Citation Nr: 21014200 Decision Date: 03/11/21 Archive Date: 03/11/21 DOCKET NO. 17-08 692 DATE: March 11, 2021 ORDER The issue of whether new and material evidence has been received to reopen a previously denied claim for entitlement to service connection for vertigo is dismissed. New and material evidence having been received, the previously denied claim for entitlement to service connection for posttraumatic stress disorder (PTSD) is reopened. New and material evidence having been received, the previously denied claim for entitlement to service connection for diabetes is reopened. Entitlement to service connection for PTSD is granted. Entitlement to service connection for diabetes mellitus type II is granted. Entitlement to service connection for Parkinson’s disease is granted. Entitlement to special monthly compensation (SMC) based on the need for the regular aid and attendance of another person is granted, subject to controlling regulations governing the payment of monetary awards. FINDINGS OF FACT 1. During the September 2020 Board of Veterans’ Appeals (Board) hearing, prior to the promulgation of a decision in the appeal, the Veteran testified that he wished to withdraw his appeal as to the issue of whether new and material evidence has been received to reopen a previously denied claim for entitlement to service connection for vertigo. 2. In a July 2009 rating decision, the agency of original jurisdiction (AOJ) denied the Veteran's service connection claim for PTSD. Although the Veteran filed a notice of disagreement in August 2009, and a statement of the case was issued in June 2010, he did not file a timely substantive appeal, and no new and material evidence was received prior to the expiration of the appeal period. 3. The evidence received since the June 2010 statement of the case, by itself, or in conjunction with previously considered evidence, relates to an unestablished fact necessary to substantiate the Veteran's service connection claim for PTSD. 4. In an October 2009 rating decision, the AOJ denied the Veteran's service connection claim for diabetes. The Veteran was notified of the decision and his appellate rights, but he did not appeal or submit new and material evidence within the one-year period thereafter. 5. The evidence received since the October 2009 rating decision, by itself, or in conjunction with previously considered evidence, relates to an unestablished fact necessary to substantiate the Veteran's service connection claim for diabetes. 6. The Veteran has been diagnosed with PTSD based on an established, in-service stressor. 7. The Veteran was exposed to herbicide agents in the Republic of Vietnam during his active duty service in 1968. 8. The Veteran has been diagnosed with diabetes mellitus type II. 9. The Veteran has been diagnosed with Parkinson’s disease. 10. The Veteran requires assistance in accomplishing activities of daily living and is unable to protect himself from the hazards and dangers of his daily environment on account of service-connected disabilities. CONCLUSIONS OF LAW 1. The criteria for withdrawal of the issue of whether new and material evidence has been received to reopen a previously denied claim for entitlement to service connection for vertigo by the Veteran have been met. 38 U.S.C. § 7105; 38 C.F.R. § 20.205. 2. The July 2009 rating decision that denied the Veteran's service connection claim for PTSD is final. 38 U.S.C. § 7105(c); 38 C.F.R. § 20.1103. 3. The evidence received since the July 2009 rating decision is new and material, and the claim of entitlement to service connection for PTSD is reopened. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 4. The October 2009 rating decision that denied the Veteran's service connection claim for diabetes is final. 38 U.S.C. § 7105(c); 38 C.F.R. § 20.1103. 5. The evidence received since the October 2009 rating decision is new and material, and the claim of entitlement to service connection for diabetes is reopened. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 6. The criteria to establish entitlement to service connection for PTSD have been met. 38 U.S.C. §§ 1101, 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304. 7. The criteria to establish entitlement to service connection for diabetes mellitus type II have been met. 38 U.S.C. §§ 1110, 1116, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 8. The criteria to establish entitlement to service connection for Parkinson’s disease have been met. 38 U.S.C. §§ 1110, 1116, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 9. The criteria for SMC based on the regular need for the aid and attendance of another person have been met. 38 U.S.C. § 1114(l); 38 C.F.R. §§ 3.350(b), 3.352(a). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty service in the United States Air Force from March 1966 to February 1970. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from rating decisions dated in February 2015 and July 2018. In September 2020, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. A transcript from that proceeding is associated with the claims file. As discussed in greater detail below, the Veteran's service connection claim for diabetes was previously denied by a final October 2009 rating decision. In the July 2017 statement of the case, the AOJ reopened the Veteran's previously denied service connection claim for diabetes before denying the issue on its merits. However, the Board must make its own determination as to whether new and material evidence has been received to reopen the claim. Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001). Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service-the so-called "nexus" requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 38 F.3d 1163, 1167 (Fed. Cir. 2004)). The absence of any one element will result in denial of service connection. Service connection may also be granted for any disease initially diagnosed after service when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In addition, for Veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, including diabetes mellitus, are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.307, 3.309. For the showing of a chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. 38 C.F.R. §§ 3.303(b), 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). If a veteran was exposed to an herbicide agent during active military, naval, or air service, certain diseases shall be service-connected if the requirements of section 3.307(a)(6) are met even though there is no record of such disease during service, provided further that the rebuttable presumption provisions of section 3.307(d) are also satisfied. 38 C.F.R. § 3.309(e). Section 3.307(a)(6) provides that the term "herbicide agent" means a chemical in an herbicide used in support of the United States and allied military operations in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975. 38 C.F.R. § 3.307(a)(6)(i). Section 3.307(a)(6) also provides that a veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service. 38 C.F.R. § 3.307(a)(6)(iii). The diseases presumed to be associated with herbicide exposure include: AL amyloidosis, chloracne or other acneform diseases consistent with chloracne, type 2 diabetes (also known as type II diabetes or adult-onset diabetes), Hodgkin's disease, ischemic heart disease (including, but not limited to, acute, subacute, and old myocardial infarction; atherosclerotic cardiovascular disease including coronary artery disease (including coronary spasm) and coronary bypass surgery; and stable, unstable and Prinzmetal's angina), all chronic B-cell leukemias (including, but not limited to, hairy-cell leukemia and chronic lymphocytic leukemia), multiple myeloma, non-Hodgkin's lymphoma, Parkinson's disease, early-onset peripheral neuropathy, porphyria cutanea tarda, prostate cancer, respiratory cancers (cancer of the lung, bronchus, larynx, or trachea), and soft-tissue sarcomas (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma). 38 C.F.R. § 3.309(e). For the purposes of § 3.307, the term herbicide agent means a chemical in an herbicide used in support of the United States and allied military operations in the Republic of Vietnam during the Vietnam era. 38 C.F.R. § 3.307(a)(6)(i). Agent Orange is generally considered an herbicide agent and will be so considered in this decision. Notwithstanding the foregoing, regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d); see also Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). In other words, a presumption of service connection provided by law is not the sole method for showing causation in establishing a claim for service connection for disability due to herbicide exposure. See Stefl v. Nicholson, 21 Vet. App. 120 (2007) (holding that the availability of presumptive service connection for some conditions based on exposure to Agent Orange does not preclude direct service connection for other conditions based on exposure to Agent Orange). 1. Whether new and material evidence has been received to reopen a previously denied claim for entitlement to service connection for vertigo. The Board may dismiss any appeal which fails to identify the specific determination with which the claimant disagrees. 38 U.S.C. § 7105. An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 20.205. Withdrawal may be made by the Veteran or by his or her authorized representative. Id. In the present case, the Veteran indicated on the record during the September 2020 Board hearing that he wished to withdraw his appeal with respect to the issue of whether new and material evidence has been received to reopen a claim of service connection for vertigo. A Board determination that a claimant validly withdrew his appeal orally must include a "finding regarding whether [the appellant] understood the consequences of withdrawing his claims." Acree v. O'Rourke, 891 F.3d 1009, 1015 (Fed. Cir. 2018). In this regard, the undersigned Veterans Law Judge confirmed with the Veteran during the September 2020 hearing that he wished to withdraw from appeal the vertigo matter on appeal. The Veterans Law Judge also explained to the Veteran that if he wished to reapply for service connection for vertigo, he would have to start the claims process over from the beginning and that the effective date of any award of benefits would be the date of the new claim. Given the discussion during the Board hearing, the Board finds that the Veteran understood the consequences of withdrawing from appeal the issue of whether new and material evidence has been received to reopen a claim of service connection for vertigo. See Delisio v. Shinseki, 25 Vet. App. 45, 57 (2011) ("[W]ithdrawal of a claim is only effective where the withdrawal is explicit, unambiguous, and done with a full understanding of the consequences of such action on the part of the claimant"). As the Veteran has withdrawn the appeal as to this issue, there remains no allegations of errors of fact or law for appellate consideration with regard to this issue. Accordingly, the Board does not have jurisdiction to review this issue on appeal, and the appeal is dismissed. 2. Whether new and material evidence has been received to reopen a previously denied claim for entitlement to service connection for diabetes. 3. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for PTSD. The Veteran’s service connection claim for PTSD was initially denied in a July 2009 rating decision. The Veteran was sent notice of that decision and his appellate rights in a July 2009 letter. After the Veteran filed a timely notice of disagreement in August 2009, the AOJ issued a statement of the case that addressed this issue in June 2010. This statement of the case was enclosed with a June 2010 notification letter that also included a discussion of the Veteran's appellate rights. However, the Veteran did not file a VA Form 9. As the Veteran did not submit a timely substantive appeal in response to the June 2010 statement of the case, and no new and material evidence was received prior to the expiration of the appeal period, the July 2009 rating decision is final. 38 U.S.C. § 7105(c); 38 C.F.R. §§ 3.104, 3.156(b), 20.302, 20.1103. The Veteran’s service connection claim for diabetes mellitus was initially denied in an October 2009 rating decision. The Veteran was sent notice of that decision and his appellate rights in an October 2009 letter. However, the Veteran did not file a notice of disagreement. In general, rating decisions that are not timely appealed are final. See 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. There was also no new and material evidence submitted within one year of the date of mailing of the decision. Therefore, the rating decision is final. See 38 U.S.C. § 7105; 38 C.F.R. §§ 3.156(b), 20.200, 20.201, 20.302, 20.1103. Although a decision is final, a claim will be reopened if new and material evidence is presented. 38 U.S.C. § 5108. New and material evidence can be neither cumulative, nor redundant, of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. New evidence means existing evidence not previously submitted to VA. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. 38 C.F.R. § 3.156(a). In determining whether evidence is new and material, the credibility of the evidence is presumed. Justus v. Principi, 3 Vet. App. 510, 513(1992). The evidence need not relate specifically to the reason why the claim was last denied; rather it need only relate to any unestablished fact necessary to substantiate the claim. Shade v. Shinseki, 24 Vet. App. 110, 118 (2010). Additionally, the phrase "raises a reasonable possibility of substantiating the claim" is meant to create a low threshold that enables, rather than precludes, reopening. Id. at 117. Reopening is required when the newly submitted evidence, combined with VA assistance and considered with the other evidence of record, raises a reasonable possibility of substantiating the claim. Id. at 117. Notwithstanding the foregoing, at any time after VA issues a decision on a claim, if VA receives or associates with the claims file relevant official service department records that existed and had not been associated with the claims file when VA first decided the claim, VA will reconsider the claim. 38 C.F.R. § 3.156(c)(1). Such official service department records include, but are not limited to, records that are related to a claimed in-service event, injury, or disease, regardless of whether such records mention the Veteran by name. Such records do not include any records that VA could not have obtained when it decided the claim because the records did not exist when VA decided the claim, or because the claimant failed to provide sufficient information for VA to identify and obtain the records from the respective service department, the Joint Services Records Research Center, or from any other official source. 38 C.F.R. § 3.156(c)(2). The evidence of record at the time of the October 2009 rating decision and June 2010 statement of the case included the Veteran’s DD 214, service treatment records (STRs), military personnel records, private treatment records dated from March 2009 to September 2009, and a June 2009 VA examination. The Board notes that although additional copies of the Veteran’s STRs and military personnel records were later associated with the claims file in December 2014 and March 2015, the listed evidence for the October 2009 rating decision and the June 2010 statement of the case reflects that these documents were already of record at the time of those decisions. See also Responses from National Personnel Records Center (NPRC) in March 2009 and September 2009. Consequently, the application of 38 C.F.R. § 3.156(c) is not appropriate under these circumstances. Regarding the Veteran’s service connection claim for diabetes, the AOJ found in the October 2009 rating decision that the evidence did not show that the Veteran had a current diagnosis of diabetes, and there was no evidence to demonstrate that he had been on land in the Republic of Vietnam during his active duty service. The evidence received since the October 2009 rating decision includes an April 2018 VA treatment record. This record noted an assessment of diabetes. This evidence is new and material as it is not cumulative or redundant of the previous evidence of record, it relates to the previously unestablished question of whether the Veteran has a current diagnosis of diabetes, and it raises the reasonable possibility of substantiating the claim. Therefore, the Board finds that new and material evidence has been submitted, and the claim is reopened. 38 C.F.R. § 3.156(a). Regarding the Veteran’s service connection claim for PTSD, a September 2009 private psychological evaluation that was of record at the time of the June 2010 statement of the case noted that the Veteran denied having any psychological issues prior to service as a child or adolescent. The examining Licensed Professional Counselor (LPC) noted that during the Veteran's active service, he was stationed for a time at Tyndale Air Force Base and stationed for 18 months in Okinawa, Japan. He flew missions out of Okinawa and was a crew chief aboard F-4's and F-10's on flights to Japan, Thailand, Guam, Korea, the Philippines, and Vietnam. The Veteran indicated that bombs had been dropped during these missions, and he knew that he participated in killing people although he only observed the destruction of the bombs from the air. The Veteran also reported flying fighter jets in Korea and Vietnam with missions that included landing in Da Nang or Cam Ranh Bay in Vietnam and staying for a few days before returning to base. The Veteran recalled one incident when he was in danger of being shot down by a Russian MiG aircraft used by the Viet Cong before he escaped with a nosedive. In another incident, the Veteran described undergoing a crash landing when the plane was low on fuel. The Veteran also reported that he saw a lot of destruction in Vietnam from bombs. The runway in Da Nang only consisted of two airstrips, and a crane was present in the middle of these airstrips to remove planes that had crashed or been “shot up.” The Veteran recalled feeling distressed and upset when he saw all of the destroyed United States planes. The Veteran also reported being grounded for a month in February 1969 when he had a surgery to repair a hernia. He reported that this month was the worst time for him as he was traumatized by the injuries of other soldiers that he witnessed. The man in the bed next to the Veteran had been shot by a sniper and had a massive hole in the left side of his back. The provider noted that the Veteran was unable to talk about anything else that he saw at Naha Hospital in Okinawa as it was too upsetting. The Veteran had an additional hospitalization in Okinawa when he had symptoms of numbness on one side of his body in addition to ringing in his ears. He was returned to his duty assignment once his numbness resolved. The Veteran also reported an incident that occurred while he was stationed at Tyndale Air Force Base which involved a 55-gallon drum of paint thinner blowing up in his face and resulting in the Veteran being hospitalized for 12 days. The Axis I diagnosis was PTSD, chronic. The provider noted that the Veteran provided specific stressors where he flew into enemy territory with his life being in constant peril. He spoke of one incident where he was seconds away from having his plane blown up by a Russian aircraft that was being used by the Viet Cong. He also spoke about the runway in Da Nang where he frequently witnessed the destruction to United States planes that had been done by the enemy. He was often fearful about whether he would live or die. The most stressful experience to him was when he was in the Army hospital having hernia surgery, and he witnessed firsthand the wounds that other soldiers had received in combat. He still suffered from flashbacks and intrusive thoughts related to his experiences in Vietnam. His present difficulties were attributed directly to his experiences in the Air Force. In the June 2010 Statement of the Case, the AOJ found that although the evidence indicated that the Veteran had a current diagnosis of PTSD, but there was no credible supporting evidence of the Veteran's stressor. The evidence that has been received since the June 2010 statement of the case includes an April 2015 buddy statement from R.M. who reported being neighbors with the Veteran in an apartment complex during their service in Okinawa from 1969 to 1970. They became friends and golfed and socialized during their downtime. The Veteran would talk with R.M. about his many flights in and out of the Philippines, Taiwan, and Vietnam, including the fact that he would sometimes stay in the country for a day or two. This evidence is new and material as it is not cumulative or redundant of the previous evidence of record, it relates to the previously unestablished fact of the Veteran’s in-service stressor for PTSD, and it raises the reasonable possibility of substantiating the claim. Therefore, the Board finds that new and material evidence has been submitted, and the claim is reopened. 38 C.F.R. § 3.156(a). As the Board has reopened the Veteran's service connection claims for PTSD and diabetes, the Board has considered whether it is appropriate to address the merits of the claim without remand to the AOJ for action. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993) (holding that when the Board addresses a question not addressed by the RO, "it must consider whether the claimant has been given adequate notice of the need to submit evidence or argument on that question and an opportunity to submit such evidence and argument and to address that question at a hearing, and, if not, whether the claimant has been prejudiced thereby"). In light of the favorable outcome below, it is clear that the Veteran is not prejudiced by the Board's adjudication of the service connection claim for PTSD on a de novo basis. There is also no prejudice to the Veteran in the Board proceeding to adjudicate the service connection claim for diabetes on its merits as the AOJ has already addressed the merits of this claim. 4. Entitlement to service connection for PTSD. Similar to the requirements noted above, service connection for PTSD requires medical evidence diagnosing the condition; a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304(f). A diagnosis of PTSD must be established in accordance with 38 C.F.R. § 4.125(a), which provides that all psychiatric diagnoses must conform to the fifth edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-5). 38 C.F.R. § 3.304(f). Effective August 4, 2014, VA amended the portion of its Schedule for Rating Disabilities dealing with mental disorders and its adjudication regulations that define the term "psychosis" to remove outdated references to the DSM-IV and replace them with references to the recently updated DSM-5. See 79 Fed. Reg. 45, 094 (August 4, 2014). VA adopted as final, without change, this interim rule and clarified that the provisions of this interim final rule do not apply to claims that have been certified for appeal to the Board or are pending before the Board on or before August 4, 2014. See Schedule for Rating Disabilities - Mental Disorders and Definition of Psychosis for VA Purposes, 80 Fed. Ref. 14,308 (March 19, 2015). The DSM-5 is applicable in the present case. The pertinent regulation provides that, if the evidence establishes that the Veteran engaged in combat with the enemy and that 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. See 38 U.S.C. § 1154(b); 38 C.F.R. § 3.304(f)(1). For stressors unrelated to combat that are not based on fear of hostile military or terrorist activity, credible supporting evidence is necessary in order to grant service connection. Such evidence may be obtained from service records or other sources. See Moreau v. Brown, 9 Vet. App. 389 (1996). The United States Court of Appeals for Veterans Claims (Court) has held that the regulatory requirement for "credible supporting evidence" means that "the appellant's testimony, by itself, cannot, as a matter of law, establish the occurrence of a non-combat stressor." Dizoglio v. Brown, 9 Vet. App. 163, 166 (1996). Therefore, the Veteran's lay testimony, is insufficient, standing alone, to establish service connection. Cohen v. Brown, 10 Vet. App. 128, 147 (1997). Effective July 13, 2010, if a stressor claimed by a veteran is related to the Veteran's fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of PTSD and that the Veteran's symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the places, types, and circumstances of the veteran's service, the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. For purposes of this paragraph, "fear of hostile military or terrorist activity" means that a veteran experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the veteran or others, such as from an actual or potential improvised explosive device (IED); vehicle-imbedded explosive device; incoming artillery, rocket, or mortar fire; grenade; small arms fire, including suspected sniper fire; or attack upon friendly military aircraft, and the veteran's response to the event or circumstance involved a psychological or physiological state of fear, helplessness, or horror. See 75 Fed. Reg. 39843, 39852 (July 13, 2010) (now codified at 38 C.F.R. § 3.304(f)(3)). The Veteran contends that he has PTSD as a result of stressful experiences that occurred during active service. The Veteran's service treatment records do not show a complaint, diagnosis, or treatment related to PTSD. The Veteran's October 1965 enlistment examination noted that there were no abnormalities in his psychiatric functioning, and the Veteran did not report any relevant problems in the October 1965 Report of Medical History. There continued to be no notable reports or findings in a subsequent October 1968 Report of Medical History or February 1969 service examination. The Veteran's psychiatric functioning was also noted to be normal in his February 1970 separation examination. The Veteran additionally denied having any psychiatric complaints in the February 1970 Report of Medical History. As noted above, the Veteran has identified different in-service stressors as the source of his current PTSD, including the upsetting nature of the injuries that he observed in fellow servicemembers while he was hospitalized at an Army hospital for surgical treatment of a hernia during his active duty service in Okinawa. See also June 2015 Statement in Support of Claim for Service Connection for PTSD. During the September 2009 psychological evaluation, the Veteran indicated that the surgery took place close to February 1969, and he spent approximately one month in the hospital. The Veteran's STRs include a January 28, 1969 clinical record cover sheet that noted a diagnosis of indirect right inguinal hernia. The document further noted that the Veteran underwent a right inguinal herniorrhaphy on January 7, 1969. The name and location of the medical treatment facility was identified as the United States Army Hospital, Rhyku Islands in Japan. Under the section for days duration at the facility, the total was 22 days consisting of 4 days in the hospital or infirmary and 18 days of leave. The record stated that the Veteran had been placed on convalescence leave on January 10, 1969. However, the narrative summary stated that he was hospitalized for 22 days, and he was initially discharged to be followed in the surgical clinical after an uncomplicated post-operative course. He was not discharged to duty until January 28, 1969. In light of this supporting information for the Veteran's account in his STRs, the Board finds that there is credible supporting evidence for the Veteran’s reported details concerning his hernia surgery during service. The Board consequently finds that the Veteran's stressor has been established. Thus, the only remaining question is whether the Veteran has a current diagnosis of PTSD based on his established stressor. In an August 2016 VA treatment record, a VA provider, Master of Social Work (MSW), noted the Veteran's report that he flew in and out of Vietnam during his service in Okinawa. The Veteran also reported that during a hospitalization from surgery for a hernia, he was in the same ward as those who had been injured from direct combat in Vietnam. The Veteran reported having nightmares, flashbacks, avoidance, and trouble recalling details. The diagnostic impression was PTSD, rule out unspecified depressive disorder. The provider added that all diagnoses were based on the DSM-5 criteria. As the provider considered the Veteran’s established stressor regarding the hernia surgery before rendering this diagnosis, the Board finds that the diagnosis is at least partly based on this stressor. Notably, there is no medical opinion to suggest that the Veteran’s PTSD is not based on this stressor. The Board finds that the August 2016 VA provider’s determination is entitled to probative weight as the record reflects that the provider considered the Veteran’s relevant medical history and current clinical findings before making a determination. Moreover, the August 2016’s VA provider’s finding is consistent with the prior conclusion of the private provider in September 2009 that the Veteran had PTSD that was partly attributable to his established stressor. Based on the foregoing, Board finds that the weight of the evidence supports finding that the Veteran has a current diagnosis of PTSD under the DSM-5 criteria that is related to his established stressor. With resolution of reasonable doubt in favor of the Veteran, entitlement to service connection for PTSD is warranted. 38 U.S.C. §§ 101, 1110; 38 C.F.R. §§ 3.6, 3.102, 3.303, 3.304(f), 4.125(a). The Board notes that the Veteran has been diagnosed with other psychiatric disorders during the appeal period, including depression. See September 2016 VA treatment record. However, the evidence does not differentiate the symptoms attributable to PTSD versus those due to other diagnoses. See Mittleider v. West, 11 Vet. App. 181 (1998). Therefore, the Board considers all manifested psychiatric symptoms as being due to his PTSD. 5. Entitlement to service connection for diabetes mellitus type II, to include as due to exposure to herbicide agents. 6. Entitlement to service connection for Parkinson’s disease, to include as to due to exposure to herbicide agents. The Veteran contends that he has diabetes mellitus type II and Parkinson’s disease that are related to his exposure to herbicide agents during his active duty service in the Republic of Vietnam. The record reflects that the Veteran has a current diagnosis of Parkinson’s disease. See April 2018 VA treatment record. An April 2018 VA treatment record also noted an assessment of diabetes, and an active problem list in a January 2017 VA treatment record more specifically noted that the Veteran had type 2 diabetes mellitus. The Veteran’s STRs do not show any complaint, treatment, or diagnosis for diabetes or Parkinson’s disease. Regarding the Veteran’s reported exposure to herbicide agents, and as indicated above, the Veteran has reported that he flew into Vietnam aboard aircraft that landed in the country. The Veteran's representative testified during the September 2020 Board hearing that in the course of the Veteran's duties as an airplane mechanic while he was stationed at Kadena Air Base in Okinawa, he participated in approximately 20 to 24 flights into Vietnam at Cam Ranh Bay and Da Nang. The Veteran then helped to repair aircraft while in Vietnam. With the assistance of his wife, the Veteran testified that the flights occurred in September, October, and November of 1968. The Veteran's Chronological Listing of Service in his military personnel records shows that he served at Kadena Air Base in Okinawa from September 1968 to February 1970. His duty title during this period was noted to be aircraft maintenance specialist. A TSGT, SSGT, and SGT Performance Report for the period from July 1968 to January 1969 listed the relevant location as Kadena Air Base. The record noted that the Veteran's current duty was jet aircraft mechanic, assistant crew chief. The Veteran's duties in the role included servicing aircraft, troubleshooting the various systems, and performing minor and major maintenance. In addition, the previously discussed April 2015 statement from the Veteran’s buddy indicated that while the buddy was serving with the Veteran in Okinawa from 1969 to 1970, the Veteran informed the buddy that his prior missions included landings in the Republic of Vietnam. Resolving all doubt in favor of the Veteran, the Board finds that he had active duty service in the Republic of Vietnam in 1968. Thus, his exposure to herbicide agents is presumed. 38 C.F.R. § 3.307(a)(6)(iii). As noted above, the Veteran's diabetes mellitus type II and Parkinson’s disease are presumptively associated with his established exposure to herbicide agents under 38 C.F.R. § 3.309(e). There is also no affirmative evidence indicating that these disorders are not related to his exposure to herbicide agents. Accordingly, the Veteran is entitled to service connection for diabetes mellitus type II and Parkinson’s disease on a presumptive basis as due to herbicide exposure. 38 U.S.C. §§ 1116, 5107; 38 C.F.R. §§ 3.102, 3.307(a)(6); 3.309(e). 7. Entitlement to SMC based on the need for regular aid and attendance or by reason of being housebound. SMC at the aid and attendance rate is payable when a veteran, due to service-connected disability, has suffered the anatomical loss or loss of use of both feet or one hand and one foot, or is blind in both eyes, or is permanently bedridden or so helpless as to need regular aid and attendance. See 38 U.S.C. § 1114(l); 38 C.F.R. § 3.350(b). Pursuant to 38 C.F.R. § 3.350(b)(3) and (4), the criteria for determining that a veteran is so helpless as to need regular aid and attendance, including a determination that he is permanently bedridden, are contained in 38 C.F.R. § 3.352(a). That regulation provides that the following will be accorded consideration 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 to feed himself through the loss of coordination of upper extremities or through extreme weakness; inability to attend to the wants of nature; or incapacity, physical or mental, which requires care or assistance on a regular basis to protect him from hazards or dangers incident to his daily environment. "Bedridden" is defined as that condition, which, through its essential character, requires that a claimant remain in bed, and is a proper basis for this determination. The fact that a claimant has voluntarily taken to bed or that a physician has prescribed rest in bed for the greater or lesser part of the day to promote convalescence or cure will not suffice. It is not required that all the above disabling conditions be found to exist before a favorable rating may be made. The particular personal functions that a 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 a veteran is so helpless as to need regular aid and attendance, not that there is a constant need. Determinations that a veteran is so helpless as to need regular aid and attendance will not be based solely upon an opinion that his condition is such as would require him to be in bed. They must be based on the actual requirement of personal assistance from others. See 38 C.F.R. § 3.352(a). The Board notes that service connection is currently in effect for diabetes mellitus type II, Parkinson’s disease, PTSD, tinnitus, and hearing loss. In May 2018, the Veteran submitted an April 2018 VA Form 21-2680, Examination for Housebound Status or Permanent Need for Regular Aid and Attendance, completed by Dr. S., MD. In the examination report, Dr. S. noted that the relevant diagnoses included Parkinson's disease, diabetes mellitus, hypertension, and gait dysfunction. However, Dr. S. identified Parkinson's disease as the sole disability that restricted the listed activities/functions. The Veteran was not legally blind, and Dr. S. did not indicate that he required nursing home care. Regarding a section of the report that requested for Dr. S. to specify the number of hours that the Veteran was confined to bed between 9 PM to 9 AM and 9 AM to 9 PM, Dr. S. appeared to place a check mark next to each category. Dr. S. also reported that the Veteran did not have the ability to manage his own financial affairs. The Veteran required assistance with medication management as well as bathing and tending to other hygiene needs. Although the Veteran was able to feed himself, he was unable to prepare his own meals. In addressing the restrictions of each upper extremity, Dr. S. also indicated that the Veteran was only able to feed himself when he had some assistance. The Veteran's gait and posture were described as unsteady. In addressing the restrictions of each lower extremity as well as the spine, trunk, and neck; Dr. S. noted Parkinson's disease and humerus fracture. The Veteran was also sometimes bladder incontinent. Once a week, the Veteran was able to leave home with a family caregiver. Dr. S. further indicated that the Veteran required an assistive device for locomotion, and he was limited to traveling one block. In an April 2018 letter, Dr. D., MD, reported that the Veteran was a patient under her care for advancing Parkinson's disease. Dr. D. added that the Veteran had reached a point in his disease where he required fulltime care. In a subsequent November 2020 letter, Dr. D. reported that the Veteran had been under her care for the treatment of Parkinson's disease. Dr. D. explained that as a result of his illness, he had significant issues with gait and balance. The Veteran had experienced continued issues with falls, and some falls had caused significant injury. The Veteran was requiring further assistance with activities of daily living ranging from supervision to hands on assistance. As a result, he required additional hours of assistance from aides to ensure his safety throughout the day. The Board finds that the Dr. D.’s opinion provides great probative value as Dr. D. supported her conclusion with an explanation, and her conclusion is consistent with the findings noted by Dr. S. in the April 2018 VA Form 21-2680. There is no negative opinion or other contradictory evidence to weigh against Dr. D.’s opinion. Based on the foregoing, the Board finds that the weight of the evidence supports finding that the Veteran is so helpless as to be in need of regular aid and attendance of another person due to the manifestations of his service-connected Parkinson’s disease, which require care or assistance on a regular basis to perform daily activities and to protect him from the hazards or dangers inherent in his daily environment. Thus, entitlement to SMC based on the regular need for the aid and attendance of another person is granted. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). SMC based on housebound status is a lesser benefit than SMC at the aid and attendance rate. See 38 U.S.C. § 1114(l), (s); 38 C.F.R. § 3.350(i). Consequently, the award of SMC at the aid and attendance rate renders the housebound issue moot. GAYLE STROMMEN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K.C. Spragins, 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.