Citation Nr: 21006061 Decision Date: 02/03/21 Archive Date: 02/03/21 DOCKET NO. 19-13 711 DATE: February 3, 2021 ORDER Entitlement to a 100 percent disability rating for service-connected coronary artery disease (CAD) is granted. Entitlement to a compensable rating for service-connected bilateral hearing loss, prior to August 25, 2020, is denied. Entitlement to a 10 percent disability rating for service-connected bilateral hearing loss, effective August 25, 2020, is granted. Entitlement to service connection for post-traumatic stress disorder (PTSD) is granted. Entitlement to service connection for a lower back condition is granted. Entitlement to service connection to lower left extremity radiculopathy (claimed as sciatica) is granted. Entitlement to service connection for lower right extremity radiculopathy (claimed as sciatica) is granted. Entitlement to special monthly compensation (SMC) based on aid and attendance is granted. REMANDED Entitlement to an effective date prior to April 15, 2014, for service-connected CAD is remanded. Entitlement to an effective date prior to April 15, 2014, for service-connected bilateral hearing loss is remanded. FINDINGS OF FACT 1. Throughout the appeal, the Veteran’s service-connected CAD has required continuous medication and has been manifested by a workload between 1 and 3 METs. 2. Prior to August 25, 2020, at worse, the Veteran’s bilateral hearing loss is manifested by Level III for the Veteran’s right ear and Level III for his left ear 3. From August 25, 2020, the Veteran’s bilateral hearing loss is manifested by Level IV for the Veteran’s right ear and Level IV for his left ear. 4. The Veteran’s PTSD is at least as likely as not etiologically related to his active duty service. 5. The Veteran’s lower back condition is at least as likely as not etiologically related to his active duty service. 6. The Veteran’s lower left extremity radiculopathy (claimed as sciatica) is at least as likely as not etiologically related to his active duty service. 7. The Veteran’s lower right extremity radiculopathy (claimed as sciatica) is at least as likely as not etiologically related to his active duty service. 8. For the period on appeal, the Veteran’s service-connected disabilities have resulted in functional impairments that necessitated the regular aid and attendance of another person. CONCLUSIONS OF LAW 1. The criteria for establishing entitlement to a 100 percent disability rating for service-connected CAD have been met. 38 U.S.C. § 1155, 5103, 5103A, 5107; 38 C.F.R. § 3.159, 3.321, 4.104, Diagnostic Code (DC) 7005. 2. The criteria for establishing entitlement to a compensable rating for service-connected bilateral hearing loss, prior to August 25, 2020, have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321, 4.1, 4.85, 4.86, Diagnostic Code 6100. 3. The criteria for establishing entitlement to a 10 percent disability rating for service-connected bilateral hearing loss, effective August 25, 2020, have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321, 4.1, 4.85, 4.86, Diagnostic Code 6100. 4. The criteria for establishing entitlement to service connection for PTSD have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 5. The criteria for establishing entitlement to service connection for a lower back condition have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 6. The criteria for establishing entitlement to service connection to lower left extremity radiculopathy (claimed as sciatica) have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310. 7. The criteria for establishing entitlement to service connection for lower right extremity radiculopathy (claimed as sciatica) have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310. 8. The criteria for establishing entitlement to special monthly compensation based on aid and attendance have been met. 38 U.S.C. §§ 1114(l), 5107; 38 C.F.R. §§ 3.102, 3.350(b), 3.352(a). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Navy from August 1954 to August 1958, and the Air force from September 1958 to December 1974. This appeal comes before the Board of Veterans’ Appeals (Board) from September 2018 and December 2018 rating decisions by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran previously submitted a claim of entitlement to service connection for PTSD, low back injury, and CAD which were denied in a December 2015 rating decision. This rating decision became final because and the Veteran did not submit a Notice of Disagreement or new evidence in connection with the claims within the appeal period. See 38 C.F.R. § 3.156(b). In connection with the Veteran’s claim to reopen, he submitted additional medical records and lay statements regarding his claimed condition; and the Veteran was provided with VA examinations. Thus, the Board finds that new and material evidence has been received sufficient to reopen his previously denied claims. 38 C.F.R. § 3.156(a); Shade v. Shinseki, 24 Vet. App. 110, 117-18 (2010); Justus v. Principi, 3 Vet. App. 510, 513 (1992). Increased Rating—Legal Criteria Disability ratings are determined by applying the criteria set forth in VA’s Schedule for Rating Disabilities. Ratings are based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of the two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise the lower rating will be assigned. See 38 C.F.R. § 4.7. In both initial rating claims and normal increased rating claims, the Board must discuss whether “staged ratings” are warranted, and if not, why not. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. The severity of hearing loss is determined by comparing audiometric test results with the specific criteria. 38 C.F.R. § 4.85, Diagnostic Codes 6100 through 6110. Evaluations of defective hearing range from noncompensable to 100 percent based on organic impairment of hearing acuity as measured by the results of controlled speech discrimination tests together with the average hearing threshold level as measured by puretone audiometry tests in the frequencies 1000, 2000, 3000, and 4000 Hertz. The Rating Schedule allows for such audiometric test results to be translated into a numeric designation ranging from Level I to Level XI, in order to evaluate the degree of disability from service-connected defective hearing. The evaluations derived from the Rating Schedule are intended to make proper allowance for improvement by hearing aids. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must weigh against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996) (citing Gilbert, 1 Vet. App. At 54). CAD The Veteran’s CAD is currently rated as 10 percent disabling pursuant to Diagnostic Code 7005. For the reasons explained below, the Board finds that the evidence is at least in equipoise that the Veteran is entitled to a total, 100 percent disability rating. Under DC 7005, a 10 percent rating is warranted when the Veteran has a workload of greater than 7 METs but not greater than 10 METs which results in dyspnea fatigue, angina, dizziness, or syncope, or when continuous medication is required. A 30 percent rating is warranted when there is a workload of greater than 5 METs but not greater than 7 METs which results in dyspnea, fatigue, angina, dizziness, or syncope or; evidence of cardiac hypertrophy or dilation on echocardiogram, EKG, or X-ray. A 60 percent rating is warranted when there is more than one episode of acute congestive heart failure in the past year; a workload of greater than 3 METs (metabolic equivalent), but not greater than 5 METs, resulting in dyspnea, fatigue, angina, dizziness, or syncope; or for left ventricular dysfunction with an ejection fraction of 30 to 50 percent. A 100 percent rating is warranted when there is chronic congestive heart failure; a workload of 3 METs or less resulting in dyspnea, fatigue, angina, dizziness, or syncope; or left ventricular dysfunction with an ejection fraction of less than 30 percent. 38 C.F.R. § 4.104, DC 7005. For rating diseases of the heart, one MET (metabolic equivalent) is the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute. When the level of METs at which dyspnea, fatigue, angina, dizziness, or syncope develops is required for rating, and a laboratory determination of METs by exercise testing cannot be done for medical reasons, an estimation by a medical examiner of the level of activity (expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow) that results in dyspnea, fatigue, angina, dizziness, or syncope may be used. 38 C.F.R. § 4.104, Note 2. The pertinent evidence of record reveals that, throughout the appeal period, the Veteran’s CAD has required continuous medication and has been manifested by LVEF of 55 to 60 percent and a workload of at worst 1 to 3 METs. The Veteran’s VA treatment records do not record symptoms that are worse than the below cited VA and private examinations. Additionally, the lay and medical evidence does not reflect that the Veteran’s condition has ever resulted in congestive heart failure The Veteran was initially provided a VA Heart conditions examination in November 2015. The examiner diagnosed the Veteran with coronary artery disease and indicated that continuous medication was required for the control of the Veteran’s heart condition. The Veteran’s METs were estimated to be between 1-3 METs, due to symptoms of dyspnea and his LVEF measured 65 percent. However, the examiner reported that the Veteran’s dyspnea was due to his chronic obstructive pulmonary disease (COPD), not a cardiac condition, and then reported that the Veteran’s METs based solely on his cardiac condition would be between 7-10. The examiner indicated that METS is based on general conditioning, and that the Veteran’s LVEF was therefore a more accurate representation of his cardiac function. (The Board notes that neither the Veteran’s VA treatment records, nor his private treatment records show a diagnosis of, or treatment for, COPD). The Veteran was next afforded a July 2018 VA Heart Conditions examination. Upon examination, the Veteran’s LVEF was measured at 58 percent. The examiner noted that the Veteran denied experiencing symptoms attributable to a cardiac condition with any level of physical activity. As such, no METs level was recorded. No congestive heart failure was reported, though continuous medication was required to control the Veteran’s heart condition. The Veteran submitted a September 2020 private examination from a Dr. M.S. Within the examination report, Dr. M.S. noted that he conducted a review of the entire claims file, and an interview with the Veteran. Dr. M.S. noted that an August 2018 EKG revealed that the Veteran had left ventricular hypertrophy. Further, Dr. M.S. indicated that the Veteran’s METs levels were between 1-3 METs which results in dyspnea, fatigue, and dizziness due to his heart condition, and has been at this level since around 2011. Dr. M.S. particularly noted that while the Veteran is eating, he experiences severe dyspnea and must rest his body. Dr. M.S. disagreed with the November 2015 VA examiner’s statement that the Veteran’s LVEF is an accurate representation of his cardiac function and cited to multiple studies cautioning a sole reliance on LVEF. Next, the Veteran was provided with a November 2020 VA Heart Conditions examination. No congestive heart failure was reported, though continuous medication was required to control the Veteran’s heart condition. The Veteran’s LVEF was recorded as between 55-60 percent. The examiner indicated that the Veteran is not experiencing any symptoms attributable to his cardiac conditions and therefore did not report any METs findings. Finally, the Veteran submitted a private October 2020 Heart Conditions examination. The examiner indicated that the Veteran was not experiencing congestive heart failure. The examiner also did not provide any METs measurements. However, the examiner indicated that due to his heart condition, the Veteran is unable to do any physical activity. Specifically, the examiner noted that the Veteran does not drive, is fragile in stature and appearance, becomes short of breath with any exertion, and experiences ongoing issues with activities of daily living and ability to walk, even if attempting a slow pace within his own home. Based on the foregoing, resolving all reasonable doubt in favor of the Veteran, the Board finds that a disability rating in of 100 percent is warranted for the Veteran’s CAD for the period on appeal. In weighing the evidence of record, particularly the Veteran’s treatment notes, VA examinations, private examinations, and competent lay statements the Board finds that the evidence is at least in equipoise regarding whether the Veteran is entitled to a 100 percent disability rating for his service-connected CAD disability. As the reasonable doubt created by this relative equipoise must be resolved in favor of the Veteran, entitlement to a total disability rating is warranted. 38 U.S.C.§ 5107(b); 38 C.F.R. § 3.102. As 100 percent is the maximum rating allowed under Diagnostic Code 7005, this constitutes a full grant of the benefits sought on appeal. Bilateral Hearing Loss The Veteran is seeking ratings in excess of those already assigned to his service-connected bilateral hearing loss. VA treatment notes indicate that the Veteran has received treatment for his bilateral hearing loss, and the Veteran has undergone prior July 2018 VA hearing loss examinations. However, the audiological tests and findings contained within those examinations indicate that the Veteran was not entitled to a compensable disability rating for his hearing loss at the time of those examinations. The July 2018 VA audiological evaluation, which revealed puretone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 AVG RIGHT 35 50 60 70 75 54 LEFT 40 55 60 65 65 55 Speech audiometry revealed speech recognition ability of 88 percent in the right ear and 86 percent in the left ear. The rating criteria provide for rating exceptional patterns of hearing impairment under the provisions of 38 C.F.R. § 4.86. The Veteran met the criteria for an exceptional pattern of hearing loss because the puretone thresholds are 55 decibels or more at the 1000, 2000, 3000, and 4000 Hertz levels. As such, a rating for an exceptional pattern of hearing impairment is warranted for this period. 38 C.F.R. § 4.86(a). This means that the Roman numeral designation for hearing impairment is drawn either Table I or Table VIa, whichever results in the higher numeral. Applying the July 2018 audiometric results to the Rating Schedule reveals a numeric designation of Level III for the Veteran’s right ear and Level III for the Veteran’s left ear. See C.F.R. § 4.85, Table VIa, Diagnostic Code 6100. Applying these numeric designations to Table VII results in a 0 percent disability rating from this examination. See 38 C.F.R. § 4.85, Table VII, Diagnostic Code 6100. In August 2020, the Veteran underwent his most recent VA audiological evaluation, which revealed puretone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 AVG RIGHT 50 55 60 65 65 61.25 LEFT 50 55 55 65 65 60 Speech audiometry revealed speech recognition ability of 84 percent in the right ear and 80 percent in the left ear. The rating criteria provide for rating exceptional patterns of hearing impairment under the provisions of 38 C.F.R. § 4.86. The Veteran met the criteria for an exceptional pattern of hearing loss because the puretone thresholds are 55 decibels or more at the 1000, 2000, 3000, and 4000 Hertz levels. As such, a rating for an exceptional pattern of hearing impairment is warranted for this period. 38 C.F.R. § 4.86(a). This means that the Roman numeral designation for hearing impairment is drawn either Table VI or Table VIa, whichever results in the higher numeral. Applying the August 2020 audiometric results to the Rating Schedule reveals a numeric designation of Level IV for the Veteran’s right ear and Level IV for the Veteran’s left ear. See C.F.R. § 4.85, Table VIa, Diagnostic Code 6100. Applying these numeric designations to Table VII results in a 10 percent disability rating from this examination. See 38 C.F.R. § 4.85, Table VII, Diagnostic Code 6100. Disability ratings for hearing impairment are derived by a mechanical application of the Rating Schedule to the numeric designations assigned after audiometric evaluations are rendered. Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). Thus, based on the audiometric findings of record, a disability rating of 10 percent for bilateral hearing loss is warranted effective August 25, 2020, the date the evidence showed an increase was warranted. The Board, considering the available objective data, finds that staging the disability ratings is appropriate in this case. As noted above, the Veteran’s symptomatology has been stable throughout the appeal period prior to August 25, 2020, and as demonstrated by the July 2018 VA examination, the objective criteria for a compensable rating prior to August 25, 2020, has not been met, and therefore, the Veteran’s rating will remain noncompensable for this period. However, as demonstrated by the August 25, 2020 VA examination, the Veteran’s hearing acuity after this date reaches the objective criteria of a 10 percent rating, and as such, a higher staged rating after the date of the examination is warranted. In sum, the Board finds that the preponderance of the evidence shows that the Veteran is entitled to a 10 percent disability rating for his service-connected bilateral hearing loss, effective August 25, 2020, but no sooner. Service Connection—Legal Criteria Establishing service connection generally requires evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Service connection may be granted for any disease initially diagnosed after service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection may be granted on a secondary basis for a disability which is aggravated by, proximately due to, or the result of a service-connected disease or injury under 38 C.F.R. § 3.310. Allen v. Brown, 7 Vet. App. 439 (1995). In order to establish service connection on a secondary basis, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical evidence establishing a link between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). Service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the in-service stressor occurred. 38 C.F.R. § 3.304(f). If the evidence establishes that a veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran’s service, the veteran’s lay testimony alone may establish the occurrence of the claimed in-service stressor. 38 C.F.R. § 3.304(f)(2). The Board must fully consider the lay evidence of record. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). A layperson is competent to report on the onset of disability and, when applicable, continuity of his or her current symptomatology. Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient to establish a diagnosis if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Jandreau v. Nicholson, 492 F. 3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent, the Board must determine, on a case-by-case basis, whether the Veteran’s particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau, supra. The Board is charged with the duty to assess the credibility and weight given to evidence. Wensch v. Principi, 15 Vet. App. 362, 367 (2001). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, and consistency with other evidence submitted on behalf of the Veteran, and the Veteran’s demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza, 7 Vet. App. at 511, aff’d per curiam, 78 F.3d 604 (Fed. Cir. 1996). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant. To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). PTSD The Veteran’s in-service stressors have been conceded, meaning the issues before the Board are whether the Veteran had a current diagnosis of PTSD, and whether there is a nexus between the Veteran’s reported stressors and his PTSD. The Veteran’s service treatment records (STRs) are silent as to psychiatric issues. However, the Board notes that the Veteran’s VA and private treatment records have diagnosed him with PTSD, and he has received treatment for psychiatric conditions throughout the period of the claim. The Veteran underwent a November 2015 VA PTSD examination. The examiner indicated that the Veteran did not have a diagnosis of PTSD, and did not have any diagnosed psychiatric conditions which conform to the DSM-V. The Veteran then submitted a June 2020 private psychological examination by a Dr. E.L. In this examination, Dr. E.L. diagnosed the Veteran with PTSD and Major Depressive Disorder dues to the stressors from his active duty service. Dr. E.L. based his diagnosis and determination off of a review of the entire claims file, and an interview with the Veteran. Further, Dr. E.L. indicated that he strongly disagreed with the November 2015 VA examiner, as a review of the Veteran’s medical records shows that the Veteran met the full diagnostic criteria for PTSD at the time of the VA examination. The Veteran was then afforded a November 2020 VA Mental Disorders examination. The examiner diagnosed the Veteran with an unspecified trauma and stressor related disorder. In providing a rationale, the examiner indicated that the Veteran’s diagnosis is related to the stressors he experienced in service and is not related to the stroke he suffered in 2011. Given the conflicting diagnoses of PTSD, the Board finds that the evidence of record is approximately evenly balanced as to whether the Veteran meets the diagnostic criteria for PTSD. Cohen v. Brown, 10 Vet. App. 128, 139, 140 (1997) (mental health professionals are presumed to know the requirements applicable to their practice and to have taken them into account when diagnosing PTSD). As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, the Board finds that the Veteran met the current disability requirement with regard to the claim for service connection for PTSD. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. As there is medical evidence of PTSD and conceded in-service stressors, the remaining question is whether there is a relationship between the two. Given the nexus opinions provided by the VA examiners, the Veteran’s private physician, and the Veteran’s competent lay statements, the Board finds that the evidence of record is approximately evenly balanced as to whether the Veteran’s PTSD disability is etiologically related to his active duty service and conceded in service stressors. Therefore, the evidence is thus at least evenly balanced as to whether the Veteran had PTSD that was related to his conceded in-service stressors. As the reasonable doubt created by this relative equipoise must be resolved in favor of the Veteran, entitlement to service connection for PTSD is warranted. 38 U.S.C.§ 5107(b); 38 C.F.R. § 3.102. In sum, the Board is satisfied that the evidence supporting the claim is at least in equipoise with that against the claim. Therefore, the Veteran is entitled to service connection for his PTSD. Lower Back and Bilateral Lower Extremity Radiculopathy The Veteran seeks service connection for a lower back condition and bilateral lower extremity radiculopathy, which he contends originated in service. The medical evidence confirms that the Veteran has a current diagnosis of lumbosacral strain with radiculopathy to the bilateral lower extremities. See November 2015 VA Back Conditions examination; see also June 2020 private examination report. The central issue that must be resolved is whether the Veteran’s current disabilities originated in service or are otherwise related to service. See Newhouse v. Nicholson, 497 F.3d 1298 (Fed. Cir. 2007); Gonzalez v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). The Veteran’s available STRs do contain multiple complaints of and treatment for lower back and sciatica conditions while in service. Additionally, the Veteran has provided lay statements wherein he testified that he injured his back in service, and has been experiencing pain from service to present day. Further, the Veteran has submitted lay buddy statements from his spouse and sister which document his in-service back injuries. The Veteran is competent to report that he had lower back problems during and since service. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Additionally, the Veteran, his spouse, and his sister are competent to relay what they have directly observed. See Layno v. Brown, 6 Vet. App. 465 (1994). The Board also finds the Veteran to be credible as the information he provided regarding treatment for his claimed conditions is largely consistent with the record. The Veteran was afforded a November 2015 VA back conditions examination. The examiner diagnosed the Veteran with degenerative arthritis of the spine. However, the examiner opined that the Veteran’s claimed back condition was less likely than not (less than a 50 percent probability) incurred or caused by the Veteran’s active duty service. The rationale provided was that there was no documentation in the Veteran’s STRs for back pain, and the Veteran’s spine was normal upon his exit examination. The Veteran submitted a June 2020 private examination from a Dr. V.F. regarding his back condition. Dr. V.F. indicated that he based his examination on a review of the entire claims file, and an interview with the Veteran. Dr. V.F. noted that the Veteran had a history of lower back injuries in his STRs and noted that the Veteran has a current diagnosis of degenerative disc disease with bilateral lower extremity radiculopathy. Dr. V.F. opined that it was more likely than not (greater than 50 percent probability) that the Veteran’s current lower back condition was caused by his in-service injuries. Additionally, Dr. V.F. noted that the Veteran’s lower extremity radiculopathy is caused by his lower back condition. In this case, the Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The evaluation of evidence generally involves a 3-step inquiry. First, the Board must determine whether the evidence comes from a “competent” source. The Board must then determine if the evidence is credible, or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303 (2007) (Observing that once evidence is determined to be competent, the Board must determine whether such evidence is also credible). The third step of this inquiry requires the Board to weigh the probative value of the proffered evidence in light of the entirety of the record. The Board also notes that under certain circumstances, lay evidence may be sufficient to establish a nexus. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); see also Layno v. Brown, 6 Vet. App. 465, 469 (1994). Lay evidence has been found to be competent with regard to a disease that has “unique and readily identifiable features” that are “capable of lay observation.” See Barr v. Nicholson, 21 Vet. App. 303, 308-09 (2007); see also Petitti v. McDonald, 27 Vet. App. 415, 427-28 (2015) (where the Court of Appeals for Veterans Claims found objective evidence of pain need not come from a medical professional; a lay person may provide the requisite confirmation). The November 2015 VA examiner’s opinion was based on the lack of evidence of treatment in the Veteran’s medical records. However, the Board notes, “symptoms, not treatment, are the essence of any evidence of continuity of symptomatology.” Savage v. Gober, 10 Vet. App. at 496. As noted below, the Veteran has offered competent and credible evidence of continuity of symptomatology. The medical opinion based on a lack of treatment records regarding the Veteran’s lower back are therefore of limited probative weight. Buchanan v. Nicholson, 451 F.3d 1331, 1336 n. 1 (Fed. Cir. 2006) (noting that VA’s examiner’s opinion, which relied on the absence of contemporaneous medical evidence, “failed to consider whether the lay statements presented sufficient evidence of the etiology of [the veteran’s] disability such that his claim for service connection could be proven without contemporaneous medical evidence”). Additionally, the VA examiner’s reports of no treatment for back pain in the Veteran’s STRs is demonstrably false, as the Veteran has multiple treatment notes regarding his spine in his service medical records. The Board has considered the Veteran’s lay statements in support of his claim. He is competent to report symptoms, such as pain, because this requires only personal knowledge as it comes to him through his senses. Layno v. Brown, 6 Vet. App. 465, 469 (1994). However, he is not competent to offer an opinion as to the etiology of his current disorder due to the medical complexity of the matter involved. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Woehlaert v. Nicholson, 21 Vet. App. 456, 462. In this case, the Veteran has reported that he experienced lower back pain while in active duty service which has persisted ever since. The Board finds the Veteran competent to report such manifestations. It is generally within the competence of a lay person to identify and observe the effect of a disability under the ordinary conditions of daily life. Many symptoms are readily observable by a lay person. Accordingly, the lay evidence provided by the Veteran is unquestionably competent evidence. In this respect, the Board finds the Veteran’s own reports of experiencing ongoing pain to be at least as probative as the above-noted examiner’s findings, as the Veteran is truly the only person capable of such observation. The Board finds that the totality of the evidence is thus at least evenly balanced as to whether the Veteran’s current lower back disability is etiologically related to his active duty service. As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, entitlement to service connection for a lower back condition is granted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Additionally, as evidence shows that the Veteran is diagnosed with bilateral lower extremity radiculopathy due to his now service-connected lower back disability, the Veteran is entitled to service-connection for his claimed left lower extremity radiculopathy. As such, service connection for the Veteran’s bilateral lower extremity radiculopathy is also granted. SMC Aid and Attendance (A&A)—Legal Criteria Special monthly compensation is payable under 38 U.S.C. § 1114(l) if, as the result of service-connected disability, the Veteran is permanently bedridden or is so helpless as to be in need of regular aid and attendance of another person. 38 U.S.C. § 1114(l); 38 C.F.R. § 3.350(b). The need for aid and attendance means being so helpless as to require the regular aid and attendance of another person. 38 C.F.R. § 3.350(b). As it pertains to the present case, criteria for establishing such need include whether the Veteran is so helpless as to be in need of regular aid and attendance as determined under criteria enumerated under 38 C.F.R. § 3.352(a). Under 38 C.F.R. § 3.352(a), the following factors will be accorded consideration in determining whether the Veteran is in need of regular aid and attendance of another person: (1) inability of the Veteran to dress or undress himself, or to keep himself ordinarily clean and presentable; (2) frequent need of adjustment of any special prosthetic or orthopedic appliances which by reason of the particular disability cannot be done without such aid; (3) inability of the Veteran to feed himself because of the loss of coordination of upper extremities or because of extreme weakness; (4) inability to attend to the wants of nature; or (5) physical or mental incapacity which requires care or assistance on a regular basis to protect the Veteran from the hazards or dangers incident to his 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 is unable to perform should be considered in connection with his condition as a whole. It is only necessary that the evidence establish that the Veteran is so helpless as to need regular aid and attendance not that there is a constant need for aid and attendance. 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). Analysis The Veteran asserts that his service-connected disabilities have rendered him so helpless that he requires the regular aid and attendance of another person. The Board agrees. The Board observes that the Veteran is now service connected for tinnitus, CAD, bilateral hearing loss, thrombosis, a lower back condition, bilateral lower extremity radiculopathy, and PTSD. In a December 2019 VA Aid and Attendance or Housebound examination, the examiner noted that the Veteran was able to feed himself with the assistance of a caregiver, was unable to prepare his own meals, needed assistance in bathing and tending to hygiene needs, and that his wife/caregiver takes care of his activities of daily living and manages his medications. The examiner noted that the Veteran is a fall risk and cannot stand for very long. The Veteran’s submitted a June 2020 private examination from Dr. V.F. regarding his need for A&A. The examiner noted that the Veteran has been in need of regular aid an attendance because of his back issues since at least October 2018. Dr. V.F. concluded that the Veteran’s severe lumbar degenerative disc disease and lower extremity radiculopathy limit his function and require him to obtain regular A&A due to these conditions. The Veteran’s spouse also submitted a statement wherein she noted that she has to prepare the Veteran’s meals, help him bathe, help him shave, help him walk, manages the Veteran’s medications, and does all the driving when they need to go somewhere. Based on the evidence of record, the Board finds that the Veteran required aid and assistance due to his service-connected disabilities. Moreover, the well-documented fact of his inability to stand, walk, or do his activities of daily living persuades the Board that he would have required aid and assistance to dress and undress himself, as well as attend to the wants of nature. The Board recognizes that the probative private examination report concluded that it was the Veteran’s lower back and radiculopathy disabilities that contributed to his total disability, and thus the need for aid and attendance. As the Veteran is now service connected for his back and lower extremity radiculopathy, the Board finds that the Veteran’s need for aid and assistance was due to his service-connected disabilities. 38 U.S.C. § 1114(l); 38 C.F.R. § 3.350(b). Accordingly, the Board finds that special monthly compensation for aid and assistance is warranted. REASONS FOR REMAND Earlier Effective Dates for Bilateral Hearing Loss and CAD. The AOJ granted the Veteran’s entitlement to service connection for CAD and bilateral hearing loss in a December 2015 rating decision. After an April 2017 finding of clear and unmistakable error, the AOJ granted the Veteran an effective date of April 15, 2014, for his bilateral hearing loss and CAD claims in an April 2017 rating decision. In May 2018, the Veteran filed a claim for an increased disability rating for his CAD and bilateral hearing loss claims which were denied in a September 2018 rating decision. In a October 2018 notice of disagreement, the Veteran expressed disagreement with the effective date of his claims. The AOJ issued a statement of the case (SOC) in March 2020 addressing the Veteran’s increased rating claims and service connection claims. However, the AOJ has yet to issue a Statement of the Case (SOC) with regard to the Veteran’s earlier effective date claim. A remand is therefore necessary. Manlincon v. West, 12 Vet. App. 238 (1999). The matters are REMANDED for the following action: (Continued on the next page)   The AOJ must issue a Statement of the Case (SOC) addressing the Veteran’s earlier effective date for his service-connected CAD and bilateral hearing loss claims. The Veteran is hereby notified that, following the receipt of the SOC concerning this issue, he must file a timely substantive appeal if he desires appellate review by the Board. If, and only if, the Veteran files a timely substantive appeal, the AOJ should return these issues to the Board for appellate review. Zi-Heng Zhu Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Gresham 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.