Citation Nr: 21024558 Decision Date: 04/23/21 Archive Date: 04/23/21 DOCKET NO. 09-22 011 DATE: April 23, 2021 ORDER Entitlement to service connection for a traumatic brain injury (TBI) is denied. Entitlement to a compensable disability evaluation for erectile dysfunction is denied. Entitlement to a disability evaluation in excess of 10 percent for left testicular atrophy is denied. Entitlement to a disability evaluation in excess of 10 percent for neurodermatitis is denied. Entitlement to a 70 percent disability evaluation for generalized anxiety disorder (GAD) from September 27, 2005 is granted. Entitlement to a 100 percent disability evaluation for GAD is denied. Entitlement to a total disability evaluation based upon individual unemployability due to service-connected disabilities (TDIU) from March 28, 2006, is granted. Entitlement to compensation under 38 U.S.C. § 1151 for loss of balance due to brain biopsy performed at a VA facility in January 2006 is denied. Entitlement to compensation under 38 U.S.C. § 1151 for meningitis and paralysis of the lower extremities due to Baclofen pump installation performed at a VA facility in February 2010 is denied. Entitlement to special monthly compensation (SMC) based on the need for regular aid and attendance is granted. REMANDED Entitlement to service connection for a bilateral foot disability, to include a joint disorder, is remanded. Entitlement to service connection for a bilateral knee disability, to include a joint disorder, is remanded. Entitlement to service connection for a bilateral hand disability, to include a joint disorder, is remanded. FINDINGS OF FACT 1. A TBI, or residuals thereof, of service origin has not been demonstrated. 2. The Veteran's erectile dysfunction is not characterized by a penile deformity. 3. Complete atrophy of both testes has not been shown at any time. 4. The Veteran’s neurodermatitis has not been shown to result in characteristic lesions involving 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected; systemic therapy, including, but not limited to, corticosteroids, phototherapy retinoids, biologics, photochemotherapy, (psoralen with long-wave ultraviolet-A light (PUVA) or other immunosuppressive drugs required for a total duration of 6 weeks or more, but not constantly, over any 12-month period has also not been shown. 5. For the entire appeal period, psychiatric symptoms due to GAD, and the severity of such, more nearly approximated a rating based on occupational and social impairment with deficiencies in most areas, such as work, family relations, and mood. 6. The Veteran’s GAD did not result in total social and industrial impairment at any time during the appeal period. 7. The Veteran's service-connected disabilities have precluded substantially gainful employment consistent with his education and occupational experience since March 28, 2006. 8. The brain biopsy/craniotomy performed at a VA facility in January 2006 did not cause loss of balance. 9. No additional disability of the lower extremities has been shown to be caused by hospital care, medical or surgical treatment, or examination furnished the Veteran by VA or in a VA facility in connection with installation of the Baclofen pump. 10. The Veteran’s meningitis, while the result of the installation of the Baclofen pump installation, was a reasonably foreseeable event that was specifically discussed in the consent form, with no departure from accepted levels of medical care or the performance of professional duties expected of a reasonable health care provider. 11. The Veteran’s service-connected disabilities render him so helpless as to be in need of regular aid and attendance. CONCLUSIONS OF LAW 1. The criteria for service connection for a TBI, or residuals thereof, have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2019). 2. The criteria for a compensable rating for erectile dysfunction have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 4.1-4.14, 4.31, 4.115b, Diagnostic Code (DC) 7522 (2019). 3. The criteria for a 20 percent disability evaluation for left teste atrophy have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.155b, Diagnostic Code 7599-7523. 4. The criteria for a disability evaluation in excess of 10 percent for neurodermatitis have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.321(b)(1), 4.118, DC 7806 (2019). 5. The criteria for a 70 percent disability evaluation for GAD have been met from September 27, 2005. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.7, 4.126, 4.130, DC 9400 (2019). 6. The criteria for a 100 disability evaluation for GAD have not been met at any time. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.7, 4.126, 4.130 DC 9400 (2019). 7. The criteria for a TDIU have been met from March 28, 2006. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 3.340, 3.341, 4.16 (2019). 8. The criteria for compensation under 38 U.S.C. § 1151 for loss of balance resulting brain biopsy/craniotomy performed by VA in January 2006 have not been met. 38 U.S.C.§ 1151 (2012); 38 C.F.R. § 3.361 (2019). 9. The criteria for compensation under 38 U.S.C. § 1151 for meningitis and paralysis of the lower extremities due to Baclofen pump installation performed at a VA facility in February 2010 have not been met. 38 U.S.C.§ 1151 (2012); 38 C.F.R. § 3.361 (2019). 10. Resolving reasonable doubt in favor of the Veteran, the criteria for entitlement to special monthly compensation based on the need for the regular aid and attendance of another person have been met. 38 U.S.C. §§ 1114, 5107 (2012); 38 C.F.R. §§ 3.102, 3.350, 3.352 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran, who is the appellant, had active service from April 1981 to April 1984. These matters come before the Board of Veterans’ Appeals (Board) on appeal from various rating determinations of the Regional Office (RO) of the Department of Veterans Affairs (VA). This matter was previously before the Board in August 2011, at which time it was remanded for further development. Subsequent to the August 2011 Board decision, additional issues were perfected for appeal and are listed on the title page of this decision. The Veteran appeared at a Travel Board hearing before a Veterans Law Judge who is no longer employed by the Board in February 2011. The Veteran also testified at a hearing before the undersigned Veterans Law Judge in April 2017. Transcripts of the hearings are of record. The matter was once again remanded in April 2018 for further development. TBI Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). As a general matter, service connection for a disability requires evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004); see also Hickson v. West, 12 Vet. App. 247, 253 (1999), citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996). Generally, lay evidence is competent with regard to a disease with "unique and readily identifiable features" that is "capable of lay observation." See Barr v. Nicholson, 21 Vet. App. 303, 308-09 (2007) (concerning varicose veins); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (a dislocated shoulder); Charles v. Principi, 16 Vet. App. 370, 374 (2002) (tinnitus); Falzone v. Brown, 8 Vet. App. 398, 405 (1995) (flatfoot); 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 be competent and sufficient evidence of 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 Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). In weighing credibility, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self-interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. Caluza v. Brown, 7 Vet. App. 498 (1995). As it relates to the claim of service connection for residuals of a TBI, the Board notes that that the Veteran has consistently reported having been involved in a jeep accident while stationed in Germany in December 1983. Although treatment records do not reveal that the Veteran was involved in a jeep accident at that time, the Board finds that his consistent reports of having been in a jeep accident at that time are consistent with the facts of his service. Moreover, the Veteran's claimed jeep accident occurred subsequent to his service separation examination. Given the above, the Board will find that his statements with regard to the jeep accident, including the jeep having flipped over and his being hospitalized, are credible. Based upon the above, the Board, in its August 2018 remand, requested that the Veteran be scheduled for a VA examination to determine the nature and etiology of any current residuals of a traumatic brain injury. The examiner was requested to render the following opinions: Did the Veteran have a currently diagnosed traumatic brain injury or residuals thereof? If so, was it at least as likely as not (50 percent probability or greater) that it had its onset in service or was otherwise related to service? For purposes of rendering this opinion, the examiner was to note that the Board had found the Veteran's statements as to having been involved in a jeep accident in service to be credible. In conjunction with his claim, the Veteran was afforded a VA examination in September 2020. Following examination of the Veteran and review of the record, the examiner indicated that the Veteran did not have residuals of a TBI. The examiner specifically indicated that upon review of the medical record, there was no medical evidence of a TBI. After reviewing all the evidence, both lay and medical, service connection for a TBI, or residuals thereof, is not warranted. To date, there has been no medical evidence submitted or received demonstrating that the Veteran has a TBI or had a TBI at any time throughout the appeal period. The Veteran was afforded the opportunity to submit evidence demonstrating a relationship between any current TBI and his period of service and has not done so. Moreover, the VA examiner indicated that the Veteran did not have a TBI and had not been diagnosed as having a TBI when reviewing the file. Congress, as a general rule, limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. See 38 U.S.C. § 1110, and see Brammer v. Derwinski, 3 Vet. App. 223 (1992). In Degmetich v. Brown, 104 F.3d 1328 (Fed. Cir. 1997), it was observed that 38 U.S.C. § 1110, as well as other relevant statutes, only permitted payment for disabilities existing on and after the date of application for such disorders. The Federal Circuit observed that the structure of these statutes "provided strong evidence of congressional intent to restrict compensation to only presently existing conditions," and VA's interpretation of the law requiring a present disability for a grant of service connection was consistent with the statutory scheme. Degmetich, 104 F.3d at 1332; and see Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998) (holding VA's interpretation of the provisions of 38 U.S.C.§ 1110 to require evidence of a present disability to be consistent with congressional intent); Rabideau v. Derwinski, 2 Vet. App. 141 (1992) (the law limits entitlement for service-related diseases and injuries to cases where the underlying in-service incident has resulted in a disability). Simply put, the general rule is that in the absence of proof of present disability there can be no valid claim. Based on the above, to the extent that the medical evidence addresses whether the Veteran has a TBI, or residuals thereof, it indicates that he does not. The Veteran is competent to report his current symptoms, but his reports must be weighed against the medical evidence of record. See Grover v. West, 12 Vet. App. 109, 112 (1999); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). To the extent that the Veteran has indicated that he currently has a TBI, or residuals thereof, the medical evidence showing an absence of such a disability is of greater probative weight than the Veteran's reports made during the course of his claim for VA benefits. The weight of the evidence is against a finding that the Veteran currently has a TBI or residuals thereof. A necessary element for establishing service connection-evidence of a current disability-has not been shown. For the foregoing reasons, the claim for service connection for a TBI, or residuals thereof, must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable. Higher Evaluations Disability evaluations are determined by the application of the Schedule for Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of 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. 38 C.F.R. § 4.7. It is the defined and consistently applied policy of VA to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. Any reasonable doubt regarding the degree of disability is resolved in favor of the Veteran. See 38 C.F.R. § 4.3. In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21 (2019). In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of a veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). ED The Veteran's erectile dysfunction has been assigned a noncompensable (0 percent) rating by analogy pursuant to 38 C.F.R. § 4.115b, DC 7522 (penis, deformity, with loss of erectile power). In every instance where the schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. See 38 C.F.R. § 4.31. Under DC 7522, in order for the Veteran to receive the next-higher 20 percent rating for erectile dysfunction, a physical deformity of the penis with loss of erectile power is required. 38 C.F.R. § 4.115b. A footnote to DC 7522 also indicates the disability is to be reviewed for entitlement to special monthly compensation for loss of use of a creative organ under 38 C.F.R. § 3.350(a). The Veteran maintains that he has a penis deformity. At the time of a November 2012 VA examination, the Veteran was noted to have ED. Physical examination of the penis was not performed at that time. At the time of a June 2019 VA examination, the Veteran was again found to have ED. The Veteran’s penis was not examined but he indicated that he had a normal anatomy with no penile deformity or abnormality. At the time of an August 2020 VA examination, the Veteran was again found to have erectile dysfunction. He was noted to be able to achieve an erection with the use of medication. Physical examination revealed a normal penis. Upon review of the evidence, the Veteran does not meet the criteria for a compensable rating under DC 7522. VA examination results reveal a diagnosis of erectile dysfunction. Additionally, the Veteran clearly has loss of erectile power. This fact is not in dispute. However, the evidence of record does not reveal any physical deformity of the Veteran's penis. See Melson v. Derwinski, 1 Vet. App. 334 (1991) (use of the conjunctive "and" in a statutory provision meant that all of the conditions listed in the provision must be met); compare Johnson v. Brown, 7 Vet. App. 95 (1994) (only one disjunctive "or" requirement must be met in order for an increased rating to be assigned). The requirement under DC 7522 of deformity of the penis "with" loss of erectile power clearly means that both factors are required. There is no medical support for a compensable disability rating for the Veteran's erectile dysfunction under DC 7522. Left Testicular Atrophy Diagnostic Code 7523 provides a 0 percent rating for complete atrophy of one testicle. A 20 percent rating is warranted for complete atrophy of both testes. 38 C.F.R. § 4.115b. At the time of a November 2012 VA examination, the Veteran’s left testicle was noted to be absent. At the time of a June 2019 VA examination, the Veteran’s testes were not examined per his request. The Veteran indicated that he had a normal anatomy with no testicular deformity or abnormality. At the time of an August 2020 VA examination, the Veteran was noted to have one normal testicle and one testicle that was 1/2 to 1/3 of normal. The Veteran’s voiding dysfunction was not related to his either his ED or his teste atrophy. Based upon the above, an increased evaluation is not warranted. The Veteran's disability has not caused complete atrophy of both testicles as required for a higher evaluation under Diagnostic Code 7523. Therefore, the claim for an evaluation in excess of 10 percent is not warranted. The Board notes that the application of Diagnostic Code 7523 is a mechanical one based on the objective standards outlined in the Diagnostic Code. Neurodermatitis In evaluating skin residuals, the Board notes that during the appeal period, changes were made to 38 C.F.R. § 4.118, DC 7806. Effective August 13, 2018, VA amended its regulations governing skin disabilities. VA's intent is that the claims pending prior to the effective date will be considered under both old and new rating criteria, and whatever criteria is more favorable to the veteran will be applied. For applications filed on or after the effective date, only the new criteria will be applied. 83 Fed. Reg. 32592 (July 13, 2018). Under the pre-August 2018 rating criteria, DC 7806 provided for a 0 percent rating where there is less than 5 percent of the entire body or less than 5 percent of exposed areas affected; and, no more than topical therapy required during the past 12-month period. A 10 percent rating is assigned where there is involvement of at least 5 percent, but less than 20 percent, of the entire body or at least 5 percent, but less than 20 percent, of exposed areas affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period. A 30 percent rating is assigned for dermatitis or eczema affecting 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas, or for dermatitis or eczema that requires systemic therapy, such as corticosteroids or other immunosuppressive drugs, for a total duration of six weeks or more, but not constantly, during the past 12-month period. A 60 percent disability rating is assigned for dermatitis or eczema, affecting more than 40 percent of the entire body or more than 40 percent of exposed areas, or for dermatitis or eczema that requires constant or near-constant systemic therapy, such as corticosteroids or other immunosuppressive drugs, during the past 12-month period. 38 C.F.R. § 4.118. Under the post-August 2018 rating criteria, a 0 percent rating is assigned when there is no more than topical therapy required over the past 12-month period and characteristic lesions involving less than 5 percent of the entire body affected; or characteristic lesions involving less than 5 percent of exposed areas affected. A 10 percent rating is assigned for characteristic lesions involving at least five percent but less than 20 percent of the entire body affected; or intermittent systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required over the past 12-month. A 30 percent rating is assigned for characteristic lesions involving 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected; or systemic therapy including, but not limited to, corticosteroids, phototherapy retinoids, biologics, photochemotherapy, (psoralen with long-wave ultraviolet-A light (PUVA) or other immunosuppressive drugs required for a total duration of 6 weeks or more, but not constantly, over the past 12-month period. A 60 percent rating is assigned for characteristic lesions involving more than 40 percent of the entire body or more than 40 percent of exposed areas affected; or, constant or near-constant systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required over the past 12-month period. 38 C.F.R. § 4.118 (August 13, 2018). At the time of an April 2015 VA examination, the Veteran was diagnosed with neurodermatitis. The examiner indicated that there were no systemic manifestations. The Veteran reported using antihistamines on a nearly constant basis. He also used a lotion on a near-constant basis. There had been no other treatment. There had been no debilitating episodes. There was no exposed skin area affected. There was a 5 to 20 percent area of skin affected of the total body. There were excoriations on the arms, legs, and lower abdomen. At the time of a June 2019 VA examination, the Veteran was again diagnosed with neurodermatitis. The Veteran complained of a rash from the neurodermatitis on the lower extremities, bilaterally, and on the anterior abdominal wall. He indicated that it itched. He noted using creams and ointments on and off, but they did not help. The Veteran was noted to have used topical corticosteroids for less than six weeks over the past year. He had also used a topical gel for less than six weeks in the past 12 months. There were no other treatments or procedures other than systemic or topical medications in the past 12 months. There was a 5 to 20 percent area of skin affected of the total body. At the time of an August 2020 VA examination, the Veteran was again diagnosed with neurodermatitis. He had a dry, scaly rash in places where he scratched. This was on his left inner thigh and his right distal anterior thigh. He used a cream twice a day. The area affected was between 5-20 percent of the total body. He had some small >1cm open wounds, a hyperkeratotic area approximately 5 x 5 cm on his distal right thigh and scarring and hyperpigmentation on his left lower abdomen consistent with healed lesions. He had some open wounds, a hyperkeratotic area approximately 5 x 5 cm on his distal right thigh, and hyperkeratosis and hyperpigmentation on his left lower abdomen consistent with healed lesions. Given the foregoing, the criteria for an evaluation in excess of 10 percent have not been met. The Veteran’s neurodermatitis has not been shown to result in characteristic lesions involving 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected. Systemic therapy, including, but not limited to, corticosteroids, phototherapy retinoids, biologics, photochemotherapy, (psoralen with long-wave ultraviolet-A light (PUVA) or other immunosuppressive drugs required for a total duration of 6 weeks or more, but not constantly, over any 12-month period has also not been shown. GAD The General Formula for Rating Mental Disorders, Diagnostic Code 9400, provides that a 30 percent rating is assigned for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). A 50 percent evaluation requires occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent evaluation is assigned for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. The criteria for a 70 percent rating are met if there are deficiencies in most of the areas of work, school, family relations, judgment, thinking, and mood. Bowling v. Principi, 15 Vet. App. 1, 11-14 (2001). A 100 percent evaluation is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, Diagnostic Code 9400. The symptoms cited above follow the phrase "such symptoms as" which indicates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Accordingly, the Board has not required the presence of all or most of the enumerated symptoms for any particular rating. The list of symptoms merely provides guidance as to the severity of symptoms contemplated for each rating, in addition to permitting consideration of other symptoms, particular to each veteran and disorder, and the effect of those symptoms on the claimant's social and work situation. The Board must consider all symptoms of the veteran's condition which affect the level of occupational and social impairment. If the evidence demonstrates that a claimant suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code, the appropriate, equivalent rating will be assigned. Mauerhan v. Principi, 16 Vet. App. 436, 441-443 (2002). The Veteran maintains that the symptomatology associated with his service-connected GAD warrants disability evaluations higher than those which are currently assigned. Resolving reasonable doubt in favor of the Veteran, the Board will find that his PTSD symptoms have warranted a 70 percent disability evaluation since September 27, 2005. At the time of a February 2006 VA examination, the Veteran reported having fears of dying. He was anxious and depressed and scared. He reported panic attacks. The Veteran hyperventilated and sweat. He had constant worrying. The Veteran also had arguments with his fiancé all the time. He was irritable, could not sleep, and was tired all the time. He isolated and did not socialize. He could not concentrate and could not sit still. There had been talks about breaking up with his fiance. He reported no real remissions in his symptoms. He worked 32 hours a week in security and had not missed any work in the past year. In an April 2006 letter, the Veteran’s treating neurologist indicated that he was experiencing extreme psychological distress. In a June 2006 letter, the Veteran’s treating psychiatrist indicated that the Veteran complained of anxiety, depression, and being afraid of dying. He had been moody for the past six months and had had no patience. The Veteran was noted to have a panic disorder and was under stress. The psychiatrist indicated that the Veteran now realized the extent of his physical problems and was becoming gradually more depressed to a suicidal proportion. He was considered disabled and unable to be gainfully employed for the time and the foreseeable future. The examiner found the Veteran’s stressors to be moderately severe. The Veteran was also noted to have moderately severe psychosocial stressors in a February 2007 report prepared by his treating VA physician. He was found to be having visual hallucinations at that point but there were no suicidal/homicidal ideations. He was considered to be unable to be gainfully employable. Although the Veteran was found to have occupational impairment with reduced reliability and productivity at the time of an April 2015 VA examination, the criteria for a 50 percent disability evaluation, his symptoms included depressed mood, anxiety, panic attacks, chronic sleep impairment, impaired abstract thinking, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, including work or a worklike setting. Moreover, in a May 2017 private psychological report, Q. A-S, Ph.D., indicated that based on the totality of evidence an accurate psychiatric assessment for the Veteran would involve generalized anxiety disorder, severe; major depressive disorder, moderate, chronic without psychotic features; and provisional diagnosis of mild neurocognitive disorder. Dr. S stated that it was the Veteran’s generalized anxiety disorder that rendered him homebound. It was his generalized anxiety disorder that interfered with his interpersonal functioning, social functioning, and ability to participate meaningfully in his community. It was his anxiety disorder that kept him from engaging in treatment for both his physical conditions and his psychiatric conditions. Dr. S. indicated that it was unlikely that even with treatment that his psychiatric conditions would remit substantially to the point where the Veteran could be restored to employability. In addition, at the time of June 2019 and August 2020 VA examinations, the Veteran was found to have occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood, which are the criteria for a 70 percent disability evaluation. The Board has reviewed all of the evidence of record, lay and medical, and finds that the Veteran has not met the criteria for a higher 100 percent disability rating for PTSD. See 38 C.F.R. § 4.130. The record does not indicate total occupational and social impairment, due to symptoms of such a severity as described for a 100 percent evaluation for PTSD. The examiners, both VA and private, have indicated that the Veteran has had occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. These are the criteria associated with a 70 percent disability evaluation. Moreover, the Board finds that total social impairment has not been indicated as the Veteran has been able to maintain relationships with his fiance/wife until recently and still has a relationship with other family members, albeit somewhat distant. As noted above the list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the evaluation, but are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific evaluation. Mauerhan v. Principi, 16 Vet. App. 436, 442-3 (2002). On the other hand, if the evidence shows that the Veteran suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code, the appropriate equivalent rating will be assigned. Mauerhan v. Principi, at 443. The Court of Appeals for the Federal Circuit has embraced the Mauerhan Court's interpretation of the criteria for rating psychiatric disabilities. Sellers v. Principi, 372 F.3d 1318, 1326 (Fed. Cir. 2004). Ultimately, in Mauerhan, the Court upheld the Board's decision noting that the Board had considered all of the veteran's psychiatric symptoms, whether listed in the applicable rating criteria or not, and had assigned a rating based on the Veteran's level of occupational and social impairment. Mauerhan v. Principi, at 444. Applying this analysis to the criteria for the 100 percent rating, it follows that the Veteran would be entitled to that rating if PTSD caused total occupational and social impairment, regardless of whether he had some, all, or none of the symptoms listed in the rating formula, and regardless of whether his symptoms were listed or not. The Board concludes that the Veteran's disability picture does not more nearly approximate the criteria for a 100 percent rating criteria under DC 9411 for any period. 38 C.F.R. § 4.130. The weight of the evidence shows that the Veteran has not had total occupational and social impairment due to such symptoms as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; disorientation to time or place; memory loss for names of close relatives, own occupation, or own name for any period. The Board is keenly aware of the Veteran’s memory loss problems; however, the symptoms more closely approximate those associated with a 70 percent disability evaluation throughout the appeal period. Moreover, as will be discussed in greater detail below, the Board has assigned a TDIU from March 28, 2006, the last date of his employment, of which the Veteran’s GAD played the predominant role in the assignment of the TDIU. TDIU A TDIU may be assigned when a Veteran has one service-connected disability rated at 60 percent or more, or two or more service-connected disabilities with at least one rated at 40 percent or more and he has a combined rating of at least 70 percent. 38 C.F.R. § 4.16(a). In calculating whether a Veteran meets that 60/70 percent schedular criteria, disabilities resulting from common etiology or a single accident, or disabilities affecting a single body system, are considered one disability. The record must also show that the service-connected disabilities alone result in such impairment of mind or body that the average person would be precluded from securing or following a substantially gainful occupation. 38 C.F.R. § 4.16(a). In any event, it is the policy of the VA that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disability shall be rated totally disabled. 38 C.F.R. § 4.16(b); see 38 C.F.R. §§ 3.340, 3.341, 4.15 (2019). In this regard, in Hatlestad v. Derwinski, 1 Vet. App. 164 (1991), the Court referred to apparent conflicts in the regulations pertaining to individual unemployability benefits. Specifically, the Court indicated that there was a need to discuss whether the standard delineated in the controlling regulations was an "objective" one based on the average industrial impairment or a "subjective" one based upon a Veteran's actual industrial impairment. In a pertinent precedent decision, VA General Counsel concluded that the controlling VA regulations generally provide that veterans who, in light of their individual circumstances, but without regard to age, are unable to secure and follow a substantially gainful occupation as the result of service-connected disability shall be rated totally disabled, without regard to whether an average person would be rendered unemployable by the circumstances. Thus, the criteria for determining unemployability include a subjective standard. It was also determined that "unemployability" is synonymous with inability to secure and follow a substantially gainful occupation. VAOPGCPREC 75-91 (O.G.C. Prec. 75-91); 57 Fed. Reg. 2317 (1992). The Court has also held that a Veteran's advancing age and nonservice-connected disabilities may not be considered in the determination of whether a Veteran is entitled to a TDIU. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321, 3.340, 3.341, 4.16(a)(b), 4.19; Van Hoose v. Brown, 4 Vet. App. 361 (1993). For a Veteran to prevail on a claim based on unemployability, it is necessary that the record reflect some factor which places him in a different position than other Veterans with the same disability rating. The sole fact that a Veteran is unemployed or has difficulty obtaining employment is not enough to prove unemployability. Additionally, it is noted that a high rating in and of itself is recognition that the impairment makes it difficult to obtain and keep employment. Thus, the question is whether the Veteran is capable of performing the physical and mental acts required by employment, not whether the Veteran can find employment. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). Furthermore, marginal employment shall not be considered substantially gainful employment. Marginal employment generally shall be deemed to exist when a veteran's earned annual income does not exceed the amount established by the U.S. Department of Commerce, Bureau of the Census, as the poverty threshold for one person. Marginal employment may also be held to exist, on a facts found basis (includes but is not limited to employment in a protected environment such as a family business or sheltered workshop), when earned annual income exceeds the poverty threshold. Consideration shall be given in all claims to the nature of the employment and the reason for termination. 38 C.F.R. § 4.16(a). Based upon the above actions, as of September 27, 2005, service connection was in effect for GAD, rated as 70 percent disabling; left testicular atrophy, rated as 10 percent disabling, and ED, rated as noncompensable. Thus, the Veteran met the criteria for consideration of 4.16(a) at the time of his request for an increased evaluation for GAD. The date of the Veteran’s last full-time employment is March 28, 2006. He has been unemployed and unemployable since this time. In a May 2007 letter, the Veteran’s treating physician indicated that the Veteran’s mental condition had worsened due to his physical condition and that he was not able to work causing marital discord and financial difficulty. He was noted to be anxious and depressed to the proportion of committing suicide. He was considered disabled, unable to be gainfully employed at that time and in the future. This finding is supported by the results of an August 2007 VA examination, wherein the Veteran was noted to have had an increase of his depressive symptoms as well as a decrease in his functioning especially in terms of having greater interpersonal conflicts, angry outbursts, increased social isolation and avoidance. The Board does note the findings of the May 2008 VA examiner that the Veteran’s work impairment arose from his physical condition; however, the examiner did indicate that the Veteran’s excessive ruminations and generalized anxiety would have an impairment on his occupational status. The Board further observes that the Veteran was found to be disabled as of February 2006 by the Social Security Administration with a primary diagnosis of sarcoidosis for which service connection is not in effect. However, as noted above, the Veteran’s physical condition substantially impacts his service-connected mental health condition, exacerbating his symptoms, as noted by his treating physicians. Based upon the above findings, it is evident that the Veteran cannot work in the field in which he has training and experience. The Board finds that the weight of the evidence, including the examiners' findings, along with the Veteran's statements and work history, demonstrate that he has met the criteria set forth in § 4.16, and that a TDIU based upon service-connected disabilities from March 28, 2006, the date of his last full-time employment, is warranted. 1151 Under certain circumstances, VA provides compensation for additional disability resulting from VA medical treatment in the same manner as if such disability were service-connected. For a claimant to qualify for such compensation, the additional disability must not be the result of the veteran's willful misconduct. When additional disability is caused by VA hospital care, medical or surgical treatment, or examination, the proximate cause of the additional disability must be: (A) carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA in furnishing the care, treatment, or examination; or (B) an event not reasonably foreseeable. 38 U.S.C. § 1151; see also 38 C.F.R. § 3.361. The United States Court of Appeals for Veterans Claims (Court) has indicated that Section 1151 claims for additional disability are treated similarly to claims for service connection. See Jones v. West, 12 Vet. App. 383 (1999); Boggs v. West, 11 Vet. App. 334 (1998). Hence, to establish entitlement, there must be (1) medical evidence of a current disability; (2) medical evidence, or in certain circumstances lay evidence, of incurrence or aggravation of an injury as the result of hospitalization, medical or surgical treatment; and (3) competent evidence of a nexus between that asserted injury or disease and the current disability. To determine whether a veteran has additional disability, VA compares the veteran's condition immediately before the beginning of the medical care or examination to the veteran's condition after such care or examination. 38 C.F.R. § 3.361(b). VA considers each involved body part or system separately. Id. In Viegas v. Shinseki, the United States Court of Appeals for the Federal Circuit (Federal Circuit Court) noted that Section 1151 delineates three prerequisites for obtaining disability compensation. First, a claimant must incur a "qualifying additional disability" that was not the result of his own "willful misconduct." 38 U.S.C. § 1151(a). Second, that disability must have been "caused by hospital care, medical or surgical treatment, or examination furnished the veteran" by VA or in a VA facility. Finally, the "proximate cause" of the veteran's disability must be "carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault" on the part of VA, or "an event not reasonably foreseeable." See Viegas v. Shinseki, 705 F.3d 1374 (Fed. Cir. 2013); §§ 1151(a)(1)(A), 1151(a)(1)(B). Thus, Section 1151 contains two causation elements - a veteran's disability must not only be caused by the medical care he received from VA, but also must be proximately caused by the VA's fault or by an unforeseen event. Section 1151 does not extend to the "remote consequences" of VA medical treatment, and a veteran is not entitled to obtain section 1151 disability benefits simply because he was in a VA medical facility at the time he sustained an injury. Viegas, supra, citing Brown v. Gardner, 513 U.S. 115, 119, 115 S. Ct. 552, 130 L. Ed.2d 462 (1994). However, the Federal Circuit Court stated in Viegas that "Congress intended to encompass not simply the actual care provided by VA medical personnel, but also treatment-related incidents that occur in the physical premises controlled and maintained by the VA." Id. at 1378 (Fed. Cir. 2013). In determining whether a veteran's disability was actually caused by VA medical treatment, only a causal connection, and not direct causation, is required. Viegas, 705 F.3d at 1380; see also Brown v. Gardner, 513 U.S. 115, 119 (1994). However, a mere showing of additional disability after VA treatment will not establish cause. The evidence must show that the treatment resulted in the veteran's additional disability. 38 C.F.R. § 3.361(c)(1). The proximate cause of disability is the action or event that directly caused the disability, as distinguished from a remote contributing cause. 38 C.F.R. § 3.361(d). To establish that carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA's part in furnishing medical treatment or examination proximately caused a veteran's additional disability, it must be shown that the medical treatment or examination caused the veteran's additional disability and (1) VA failed to exercise the degree of care that would be expected of a reasonable health care provider, or (2) VA furnished the hospital care, medical or surgical treatment, or examination without the veteran's or, in appropriate cases, the veteran's representative's, informed consent. 38 C.F.R. § 3.361(d)(1). Whether the proximate cause of a veteran's additional disability was an event not reasonably foreseeable is in each claim to be determined based on what a reasonable health care provider would have foreseen. 38 C.F.R. § 3.361(d)(2). The event need not be completely unforeseeable or unimaginable, but must be one that a reasonable health care provider would not have considered to be an ordinary risk of the treatment provided. Id. In determining whether an event was reasonably foreseeable, VA will consider whether the risk of that event was the type of risk that a reasonable health care provider would have disclosed in connection with the informed consent procedures of 38 C.F.R. § 17.32. 38 C.F.R. § 3.361(d)(2). The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a claim, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107. To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. Brain Biopsy/Craniotomy Resulting in Loss of Balance The Veteran maintains that he currently has loss of balance resulting from a brain biopsy performed in January 2006 in connection with his sarcoidosis. In a June 2007 letter, the Veteran’s treating VA physician indicated that the Veteran suffered from sarcoidosis that had caused permanent damage to his central nervous system. It was indicated that because of this condition, the Veteran had marked weakness of his legs and was unable to walk normally. In August 2020, an opinion was obtained with regard to the 1151 claim. As it related to the questions of whether it was as likely as not that VA medical treatment caused additional disability in this Veteran; or (b) was it more likely that the loss of balance was unrelated caused by or aggravated by VA medical treatment, or; (c) the examiner could not offer an opinion because such knowledge was not available in the medical literature and any opinion would be speculation; the examiner indicated that he could not offer an opinion because such knowledge was not available in the medical literature and any opinion would be speculation. The examiner stated there was insufficient documentation of severity before and after the brain biopsy to differentiate abrupt exacerbation from progression of the neurosarcoidosis. As to the question of whether the Veteran's record of treatment for right frontal craniotomy and brain biopsy indicated any departure from accepted levels of medical care or the performance of professional duties expected of a reasonable health care provider; the examiner indicated that while the procedure appeared to have been challenging due to the Veteran's disease process, there did not appear to be any departure from acceptable levels of medical care or the performance of professional duties expected of a reasonable health care provider. The examiner indicated that a brain biopsy by its very nature involved a small amount of damage to the brain directly by removing a piece of it. It was documented that risks, benefits and alternatives were discussed with the patient. Upon entering the cranial vault, the tissues were found to be inflamed, thickened and adherent to one another. The surgeon made note of this difficulty and his effort to minimize damage to the brain itself while attempting to remove its’ covering layers to expose the area to be biopsied. This would be a reasonable thought process in this situation. As to the question of whether the outcome of the right frontal craniotomy and brain biopsy was an ordinary risk or a reasonably foreseeable event of that type of procedure treatment, etc., the examiner indicated that MRI demonstrated anatomy well. It could not indicate what was attached to neighboring structures or how tightly, only that they were touching each other. The difficulty in this procedure arose primarily from the fact that the dura, the arachnoid, and the brain itself were stuck to each other and were difficult to separate. Separation was necessary to assure visualization of the correct place to perform the biopsy and the avoidance of blood vessels, the undetected puncture of which could cause dangerous, even life-threatening bleeding complications. These abnormalities were known to occur in inflammatory disease processes and it appeared were not unexpected by the surgeon. The examiner stated that if the question is requesting an opinion regarding a balance problem constituting "the outcome", he did not appreciate evidence that a balance problem was an outcome of the craniotomy. There was documentation in the medical record of balance problems in 2004 attributed to his neurosarcoidosis. The Veteran was documented on post-op day 1 as ambulating apparently without assistance to the bathroom with a "slightly unsteady gait". He stated that he was unable to determine that the brain biopsy itself caused a significant change in the Veteran's balance from earlier. To the extent that the appellant has argued fault on VA's behalf, the question of causation for purposes of 38 U.S.C. § 1151 claims is whether the proximate cause of the disability was carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA, or an event not reasonably foreseeable, there is no indication that the appellant possesses the requisite medical expertise to provide a competent opinion on this question. Cf. Jandreau, 492 F.3d 1372. The August 2020 VA medical opinion is persuasive that it is less likely than not that the Veteran's craniotomy/brain biopsy itself caused a significant change in the Veteran's balance from earlier. It was based upon a complete review of the file with numerous treatment records being cited in the report when rendering the opinion. The weight of the evidence of record is against a finding of carelessness, negligence, lack of proper skill, error in judgment on the part of VA as it relates to this issue. Likewise, causation has not been attributed to an event not reasonably foreseeable. Thus, the criteria for compensation under 38 U.S.C. § 1151 have not been met. The Board finds that the preponderance of the evidence is against the Veteran’s claim for compensation under 38 U.S.C. § 1151 as it relates to the claim for loss of balance due to the brain biopsy/craniotomy. Meningitis and Paralysis of the Bilateral Lower Extremities Due to Baclofen Pump Installation The Veteran contends that that he suffers from meningitis and paralysis of the lower extremities due to insertion of Baclofen pump performed at the Tampa VAMC in February2010. In August 2020, an opinion was obtained with regard to the 1151 claim. As it related to the questions of whether it was as likely as not that VA medical treatment caused additional disability in this Veteran; or (b) was it more likely that the loss of balance was unrelated caused by or aggravated by VA medical treatment, or; (c) the examiner could not offer an opinion because such knowledge was not available in the medical literature and any opinion would be speculation; the examiner responded neither of the Veteran's lower extremities were paralyzed. He did have some mild to moderate weakness or paresis in his left lower (and upper) extremities. This was documented as present prior to the meningitis. There was insufficient clarity in the medical record of severity prior and after the incident to show worsening due to the meningitis vs. other causes. i.e. progression of neurosarcoidosis or radiculopathy. The meningitis was more likely than not a result of baclofen pump installation. As to the question of whether the Veteran's record of treatment for baclofen pump installation indicated any departure from accepted levels of medical care or the performance of professional duties expected of a reasonable health care provider; the examiner indicated the record of treatment did not indicate any departure from accepted levels of medical care or the performance of professional duties expected of a reasonable health care provider. As to the question of whether the outcome of the baclofen pump was an ordinary risk or a reasonably foreseeable event of that type of procedure, treatment, etc., the examiner indicated that the infection was a reasonable foreseeable event and that it was specifically discussed in the consent. It was one of the primary concerns of any implanted device, that it became infected. As to the questions of whether it was at least as likely as not that the claimed disability of meningitis and paralysis of the lower extremities due to baclofen pump installation performed at a VA facility in February 2010 was caused by or became worse as a result of the treatment at issue; the additional disability resulted from carelessness, negligence, lack of skill or similar incidence of fault on the part of the attending physician; or the additional disability resulted from an event that could have not reasonably been foreseen by a reasonable health care provider and/or failure on the part of VA to timely diagnose and/or properly treat the claimed disease or disability allowed the disease or disability to continue the process; the examiner responded that the claimed disability of meningitis due to baclofen pump installation performed at the VA facility in February 2010 was caused by the VA treatment at issue. The examiner further indicated that the claimed disability of paralysis of the lower extremities was less likely than not due to baclofen pump installation performed at the VA facility in February 2010, nor was it caused by or became worse as a result of the VA treatment at tissue. The examiner further opined that it was less likely that the additional disability resulted from carelessness, negligence, lack of skill, or similar incidence of fault on the part of the attending physician. The examiner also indicated that it was less likely than not that the additional disability resulted from an event that could have not reasonably been foreseen by a reasonable health care provider. The examiner further stated that it was less likely than not that failure on the part of VA to timely diagnose and/or properly treat the claimed disease or disability allowed the disease or disability to continue to progress. The examiner also indicated that it was highly unlikely that the Veteran would have developed the infection if the pump had not been implanted. There was no paralysis for the meningitis to have caused. There was no evidence in the record of carelessness, negligence or lack of skill. The infection was a reasonably foreseeable event. It was specifically discussed in the consent. The record indicated that the condition was treated as soon as signs of it were discovered. To the extent that the appellant has argued fault on VA's behalf, the question of causation for purposes of 38 U.S.C. § 1151 claims is whether the proximate cause of the disability was carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA, or an event not reasonably foreseeable. There is no indication that the appellant possesses the requisite medical expertise to provide a competent opinion on this question. Cf. Jandreau, 492 F.3d 1372. The August 2020 VA medical opinion is persuasive that it is less likely than not that the baclofen pump installation itself caused paralysis of the lower extremities. The examiner responded that neither of the Veteran's lower extremities were paralyzed. While he did have some mild to moderate weakness or paresis in his left lower (and upper) extremities; this was documented as present prior to the meningitis. He indicated that there was insufficient clarity in the medical record of severity prior and after the incident to show worsening due to the meningitis vs. other causes. i.e. progression of neurosarcoidosis or radiculopathy. His opinion was based upon a complete review of the file with numerous treatment records being cited in the report when rendering the opinion. As to the claimed meningitis, while the examiner attributed the meningitis to the baclofen pump installation, he specifically found the record of treatment did not indicate any departure from accepted levels of medical care or the performance of professional duties expected of a reasonable health care provider. The examiner further indicated that the infection was a reasonably foreseeable event and that it was specifically discussed in the consent. It was noted that one of the primary concerns of any implanted device was that it became infected. There was no evidence in the record of carelessness, negligence or lack of skill. The examiner also stated that it was less likely than not that failure on the part of VA to timely diagnose and/or properly treat the claimed disease or disability allowed the disease or disability to continue to progress. Based upon the above, the Board finds that the preponderance of the evidence is against the appellant's claim for compensation under 38 U.S.C. § 1151 as it relates to the claim for paralysis of the lower extremities or meningitis from installation of the baclofen pump. SMC Based Upon the Need for Aid and Attendance Compensation at the aid and attendance rate is payable when the 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 be in need of regular aid and attendance. 38 U.S.C. § 1114(l); 38 C.F.R. § 3.350(b). Determinations as to the need for regular aid and attendance are factual and must be based upon the actual requirements for personal assistance from others. In making such determinations, consideration is given to such conditions as: The inability of the 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 assistance. The inability of the claimant to feed himself through loss of coordination of upper extremities or through extreme weakness; inability to attend to the wants of nature; or incapacity, either physical or mental, which requires care or assistance on a regular basis to protect a claimant from hazards or dangers incident to one's daily environment. It is not required that all of the disabling conditions enumerated be present before a favorable rating is made. The particular personal functions that the claimant is unable to perform should be considered in connection with his condition as a whole. It is only necessary that the claimant be so helpless as to be in need of regular aid and attendance, not that there is a constant need. "Bedridden" constitutes a condition which, through its essential character, actually requires that an individual remain in bed. The fact that a claimant has voluntarily taken to bed, or that a physician has prescribed bed rest for a lesser or greater portion of the day will not suffice. 38 C.F.R. § 3.352(a). In Turco v. Brown, 9 Vet. App. 222, 224 (1996), the Court held that eligibility for special monthly compensation by reason of regular need for aid and attendance requires that at least one of the factors set forth in VA regulation is met. In addition, determinations that the claimant is so helpless as to be in need of regular aid and attendance will not be based solely upon an opinion that the claimant's condition is such as would require him or her to be in bed. They must be based on the actual requirement of personal assistance from others. See Turco, 9 Vet. App. 222, 224. The evidence must show that the claimant is so helpless as to need regular and attendance; constant need for aid and attendance is not required. 38 C.F.R. § 3.352(a). Service connection is currently in effect for GAD, rated as 70 percent disabling; degenerative arthritis of the low back, rated as 40 percent disabling; right lower extremity radiculopathy, rated as 20 percent disabling; left lower extremity radiculopathy, rated as 20 percent disabling; left testicular atrophy, rated as 10 percent disabling; neurodermatitis, rated as 10 percent disabling; and ED, rated as noncompensable. The Veteran has been assigned a total disability evaluation based upon individual unemployability (TDIU) since March 28, 2006. In conjunction with the Board remand, the Veteran was afforded a VA examination in August 2020. At the time of the examination, the Veteran reported that he would get up and shower with assistance. He had an in-home assistant for three hours. She made his bed, cooked, cleaned, and helped him shower. He used his walker to walk around in the grocery store and used his electric wheelchair to get to the mailbox or to get to the grocery store when he could not get a ride. He was able to self-feed, dress himself, toilet, and groom himself. He required assistance for bathing. In an opinion accompanying the examination, the examiner stated that the Veteran required the services of another for the purposes of housework, bathing and dressing, all of which were necessary functions. He was unable to perform these activities because of the arthritis in his back, his bilateral lower extremity radiculopathy, and balance problems related to the above conditions and neurosarcoidosis. The Board finds that the evidence is in equipoise on the question of whether the Veteran required the regular aid and attendance of another person for dressing or undressing himself and bathing as the result of his service-connected disabilities alone. Although service connection is not currently in effect for neurosarcoidosis, the examiner specifically indicated that the Veteran’s low back disorder and resulting lower extremity radiculopathy were also the cause of his inability to undress and dress himself and bathe. 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. It is logical to infer, however, a threshold requirement that "at least one of the enumerated factors be present." Turco, at 224. The performance of the necessary aid and attendance service by a relative or other member of the household will not prevent the granting of the additional allowance. 38 C.F.R. § 3.352 (c). Thus, on this record, and resolving reasonable doubt in favor of the appellant, the Board finds that the claim for special monthly compensation based on the need for regular aid and attendance is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. 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). The grant of SMC at the aid and attendance rate renders the housebound issue moot. Accordingly, the claim is granted to the extent indicated, based on requirement for aid and attendance. REASONS FOR REMAND As it relates to the claims of service connection for bilateral hand, knee, and foot disorders, the Board, in its prior remand, noted that as it related to the claims of service connection for joint disorders, the Veteran had consistently reported having been involved in a jeep accident while stationed in Germany in December 1983. The Board observed that although treatment records did not reveal that the Veteran was involved in a jeep accident at that time, the Board found that his consistent reports of having been in a jeep accident at that time were consistent with the facts of his service. Moreover, the Veteran's claimed jeep accident occurred subsequent to his service separation examination. The Board stated that given the above, the Veteran’s statements with regard the jeep accident, including the jeep having flipped over and his being hospitalized, were credible. The Board requested that the Veteran be afforded a VA examination to determine the presence and etiology of any current joint disorder, to include a joint disease of the hands, feet, and knees. The examiner was to indicate whether it was least as likely as not (50 percent probability or greater) that they had their onset in service or were otherwise related to service. For purposes of rendering the opinions, the examiner was to note that the Board had found the Veteran's statements as to having been involved in a jeep accident in service to be credible. In an August 2020 medical opinion prepared in conjunction with the Board remand, the VA examiner indicated that it was less likely than not that the Veteran’s claimed joint disorder of the hands, knees and feet were incurred in service or caused by a claimed inservice injury, event or illness, to include having been involved in a jeep accident during service. The examiner stated that as there was no record of injury to the hands, knees, or feet during service, there was no link between these disorders and the Veteran’s jeep accident in 1984. While the requested opinion was supplied, the rationale supplied as the basis for the opinion was that there was no evidence of hand, feet, or knee injuries in service. The Board, in its prior remand, found that the Veteran’s statements with regard to the jeep accident were credible. The Veteran has reported and testified as to having sustained injuries to his hands, feet, and knees during the jeep accident. Thus, the basis for the negative opinion is based upon a faulty premise and warrants additional development. The matters are REMANDED for the following action: 1. Undertake appropriate development to obtain all outstanding VA and/or private treatment records related to the Veteran's outstanding claims. If any requested records are not available, the record should be annotated to reflect such and the Veteran notified. 2. If available, return the claims folder to the August 2020 VA examiner who provided the above opinion as to the etiology of any hand, knee, and foot disorders and their relationship, if any, to the Veteran’s period of service. Following a review of the entire record, the examiner is requested to render the following opinions: What are the Veteran’s current hand, knee, and foot disorders? Is it at least as likely as not (50 percent probability or greater) that the Veteran’s current hand, knee, or foot disorders, to include any joint disorders, had their origin in service or are otherwise related to service? When rendering these opinions, the examiner is to concede that the Veteran sustained injuries to his hands, knees and feet, during service as a result of the 1984 jeep accident. Complete detailed rationale is requested for each opinion that is rendered. K. Parakkal Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. S. Kelly, 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.