Citation Nr: 21009833 Decision Date: 02/23/21 Archive Date: 02/23/21 DOCKET NO. 18-10 897 DATE: February 23, 2021 REMANDED Entitlement to special monthly compensation (SMC) based on the need of regular aid and attendance is remanded. REASONS FOR REMAND The Veteran served on active duty from July 1960 to July 1963. This matter is on appeal from a November 2017 rating decision and was previously remanded by the Board in September 2020. The Veteran’s claim for special monthly compensation (SMC) based on the need of regular aid and attendance is remanded for further development. Based on the Veteran’s October 2017 VA Form 21-2680, Examination for Housebound Status or Permanent Need for Regular Aid and Attendance, he asserted that his poor balance and gait restricts his activities and functions. He has abnormal posture due to back pain and often ambulates with a cane and takes multiple pain medications. He indicated that he has been diagnosed with tremors, labyrinthitis, stroke, Parkinson’s, spondylolisthesis, and chronic vertigo, with dizziness and lack of balance. The Veteran is currently only service connected for anxiety disorder (not otherwise specified and alcohol dependence in full sustained remission rated at 50 percent, chronic vertigo with dizziness at 30 percent, tinnitus at 10 percent, bilateral hearing loss at a noncompensable rating. Prior to the September 2020 Board remand, the evidence suggested that the Veteran’s service-connected vertigo caused significant impairment to his daily activities, which may warrant special monthly compensation. Pursuant to the September 2020 Board remand, the Veteran was afforded a new VA evaluation in November 2020. The examining physician noted that the Veteran has been diagnosed with essential tremor, left hand spasticity, lower extremity weakness secondary to stroke, restless leg syndrome, chronic vertigo with dizziness, anxiety, tinnitus, and hearing loss. As a preliminary matter, the physician indicated that the Veteran’s newer diagnosis of essential tremor, left hand spasticity, lower extremity weakness (secondary to stroke) is separate and unrelated to his service-connected diagnoses and they do not interfere with his ability to complete activities of daily living, including driving. Further evaluation noted that the Veteran has an unsteady gait with mild stooped posture He ambulates well with a rolling walker with a seat. He is unable to ambulate without the assistance of his rolling walker due to dizziness, vertigo, and weakness of his lower extremities. The examiner found that overall, the Veteran was not confined to his bed. He appeared well-nourished with no evidence of atrophy. He is not legally blind, nor does he require nursing home care. He is not prevented from attending to the needs of nature. While he can feed himself, he is unable to prepare is own meals due to his essential tremors, rigidity, weakness secondary to a stroke and left-hand spasticity. Moreover, the Veteran requires assistance in bathing and tending to other hygiene. He requires mild to moderate assistance in dressing, bathing, grooming, toileting, keeping clean and presentable. He requires assistance in medication management and the management of his financial affairs. The physician found that the Veteran struggles with chronic medical and mental conditions that make it difficult to manage his finances or pay his bills. Specifically, his vertigo, essential tremors, unsteady gait and weakness secondary to a stroke prevents him from writing checks, driving, making payments, and discussing his accounts over the phone. The examining physician specifically noted that the Veteran’s restrictions in the grip and fine movements of the left and right hand due to the Veteran’s bilateral upper extremity weakness, essential tremors and rigidity that prevents him from being able to button his clothes and shave himself. With regard to his bowels or bladder control or the effects of advancing age such as dizziness, loss of memory, or poor balance, the Veteran is able to perform self-care, ambulate or travel beyond the premises of the home or if hospitalized, beyond the ward of the clinic area. He is able to leave his home approximately 2 or 3 times per week for activities such as grocery shopping and social gathering such as AA meetings and weekly church service. While the Board finds that the November 2020 evaluation offered more details on the Veteran’s overall condition, the report remains unclear as to whether the Veteran’s service-connected disabilities result in the need of regular aid and attendance of another since the report did not clearly distinguish the effects caused by his service-connected disabilities and his non-service-connected disabilities. In support of his claim, the Veteran submitted an October 2020 private opinion from Dr. D.G. The physician noted that the Veteran currently has osteoarthritis of the finger, melanoma of the neck, and he has had a stroke of the mid brain, in which he was cared for by VA treatment facilities. He also has hearing loss, heart murmur, history of rheumatic fever, Parkinson’s disease with essential tremor, headaches, chronic anxiety, history of depression, which also could be service related and he has a history of osteoporosis, elevated cholesterol, Barrett’s esophagus and obstructive sleep apnea, requiring CPAP therapy, chronic pulmonary disease and emphysema. He was exposed to smoking while in service. He has an L5-S1 spondylolisthesis, chronic vertigo, and dizziness. He has had surgery for the melanoma of the neck, and a corrective surgery for a right rotator cuff tear. He has also been struggling with alcoholism, which was caused by his service. He has been on various medication and required ongoing assistance at home. As of date, the Veteran continues to struggle with chronic anxiety, chronic vertigo with dizziness and chronic bilateral tinnitus, chronic obstructive pulmonary disease with nicotine exposure, alcoholism, and melanoma. He had also been struggling with unsteady gait, which caused him to fall, ultimately causing a right rotator cuff tear. In conclusion, Dr. D.G. found that the Veteran’s service-connected disabilities including his vertigo with dizziness, anxiety disorder, and tinnitus cause him to be in need of regular aid and attendance of another person. In reviewing the record, the Board finds that unfortunately, another remand is required prior to the adjudication of the claim. As part of the prior September 2020 Board remand instructions, the examiner was specifically asked to address whether the Veteran’s service-connected disabilities, including his vertigo with dizziness, are at least as likely as not, individually or collectively cause him to be in need of regular aid and attendance of another person. However, when the November 2020 VA evaluation report was obtained, the examining physician failed to specifically address the question posed by the September 2020 Board remand. Instead, the examining physician listed out the Veteran’s collective diagnoses and noted that the Veteran requires mild to moderate assistance when it comes to bathing and hygiene needs. She also noted that while the Veteran was unable to prepare his meals, he is able to feed himself. The physician highlighted the Veteran’s poor gait and balance due to his dizziness and vertigo. However, the examining physician was unclear as to whether the Veteran requires the regular aid and attendance of another person due solely to his service-connected disabilities. She often cited to the Veteran’s non-service-connected disabilities in conjunction with his service-connected disabilities in finding that the Veteran is unable to prepare his meals, management his own financial affairs, maintaining hygiene. Furthermore, the Board finds that the Veteran’s October 2020 private medical report is also inadequate as it failed to provide any supportive rationale to its conclusion. The private physician merely stated that the Veteran’s vertigo with dizziness, anxiety disorder, and tinnitus cause him to be in need of regular aid and attendance of another person. Furthermore, the physician also cited to the Veteran’s other non-service-connected disabilities in finding that the Veteran’s daily activities have been significantly limited. Therefore, upon remand, the Board finds that a medical opinion addendum is required for clarification to address the Veteran’s claim. The matters are REMANDED for the following action: 1. Obtain updated VA treatment records. 2. Obtain a medical opinion addendum from the examining physician who conducted the November 2020 VA evaluation pertaining to the Veteran’s claim for SMC based on regular aid and attendance due to his service-connected disabilities (anxiety disorder, chronic vertigo with dizziness, tinnitus, and bilateral hearing loss), without consideration of his non-service-connected disorders. Specifically, the examining physician must address the extent to which the Veteran’s anxiety disorder, chronic vertigo with dizziness, tinnitus, and bilateral hearing loss causes him difficulties on a daily basis and how each disability may or may not necessitate the aid and attendance of another. The physician must review the record in conjunction with rendering the requested opinion. The examiner should address the Veteran’s lay statements regarding his poor balance and abnormal gait, which causes him to fall often. In doing so, the physician should consider and address whether the Veteran is able to perform the following activities: dress, undress, keep ordinarily clean and presentable, bathe, feed oneself, attend to the wants and needs of nature, and protect himself against the hazards and dangers incident in his daily environment. In her conclusion, the examining physician must determine whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s service-connected disabilities are so severe as to require a need for regular aid and attendance of another. All findings should be reported in detail and all opinions must be accompanied by a clear rationale. Tiffany Dawson Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board N. Yeh, Associate 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.