD with bipolar disorder, pilonidal cyst with abscess formation and draining sinus, or postoperative residuals of the left index finger ganglion renders him helpless in the performance of the activities of daily living or in protecting himself from the everyday hazards and dangers incident to his environment. The record is clear, the Veteran's non-service-connected MSA, a Parkinson's-plus syndrome (and associated neurological disorders) and tremors restrict his activities and functions and cause him to require the need for regular aid and attendance of another. As his service-connected PTSD with bipolar disorder, pilonidal cyst with abscess formation and draining sinus, or postoperative residuals of the left index finger ganglion have not caused him to need the regular aid and attendance of another person, entitlement to SMC based upon the need for aid and attendance is denied. The preponderance of the evidence is against the Veteran's claim and the benefit-of-the-doubt standard of proof does not apply. 38 U.S.C. § 5107(b). Vito A. Clementi Veterans Law Judge Board of Veterans' Appeals Attorney for the Board G. Jackson The Board's action is binding only in this case. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.