Citation Nr: 21030640 Decision Date: 05/19/21 Archive Date: 05/19/21 DOCKET NO. 17-05 956 DATE: May 19, 2021 ISSUES 1. Entitlement to accrued benefits for service connection for metastatic cancer of the back, claimed as secondary to prostate cancer. 2. Entitlement to accrued benefits for service connection for a disability manifested by muscle weakness, aches, and pains, claimed as secondary to prostate cancer. 3. Entitlement to accrued benefits for service connection for posture impairment, claimed as secondary to prostate cancer. 4. Entitlement to accrued benefits for service connection for erectile dysfunction, claimed as secondary to prostate cancer. 5. Entitlement to accrued benefits for service connection for bladder impairment with catheter and incontinence, claimed as secondary to prostate cancer. 6. Entitlement to accrued benefits for service connection for a sleep disturbance disability, claimed as secondary to prostate cancer. 7. Entitlement to accrued benefits for special monthly compensation (SMC) based on loss of use, claimed as impotence. 8. Entitlement to accrued benefits for special monthly compensation (SMC) based on housebound status. 9. Entitlement to accrued benefits for special monthly compensation (SMC) based on aid and attendance from another. ORDER Entitlement to accrued benefits for service connection for metastatic cancer of the back, claimed as secondary to prostate cancer are denied. Entitlement to accrued benefits for service connection for a disability manifested by muscle weakness, aches, and pains, claimed as secondary to prostate cancer are denied. Entitlement to accrued benefits for service connection for posture impairment, claimed as secondary to prostate cancer are denied. Entitlement to accrued benefits for service connection for erectile dysfunction, claimed as secondary to prostate cancer are denied. Entitlement to accrued benefits for service connection for bladder impairment with catheter and incontinence, claimed as secondary to prostate cancer are denied. Entitlement to accrued benefits for service connection for a sleep disturbance disability, claimed as secondary to prostate cancer are denied. Entitlement to accrued benefits for special monthly compensation (SMC) based on loss of use, claimed as impotence are denied. Entitlement to accrued benefits for special monthly compensation (SMC) based on housebound status are denied. Entitlement to accrued benefits for special monthly compensation (SMC) based on aid and attendance from another are denied. FINDINGS OF FACT 1. The Veteran passed away in October 2020. 2. Metastatic cancer of the back was not manifest in service or within one year of separation, is not caused or aggravated by a service-connected disease or injury, and is not otherwise attributable to service. 3. A disability manifested by muscle weakness, aches, and pains, was not manifest in service or within one year of separation, is not caused or aggravated by a service-connected disease or injury, and is not otherwise attributable to service. 4. A posture impairment disability was not manifest in service or within one year of separation, is not caused or aggravated by a service-connected disease or injury, and is not otherwise attributable to service. 5. Erectile dysfunction was not manifest in service or within one year of separation, is not caused or aggravated by a service-connected disease or injury, and is not otherwise attributable to service. 6. A bladder impairment with catheter and incontinence disability was not manifest in service or within one year of separation, is not caused or aggravated by a service-connected disease or injury, and is not otherwise attributable to service. 7. A sleep disturbance disability was not manifest in service or within one year of separation, is not caused or aggravated by a service-connected disease or injury, and is not otherwise attributable to service. 8. The Veteran did not have anatomical loss or loss of use of one hand, one foot, both buttocks, one or more creative organs, blindness of one eye having only light perception, deafness of both ears, or complete organic aphonia with constant inability to communicate by speech. 9. The Veteran did not suffer the anatomical loss or loss of use of both feet, or of one hand and one foot, or was blind in both eyes, with 5/200 visual acuity or less. 10. Service connected disability did not render the Veteran bedridden, helpless, or housebound. 11. The Veteran was not service-connected for a prostate disability or its residuals. 12. The Veteran did not have a service connected disability rated as total and others rated as 60 percent. CONCLUSIONS OF LAW 1. Metastatic cancer of the back was not incurred in or aggravated by service, malignant tumors may not be presumed to have been incurred therein, and is not proximately due to, the result of, or aggravated by service connected disease or injury. 38 U.S.C. §§ 1110, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310 (2018). 2. A disability manifested by muscle weakness, aches, and pains, was not incurred in or aggravated by service, organic disease of the nervous system may not be presumed to have been incurred therein, and is not proximately due to, the result of, or aggravated by service connected disease or injury. 38 U.S.C. §§ 1110, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310 (2018). 3. A posture impairment disability was not incurred in or aggravated by service, arthritis may not be presumed to have been incurred therein, and is not proximately due to, the result of, or aggravated by service connected disease or injury. 38 U.S.C. §§ 1110, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310 (2018). 4. Erectile dysfunction was not incurred in or aggravated by service, organic disease of the nervous system may not be presumed to have been incurred therein, and is not proximately due to, the result of, or aggravated by service connected disease or injury. 38 U.S.C. §§ 1110, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310 (2018). 5. A bladder impairment with catheter and incontinence disability was not incurred in or aggravated by service, organic disease of the nervous system may not be presumed to have been incurred therein, and is not proximately due to, the result of, or aggravated by service connected disease or injury. 38 U.S.C. §§ 1110, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310 (2018). 6. A sleep disturbance disability was not incurred in or aggravated by service, organic disease of the nervous system may not be presumed to have been incurred therein, and is not proximately due to, the result of, or aggravated by service connected disease or injury. 38 U.S.C. §§ 1110, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310 (2018). 7. The criteria for special monthly compensation based upon a loss of use have not been met or approximated. 38 U.S.C. §§ 1114, 1155, 5103, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.350. 8. The criteria for special monthly compensation (SMC) based on housebound status have not been met or approximated. 38 U.S.C. §§ 1114, 5107 (2012); 38 C.F.R. § 3.350, 3.352 (2018). 9. The criteria for special monthly compensation (SMC) based on aid and attendance from another have not been met or approximated. 38 U.S.C. §§ 1114, 5107 (2012); 38 C.F.R. § 3.350, 3.352 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from September 1952 to June 1954. This matter is before the Board of Veterans Appeals (Board) on appeal from a February 2015 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Louisville, Kentucky, which is responsible for processing all claims involving exposure to contaminated water at Camp Lejeune. See VBA Fast Letter 11-03 (Revised Jan. 28, 2013). Jurisdiction over this case was subsequently transferred to the RO in St. Petersburg, Florida. The record shows that the Veteran passed away in October 2020. The appellant is his surviving spouse. Her substitution was accepted by VA by way of a letter dated December 7, 2020 containing the relevant information. We will proceed accordingly. During the pendency of the appeals, Veteran and his grandson testified before the undersigned Veterans Law Judge (VLJ) in April 2017. A copy of the hearing transcript has been associated with the claims file. In October 2017, the Board remanded the issues for additional development. Later, the issues were again remanded by the Board in January 2019. The Board identified the need for a new VA medical opinion concerning contaminated water exposure at Camp Lejeune. In September 2020, the Board remanded the issues again for additional development. The Board denied service connection for prostate cancer, to include as due to exposure to contaminated water at Camp Lejeune. Recently, the Veteran's surviving spouse submitted a new claim on a November 9, 2020 VA 21-530 Application for Burial Benefits. 38 C.F.R. § 3.155. This issue has not yet been adjudicated by the RO. Therefore, the Board does not have jurisdiction over it, and it is referred to the RO for appropriate action. 38 C.F.R. § 19.9(b). Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C. §§ 5102, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2018). Unfortunately, the Veteran's Service Treatment Records (STRs) and Service Personnel Records (SPRs) were unavailable for review due to a fire-related cause. Where service records are unavailable, VA has a heightened duty to assist the appellant. Dixon v. Derwinski, 3 Vet. App. 261, 263-264 (1992); O'Hare v. Derwinski, 1 Vet. App. 365, 367 (1991). The Board has been mindful of this heightened duty, including remanding these issues in September 2020 for additional development. Importantly, the Board observes that the September 2020 Decision and Remand required that Veteran be sent a Form 21-2680 (Examination for Housebound Status or Permanent Need for Regular Aid and Attendance). This was to be completed his physician or other clinical care providers, e.g. a nurse, and returned to VA. They were sent an October 6, 2020 VA Subsequent Development Letter. No direct response has been received. Nevertheless, the Board has sufficient information to reach a decision on these appeals. Most recently, the appellant and her representative were reminded of the critical evidentiary requirements necessary to substantiate the claims by way of a March 2021 Supplemental Statement of the Case (SSOC). They were also sent an April 22, 2021 BVA Letter showing that the appeals were back before the Board. The appellant in this case has not referred to any deficiencies in either the duties to notify or assist; therefore, the Board may proceed to the merits of the claim. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015, cert denied, U.S.C. Oct. 3, 2016) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board....to search the record and address procedural arguments when the [appellant] fails to raise them before the Board"); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to an appellant's failure to raise a duty to assist argument before the Board). The Board has reviewed all of the evidence in the claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the appellant or obtained on her behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-130 (2000). Service Connection Claims for VA benefits do not survive a claimant's death. However, a qualified survivor (including a spouse) may carry on the deceased veteran's claim for benefits by submitting an application for accrued benefits within one year after the veteran's death. 38 U.S.C. § 5121 (a), (c); 38 C.F.R. § 3.1000. Accrued benefits are "periodic monetary benefits... to which an individual was entitled at death under existing ratings or decisions or those based on evidence in the file at date of death." Id. An accrued-benefits claim incorporates any prior final adjudication on claims brought by a Veteran, because it derives from the Veteran's claims. An accrued benefits claim is, under the law, derivative of, and separate from, the Veteran's claims. See Zevalkink v. Brown, 6 Vet. App. 483, 489-490 (1994), aff'd, 102 F.3d 1236 (Fed. Cir. 1996). Thus, in the adjudication of a claim for accrued benefits, the claimant is bound by the same legal requirements to which the Veteran would have been bound had he survived to have his claims finally decided. To establish service connection a Veteran must generally 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." Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also 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). For the showing of 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, as distinguished from merely isolated findings or a diagnosis including the word "Chronic." When the disease identity is established (leprosy, tuberculosis, multiple sclerosis, etc.), there is no requirement of evidentiary showing of continuity. Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303 (b). Except as provided in § 3.300(c), disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310 (a). Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected. 38 C.F.R. § 3.310 (b). As a threshold issue, the Board observes that if a veteran, or former reservist or member of the National Guard, was exposed to contaminants in the water supply at Camp Lejeune during military service and the exposure meets the requirements of § 3.307(a)(7), the listed diseases, including kidney cancer, shall be service-connected even though there is no record of such disease during service, subject to the rebuttable presumption provisions of § 3.307(d). (1) Kidney cancer. (2) Liver cancer. (3) Non-Hodgkin's lymphoma. (4) Adult leukemia. (5) Multiple myeloma. (6) Parkinson's disease. (7) Aplastic anemia and other myelodysplastic syndromes. (8) Bladder cancer. 38 C.F.R. § 3.309(f). The February 2015 Rating decision conceded exposure to contaminated water at Camp Lejeune (CLCW). The Board also observes that in Combee v. Brown, the United States Court of Appeals for the Federal Circuit held that when a Veteran is found not to be entitled to a regulatory presumption of service connection for a given disability the claim must nevertheless be reviewed to determine whether service connection can be established on a direct basis. Combee v. Brown, 34 F.3d 1039, 1043-1044 (Fed.Cir.1994), reversing in part Combee v. Principi, 4 Vet. App. 78 (1993). VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. 38 U.S.C. § 1154 (a). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a 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. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Lay evidence cannot be determined not credible merely because it is unaccompanied by contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006). However, the lack of contemporaneous medical evidence can be considered and weighed against a Veteran's lay statements. Id. The Board, as fact finder, is obligated to, and fully justified in, determining whether lay evidence is credible in and of itself, i.e., because of possible bias, conflicting statements, etc. Id. Further, a negative inference may be drawn from the absence of complaints for an extended period. See Maxson v. West, 12 Vet. App. 453, 459 (1999), aff'd sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). 1. Entitlement to accrued benefits for service connection for metastatic cancer of the back, claimed as secondary to prostate cancer 2. Entitlement to accrued benefits for service connection for a disability manifested by muscle weakness, aches, and pains, claimed as secondary to prostate cancer 3. Entitlement to accrued benefits for service connection for posture impairment, claimed as secondary to prostate cancer The Board incorporates its discussion from the sections above by reference. We note that pain as organic disease of the nervous system and arthritis are recognized chronic diseases, and as such, additional presumptive theories of entitlement are relevant in addition to direct service connection. See 38 C.F.R. §§ 3.303, 3.307, 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Since the February 2015 Rating decision, the United States Court of Appeals for the Federal Circuit (Federal Circuit) found that the term "disability" as used in 38 U.S.C. § 1110 "refers to the functional impairment of earning capacity, not the underlying cause of said disability," and held that "pain alone can serve as a functional impairment and therefore qualify as a disability." See Saunders v. Wilkie, 886 F.3d 1356 (2018). The Board observes that Saunders does not eliminate the need for underlying pathology, disease, or injury (also sometimes called a diagnosis). Recently, in Wait v. Wilkie, No. 18-4349, the United States Court of Appeals for Veterans Claims (CAVC) addressed the question of what is necessary for a claimant to demonstrate that his or her pain or other symptoms cause "functional impairment of earning capacity," and therefore meet the current disability requirement under Saunders. The CAVC held that, to meet the current disability requirement under Saunders, "there must be competent evidence specific to the claimant tending to show that his or her impairment rises to a level to affect earning capacity, which may include showing manifestations of a similar severity, frequency, and duration as those VA has determined by regulation would cause impaired earning capacity in an average person." The CAVC clarified that the Board must make the factual determination whether the appellant's manifestations rise to the level of a functional impairment in earning capacity. By way of history, a VA 21-4138 Statement in Support of Claim dated January 15, 2014 is of record. The Veteran reported prostate cancer with removal of the prostate in 1997. On page 2, he described discomfort, including muscle weakness with aches and pains, an inability to stand up straight, and a difficulty standing up from a seated position. Next, a February 2014 VA Form 21-3101 Request for Information shows that the Veteran's Service Treatment Records (STRs) were destroyed in a fire. The Service Personnel Records (SPRs) were also destroyed by the fire and could not be reconstructed. With regard to the missing STRs, the Board observes that the Court of Appeals for Veterans Claims (Court) has held that in cases where records once in the hands of the Government are lost, the Board has a heightened obligation to explain its findings and conclusions and to consider carefully the benefit-of-the-doubt rule. See O'Hare v. Derwinski, 1 Vet. App. 365, 367 (1991). Next, on March 17, 2014, VA received a series of ongoing VA treatment records from the Bond Clinic and Dr. O. A. H. On the cover page, the Veteran commented that he has suffered from being incontinent and impotent since 1997. Consistently, the private treatment records show a history of prostate cancer back to 1997. They also describe his general condition. "He seems to be doing fine without new bone pains, weight loss, or fever. He has some constipation." Next, an October 16, 2014 private treatment record from Dr. O. A. H. at the Bond Clinic shows the Veteran began therapy for prostate cancer in 1997 and in 2011. A bone scan was positive for rib metastasis. It was noted that the Veteran does not smoke or drink, and that there is no family history of cancer or blood disorder. Later, in December 2014, VA received a Request for Medical Information Needed to Reconstruct Medical Data in light of the destroyed Service Treatment Records (STRs). It shows that the Veteran had prostate cancer in the summer of 1997 with radiation seeds. He currently has bone cancer in at stage 4, as cancer had moved to the bones. He has been receiving treatment for this at the Bond Clinic in Florida. The Veteran filed a timely, August 2015 Notice of Disagreement (NOD). In September 2015, VA received a clutch of letters from private treatment providers. Two are from Dr. O. A. H. and Dr. E. H. W. of the Bond Clinic, and another from Dr. K. F. of Central Florida Dermatology. All three of the doctors stated that they reviewed the evidence and the information from the Agency for Toxic Substance & Disease Registry (ATSDR). They opined that it is at least as likely as not that the Veteran's exposure to contaminated water at Camp Lejeune was the cause of only his prostate condition. They also opined in all three letters that the Veteran has had skin cancers "for years" as well as metastatic bone cancer. As previously highlighted by the Board, none of these private medical statements identify the exact ATSDR report or what information obtained from ATSDR supported their medical conclusions. See August 2015 private medical statements from O.A.H., E.H.W., K.W.F., M.D.s. Later, at the April 2017 hearing, the Veteran testified that he has been told by a heart doctor that there is a metastasized cancer identified in the back. He explained, "So, then I have a heart doctor in Winter Haven that signed that thing, very good man, and he saw my, my PSA was nine. And he said, go downstairs, get a body scan. Went down there and, sure enough, there's a about the size of a nickel, right in my back." See April 2017 hearing Transcript, p. 15. He elaborated that he went over to an oncologist, Dr. H., and he receives shots of Zometa. He also gets shots of Lupron, which slows it. Also at the April 2017 hearing, the Veteran testified regarding pain and a posture disability. He explained, "Posture, I'm always bent over, now I can't straighten up." See April 2017 Hearing Transcript, p. 26. He testified that this is because of his back. Id. Regarding muscle pain and weakness, he now uses a cane. Id. Next, the September 2020 Board decision denied service connection for prostate cancer. This ended any secondary service connection theory of entitlement to prostate cancer. 38 C.F.R. § 3.310. Recently, in late 2020 and early 2021, the appellant was afforded a lengthy series of VA medical opinions. We will address the two clusters in chronological order. First, the appellant was afforded a set of October 2020 VA medical opinions performed by A. H., M.D. The physician sympathetically reviewed the entire claims file. For the back, she identified metastatic cancer of the back with a date of diagnosis of 2013. Dr. A. H. opined, "The diagnosis of metastatic cancer of the back is confirmed and is less likely as not caused by or a result of the Veteran's exposure to CLCW." She also concluded, "Given that the metastatic cancer of the back was due to a primary prostate cancer, it would be due to that, not to other causes. Therefore, it was less likely as not caused by or related to Mr. [Veteran's] exposure to CLCW." Next, Dr. A. H. emphasized that there was no documentation of any posture impairment in the claims file. She concluded, "The diagnosis of posture impairment has not been confirmed and no significant association was documented between exposure to trichloroethylene, tetrachloroethylene, benzene, or vinyl chloride and posture impairment, so it is my opinion that any posture dysfunction was less likely as not caused by or related to Mr. [Veteran's] exposure to CLCW." Third, for muscle weakness, Dr. A. H. emphasized that there was no documentation of any muscle weakness in the claims file. She concluded, "Given that no muscle weakness was confirmed, it is less likely as not caused by or related to Mr. [Veteran's] exposure to CLCW." In short, regardless of a diagnosed chronic disability, there were no positive nexus opinions to events in service. Months later, in early March 2021, another set of VA medical opinions was obtained. Dr. P. G., the VA examiner, reviewed the entire claims file. The VA examiner rendered negative nexus opinions for all claimed conditions, implicitly encompassing all theories of direct and presumptive service connection. For metastatic cancer of the back, the VA examiner rendered a negative nexus opinion. The VA examiner described, "Prostate cancer metastasized to Veteran's T12, L2, L3, and L4. Therefore, if it wasn't for the veteran's prostate cancer, he would not have had to contend with the cancer that spread to his..." The remaining text is cut off, but the rationale is still clear. Second, the VA examiner ultimately indicated a negative nexus opinion for any disability manifested by muscle weakness. The VA examiner reasoned: Veteran's disability manifested by muscle weakness was due to the metastatic back cancer caused by the service connected prostate cancer. Therefore, if it wasn't for the veteran's prostate cancer, he would not have had to contend with the cancer that spread to his back thus impairing his posture and causing his disability manifested by muscle weakness. Third, the VA examiner rendered a negative nexus opinion for a disability manifested by impaired posture. The VA examiner described, "Veteran's impaired posture was due to the metastatic back cancer caused by the service connected prostate cancer. Therefore, if it wasn't for the veteran's prostate cancer, he would not have had to contend with the cancer that spread to his back thus impairing his posture." Ongoing VA treatment and private records are substantially the same. The appellant contends that she is entitled to accrued benefits for service connection for metastatic cancer of the back, a disability manifested by muscle weakness, aches, and pains, and a disability manifested by posture impairment; all claimed as secondary to prostate cancer. The Veteran was competent to provide evidence of that which he experienced, including his symptomatology and medical history. Layno v. Brown, 6 Vet. App. 465, 469 (1994). He was competent to report prostate changes in 1997 and subsequent treatment. The Veteran was also competent to relate what he was told by a professional. He was competent to report when he began receiving treatment for the back, that he has impairment, and when disability was first identified by physicians. He competently testified that private providers have reviewed the ATDSR and rendered positive nexus opinions. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The Veteran's own lay opinions as to the diagnosis and cause of an arthritic or musculoskeletal disability are not probative evidence, although the Veteran's observed symptoms described may be useful to an expert in evaluating whether the Veteran has a disability and in determining the etiology thereof. See Kahana v. Shinseki, 24 Vet. App. 428, 438 (2011). Because the record does not indicate that the Veteran had medical expertise, the Veteran's lay opinion beyond a description of his symptoms is of limited probative value. The most probative evidence is the October 2020 and March 2021 VA medical opinions, in addition to the Veteran's own lay history, to the extent it is competent. First, we have considered our heightened duty in light of the missing STRs. The Veteran's own lay reporting establishes the onset of claimed disease entities several years after separation. The Veteran's theory of entitlement was largely one of secondary to service connection to prostate cancer. Thus, the earliest record of the Veteran having the claimed disabilities was still several decades removed from separation. Therefore, we assign substantial probative weight to the Veteran's lay history. Second, we assign the most probative weight to the October 2020 and March 2021 VA medical opinions. The VA physicians reviewed the claims file, and rendered a series of negative nexus opinions. They based these upon their medical expertise. There are no positive nexus opinions, given that prostate cancer is not service-connected. The VA examiners cited other factors. First, in October 2020, there was not necessarily a diagnosed posture or muscle disability. However, liberally construing the Veteran's claims under Saunders, there were lay reports of impairment even without a formal diagnosis. The issue remained a nexus. Most recently, the March 2021 VA examiner described the onset of the disease entities in relation to the Veteran's overall medical history. For metastatic cancer of the back, the physician explained, "Prostate cancer metastasized to Veteran's T12, L2, L3, and L4. Therefore, if it wasn't for the veteran's prostate cancer, he would not have had to contend with the cancer that spread to his..." For any disability manifested by muscle weakness, the March 2021 VA examiner reasoned, "Therefore, if it wasn't for the veteran's prostate cancer, he would not have had to contend with the cancer that spread to his back thus impairing his posture and causing his disability manifested by muscle weakness." We assign the most probative weight to the October 2020 and March 2021 VA medical opinions by Dr. A. H. and Dr. P. G. In obtaining these medical opinions, we note that if the medical evidence of record is insufficient, or, in the opinion of the Board, of doubtful weight or credibility, the Board is always free to supplement the record by seeking an advisory opinion, ordering a medical examination or citing recognized medical treatises in its decisions that clearly support its ultimate conclusions. However, it is not free to substitute its own judgment for that of such an expert. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). Here, regarding direct or presumptive service connection, we find that the Veteran did not have the characteristic manifestations necessary to identify the disease entities in service. Metastatic cancer of the back, a disability manifested by muscle weakness, aches, and pains, and a disability manifested by posture impairment were not manifest in service or within one year from separation, and are not otherwise attributable to service. There is no probative evidence to the contrary. In addition, the Board finds that while competent to report what he has been told by his physician and to report being diagnosed with prostate cancer in the summer of 1997, the Veteran's own lay opinion regarding identifying a potential chronic disease entity, such as back cancer or other musculoskeletal disability, pales in probative weight when compared to the objective medical evidence of record. Additional causal evidence against the claims, and while not dispositive, is the lapse of so many years between discharge and the first documented medical complaints leading to a diagnosis and treat several decades removed from separation. Indeed, the Veteran's own history of seeking treatment places the onset of impairment many decades after discharge. This multi-year gap after service provides highly probative evidence against these claims. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (indicating that "evidence of a prolonged period without medical complaint can be considered, along with other factors concerning the [V]eteran's health and medical treatment during and after military service, as evidence of whether a pre-existing condition was aggravated by military service"). With regard to the series of private medical opinions received in September 2015, and afterward, we have considered these. As previously highlighted by the Board, none of these private medical statements identify the exact ATSDR report or what information obtained from ATSDR supported their medical conclusions. The Veteran has had years to supplement these medical opinions. Moreover, they do not show that the entire claims file was reviewed, or provide a more detailed rationale than the short paragraph. Therefore, they are afforded only moderate probative weight. An alternative method of establishing the second and third Shedden element, under 38 C.F.R. § 3.303 (b), is through a demonstration of continuity of symptomatology if the disability claimed qualifies as a chronic disease listed in 38 C.F.R. § 3.309 (a). Consideration of entitlement to service connection via the demonstration of continuity of symptomatology is applicable in the present case. However, the most probative evidence in the Veteran's lay statements and VA medical opinions does not demonstrate such continuity. The VA examining physicians described the Veteran's medical history showing the remote onset of the claimed disease entities several decades after separation. Consequently, we find that service connection on a direct and presumptive basis for metastatic cancer of the back, a disability manifested by muscle weakness, aches, and pains, and a disability manifested by posture impairment is not warranted. Next, it appears the Veteran's central theory of entitlement to service connection for metastatic cancer of the back, a disability manifested by muscle weakness, aches, and pains, and a disability manifested by posture impairment was also one of secondary service connection. More specifically, he contended that these disabilities are secondary to his prostate cancer and related and functional impairment. 38 C.F.R. § 3.310. The Board has considered the evidence of record, and finds that metastatic cancer of the back, a disability manifested by muscle weakness, aches, and pains, and a disability manifested by posture impairment are not related to service, and are less likely than not proximately due to, the result of, or aggravated by any service connected disability. Indeed, the aforementioned VA examiners linked any metastatic cancer in the back to prostate cancer. Service connection has not been established for prostate cancer. See September 2020 Board Decision and Remand. There is no other link or nexus to another service-connected disease or injury. The Board has liberally considered the Veteran's claims for all theories of entitlement, including secondary service connection. For example, for any muscle aches or posture impairment, the October 2020 VA examiner suggested that there is no diagnosed chronic condition. Still, we considered impairment due to pain and other functional impairment. However, there is still no link to service-connected disease or injury, as required for secondary service connection. The VA examiners consistently noted other, post-service factors. We have assigned the most probative weight to their medical conclusions regarding the etiology of these disease entities. Therefore, service connection under a secondary theory of entitlement for metastatic cancer of the back, a disability manifested by muscle weakness, aches, and pains, and a disability manifested by posture impairment is not warranted. 38 C.F.R. § 3.310. In addition, such disease entities, even if variously diagnosed, are not presumptive diseases based upon his time at Camp Lejeune, and there is no competent evidence linking the remote onset to service. 38 C.F.R. § 3.309(f). There are not diagnostic impressions of disabilities for which the Camp Lejeune presumption is applicable, and there is no probative evidence demonstrating relationship between the claimed conditions and service. See Combee, supra. In short, the most probative evidence is the Veteran's lay reported history and the October 2020 and March 2021 VA medical opinions of the examining physicians. They sympathetically reviewed the Veteran's medical history and considered his lay contentions. The most probative evidence establishes a remote onset of any back, muscle, and skeletal pathology several years after discharge. We have considered direct service connection and theories of both a chronic disease manifesting within one year from separation and continuity of symptomatology where applicable. 38 C.F.R. §§ 3.303, 3.307, 3.309. In this regard, we have specifically considered Saunders. Even assuming conclusive back pathology aside from metastatic cancer were competently identified decades earlier, though we do not concede this, there is still no nexus to service. Our heightened duty has been fulfilled considering the Veteran's lay statements and also affording him two examinations by skilled physicians. The private medical opinions are outweighed by the more probative VA medical opinions, which include complete reasons and bases citing to medical literature and evidence in the claims file. The most probative evidence establishes the remote onset of any back or muscle impairment. There is also no nexus to other service-connected disability. 38 C.F.R. § 3.310. Therefore, accrued benefits for service connection for metastatic cancer of the back, a disability manifested by muscle weakness, aches, and pains, and a disability manifested by posture impairment, to include as secondary to prostate cancer, are not warranted. 4. Entitlement to accrued benefits for service connection for erectile dysfunction, claimed as secondary to prostate cancer 5. Entitlement to accrued benefits for service connection for bladder impairment with catheter and incontinence, claimed as secondary to prostate cancer 6. Entitlement to accrued benefits for service connection for a sleep disturbance disability, claimed as secondary to prostate cancer The Board incorporates its discussion from the sections above by reference. As a threshold issue, except as provided in § 3.300(c), disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310 (a). This decision has denied service connection for prostate cancer, this theory of entitlement is precluded. Nevertheless, the Veteran may still pursue avenues of service connection based upon direct service connection, presumptive service connection as a chronic disease manifesting in service or within one year from separation, and based upon conceded CLCW exposure. See Shedden, Combee, both supra; 38 C.F.R. § 3.309. In addition, the Board observes that the Veteran has claimed service connection for bladder impairment. We note that only diagnosed bladder cancer is a presumptive condition for CLCW. 38 C.F.R. § 3.309(f). By way of history, a VA 21-4138 Statement in Support of Claim dated January 15, 2014 is of record. The Veteran reported prostate cancer with removal of the prostate in 1997. On page 2, he described discomforts, including not getting proper sleep because of needing to empty his catheter every 2-21/2 hours. Many years later, at the April 2017 hearing, the Veteran presented competent testimony regarding erectile and bladder impairment. First, the Veteran testified that since 1969, he has been unable to satisfy his wife. See April 2017 Hearing Transcript, p. 25. The Veteran testified that he gets infections from pads in his shorts when they get filled up. He has a catheter he wears. He explained, "And it lasts for 20, 24 hours, and it takes care of the leakage." They still leak if you do not get them on just right. The Veteran explained his treatment history, "So, I had all these urologists, I have 15 over the course of the year now, you know, we'll watch it, we'll watch it. Well, the PSA went from, low six, after I had seeds put in, and this after I had the seeds, well, the cancer center put, Dr. [F.] (phonetic sp.). And, and then I thought it was okay, and I wasn't okay, because the cancer is like, it's in a cage, and it's a lion in the cage, and it escapes." See April 2017 Hearing Transcript, p. 14. Also at the April 2017 hearing, the Veteran also provided competent lay testimony of experiencing sleep disturbances. He explained, "Well, I have to get up between four and seven times a night to empty my catheter." See April 2017 hearing Transcript, p. 24. The previous night, he slept about three hours. Id. at p. 17. Next, a VA problem list from the July 2018 VA treatment records includes hypertonicity of the bladder, with a date of August 28, 2007. It does not show a diagnosis of bladder cancer. Additional VA treatment records show remote notations of bladder impairment, and are substantially the same. Recently, the appellant was afforded a lengthy series of VA medical opinions in late 2020 and early 2021. We will address the two clusters in chronological order. First, the Veteran was afforded a set of October 2020 VA medical opinions performed by A. H., M.D. Both physicians sympathetically reviewed the entire claims file. First, in October 2020, Dr. A. H. provided a medical opinion regarding erectile dysfunction (ED). In her review of the records, under Contention 1, she wrote, "The Veteran does not have an established diagnosis of erectile dysfunction." Under Contention 2, she opined, "The diagnosis of erectile dysfunction is not confirmed and is less likely as not caused by or a result of the Veteran's exposure to CLCW." On the last page is a detailed rationale citing to medical literature. The physician concluded, "Mr. [Veteran] claimed to have erectile dysfunction, but no urology records or other records regarding this complaint were provided for review. Most men of Mr. [Veteran's] age have erectile dysfunction. Erectile dysfunction is very common after treatment for prostate cancer. Mr. [Veteran] also has risk factors of hypertension and hyperlipidemia." Turning to the bladder, Dr. A. H. similarly rendered a negative nexus opinion. Under Contention 1 she found diagnosed bladder impairment, however no relationship to CLCW under Contention 2. Dr. A. H. ultimately determined, "Given that the bladder impairment was characterized as irritability secondary to radiation cystitis, it would be due to that, not to other causes. Therefore, it was less likely as not caused by or related to Mr. [Veteran's] exposure to CLCW." She cited medical principles and evidence from the lengthy claims file to support her conclusion. For sleep impairment, the October 2020 VA examiner found no diagnosed chronic disability. She described, "Mr. [Veteran] claimed sleep disturbance as having to get up multiple times at night to empty his urinary catheter. This would not be a primary sleep disorder and no sleep disorders were documented in the file provided for review. No primary sleep disorder was confirmed, so it was less likely as not caused by or related to Mr. [Veteran's] exposure to CLCW." Next, regarding a sleep disability, the Veteran was afforded a February 24, 2021 VA examination, received by VA in March 2021. S. J., a psychologist, reviewed the entire claims file. S. J. ultimately indicated a positive nexus opinion for direct service connection for any sleep impairment. Her rationale, however, does not conclusively establish that she intended to indicate that sleep disturbance was directly related to service. She described a history of sleep complaints back to 2007 due to his overactive bladder from prostate cancer. She provided a rationale that includes a secondary service connection nexus opinion, but a negative nexus for direct service connection. S. J. concluded: Therefore, if there does not have to be a formal diagnosis of sleep disorder and the VA only needs to know if the veterans complaints of sleep are secondary to the Prostate cancer, then it is in my medical opinion that the veterans reported sleep issues at least as likely as not stem from the overactive bladder from his Prostate Cancer. Research is supportive that sleeping is a common issue for men with prostate cancer (3-2020, prostate.org). A study following 3,348 men with prostate cancer found that 19% of them indicated severe sleep issues due to many issues including urinary symptoms of needing to urinate more. This is consistent with the veterans reports from back in 2007 as mentioned above. . . . . His sleep disorder is less likely than not a direct result of his time in service as he did not have reported sleep problems in the service and his first report of sleep issues was due to his over active bladder. He has reported sleep issues as a result of his overactive bladder which is directly related to his Prostate cancer. Days later, in March 2021, the appellant was afforded another set of VA medical opinions from Dr. P. G. Dr. P. G. provided a detailed history of the relevant treatment records. He ultimately rendered negative nexus opinions, implicitly encompassing all theories of direct and presumptive service connection. The physician provided a rationale, "[N]o complaints found in records for erectile dysfunction during service. Although it would be presumed that erectile dysfunction could be secondary to prostate cancer, Veteran has other factors such as age, which was the biggest risk factor for him." Consistent with previous examination results, the physician rendered a negative nexus opinion for bladder impairment. The VA examiner explained, "Veteran's bladder impairment is secondary to the service connected prostate cancer. Bladder impairment resulted in incontinence and catheter usage. It is noted that the veteran had bladder irritability secondary to radiation cystitis, which per medical record review, persisted." The appellant contends that she is entitled to accrued benefits for service connection for erectile dysfunction, bladder impairment, and sleep disturbance disabilities, all claimed as secondary to prostate cancer. The Veteran was competent to provide evidence of that which he experienced, including his symptomatology and medical history. Layno v. Brown, 6 Vet. App. 465, 469 (1994). He was competent to report prostate changes in 1997 and subsequent impairment in his bladder, ability to maintain an erection, and an impact on sleep. The Veteran was also competent to relate what he has been told by a professional. He is competent to report when he began receiving treatment for erectile dysfunction, that he has impairment, and when disability was first identified by physicians. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The most probative evidence is the October 2020 and March 2021 VA medical opinions, in addition to the Veteran's own lay reported history, to it is competent. First, we have considered our heightened duty in light of the missing STRs. The Veteran's own lay reporting establishes the onset of claimed disease entities several years after separation. For example, at the April 2017 hearing, the Veteran presented competent testimony regarding erectile and bladder impairment. First, the Veteran testified that since 1969, he has been unable to satisfy his wife. See April 2017 Hearing Transcript, p. 25. This onset is more than one decade removed from separation. Nevertheless, the Veteran's theory of entitlement was largely one of secondary to service connection to prostate cancer. Thus, the earliest record of the Veteran having the claimed disabilities was still several decades removed from separation. Therefore, we assign substantial probative weight to the Veteran's lay testimony, to the extent it is competent. Second, we assign the most probative weight to the October 2020 and March 2021 VA medical opinions. The VA examiners reviewed the claims file, and rendered a series of negative nexus opinions. They based these upon their medical expertise. There are no positive nexus opinions for any theory of entitlement, given that prostate cancer is not service-connected. The VA examiners cited other factors. First, in October 2020, there was not necessarily a diagnosed, chronic bladder or sleep disability. However, liberally construing the Veteran's claims under Saunders, there were lay reports of impairment even without a formal diagnosis. Turning to sleep disturbance, the February 2021 VA medical opinion from S. J., received in March 2021, describes the etiology of sleep interruption. Although a positive nexus is generally indicated, the psychologist clarified her findings, "His sleep disorder is less likely than not a direct result of his time in service as he did not have reported sleep problems in the service and his first report of sleep issues was due to his over active bladder. He has reported sleep issues as a result of his overactive bladder which is directly related to his Prostate cancer." In short, there was not a formal diagnosis of a sleep disturbance disability, but even liberally construing reports of impairment, sleep disturbances were not related to service or service-connected disability. Days later, the March 2021 VA examiner most recently described the onset of the disease entities in relation to the Veteran's overall medical history. The physician provided a rationale, "Although it would be presumed that erectile dysfunction could be secondary to prostate cancer, Veteran has other factors such as age, which was the biggest risk factor for him." Consistent with previous examination results, the physician rendered a negative nexus opinion for bladder impairment. The VA examiner explained, "Bladder impairment resulted in incontinence and catheter usage. It is noted that the veteran had bladder irritability secondary to radiation cystitis, which per medical record review, persisted." Therefore, we assign the most probative weight to the October 2020 and March 2021 VA medical opinions by Dr. A. H., S. J, and Dr. P. G. In obtaining these medical opinions, we note that if the medical evidence of record is insufficient, or, in the opinion of the Board, of doubtful weight or credibility, the Board is always free to supplement the record by seeking an advisory opinion, ordering a medical examination or citing recognized medical treatises in its decisions that clearly support its ultimate conclusions. However, it is not free to substitute its own judgment for that of such an expert. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). Here, regarding direct or presumptive service connection, we find that the Veteran did not have the characteristic manifestations necessary to identify the disease entities in service. Erectile dysfunction, bladder impairment, and sleep disturbance disabilities were not manifest in service or within one year from separation, and are not otherwise attributable to service. There is no probative evidence to the contrary. In addition, the Board finds that while competent to report what he has been told by his physician and to report being diagnosed with prostate cancer in the summer of 1997, the Veteran's own lay opinion regarding identifying a potential chronic disease entity, such as organic disease of the nervous system, pales in probative weight when compared to the objective medical evidence of record. Additional causal evidence against the claims, and while not dispositive, is the lapse of so many years between discharge and the first documented medical complaints leading to a diagnosis and treat several decades removed from separation. Indeed, the Veteran's own history of seeking treatment places the onset of impairment many decades after discharge. This multi-year gap after service provides highly probative evidence against these claims. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (indicating that "evidence of a prolonged period without medical complaint can be considered, along with other factors concerning the [V]eteran's health and medical treatment during and after military service, as evidence of whether a pre-existing condition was aggravated by military service"). An alternative method of establishing the second and third Shedden element, under 38 C.F.R. § 3.303 (b), is through a demonstration of continuity of symptomatology if the disability claimed qualifies as a chronic disease listed in 38 C.F.R. § 3.309 (a). Consideration of entitlement to service connection via the demonstration of continuity of symptomatology is applicable in the present case. However, the most probative evidence in the Veteran's lay statements and VA medical opinions does not demonstrate such continuity. The VA examining physicians described the Veteran's medical history showing the remote onset of the claimed disease entities several decades after separation. Consequently, we find that service connection on a direct and presumptive basis for erectile dysfunction, bladder impairment, and sleep disturbance disabilities is not warranted. Next, it appears the Veteran's central theory of entitlement to service connection for erectile dysfunction, bladder impairment, and sleep disturbance disabilities was also one of secondary service connection. More specifically, he contended that these disabilities are secondary to his prostate cancer and related and functional impairment. 38 C.F.R. § 3.310. The Board has considered the evidence of record, and finds that erectile dysfunction, bladder impairment, and sleep disturbance disabilities are not related to service, and are less likely than not proximately due to, the result of, or aggravated by any service connected disability. Indeed, the aforementioned VA examiners linked any erectile, bladder, and sleep impairment to prostate cancer and other non-service-connected factors. See September 2020 Board Decision and Remand. There is no other link or nexus to another service-connected disease or injury. We have liberally construed the Veteran's claims. For example, for any sleep impairment, the October 2020 VA examiner suggested that there is no diagnosed chronic condition. Still, the subsequent VA examiner, S. J., considered impairment due to pain and other functional impairment of the ability to sleep. Unfortunately, there is still no link to service-connected disease or injury, as required for secondary service connection. The VA examiners consistently noted post-service factors. We have assigned the most probative weight to the VA examiners' medical conclusions regarding the etiology of the disease entities. Therefore, service connection under a secondary theory of entitlement for erectile dysfunction, bladder impairment, and sleep disturbance disabilities is not warranted. 38 C.F.R. § 3.310. In short, the most probative evidence is the Veteran's lay reported history and the October 2020 and March 2021 VA medical opinions of the examining clinicians. They sympathetically reviewed the Veteran's medical history and considered his lay contentions. The most probative evidence establishes a remote onset of any nerve or genitourinary pathology several years after discharge. These disease entities are not presumptive diseases based upon his time at Camp Lejeune, such as bladder cancer. 38 C.F.R. § 3.309(f). There is also no probative evidence demonstrating relationship between the claimed conditions and events in service. See Combee, supra. We have considered direct service connection and theories of both a chronic disease manifesting within one year from separation and continuity of symptomatology where applicable. 38 C.F.R. §§ 3.303, 3.307, 3.309. In this regard, we have specifically considered Saunders. Even assuming a chronic sleep disability were competently identified decades earlier, though we do not concede this, there is still no nexus to service. Our heightened duty has been fulfilled considering the Veteran's lay statements and also affording him two examinations by skilled physicians. The private medical opinions are outweighed by the more probative VA medical opinions, which include complete reasons and bases citing to medical literature and evidence in the claims file. There is also no nexus to other service-connected disability. 38 C.F.R. § 3.310. Therefore, accrued benefits for service connection for erectile dysfunction, bladder impairment, and sleep disturbance disabilities are not warranted. Special Monthly Compensation (SMC) 7. Entitlement to accrued benefits for special monthly compensation (SMC) based on loss of use, claimed as impotence The Board incorporates its discussion from the sections above by reference. 38 C.F.R. § 3.350 Special monthly compensation ratings. The rates of special monthly compensation stated in this section are those provided under 38 U.S.C. § 1114. (a) Ratings under 38 U.S.C. § 1114(k). Special monthly compensation under 38 U.S.C. § 1114(k) is payable for each anatomical loss or loss of use of one hand, one foot, both buttocks, one or more creative organs, blindness of one eye having only light perception, deafness of both ears, having absence of air and bone conduction, complete organic aphonia with constant inability to communicate by speech or, in the case of a woman veteran, loss of 25% or more of tissue from a single breast or both breasts in combination (including loss by mastectomy or partial mastectomy), or following receipt of radiation treatment of breast tissue. This special compensation is payable in addition to the basic rate of compensation otherwise payable on the basis of degree of disability, provided that the combined rate of compensation does not exceed the monthly rate set forth in 38 U.S.C. § 1114(l) when authorized in conjunction with any of the provisions of 38 U.S.C. § 1114 (a) through (j) or (s). When there is entitlement under 38 U.S.C. § 1114 (l) through (n) or an intermediate rate under (p) such additional allowance is payable for each such anatomical loss or loss of use existing in addition to the requirements for the basic rates, provided the total does not exceed the monthly rate set forth in 38 U.S.C. § 1114(o). The limitations on the maximum compensation payable under this paragraph are independent of and do not preclude payment of additional compensation for dependents under 38 U.S.C. § 1115, or the special allowance for aid and attendance provided by 38 U.S.C. § 1114(r). (1) Creative organ. (i) Loss of a creative organ will be shown by acquired absence of one or both testicles (other than undescended testicles) or ovaries or other creative organ. Loss of use of one testicle will be established when examination by a board finds that: (a) The diameters of the affected testicle are reduced to one-third of the corresponding diameters of the paired normal testicle, or (b) The diameters of the affected testicle are reduced to one-half or less of the corresponding normal testicle and there is alteration of consistency so that the affected testicle is considerably harder or softer than the corresponding normal testicle; or (c) If neither of the conditions (a) or (b) is met, when a biopsy, recommended by a board including a genitourologist and accepted by the veteran, establishes the absence of spermatozoa. (ii) When loss or loss of use of a creative organ resulted from wounds or other trauma sustained in service, or resulted from operations in service for the relief of other conditions, the creative organ becoming incidentally involved, the benefit may be granted. (iii) Loss or loss of use traceable to an elective operation performed subsequent to service, will not establish entitlement to the benefit. If, however, the operation after discharge was required for the correction of a specific injury caused by a preceding operation in service, it will support authorization of the benefit. When the existence of disability is established meeting the above requirements for nonfunctioning testicle due to operation after service, resulting in loss of use, the benefit may be granted even though the operation is one of election. An operation is not considered to be one of election where it is advised on sound medical judgment for the relief of a pathological condition or to prevent possible future pathological consequences. (iv) Atrophy resulting from mumps followed by orchitis in service is service connected. Since atrophy is usually perceptible within 1 to 6 months after infection subsides, an examination more than 6 months after the subsidence of orchitis demonstrating a normal genitourinary system will be considered in determining rebuttal of service incurrence of atrophy later demonstrated. Mumps not followed by orchitis in service will not suffice as the antecedent cause of subsequent atrophy for the purpose of authorizing the benefit. 38 C.F.R. § 3.350. If the veteran, as the result of service-connected disability, has suffered the anatomical loss or loss of use of one or more creative organs, or one foot, or one hand, or both buttocks, or blindness of one eye, having only light perception, has suffered complete organic aphonia with constant inability to communicate by speech, or deafness of both ears, having absence of air and bone conduction, or, in the case of a woman veteran, has suffered the anatomical loss of 25 percent or more of tissue from a single breast or both breasts in combination (including loss by mastectomy or partial mastectomy) or has received radiation treatment of breast tissue, the rate of compensation therefor shall be $96 per month for each such loss or loss of use independent of any other compensation provided in subsections (a) through (j) or subsection (s) of this section but in no event to exceed $3,327 per month; and in the event the veteran has suffered one or more of the disabilities heretofore specified in this subsection, in addition to the requirement for any of the rates specified in subsections (l) through (n) of this section, the rate of compensation shall be increased by $96 per month for each such loss or loss of use, but in no event to exceed $4,667 per month. 38 U.S.C. § 1114(k). By way of background, a VA 21-4138 Statement in Support of Claim dated January 15, 2014 is of record. The Veteran reported that in 1996 his urologist misdiagnosed his PSA results which resulted in full-blown prostate cancer. On page 2, he writes that he has not had a physical erection since 1997 which puts a strain on his marriage. Next, at the April 2017 hearing, the Veteran testified that since 1969, he has been unable to satisfy his wife. See April 2017 Hearing Transcript, p. 25. Later, the October 2020 and March 2021 VA examiners found remote impressions of erectile dysfunction. Earlier in this Decision, the Board denied accrued benefits for service connection for erectile dysfunction. This claim remains. The appellant contends that she is entitled to accrued benefits for SMC under 38 U.S.C. § 1114 (k) based upon loss of use. The Veteran was competent to report erectile impairment. Layno v. Brown, 6 Vet. App. 465, 469 (1994). The Veteran was competent to relate what he has been told by a professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The most probative evidence is the contemporaneous treatment records, lay testimony, and the findings of the October 2020 and March 2021 VA examiners. First, the Veteran's own lay history places the onset of erectile impairment to 1969. He later had prostate cancer in 1997. Private treatment records are generally consistent with this history. We assign substantial probative weight to the Veteran's lay history to the extent it is competent and corroborated by the treatment records. Second, the Board assigns the most probative weight to the findings of the October 2020 and March 2021 VA examiners. The October 2020 VA examiner found no "confirmed" diagnosis of erectile dysfunction. The March 2021 VA examiner did not find a medical history of erectile dysfunction, however he opined that any impairment would presumably be attributable to other, non-service connected factors. Still, under Saunders, the absence of a formally diagnosed chronic condition does not preclude compensation. Here, we find that pursuant to the specific statutory requirements, entitlement to accrued benefits for special monthly compensation based on loss of use is not warranted. The Veteran still did not meet the specific criteria, regardless of a formal diagnosis. The criteria for entitlement are not met because the objective medical evidence does not demonstrate loss of use of a creative organ due to one or more service-connected disabilities. The most probative evidence in the VA examination results has failed to identify a current service connected disability resulting in loss of erectile power or deafness in the ears, as required by the governing statute. The medical evidence also did not demonstrate deafness of both ears. Overall, the Veteran did not have anatomical loss or loss of use of one hand, one foot, both buttocks, one or more creative organs, blindness of one eye having only light perception, deafness of both ears, or complete organic aphonia with constant inability to communicate by speech. Several years passed during which the Veteran and his representative were able to supplement the claims file. There is no probative evidence to the contrary. There is no doubt to resolve. Therefore, SMC 1114(k) based on loss of use is not warranted. 8. Entitlement to accrued benefits for special monthly compensation (SMC) based on housebound status 9. Entitlement to accrued benefits for special monthly compensation (SMC) based on aid and attendance from another The Board incorporates its discussion from the sections above by reference. If the Veteran, as the result of service-connected disability, has suffered the anatomical loss or loss of use of both feet, or of one hand and one foot, or is blind in both eyes, with 5/200 visual acuity or less, or is permanently bedridden or with such significant disabilities as to be in need of regular aid and attendance, the monthly compensation shall be $3,327. 38 U.S.C. § 1114 (l). The special monthly compensation provided by 38 U.S.C. § 1114(l) is payable for anatomical loss or loss of use of both feet, one hand and one foot, blindness in both eyes with visual acuity of 5/200 or less, or being permanently bedridden, or so helpless as to be in need of regular aid and attendance. 38 C.F.R. § 3.350 (b). If the Veteran has a service-connected disability rated as total, and (1) has additional service-connected disability or disabilities independently ratable at 60 percent or more, or, (2) by reason of such veteran's service-connected disability or disabilities, is permanently housebound, then the monthly compensation shall be $2,993. For the purpose of this subsection, the requirement of "permanently housebound" will be considered to have been met when the veteran is substantially confined to such veteran's house (ward or clinical areas, if institutionalized) or immediate premises due to a service-connected disability or disabilities which it is reasonably certain will remain throughout such veteran's lifetime. 38 U.S.C. § 1114 (s). The following will be accorded consideration in determining the need for regular aid and attendance (§ 3.351(c)(3): inability of claimant to dress or undress himself (herself), or to keep himself (herself) ordinarily clean and presentable; frequent need of adjustment of any special prosthetic or orthopedic appliances which by reason of the particular disability cannot be done without aid (this will not include the adjustment of appliances which normal persons would be unable to adjust without aid, such as supports, belts, lacing at the back, etc.); inability of claimant to feed himself (herself) through 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 the claimant from hazards or dangers incident to his or her daily environment. "Bedridden" will be a proper basis for the determination. For the purpose of this paragraph "bedridden" will be that condition which, through its essential character, actually requires that the claimant remain in bed. The fact that 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 of the disabling conditions enumerated in this paragraph be found to exist before a favorable rating may be made. The particular personal functions which the veteran is unable to perform should be considered in connection with his or her condition as a whole. It is only necessary that the evidence establish that the veteran is so helpless as to need regular aid and attendance, not that there be a constant need. Determinations that the veteran 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. 38 C.F.R. § 3.352 (a). By way of background, a prostate cancer Disability Benefits Questionnaire (DBQ) is of record completed by R. K., received by VA in August 2013. It shows that the Veteran was on chemotherapy for prostate cancer. He used a liberty appliance for voiding. Weeks later, on August 21, 2013, VA received a cache of documents labeled "Congressionals." Within the cache is a VA 21-2680 Examination for Housebound Status or Permanent Need for Regular Aid and Attendance. It does not contain a date, though the upper left of the facsimile shows August 21, 2013 at 10:40 AM. The heading shows that the claimant is the Veteran's wife. The Veteran was able to feed himself, prepare his own meals, and manage his own financial affairs. The Veteran did not need assistance bathing, was not legally blind, did not require nursing home care, and did not require medication management. His gait was "jerky." The Veteran had poor balance which caused falls. Still, he was able to leave the house anytime, though he leaned on shopping carts in stores. Dr. A. H. is written in as the examining physician, however, the form is not signed and dated at the end. Next, a VA 21-4138 Statement in Support of Claim dated January 15, 2014 is of record. The Veteran reported prostate cancer with removal of the prostate in 1997. On page 2, he described discomforts, including not getting proper sleep because of needing to empty his catheter every 2-21/2 hours. The August 2015 Notice of Disagreement (NOD) lists the issues but contains no specific argument or reasons for why the benefits sought are warranted. Later, on remand in September 2020, the Board ordered that VA should assist the Veteran and his representative to fully develop these SMC claims. This includes completion and submission of a VA Form 21-2680 (Examination for Housebound Status or Permanent Need for Regular Aid and Attendance). VA sent a copy of this as part of the duty to assist as part of a development letter dated October 6, 2020. No response was received. The appellant contends that she is entitled to accrued benefits for special monthly compensation based on housebound status and aid and attendance. In this case, the Board is considering the issue of entitlement to accrued benefits for SMC based upon the need for aid and attendance or based upon housebound status. Each benefit is contingent upon the severity of service-connected disability. The Veteran was not currently service-connected for any disabilities, and was not in receipt of a total disability rating based on individual unemployability (TDIU). There is only a dated August 2013 VA Examination for Housebound Status or Permanent Need for Regular Aid and Attendance, with an uncertain author. Whether completed by a physician or his spouse, the Board has no reason to doubt the truth that the Veteran was largely self-sufficient. We have also considered his lay argument and descriptions of his medical history throughout the appeals period. The Veteran appears to have asserted the need for aid and attendance primarily due to non-service-connected prostate cancer. In other words, service connection has not been granted for this disability. It has also not been established for a back disability. The Veteran and his spouse were competent to report that the Veteran was diagnosed with prostate cancer. It was their belief that he required home care, and that aid and attendance was necessary. We have fully considered these contentions. Unfortunately, special monthly compensation based on aid and attendance is not warranted based on the Veteran's non-service connected disabilities. The above referenced August 2013 VA Form 21-2680 explicitly indicates the Veteran was able to feed himself, prepare his own meals, and manage his own financial affairs. The Veteran did not need assistance bathing, was not legally blind, did not require nursing home care, and did not require medication management. His gait was "jerky." The Veteran had poor balance which caused falls. Still, he was able to leave the house anytime, though he leaned on shopping carts in stores. The Veteran is not service connected for gait disability. Ongoing VA and private treatment records show impairment, but do not show that he was helpless due to service-connected disability. Here, the most probative evidence establishes that his need for additional care is due to prostate cancer and its residuals. The Veteran was able to leave the home "anytime." This is capable of lay observation, even without a physician signing the August 2013 examination. In short, he was not 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 He is not service-connected for any disabilities. 38 C.F.R. § 3.352 (a). He was able to dress or undress himself, or to keep himself ordinarily clean and presentable. Id. In addition, he had not suffered the anatomical loss or loss of use of both feet, or of one hand and one foot, or is blind in both eyes, with 5/200 visual acuity or less. Even if he had a total disability (TDIU) due to a single service connected disability, though this was not the case, he did not have separately ratable disability rated as 60 percent disabling. 38 C.F.R. § 3.350 (b). The Board is sympathetic to the appellant's circumstances, however, we are bound by the criteria in the governing statutes. Regrettably, accrued benefits for special monthly compensation based on housebound status and aid and attendance are denied. Neither the appellant nor her representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). In reaching these conclusions, the Board is very sympathetic to the appellant's circumstances and the emotional hardship that she has endured in the loss of her husband, the Veteran. Unfortunately, the Board finds that the preponderance of the evidence is against the claims for accrued benefits, and as such, the benefit of the doubt rule is not for application, and the claims must be denied. 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Michael A. Pappas Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Bodi, 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.