Citation Nr: 21042836 Decision Date: 07/14/21 Archive Date: 07/14/21 DOCKET NO. 17-09 205 DATE: July 14, 2021 ORDER Entitlement to service connection for a neurologic condition, to include infiltrating astrocytoma with secondary vasculitis (claimed as CNS lymphoma) is denied. Entitlement to SMC based on the need for aid and attendance or on housebound status is denied. FINDINGS OF FACT 1. The preponderance of the evidence is against finding that infiltrating astrocytoma with secondary vasculitis (claimed as CNS lymphoma) began during active service, or is otherwise related to an in-service injury or disease. 2. The Veteran's service-connected disabilities themselves do not cause the need for regular aid and attendance of another person. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a neurologic condition, to include infiltrating astrocytoma with secondary vasculitis (claimed as CNS lymphoma) are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307. 3.309. 2. The criteria for entitlement to SMC for aid and attendance are not been met. 38 U.S.C. §§ 1114(l), 5107; 38 C.F.R. §§ 3.102, 3.350, 3.352(a). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from March 1966 to December 1969, to include in the Republic of Vietnam. He is in receipt of the Combat Action Ribbon. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a September 2016 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In January 2020, the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge; a transcript of the hearing is of record. In November 2020, the Board remanded the issues on appeal for further development. There has been substantial compliance with remand directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). 1. Entitlement to service connection for a neurologic condition, to include infiltrating astrocytoma with secondary vasculitis (claimed as CNS lymphoma) is denied. The Veteran asserts that his current neurologic condition, previously claimed as CNS lymphoma, is due to his exposure to Agent Orange and Camp Lejeune contaminated water (CLCW). At the outset, service connection for an infiltrating astrocytoma with secondary vasculitis (astrocytoma) is not warranted on a presumptive basis. Service connection for astrocytoma, as a chronic disease per 38 C.F.R. § 3.309(a), is not warranted. There is no competent medical evidence showing the onset or development of a malignant tumor, or astrocytoma (manifesting as a tumor of the brain or spinal cord) in service or within one year of discharge. There also is no credible or competent report of symptoms that were noted in service or within a presumptive period with continuity thereafter that are shown to be initial manifestations of the current astrocytoma. Hence, service connection for astrocytoma may not be presumed as a chronic disease. See 38 C.F.R. §§ 3.307(a)(3), 3.309(a). The service personnel records show the Veteran served in the Republic of Vietnam during the Vietnam War era. He also is noted to have had service of at least 30 days at Camp Lejeune during the applicable time period, such that exposure to contaminated drinking water is conceded. However, the Veteran's astrocytoma is not one of the qualifying chronic diseases listed under 38 C.F.R. §§ 3.307(a)(6,)(7); 3.309(e), (f). Further, a VA examiner (who is also a CLCW subject matter expert) opined that the Veteran's astrocytoma is not caused by or related to exposure to herbicide agents or CLCW exposures. Therefore, presumptive service connection based on exposure to either herbicide agents or CLCW is not warranted. See 38 C.F.R. §§ 3.307(a)(6,)(7); 3.309(e), (f). Nevertheless, the Veteran is not precluded from establishing service connection with proof of direct causation, or on any other recognized basis. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). The question for the Board then, is whether the Veteran's current astrocytoma began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that, while the Veteran has a current diagnosis of infiltrating astrocytoma with secondary vasculitis (astrocytoma), the preponderance of the evidence weighs against finding that this condition began during service or is otherwise related to an in-service injury, event, or disease, to include exposure to herbicide agents and CLCW. Turning to the evidence of record, service treatment records are silent for complaints/treatment or diagnosis of astrocytoma. VA treatment records show the Veteran was not diagnosed with astrocytoma until February 2012, over 40 years after his separation from service. While the Veteran is competent to report symptoms of tremors and having strokes and seizures, he is not competent to provide a diagnosis in this case or determine that these symptoms were manifestations of astrocytoma. The issue is medically complex, as it requires interpretation of complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). It is noted, between July 2010 and April 2015, VA treatment records and VA medical opinions reveal that the Veteran underwent various testing to determine his diagnosis. The findings, as noted in an April 2015 VA examination report concluded and confirmed that the Veteran's previously claimed diagnosis of central nervous system (CNS) lymphoma, was incorrect. Rather, the diagnosis was a primary tumor of the brain astrocytoma. However, there was no nexus opinion of record to explain the nature and etiology of this condition, as the only assessment at the time was whether the Veteran had a current diagnosis of CNS lymphoma, which he does not. During the course of this appeal, the Veteran, through his family members, testified at a Board hearing in January 2020. The Veteran asserted that medical literature supports a nexus between his astrocytoma and exposure to herbicide agents. The Veteran cited symptoms he suffered from, such as tremors, strokes, and seizures, to demonstrate a similarity between Parkinson's disease (a presumptive condition for which he is not service connected) and astrocytoma. In March 2020, the Veteran also submitted a favorable medical opinion from a private neuroradiologist, C.B. Dr. C.B. opined that the Veteran's astrocytoma more likely than not was a result of his exposure to herbicides in Vietnam and exposure to contaminated water at Camp Lejeune, North Carolina. Dr. C.B. further opined that the Veteran's astrocytoma caused stroke with hemiplegia, seizure disorder, vascular dementia, bowel and bladder incontinence and neurocognitive symptoms. The rationale noted the Veteran's service records and his documented service in Vietnam and Camp Lejeune as in-service events, "potentially responsible for the claimed condition." Dr. C.B. stated that Camp Lejeune water was contaminated and identified two main chemicals, noting that there were more than 70 contaminants at Camp Lejeune. Dr. C.B. indicated that the Veteran's exposure to chemical contaminants at Camp Lejeune constituted another in-service event, "potentially responsible for the claimed condition." Dr. C.B. noted the Veteran's diagnosis of astrocytoma and indicated that the Veteran submitted literature which described the nature of this diagnosis and risk factors, including genetic predisposition, radiation exposure, chemical exposure, and viral disease. Dr. C.B. refuted a May 2013 VA medical opinion, which described astrocytoma as a "common" disease and noted that the Veteran did not report a history of radiation exposure and service records did not show evidence of a viral disease of the brain. Thus, Dr. C.B. determined that chemical exposure was left as the most likely etiology of the astrocytoma in this case, noting that medical literature, described both a correlation with exposure to dioxin and an explanation describing causation through cell alteration. Dr. C.B. ended by stating that the Veteran experienced a "double hit" in that, the chemical exposure from CLCW represented a second toxic exposure, "placing the Veteran at a yet higher risk for the development of astrocytoma." In November 2020 the Board remanded the Veteran's claim for service connection, to obtain a VA addendum opinion because Dr. C.B.'s rationale did not adequately explain how the Veteran's condition was related to the chemical exposures asserted. Rather, Dr. C.B. indicated that these two events of exposure to herbicide agents and CLCW, were potentially responsible for the Veteran's condition and provided citations to various studies/articles on astrocytoma, without the full text or sufficient explanation of the relevance to this Veteran's circumstances. Thus, Dr. C.B.'s March 2020 opinion had little probative value. Pursuant to the Board's remand, the RO obtained an addendum opinion in February 2021. The VA examiner, a CLCW subject matter expert, opined that the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. As this examiner's rationale explains at length, both why and how astrocytoma is less likely related to the Veteran's asserted exposure to CLCW and herbicide agents, for the sake of brevity, the Board will provide a summary. The VA examiner's rationale provided an overview of the Veteran's circumstances and assessed personal risk factors. Specifically, the examiner considered the Veteran's demographic including lifestyle, health, and post-service employment among other things and found that combined, his personal risk factors outweighed his in-service exposures, and thus, were more likely the cause of his brain tumor. The examiner cited to medical research and explained their findings and relevancy to the Veteran's particular case. One of the Veteran's risk factors discussed was his smoking. The VA examiner explained that the Veteran's smoking history of over 30 years, was a source of N-nitroso compounds that may have increased the Veteran's risk of developing a brain tumor. The VA examiner also discussed another notable personal risk factor, which was the Veteran's 35 years employment as a machinist. The examiner explained that doing injection molding was considered as increasing the Veteran's risk of brain cancer. The examiner explained how the Veteran's job involved die design, machining, grinding, injection process simulation and inspection. During the process of opening the injection molding machine and removing products, workers could be exposed to fumes released from the melted resins (acrylonitrile-butadiene-styrene (ABS), polyethylene (PE), polypropylene (PP), nylon, acetal, and polybutylene terephthalate (PBT)) and the risk of exposure to a large amount of fumes was especially high while the residual resin left in the injector was removed to change the dye. The examiner referenced the Agency for Toxic Substances and Disease Registry (ATSDR) fact sheet for acrylonitrile, which indicates that this chemical "may increase the risk of brain cancer in humans and has been linked to brain cancer in animals." In addition to the exposure from the resins, there were low levels of exposure to formaldehyde, acetaldehyde, and diphenylamine. Thus, according to the VA examiner, the Veteran's personal risk factors (ethnicity white; age 64; gender male; overweight; long-time smoker) and post-service workplace exposures to multiple carcinogens for over 35 years markedly increased his risk of brain cancer, particularly from the acrylonitrile and outweighed any short-term exposure of four months exposure at Camp Lejeune to solvents that have not been linked to brain cancer and the Veteran's tour of duty in Vietnam. The examiner continued that the International Agency for Research on Cancer (IARC) and National Academy of Science did not find a link between Agent Orange exposure with its dioxin contaminants and was not shown to be linked to brain cancer. The examiner discussed different workplace studies, including one by the ATSDR of Marines and Navy personnel exposed to TCE/PCE contaminated drinking water at USMC base at Camp Lejeune that was published in April 2018, which showed no significant increase hazard ratio of brain cancer when Camp Lejeune service members were compared with Camp Pendleton service members. Similar results were found for civilian workers at Camp Lejeune. The examiner explained that based on ATSDR assessment, the average duration of exposure to contaminated water at Camp Lejeune was 22 months for the average service member who was stationed there. The Veteran was only stationed there for four months, so his risk was 75 percent less than the average service member stationed at Camp Lejeune. Concluding that "this makes it extremely unlikely that the Veteran's short-term exposure to low levels of solvents in the drinking water at Camp Lejeune cause the Veteran's astrocytoma." The VA examiner also noted the Veteran's contention that exposure to herbicide agents increased his risk of developing brain cancer and astrocytoma. However, the examiner reported that the most recent Agent Orange update indicated that there was no association between Agent Orange and risk of astrocytoma. Specifically, the examiner reported that the latest 2018 Agent Orange Update noted that the scientific literature regarding exposure to dioxin and brain and other nervous system cancers, including glioblastoma and astrocytoma, was examined since the first VAO report. The body of evidence that has been developed did not find statistically significant associations between exposure and any relevant outcome in studies performed on Vietnam-veteran, occupational, or environmental cohorts. The VA examiner addressed Dr. C.B.'s March 2020 rationale noting that his reference to the NORD website regarding risk factors for astrocytoma, states that the cause of most astrocytomas is not known. The VA examiner noted that researchers speculate that genetic and immunologic abnormalities, environmental factors, diet, stress, and/or other factors may play a contributing role in causing specific types of cancer. The examiner explained that Dr. C.B. did not discuss the Veteran's age, ethnicity, gender, diet and weight, which taken together increase the Veteran's risk of developing brain cancer- astrocytoma. The examiner reiterated the Veteran's long-term smoking history and its link to brain cancer, including gliomas and meningiomas. The examiner also explained how Dr. C.B. did not mention the Veteran's 35-year work history as a machinist and his routine exposure to multiple resins. The examiner acknowledged Dr. C.B.'s claim that "medical literature submitted by the Veteran described both a correlation with exposure to dioxin and an explanation describing causation through cell alteration" and explained that while there "may be some evidence of a correlation that some event is related to some factor... it is not proof of causation. The bar for proving causation is set higher in terms of the medical science." The VA examiner continued to address Dr. C.B.'s assertions and articles, which generally appeared to be inaccurate excerpts of the studies mentioned or unavailable for review. The VA examiner did agree with Dr. C.B.'s rebuttal of the May 2013 VA opinion, which described astrocytoma as a "common" disease. The examiner indicated that astrocytoma was a rare cancer and reclassified by the World Health Organization (WHO) in 2016; however, "this has no bearing on whether astrocytoma can be caused by TCDD." The VA examiner also addressed the January 2020 lay report (opinion) provided by the Veteran's son, K.G., noting that he was not a physician, did not have an advance science degree like a Master's Degree in Epidemiology or Public Health and has not been trained on association, and causations and the key characteristics of a quality research study. The VA examiner explained that the medical literature provided by K.G. did not support the Veteran's contention because each veteran's particulars are different, notably, the Veteran's personal risk factors markedly increased his cancer risk and far outweighed any environmental risk due to Agent Orange in Vietnam and solvent exposure at Camp Lejeune. Scientific information submitted by K.G. was also acknowledged; however, the VA examiner explained that it did not show proof of causation between exposure to dioxin and solvents including TCE, PCE, vinyl chloride and benzene and astrocytoma. Notably, the examiner explained that while it is true that TCDD promotes tumor growth, it does so for Non-Hodgkin's lymphoma and soft tissue sarcoma and some other tumors of the blood forming organs. However, the IARC monograph in 2012 and the Agent Orange Update in 2018 both indicated that there was no link between dioxin exposure and risk of brain cancer to include astrocytoma. The Board finds the VA examiner's opinion highly probative because it was exceptionally thorough and comprehensive, and was based on review of the Veteran's relevant history and provides a detailed explanation supported by clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). In March 2021, a VA examiner opined that a neurologic condition, to include infiltrating astrocytoma with secondary vasculitis (claimed as CNS lymphoma) was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner's rationale explained that although Agent Orange was known to cause cancer, astrocytoma was not included in the list. Thus, it would be too speculative to conclude that astrocytoma was etiologically related to dioxin exposure. In May 2021, Dr. C.B. provided a rebuttal opinion to the VA examiners' opinion. Beginning with the March 2021 VA medical opinion, Dr. C.B. asserts that the rationale provided is inadequate. The Board notes that while the rationale is brief, it is based on accurate facts and thus, probative. Regarding the February 2021 VA medical opinion, Dr. C.B. asserts a bias because the VA examiner "goes to extreme lengths to rule out an association between this Veteran's exposures to toxins in service and this Veteran's astrocytoma." The Board notes that the comprehensive VA opinion from February 2021 was provided by a CLCW subject matter expert. Thus, in this regard, it is unsurprising that such thought and detail went into addressing the Veteran's asserted link which the examiner discussed both CLCW and Agent Orange exposure; the Veteran's contentions; and the various medical treatises provided in support of the claim. Accordingly, the Board does not find a bias in the February 2021 VA examiner's opinion, rather, a well-explained assessment as to how and why the Veteran's astrocytoma is less likely due to, caused by, or associated with an exposure to chemicals in-service. Dr. C.B. furthers that the examiner's bias is exposed in his application of statistical analysis; the way he discusses the analysis; and the examiner's rebuttal of his medical literature. Dr. C.B. claims that the examiner contradicted his own statistical analysis however, in reading the studies, the Board does not find a contradiction. Where the examiner indicates that "correlation is not evidence of causation," there is no statistical analysis, rather an explanation as to why Dr. C.B.'s reference to a medical literature describing a correlation is insufficient because it does not prove causation. Dr. C.B. claims that the VA examiner did not consider risk factors favorable to the claim such as the "fact there is no family history of brain tumors," which the examiner did not clearly rule out. However, the Veteran's family history was specifically contemplated in the examiner's assessment. The VA examiner noted that while about 5 percent of brain tumors may be linked to heredity, genetic factors or conditions (including Li-Fraumeni syndrome, neurofibromatosis, nevoid basal cell carcinoma syndrome, tuberous sclerosis, Turcot syndrome, and von Hippel-Lindau disease), the Veteran's claim file has no information regarding any of the genetic conditions listed above and he did not have a family history of brain cancer. Regarding Dr. C.B.'s claim that the examiner's "rebuttal" of his use of medical literature shows bias, the Board notes, that the examiner provided an explanation for the "average reader" (per Dr. C.B.) because his statement of cell mutation was misleading. It appears that because Dr. C.B. provided a favorable excerpt or snapshot to support the Veteran's claim, without explaining its relevance or application to the Veteran's specific case, the VA examiner had to review the full context to assess whether it indeed supported the claim, which apparently it did not. Dr. C.B. provided a rebuttal to the VA examiner's consideration of the Veteran's personal risks. Regarding smoking, he indicated that it cannot be said with reasonable certainty that it was more likely than not the cause of the Veteran's astrocytoma. Regarding the Veteran's post-service employment as a machinist, he indicated that the VA examiner did not discuss whether the Veteran was protected from chemical exposure during his work and noted that the Veteran provided a sworn statement (submitted with Dr. C.B.'s rebuttal opinion in May 2021) of such per OSHA guidelines. Dr. C.B. also addressed the Veteran's family history of no astrocytoma, his gender, and age. He reported that the VA examiner's opinion relied "significantly on the latest (2018) Agent Orange update to argue against service connection" and that the examiner admitted that "these studies have by and large been underpowered because of the relative rarity of these cancers" and explained that "we must turn to medical knowledge and reasoning." The Board acknowledges Dr. C.B.'s rebuttals and finds that in comparison to the February 2021 VA examiner opinion, it is less persuasive and less probative. In reviewing the two conflicting opinions, one can clearly see the thorough application of research and studies and the consideration of various factors used by the VA examiner. Whereas, Dr. C.B.'s opinion attempts to rebut findings but with less detail. Dr. C.B. also appears to manipulate the VA examiner's findings to portray a bias that does not exist. For example, regarding the Veteran's smoking and work history. Indeed, it would be difficult for an average person to assess whether the Veteran's smoking "more than likely" caused his astrocytoma; however, here, the VA examiner did not make that statement. The VA examiner's finding was that the Veteran's combined (emphasis added) risk factors, meaning, when taken together, his personal risks; plus his 35 year smoking history; and 35 years of working at a facility which would expose him to chemicals, was more than likely the cause of the Veteran's brain tumor as there were medical/scientific links demonstrating this. Whereas, in comparison, the Veteran's four months at Camp Lejeune and exposure to herbicide agents (because he carried 50-gallon intact drums) was less likely the cause of his condition, noting that the official guidance from the Veterans and Agent Orange: Update 11 (2018) found no link between herbicide agents and brain tumor astrocytoma. Certainly, the Veteran provided a sworn statement regarding his compliance with OSHA guidelines at work. While it is acknowledged and covers all bases of exposure, the Board cannot assign much probative value to it, particularly because the record also indicates he suffers from severe dementia. Accepting the reports of Dr. R.J. as true from the VA 21-2680 application, the Veteran's ability to recall that he wore safety goggles and respirators when required throughout his career and that the buildings he worked in had OSHA guideline ventilation systems, seems questionable. The Board acknowledges Dr. C.B.'s discontentment with the VA examiner's rationale, particularly because it is unfavorable. However, it must be noted that the rationale was obtained because the initial March 2020 opinion with rationale was inadequate as discussed earlier. To that end, additional development was needed to further adjudicate the claim. Although the VA examiner indicated that the opinion pertained to CLCW subject matter only, this examiner exceeded expectations by providing an opinion and detailed explanation as to why the likelihood was less likely for both CLCW and herbicide agent exposure and the summary is that not only do studies report no link for herbicide agents and brain tumor astrocytoma, but coupled with the Veteran's personal risks it's simply less likely that CLCW caused his current astrocytoma. It is noted that the Veteran submitted other Board decisions in support of his claim. However, Board decisions are nonprecedential in nature, and each case presented to the Board will be decided on the basis of the individual facts of the case. See 38 C.F.R. § 20.130. This means that other Board decisions, favorable or unfavorable, are not binding upon the Board in this case. The Veteran and his family believe his astrocytoma is related to his presumed exposure to herbicides and CLCW; however, in this case, they are not competent to provide a nexus opinion regarding this issue. The issue is medically complex and thus, is outside their competence in this case because the record does not show that they have the medical training or credentials to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Consequently, the Board gives more probative weight to the comprehensive and detailed February 2021 VA examination report. In sum, the preponderance of the evidence weighs against finding that astrocytoma is related to service, to include exposure to Agent Orange and/or CLCW. As such the benefit of the doubt doctrine does not apply, and service connection is denied. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). 2. Entitlement to SMC based on the need for aid and attendance or on housebound status is denied. The Veteran seeks compensation based on need of the regular aid and attendance of another or housebound status. For the reasons that follow, the Board finds that SMC based on aid and attendance or housebound status is not warranted. Compensation at the aid and attendance rate is payable when a Veteran's service-connected disability or disabilities cause the anatomical loss or loss of use of both feet or one hand and one foot, cause the Veteran to be blind in both eyes, or render him 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; the 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 SMC 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. at 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). SMC is also payable at the housebound rate where the Veteran has a single service-connected disability rated as 100 percent and, in addition: (1) has a service-connected disability or disabilities independently ratable at 60 percent, separate and distinct from the 100 percent service-connected disability, and involving different anatomical segments or bodily systems, or (2) is permanently housebound by reason of service-connected disability or disabilities. 38 U.S.C. § 1114(s); 38 C.F.R. § 3.350(i). The requirement of "permanently housebound" status will be considered to have been met when the Veteran is substantially confined to his house (or ward or clinical areas, if institutionalized) or immediate premises due to disability or disabilities which it is reasonably certain will remain throughout his lifetime. See 38 U.S.C. § 1502(c); 38 C.F.R. § 3.351(d)(2). The Veteran is service-connected for posttraumatic stress disorder (PTSD) (30 percent rating from November 19, 2010); tinnitus (10 percent rating from November 19, 2010); and has noncompensable ratings for bilateral hearing loss and dermatitis. His combined disability rating from November 19, 2010 is 40 percent. In April 2016, the Veteran submitted his VA Form 21-2680 Examination for Housebound Status or Permanent Need for Regular Aid and Attendance, which was completed by a private physician, R.J. Dr. R.J. reported that the Veteran was able to feed himself, but unable to prepare meals, or manage his finances due to his service-connected PTSD and hearing loss, along with his non-service-connected vascular dementia, seizure, Crohn's, astrocytoma brain radiation, and tumor. He was not able to bathe unassisted due to decreased coordination of fine motor, right hand. There was no report that the Veteran was legally blind. Dr. R.J. also reported that the Veteran required nursing home care and medication management, due to severe dementia. Upon review of the evidence, the Board finds that the Veteran does not qualify for SMC based on the need for aid and attendance or housebound status. The evidence demonstrates the Veteran is not so helpless as to be in need of regular aid and attendance within the meaning of 38 C.F.R. § 3.352(a) as a result of his service-connected disabilities. The Veteran's claim and VA Form 21-2680 reveal that his need for aid attendance is due to his non-service-connected vascular dementia. VA treatment records do not report any of his service-connected disabilities as necessitating aid and attendance. The competent evidence does not support a finding that the Veteran's service-connected disabilities impair his mobility; it is not evident that the assistance of another person is necessary solely as a result of his service-connected disabilities. Rather, the April 2016 VA A&A examination report and the report from Dr. R.J. show his need for aid and attendance of another is due to his nonservice-connected dementia. To the extent he needs help with setting up medication, bathing, and dressing, it is reportedly due to his fine motor ability with his right hand, which is "related to CVA/brain tumor," and other non-service-connected disabilities. While the Veteran requires nursing home care and is unable to manage his own financial affairs, he has multiple nonservice-connected disabilities that contribute to his overall problem with the performance of activities of daily living, to specifically include his vascular dementia, Crohn's, and astrocytoma. The Veteran is also reportedly able to leave the home or immediate premises, daily. The record does not contain any competent medical evidence that the Veteran's service-connected disabilities, alone, render him physically helpless in the performance of the activities of daily living or in protecting himself from the everyday hazards and dangers incident to his environment. To the extent the Veteran asserts the opinion of his son, K.G., the Board notes that he is not a medical professional. Although Dr. C.B. provided a favorable nexus opinion regarding the Veteran's need for aid and attendance, it was based solely on the non-service-connected astrocytoma. As such, the preponderance of the evidence is against a finding that the Veteran's service-connected disabilities alone result in his needing the regular aid and attendance of another person within the meaning of the cited legal authority. Accordingly, the preponderance of the evidence is against a finding that his service-connected disabilities alone result in his needing the regular aid and attendance of another person within the meaning of the cited legal authority. Regarding the criteria necessary for housebound status, the Veteran does not have a single, permanent service-connected disability rated 100 percent disabling, with additional service-connected disabilities independently ratable at 60 percent. See 38 U.S.C. § 1114(s); 38 C.F.R. § 3.350(i)(1). The Veteran's highest rated service-connected disability is 30 percent, and his combined rating is 40 percent. Thus, he does not meet the legal criteria for SMC at the housebound rate. Moreover, the competent and persuasive evidence fails to show the Veteran is permanently housebound or substantially confined to his house or its immediate premises due to service-connected disabilities. As previously noted, the Veteran is reportedly able to leave the home or immediate premises, daily. The Board acknowledges the Veteran is competent to report those symptoms which are capable of lay observation and describe his physical limitations. See Kahana v. Shinseki, 24 Vet. App. 428, 438 (2011). The Board acknowledges that the Veteran's various health conditions and disabilities impact his life and limit his ability to do all of the things he would like to do. However, the Board finds the objective evidence provides a more accurate assessment of his physical capabilities. Id. The treatment records, his April 2016 A&A application, and Dr. C.B.'s nexus letter fail to show that symptoms from his service-connected disabilities result in the need for aid and attendance of another person or render him housebound. The evidence does not show that the Veteran's service-connected disabilities have resulted in his inability to perform activities of daily living or to protect himself in his daily environment. 38 C.F.R. § 3.352(a). As the most probative evidence shows that the Veteran's service-connected disabilities do not result in the need of aid and attendance, nor is he housebound, the preponderance of the evidence is against the claim. The benefit of the doubt doctrine is not for application and the claim must be denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). D. JOHNSON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Telamour, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.