Citation Nr: 22012876 Decision Date: 03/07/22 Archive Date: 03/07/22 DOCKET NO. 16-43 355 DATE: March 7, 2022 ORDER The discontinuance of the 100 percent rating for residuals of prostate cancer, status-post radiation therapy, effective May 1, 2015, was proper. Entitlement to a rating in excess of 20 percent from May 1, 2015 to July 19, 2015, for residuals of prostate cancer is denied. Entitlement to a rating in excess of 40 percent disabling from July 20, 2015 to May 1, 2016, for residuals of prostate cancer is denied. From November 1, 2018, a rating of 60 percent disabling, but no higher, for residuals of prostate cancer is granted. Entitlement to an increased rate of special monthly compensation (SMC) for loss of use of a creative organ is denied. Entitlement to a compensable rating for erectile dysfunction (ED) is denied. Entitlement to an effective date prior to July 20, 2015, for the 40 percent evaluation for residuals of prostate cancer is denied. Entitlement to an effective date prior to May 2, 2016, for the 100 percent evaluation for prostate cancer is denied. REMANDED Whether new and material evidence has been received to reopen the claim of entitlement to service connection for a stroke is remanded. Entitlement to service connection for peripheral neuropathy of the right lower extremity (PN RLE), to include as due to diabetes mellitus type II (diabetes) and/or herbicide agent exposure is remanded. Entitlement to service connection for peripheral neuropathy of the left lower extremity (PN LLE), to include as due to diabetes mellitus type II (diabetes) and/or herbicide agent exposure is remanded. Entitlement to service connection for peripheral neuropathy of the right upper extremity (PN RUE), to include as due to diabetes mellitus type II (diabetes) and/or herbicide agent exposure is remanded. Entitlement to service connection for peripheral neuropathy of the left upper extremity (PN LUE), to include as due to diabetes mellitus type II (diabetes) and/or herbicide agent exposure is remanded. Entitlement to service connection for arteriosclerotic heart disease/coronary artery disease (CAD), to include as due to herbicide agent exposure is remanded. Entitlement to service connection for a skin condition, to include as due to herbicide agent exposure is remanded. Entitlement to service connection for a lumbar spine disability, to include as secondary to service-connected residuals of prostate cancer is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. Entitlement to service connection for diabetes mellitus type II (diabetes), to include as due to herbicide agent exposure is remanded. Entitlement to special monthly compensation (SMC) based on aid and attendance/housebound is remanded. Entitlement to special monthly compensation (SMC) based on aid and attendance allowance for Mildred Jones is remanded. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), unspecified depressive disorder, and anxiety, to include as due to service-connected disabilities, is remanded. FINDINGS OF FACT 1. The discontinuance of the 100 percent evaluation for prostate cancer is not a formal rating reduction in this case, as the reduction was by operation of law in accordance with 38 C.F.R. § 4.115b, Diagnostic Code (DC) 7528. 2. From May 1, 2015, the evidence of record does not demonstrate that the Veteran continued to receive surgical, x-ray, antineoplastic chemotherapy, or other therapeutic procedure; had any continued active malignancy of his genitourinary system; or, had any local recurrence or metastasis of his prostate cancer, such that continued application of a 100 percent evaluation for prostate cancer would be appropriate. 3. From May 1, 2015 to July 19, 2015, the Veteran's prostate cancer residuals have been manifested by symptoms of daytime voiding intervals between one and two hours, and nighttime awakening to void three to four times. 4. From July 20, 2015, to May 1, 2016, the Veteran's urinary dysfunction manifested with nocturia five or more times per night. 5. From November 1, 2018, the Veteran's urinary dysfunction required wearing absorbent materials that had to be changed more than four times per day. 6. The Veteran is in receipt of the maximum level of SMC on the basis of loss of use of a creative organ available by law. 7. The Veteran's erectile dysfunction is not manifested by a deformity of the penis. 8. Prior to July 20, 2015, the Veteran's residuals of prostate cancer manifested with daytime voiding intervals between one and two hours, and nighttime awakening to void three to four times. 9. Prior to May 2, 2016, there was no evidence of prostate cancer recurrence. CONCLUSIONS OF LAW 1. The discontinuance of the 100 percent evaluation for prostate cancer, effective May 1, 2015, was proper. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.105 (e), 4.1, 4.7, 4.115b, Diagnostic Code (DC) 7528. 2. The criteria for a disability rating in excess of 20 percent from May 1, 2015 to July 19, 2015, for residual of prostate cancer have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.115a, 4.115b, DC 7528. 3. The criteria for a disability rating in excess of 40 percent from July 20, 2015 to May 1, 2016, for residual of prostate cancer have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.115a, 4.115b, DC 7528. 4. A rating of 60 percent, but no higher, for residuals of prostate cancer have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.115a, 4.115b, DC 7528. 5. The criteria for a compensable rating for special monthly compensation for erectile dysfunction have not been met. 38 U.S.C. § 1114 (k); 38 C.F.R. § 3.350 (a). 6. The criteria for a compensable rating for erectile dysfunction have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.3, 4.115b, Diagnostic Code (DC) 7522. 7. The criteria for an effective date prior to July 20, 2015, for the 40 percent evaluation for residuals of prostate cancer have not been met. 38 U.S.C. §§ 5107, 5110, 7105; 38 C.F.R. §§ 3.400, 4.115a, 4.115b, Diagnostic Code (DC) 7528. 8. The criteria for an effective date prior to May 2, 2016, for the 100 percent evaluation for prostate cancer have not been met. 38 U.S.C. §§ 5107, 5110, 7105; 38 C.F.R. §§ 3.400, 4.115a, 4.115b, Diagnostic Code (DC) 7528. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served active duty in the U.S. Army from August 1968 to August 1971. This case comes before the Board on appeal of a rating decisions from February 2015, February 2016, and August 2016. In July 2021, the Veteran testified before the undersigned Veterans Law Judge (VLJ) via live video conference. A transcript of the proceeding has been associated with the record. Increased Rating Disability evaluations are determined by the application of the Schedule for Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. To evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where an increase in the level of a disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). As in the instant case, separate ratings for distinct periods of time, based on the facts may be for consideration. Hart v. Mansfield, 21 Vet. App. 505 (2007). The Board has reviewed all the evidence in the record, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Hence, the Board will summarize the relevant evidence as deemed appropriate and the analysis will focus on what the evidence shows, or fails to show, as to the claims. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall resolve reasonable doubt in favor of the claimant. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 1. Rating reduction for residuals of prostate cancer, from 100 percent to 20 percent disabling, effective May 1, 2015 2. Entitlement to a rating in excess of 20 percent from May 1, 2015 to July 19, 2015, for residuals of prostate cancer The Veteran's residual of prostate cancer disability was assigned a 100 percent rated from April 8, 2013 to May 1, 2015, at which point it was reduced to 20 percent, then increased to 40 percent from July 20, 2015, and increased to 100 percent from May 2, 2016 to October 31, 2018. Since November 1, 2018, the Veteran's residual of prostate cancer disability has been rated as 40 percent disabling based on residuals (voiding dysfunction). The Veteran disagrees with the February 2015 rating decision that reduced his disability rating from 100 to 20 percent, effective May 1, 2015. Likewise, as will be discussed below, the Veteran is seeking higher evaluations for his prostate cancer residuals for all other time periods. The Veteran's prostate cancer is rated under 38 C.F.R. § 4.115b, DC 7528, which contemplates malignant neoplasms of the genitourinary system, i.e., prostate cancer. Under DC 7528, following the cessation of surgical, X-Ray, antineoplastic chemotherapy or other therapeutic procedure, a rating of 100 percent shall continue with a mandatory VA examination at the expiration of six months. If there has been no local reoccurrence or metastasis, rate on residuals as voiding dysfunction or renal dysfunction, whichever is predominant. 38 C.F.R. § 4.115b, DC 7528, Note. A rating based on the diagnostic criteria for voiding dysfunction can be accomplished in one of three ways: for urine leakage, urinary frequency, or voiding obstruction. 38 C.F.R. § 4.115a. Voiding dysfunction is rated as urine leakage, urinary frequency, or obstructed voiding. 38 C.F.R. § 4.115a. Urine leakage requiring the wearing of absorbent materials that must be changed less than two times per day warrants a 20 percent rating. A 40 percent rating is warranted when the wearing of absorbent materials which must be changed two to four times per day is required. A (maximum) 60 percent rating is warranted where the use of an appliance or the wearing of absorbent materials which must be changed more than four times per day is required. Id. Urinary frequency involving a daytime voiding interval between one and two hours or awakening to void three to four times per night warrants a 20 percent rating. A daytime voiding interval less than one hour or awakening to void five or more times per night warrants a 40 percent rating, the maximum allowable rating under urinary frequency. Id. Under obstructed voiding, urinary retention requiring intermittent or continuous catherization warrants a 30 percent rating. Under 38 C.F.R. § 3.105 (e), where a reduction in an evaluation of a service-connected disability is considered warranted, and the lower evaluation would result in a reduction or discontinuance of compensation payments currently being made, a rating proposing the reduction or discontinuance must be prepared setting forth all material facts and reasons. In addition, the AOJ must notify a veteran that s/he has 60 days to present additional evidence showing that compensation should be continued at the present level. The veteran must be informed that s/he may request a predetermination hearing, provided that the request is received by VA within 30 days from the date of the notice. If no additional evidence is received within the 60-day period and no hearing is requested, final rating action will be taken, and the award will be reduced or discontinued effective the last day of the month in which a 60-day period from the date of notice to the veteran expires. The Board notes that 38 C.F.R. § 4.115b, DC 7528, applicable to malignant neoplasms of the genitourinary system, contains a temporal element that has been met. Consequently, 38 C.F.R. § 3.344 is not applicable in this case. The Court specifically addressed this question in Rossiello v. Principi, 3 Vet. App. 430 (1992). The Court analyzed a similar diagnostic code, DC 6819, which provided that the rating would be continued for 2 years "following the cessation of surgical, x-ray, antineoplastic chemotherapy or other therapeutic procedure," and at the end of the two-year period, "if there has been no local recurrence or metastases, the rating will be made on residuals." Id. at 432. The Court found that, "[w]hile the net effect of DC 6819 may be a lower percentage rating after two years, it is not a reduction in the rating for a singular condition; rather, it is the result of an award of separate successive ratings for different conditions." The Court held that the 100 percent rating ceased to exist by operation of law, specifically DC 6819, because of the temporal element in that diagnostic code. Id. at 432-33. The Court specifically distinguished the situation presented in the typical rating reduction case as illustrated by Dofflemyer v. Derwinski, 2 Vet. App. 277 (1992), where a rating is reduced and the failure to follow 38 C.F.R. § 3.344 (a) warrants a finding that the reduction is void ab initio and found that the regulation does not apply in situations like the one in this case, where the rating is reduced pursuant to a DC with a temporal element. Thus, the reduction of the rating from 100 percent to 20 percent was procedural in nature and by operation of law. The Board only has to determine if the procedural requirements of 38 C.F.R. § 3.105 (e) were met and if the reduction was by operation of law under Diagnostic Code 7528. As discussed below, the procedural requirements were properly followed. The AOJ satisfied the due process notification requirements under 38 C.F.R. § 3.105 (e). Specifically, the Veteran underwent a VA examination for his prostate cancer in October 2014. In an October 2014 rating decision, the Veteran's 100 percent evaluation for that disability was proposed to be reduced to 20 percent on the basis of that examination. The Veteran was informed of his rights, including to a predetermination hearing and to submit additional evidence, in a November 2014 Notification Letter. The Veteran did not request a hearing and did not submit additional evidence within 60 days of the VA letter, so the RO finalized the discontinuance of the Veteran's 100 percent evaluation for prostate cancer in the February 2015 rating decision, reducing the rating to 20 percent effective May 1, 2015. In light of these facts, the particularized procedure for discontinuing the Veteran's 100 percent evaluation for his residual of prostate cancer was appropriately and adequately completed in this case. For the following reasons, there is no evidentiary basis for continuance of the 100 percent rating or a rating in excess of 20 percent for prostate cancer under Diagnostic Code 7528 from May 1, 2015, to July 19, 2015. Specifically, in the October 2014 VA examination, the examiner indicated that the Veteran's prostate cancer was in remission. It was shown that the Veteran completed radiation therapy in October 2013. The Veteran had a residual of voiding dysfunction, which caused increased urinary frequency indicated as daytime voiding interval between two and three hours, and nighttime awakening to void three to four times. The examiner indicated that his voiding dysfunction did not require the use of an absorbent appliance. There were no signs or symptoms of obstructed voiding. Likewise, it was shown that the Veteran's ED was caused by his prostate cancer. The examiner indicated that there were no other residual conditions and/or complications due to prostate cancer or treatment for prostate cancer. There was no evidence of renal dysfunction, scars, or any other pertinent findings, complications, conditions, signs, or symptoms. The Veteran's PSA was 2.6, at that time. The examiner remarked that the functional impact of the Veteran's residual of prostate cancer was he was unable to perform physical employment. In a January 2015 treatment record, the Veteran reported that he did not have urinary leakage or urgency and did not wear absorbent material. In a clinical follow-up, the Veteran reported good urinary outflow with use of medication. He denied nocturia and had less urinary frequency and urgency. The Board notes there was no other medical evidence to support a finding of metastasis or prostate cancer from May 1, 2015 to July 19, 2015. Moreover, there was no evidence of daytime voiding interval less than one hour' or awakening to void five or more times per night. Likewise, the Veteran did not report the use of absorbent materials which had to be changed two to four times per day. Furthermore, there was no evidence of urinary retention requiring intermittent or continuous catherization. For the foregoing reasons, in accordance with the provisions of Diagnostic Code 7528, the AOJ correctly discontinued the 100 percent evaluation after the October 2014 VA examination showed the Veteran's prostate cancer was in remission and there was no evidence of recurrence or metastasis of the prostate cancer from May 1, 2015 to May 1, 2016. Additionally, from May 1, 2015 to July 19, 2015, the Veteran's residual of prostate cancer most closely approximated a 20 percent rating based on awakening to void three to four times per night. Accordingly, as the preponderance of the evidence is against the claims, the benefit of the doubt doctrine is not for application and the claims must be denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 4.3. 3. Entitlement to a rating in excess of 40 percent disabling from July 20, 2015 to May 1, 2016, for residuals of prostate cancer Here, the Veteran contends that his prostate cancer residuals warranted a rating in excess of 40 percent from July 20, 2015 to May 1, 2016. Based on the evidence, the Board disagrees. Specifically, in a July 20, 2015 VA treatment record, the Veteran complained of nocturia (nighttime voiding) four to five times a night. He denied incomplete emptying or straining. However, in an October 2015 treatment record, the Veteran reported nocturia twice a night. The Board notes that subsequent treatment records failed to show that the Veteran reported the use of absorbent materials which had to be changed more than four times per day. As such, a rating in excess of 40 percent disabling, under DC 7528, is not warranted. Accordingly, as the preponderance of the evidence is against the claims, the benefit of the doubt doctrine is not for application and the claims must be denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 4.3. 4. Entitlement to a rating in excess of 40 percent disabling from November 1, 2018, for residuals of prostate cancer In this instance, the Veteran contends that he is entitled to a higher rating for residuals of prostate cancer from November 1, 2018. Based on the evidence, the Board agrees. At the outset, the AOJ reduced the Veteran's prostate cancer to 40 percent disabling, effective November 1, 2018, after completion of therapy and evidence showing awakening to void five or more times per night. In the October 2017 VA examination, the examiner indicated that the Veteran's prostate cancer was in remission. The Veteran reported problems with urinary leakage and stated that he was urinating more frequently. There was evidence of voiding dysfunction. The Veteran's urine leakage required absorbent material which had to be changed less than two times per day. Likewise, the Veteran had daytime voiding interval between one and two hours and nighttime awakening to void five or more times. There was some evidence of obstructed voiding, specifically, markedly weak stream and markedly decreased force of stream. However, there was no history of recurrent symptomatic urinary tract or kidney infections. Subsequently, in the March 2020 VA examination, it was shown that the Veteran's urinary dysfunction worsened. Specifically, during the examination, the Veteran reported voiding dysfunction that caused urine leakage. His urine leakage required the use of absorbent material which had to be changed more than four times per day. Additionally, the Veteran reported daytime voiding interval less than one hour and nighttime awakening to void five or more times. There were no signs or symptoms of obstructed voiding. Moreover, there were no other pertinent findings, complications, conditions, signs, or symptoms related to the Veteran's voiding dysfunction. The examiner indicated that the Veteran's urinary incontinence and urinary frequency caused fatigue and impaired his ability to focus and concentrate for prolonged periods of time. Based on foregoing, the Veteran's voiding dysfunction most closely approximated a 60 percent evaluation, but no higher, from November 1, 2018. Accordingly, a rating of 60 percent, but no higher, is warranted for residuals of prostate cancer from November 1, 2018. 38 C.F.R. §§ 4.115a, 4.115b, DC 7528. 5. Entitlement to an increased rate of special monthly compensation (SMC) for loss of use of a creative organ The Veteran contends he is entitled to a higher rate of SMC based on loss of use of a creative organ. Based on the law, the Board disagrees. Special Monthly Compensation (SMC) is a special statutory award granted in addition to awards based on the schedular evaluations provided by the diagnostic codes in VA's Rating Schedule. Claims for SMC are governed by 38 U.S.C. § 1114 (k) through (s) and 38 C.F.R. §§ 3.350 and 3.352. In this case, the Veteran is currently in receipt of SMC for loss of use of a creative organ pursuant to 38 U.S.C. § 1114 (k) and 38 C.F.R. § 3.350 (a). The law does not provide for a higher rate of SMC for loss of use of a creative organ. The SMC provided by 38 U.S.C. § 1114 (l), the next higher level of SMC, 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 to need regular aid and attendance. 38 C.F.R. § 3.350 (b). However, the evidence does not show that his service-connected disabilities are manifested by or result in any of the foregoing conditions enumerated in 38 U.S.C. § 1114 (l) and 38 C.F.R. § 3.350 (b). SMC rates are determined by statute and are not subject to the Board's discretion; and the Board is specifically prohibited from granting benefits that are not authorized by law. See 38 U.S.C. § 7104 (c); McTighe v. Brown, 7 Vet. App. 29, 30 (1994). As the rate for SMC for loss of use of a creative organ is a non-variable amount that is set by statute and the evidence does not contain findings that support the grant of SMC at the next higher level, the Board finds the Veteran's claim seeking a higher level of SMC for loss of use of a creative organ must be denied, and the benefit of the doubt rule is not for application. 6. Entitlement to a compensable rating for erectile dysfunction (ED) The Veteran's erectile dysfunction has been assigned a 0 percent rating under Diagnostic Code 7599-7522 as a residual of prostate cancer. 38 C.F.R. § 4.115b. To warrant a compensable 20 percent rating for erectile dysfunction, there must also be deformity of the penis. 38 C.F.R. § 4.115b, Diagnostic Code 7522. However, the record does not show that the Veteran has a deformity of the penis. The VA genitourinary examinations discussed above failed to show any penile deformity. Moreover, the Veteran has not reported any penile deformity. Thus, the Board finds that the Veteran's erectile dysfunction is not manifested by a deformity of the penis. Accordingly, a compensable rating for erectile dysfunction is not warranted. However, the Board notes that the Veteran is already receiving special monthly compensation for the loss of use of a creative organ. In conclusion, an increased rating for erectile dysfunction, currently noncompensable, is not warranted. As the preponderance of the evidence is against the claim, the claim must be denied. 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Effective Date Except as otherwise provided, the effective date of an award of benefits based on an original claim, a claim after final allowance or a claim for an increase, "will be the date of receipt of the claim or the date entitlement arose, whichever is the later." 38 C.F.R. § 3.400 (2019); see also 38 U.S.C. § 5110 (a) (2012); Sears v. Principi, 16 Vet. App. 244 (2002). The effective date of an award of increased compensation shall be the earliest date as of which it is factually ascertainable that an increase in disability had occurred, but only if the claim for an increase is received within one year from such date. See 38 U.S.C. § 5110 (b)(3); see also 38 C.F.R. § 3.400 (o)(2). Where the increase in disability occurs more than one year prior to the date of claim, the effective date for an award of increased compensation will be the date of receipt of claim or the date entitlement arose, whichever is later. See 38 U.S.C. § 5110 (a); see also 38 C.F.R. § 3.400 (o)(1); Gaston v. Shinseki, 605 F.3d 979, 980 (Fed. Cir. 2010); Swain v. McDonald, 27 Vet. App. 219, 224 (2015). 7. Entitlement to an effective date prior to July 20, 2015, for the 40 percent evaluation for residuals of prostate cancer 8. Entitlement to an effective date prior to May 2, 2016, for the 100 percent evaluation for prostate cancer Here, the Veteran is seeking an earlier effective date for the assignment of his 40 percent and 100 percent evaluation for residuals of prostate cancer. Based on the evidence, the Board disagrees. At the outset, the Veteran was assigned a 40 percent evaluation for residuals of prostate cancer effective July 20, 2015, the date it was factually ascertainable that an increase in disability had occurred. Likewise, a 100 percent rating was assigned effective May 2, 2016, as the Veteran had a biochemical recurrence of his prostate cancer. See August 2016 rating decision. In this instance, the Veteran's claim for prostate cancer was received by the AOJ on April 8, 2013. The AOJ assigned a 100 percent rating effective April 8, 2013, as the date of the claim. The Veteran's 100 percent rating was continued on April 4, 2014. However, as discussed above, the Veteran's prostate cancer was reduced to 20 percent disabling effective May 1, 2015, based on no active malignancy and urinary dysfunction resulting in nocturia three to four times per night. The AOJ increased the rating to 40 percent disabling under DC 7528, effective July 20, 2015. The Veteran did not file an increased rating claim prior to July 20, 2015. Moreover, after a thorough review of the record, the Board finds that there was not factually ascertainable worsening of the Veteran's prostate cancer residuals symptoms prior to July 20, 2015. In fact, in the October 2014 VA examination and subsequent treatment records, the Veteran reported daytime voiding between two and three hours and nighttime awakening to void three to four times per night. Similarly, prior to May 2, 2016, there was no evidence of biochemical recurrence of prostate cancer. As discussed above, the Veteran did not file an increased rating for his prostate cancer residuals. Likewise, treatment records failed to show recurrence of prostate cancer prior to May 2, 2016. In fact, in an April 2016 treatment record, the Veteran's PSA level was 3.45. Although elevated, the PSA level did not equate to biochemical recurrence of prostate cancer. In the May 2, 2016 treatment record, the urologist indicated that the Veteran had met biochemical recurrence. Accordingly, as the preponderance of the evidence is against the claims, the benefit-of-the-doubt rule does not apply, and the claims for an earlier effective date are denied. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. §§ 3.400, 4.115a, 4.115b, DC 7528. REASONS FOR REMAND Although the Board regrets the additional delay, a remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the Veteran's claim so that he is afforded every possible consideration. 38 U.S.C. § 5103A (2012); 38 C.F.R. § 3.159 (2019). 1. Whether new and material evidence has been received to reopen the claim of entitlement to service connection for a stroke is remanded. 2. Entitlement to service connection for arteriosclerotic heart disease/coronary artery disease (CAD), to include as due to herbicide agent exposure is remanded. Here, remand is necessary to determine whether the Veteran has a coronary condition that was incurred in service to include as due to herbicide agent exposure which led to his stroke. The Board notes that due to the Veteran's service near or at the demilitarized zone (DMZ), he is presumed to be have been exposed to an herbicide agent. However, it is unclear based on current treatment records on whether the Veteran has a coronary condition and if so, whether that condition caused his stroke. The Veteran testified that he was not informed on whether he had a heart condition but only that he had a heart attack. The Veteran added that he was told he had scar tissue on his heart, but he refused a scope down his throat to check. Moreover, a treatment record from November 2019, showed the Veteran had mild to moderate coronary artery calcifications. Given the foregoing, a remand is necessary to determine the etiology of the Veteran's stroke and any heart condition, if shown through testing. 3. Entitlement to service connection for diabetes mellitus type II (diabetes), to include as due to herbicide agent exposure is remanded. 4. Entitlement to service connection for peripheral neuropathy of the bilateral upper and lower extremities (PN BUE/BLE), to include as due to diabetes mellitus type II (diabetes) and/or herbicide agent exposure Here, the Veteran has complained of tingling and numbness in his bilateral extremities. In fact, the Veteran was diagnosed with peripheral neuropathy in 2016 and is on Gabapentin for treatment. See VA treatment records. The Board notes that early-onset peripheral neuropathy is a disease associated with exposure to certain herbicide agents under 3.309 (e). Early-onset peripheral neuropathy must manifest within a year since last exposure to certain herbicide agents. Yet, the Veteran's condition was diagnosed in 2016, many decades after his discharge from service. Thus, the etiology of his peripheral neuropathy is unclear. Moreover, treatment records showed that the Veteran was pre-diabetic based on testing, but there was no diagnosis of diabetes. See Private treatment records. Given the Veteran's diagnosis of peripheral neuropathy and testing that showed he was pre-diabetic, a remand is necessary to determine the etiology of his peripheral neuropathy and diabetes, if diagnosed. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). 5. Entitlement to service connection for a skin condition, to include as due to herbicide agent exposure is remanded. Here, the Veteran has complained of skin condition reported as a cyst the size of an egg. He explained that it was on the center of his back, but he had it drained and removed. However, in treatment records the Veteran reported a rash on his mid-back during the summer. The Board notes that chloracne (skin condition) is a disease enumerated under 3.309 (e) based on exposure to certain herbicide agents. In this instance, it is unclear if the Veteran's rash is recurrent. Thus, on remand the Veteran should be afforded a VA examination to determine the etiology of any skin condition identified. 6. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), unspecified depressive disorder, and anxiety is remanded. Here, the Veteran contends that his psychiatric condition was caused or aggravated by his service at the DMZ, his service-connected disabilities, and the stroke he suffered. The Board notes that the Veteran had been diagnosed with unspecified depressive disorder after his stroke. The Veteran testified he has memory and sleep difficulties due to his psychiatric condition. He explained that during his prostate cancer treatment he feared he would pass away which contributed to his psychiatric condition. Moreover, the Veteran explained that his ED and service at the DMZ have contributed as well. The Board adds that in a June 2015 medical opinion, the clinical psychologist opined that the Veteran's depressive disorder was not due to or the result of his service-connected disabilities. She reasoned that the Veteran noted no depression and did not start on medication until 2009 when he had a stroke. The psychologist continued that the Veteran was not service-connected for a stroke, only prostate cancer but was not diagnosed with prostate cancer until 2012. Thus, she concluded, his psychiatric condition could not be the cause of his depression. The Board finds the psychologist's opinion to be inadequate because there was no discussion on whether the Veteran's service-connected disabilities aggravates his psychiatric condition. See Stefl v. Nicholson, 21 Vet. App. 120 (2007). Given, the inadequacy of the opinion on record and the Veteran's contentions, remand is necessary to determine the etiology of the Veteran's psychiatric condition. 7. Entitlement to service connection for a lumbar spine disability, to include as secondary to service-connected residuals of prostate cancer is remanded. Here, the Veteran contends that his lumbar spine disability was caused or aggravated by his service-connected residuals of prostate cancer. The Veteran testified that he did not have a low back pain until after he was diagnosed with prostate cancer. He explained that he did not suffer an injury to cause his lumbar spine disability, but he felt it was related to his prostate cancer in some way. See Hearing transcript. The Board notes that the Veteran has a diagnosis of lumbar spine degenerative joint disease (DJD) and is service-connected for residuals of prostate cancer. Therefore, the Veteran should be afforded a VA examination to determine the etiology of his lumbar spine disability. 8. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. 9. Entitlement to special monthly compensation (SMC) based on aid and attendance/housebound is remanded. 10. Entitlement to special monthly compensation (SMC) based on aid and attendance allowance for Mildred Jones is remanded. Here, the claim for entitlement to a TDIU and SMC based on aid and attendance, is inextricably intertwined with the issues being remanded for further evidentiary development. Therefore, a final decision on the issue of entitlement to a TDIU and SMC cannot be rendered now. See Harris v. Derwinski, 1 Vet. App. 180 (1991) (two issues are "inextricably intertwined" when they are so closely tied together that a final decision on one issue cannot be rendered until a decision on the other issue has been rendered). The matters are REMANDED for the following action: 1. Obtain all relevant outstanding VA treatment records, and any private treatment records identified by the Veteran. All records and/or responses received should be associated with the claims file. 2. After all outstanding treatment records have been associated with the claims file, schedule the Veteran for a VA examinations to determine the etiology of his (a) stroke, (b) heart condition, if diagnosed, (c) diabetes mellitus, if diagnosed; (d) peripheral neuropathy BUE/BLE; (e) skin condition, if shown; (f) acquired psychiatric disorder; and (g) lumbar spine disability. The VA examiner must review the complete claims file and must note that review in the report. A copy of this REMAND must also be provided to the VA examiner. All necessary tests and studies should be accomplished, and all clinical findings reported in detail. The VA examiner should address the following: (a.) Whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran has a heart disability that had its onset during service or is otherwise causally related to any event or circumstance of the Veteran's service, to include as due to herbicide agent exposure. (b.) Whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's stroke was causally related to any event or circumstance of the Veteran's service, to include as being caused or aggravated by a diagnosed heart condition. (c.) Whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran has diabetes that had its onset during service or is otherwise causally related to any event or circumstance of the Veteran's service, to include as due to herbicide agent exposure. (d.) Whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's peripheral neuropathy BUE/BLE had its onset during service or is otherwise causally related to any event or circumstance of the Veteran's service, to include as due to herbicide agent exposure or, caused or aggravated by diabetes, if diagnosed. (e.) Whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran has a skin condition that had its onset during service or is otherwise causally related to any event or circumstance of the Veteran's service, to include as due to herbicide agent exposure. (f.) Whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's acquired psychiatric disorder had its onset during service or is otherwise causally related to any event or circumstance of the Veteran's service. (g.) Whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's acquired psychiatric disorder is caused by his prostate cancer and/or erectile dysfunction. (h.) Whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's acquired psychiatric disorder is aggravated (i.e., worsened beyond normal progression) by his prostate cancer and/or erectile dysfunction. (i.) Whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's lumbar spine disability had its onset during service or is otherwise causally related to any event or circumstance of the Veteran's service. (j.) Whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's lumbar spine disability was caused by his prostate cancer. (k.) Whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's lumbar spine disability is aggravated (i.e., worsened beyond normal progression) by his prostate cancer. The examiner is reminded that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as against it. For the purposes of secondary service connection, the examiner is advised that aggravation is defined as "any increase in disability." See Allen v. Brown, 7 Vet. App. 439, 448 (1995). 3. The examiner should cite to the pertinent medical and competent lay evidence of record and explain the rationale for all opinions given. If after consideration of all pertinent factors it remains that the opinion sought cannot be given without resort to speculation, it should be so stated, and the provider must (to comply with governing legal guidelines) explain why the opinion sought cannot be offered without resort to speculation. 4. Thereafter, readjudicate the issues on appeal, including the inextricably intertwined issues. KRISTI L. GUNN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board I. Umo 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.