Citation Nr: 21005537 Decision Date: 02/01/21 Archive Date: 02/01/21 DOCKET NO. 19-08 571 DATE: February 1, 2021 REMANDED Entitlement to special monthly compensation based on the need for aid and attendance is remanded. REASONS FOR REMAND The Veteran served on active duty from November 1951 to October 1955. This matter is before the Board of Veterans’ Appeals (Board) on appeal from an April 2018 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). In the rating decision on appeal, the RO also denied entitlement to special monthly compensation at the housebound rate. The Veteran disagreed with this determination, but in his March 2019 Substantive Appeal (VA Form 9), the Veteran withdrew his appeal of this issue. It is not on appeal. In his March 2019 Substantive Appeal (VA Form 9), the Veteran requested a videoconference hearing before the Board. In July 2020, the VA notified the Veteran that a hearing was scheduled for September 16, 2020. In August 2020, prior to the hearing, the Veteran withdrew his hearing request. See 38 C.F.R. § 2.704(e) (2020). 1. Entitlement to special monthly compensation based on the need for aid and attendance is remanded. The Veteran seeks entitlement to special monthly compensation based on the need for aid and attendance. Special monthly compensation is payable at a specified rate if the veteran, as the result of service-connected disability, is permanently bedridden or so helpless as to be in need of regular aid and attendance. 38 U.S.C. § 1114(l); 38 C.F.R. § 3.350(b). The Veteran has been awarded a total disability evaluation based upon individual unemployability (TDIU) since June 2004. Throughout the pertinent period, service connection has been in effect for: 1) residuals, fracture, proximal left tibia, with left knee degenerative joint disease (DJD), with a 40 percent disability evaluation; 2) right knee limitation of flexion, with a 30 percent disability evaluation; 3) left ankle residuals of fracture with DJD with a 20 percent disability evaluation; 4) right knee instability with a 20 percent disability evaluation; 5) left hip DJD, with a 10 percent disability evaluation; 6) right knee DJD with limited and painful flexion, with a10 percent disability evaluation; 7) sinusitis, rated non-compensable (zero percent); and 8) retracted left tympanic membrane, rated non-compensable. In support of his claim, the Veteran submitted a September 2017 VA Form 21-2680 (Examination for Housebound Status or Permanent Need for Regular Aid and Attendance) authored by a VA physician. However, the Board cannot discern the physicians name, or a good portion of the physician’s handwriting on the form. From what the Board can discern, the physician attributed restriction of activity and function to “weakness and macular degeneration.” In the body of the examination form, the physician notes that the Veteran is legally blind, but also notes that the Veteran has a poor gait due to leg weakness, as well as knee pain. Once VA provides an examination, it must be adequate, or VA must notify the Veteran why one will not or cannot be provided. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). An examination is adequate if it considers the records of prior medical treatment, so that the evaluation of the claimed disability will be a fully informed one. Id. at 311 (quoting Green v. Derwinski, 1 Vet. App. 121, 124 (1991)). Moreover, an examination must be based upon consideration of the Veteran’s prior medical history and examinations. Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). The Secretary has an affirmative duty to gather the evidence necessary to render an informed decision on a claim. Douglas v. Shinseki, 23 Vet. App. 19 (2009). The September 2017 examination report is insufficient to decide the claim. The examination report does not indicate the source of the weakness, or delineate the impairment resulting from the nonservice-connected macular degeneration. Accordingly, the matter is remanded to afford the Veteran a VA examination. The matters are REMANDED for the following action: 1. Schedule the Veteran for an examination with respect to his claim for and attendance. An opinion is requested as to whether the Veteran requires regular aid and attendance due to his service-connected disabilities. The claims folder must be made available to the examiner. The examiner should note in the examination report that the claims folder was reviewed. Any appropriate evaluations, studies, and testing deemed necessary by the examiner should be conducted at this time and included in the examination report. The examiner should address whether it is it at least as likely as not (a probability of 50 percent or greater) that the Veteran requires regular aid and attendance due to his service-connected disabilities [1) residuals, fracture, proximal left tibia, with left knee DJD; 2) right knee limitation of flexion; 3) left ankle residuals of fracture with DJD; 4) right knee instability; 5) left hip DJD; 6) right knee DJD with limited and painful flexion; 7) sinusitis; and 8) retracted left tympanic membrane]. The examiner should address whether the Veteran’s service-connected disabilities result in: *Inability 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 does not include the adjustment of appliances which normal persons would be unable to adjust without aid, such as supports, belts, lacking at the back, etc.); *Inability to attend to the wants of nature; *Inability to feed himself through loss of coordination of the upper extremities or through extreme weakness; 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 daily environment. The examiner is asked to provide the underlying reasons for any opinion expressed. Marissa Caylor Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Joseph R. Keselyak, 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.