Citation Nr: 22014396 Decision Date: 03/12/22 Archive Date: 03/12/22 DOCKET NO. 18-23 150A DATE: March 12, 2022 ORDER Entitlement to an initial compensable rating for bilateral hearing loss is denied. Entitlement to an initial rating in excess of 10 percent for tinnitus is denied. Entitlement to service connection for hypertension as secondary to service-connected depressive disorder is granted. Entitlement to service connection for chronic kidney disease as secondary to service-connected hypertension is granted. REMANDED Entitlement to special monthly compensation (SMC) based on the need for regular aid and attendance and/or housebound status is remanded. FINDINGS OF FACT 1. The Veteran's bilateral hearing loss has manifested by no more than Level II hearing impairment in the right ear and Level III hearing impairment in the left ear, which corresponds to a noncompensable rating. 2. The Veteran is in receipt of the maximum rating authorized under the applicable schedular rating criteria for tinnitus; his reported symptoms are reasonably contemplated by the rating criteria. 3. The Veteran's hypertension is at least as likely as not caused or aggravated by service-connected depressive disorder. 4. The Veteran's chronic kidney disease is at least as likely as not caused or aggravated by service-connected hypertension. CONCLUSIONS OF LAW 1. The criteria for an initial compensable rating for bilateral hearing loss have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.85, 4.86, Diagnostic Code 6100. 2. The criteria for entitlement to an initial rating in excess of 10 percent for tinnitus have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.87, Diagnostic Code 6260. 3. The criteria for entitlement to service connection for hypertension as secondary to service-connected depressive disorder have been met. 38 U.S.C. §§ 1101, 1110, 1112, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. 4. The criteria for entitlement to service connection for chronic kidney disease as secondary to service-connected hypertension have been met. 38 U.S.C. §§ 1101, 1110, 1112, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Navy from June 1964 to December 1967. These matters are before the Board of Veterans' Appeals (Board) on appeal from May 2016, March 2017, and December 2017 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO). In October 2019, the Board remanded these matters for additional development. As the actions specified in the most recent remand have been substantially completed, the case has been properly returned to the Board for appellate consideration. See Stegall v. West, 11 Vet. App. 268, 271 (1998); D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). Duties to Notify and Assist With respect to the Veteran's claims herein, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C. §§ 5100, 5102, 5103, 5103A; 38 C.F.R. § 3.159. The Veteran has not advanced any procedural arguments in relation to VA's duties to notify and assist; therefore, the Board will proceed with appellate review. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015). Increased Rating Disability ratings are determined by application of the criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C. § 1155; see generally 38 C.F.R. Part 4. When a question arises as to which of two ratings applies under a particular diagnostic code, the higher rating is assigned if the disability more closely approximates the criteria for the higher rating. Otherwise, the lower rating applies. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3. The veteran's entire history is to be considered when making disability evaluations. 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where, as here, the question for consideration is the propriety of the initial rating assigned, evaluation of the medical evidence since the effective date of the grant of service connection and consideration of the appropriateness of the assignment of different ratings for distinct periods of time, based on the facts found, is required. Fenderson v. West, 12 Vet. App. 119, 126 (1999); Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). Where 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(b); 38 C.F.R. § 3.102; Lynch v. McDonough, 999 F.3d 1391 (Fed. Cir. 2021), affirmed en banc 2021 U.S. App. LEXIS 37307 (Dec. 17, 2021). 1. Entitlement to an initial compensable rating for bilateral hearing loss The Veteran is in receipt of an initial noncompensable rating for service-connected bilateral hearing loss, effective December 21, 2015, pursuant to 38 C.F.R. § 4.85, Diagnostic Code 6100. The Veteran generally contends that a compensable rating is warranted because his hearing acuity is worse than contemplated by his currently-assigned disability rating. In evaluating hearing loss, disability ratings are derived by a mechanical application of the ratings schedule to the numeric designations assigned after audiometric evaluations are rendered. See Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). Hearing loss disability evaluations range from noncompensable (0 percent) to 100 percent based on organic impairment of hearing acuity. Audiological examinations used to measure impairment must be conducted by a state-licensed audiologist and must include both a controlled speech discrimination test (Maryland CNC) and a puretone audiometric test. 38 C.F.R. § 4.85(a). The ratings schedule provides a table for ratings purposes (Table VI) to determine a Roman numeral designation (I for essentially normal acuity through XI for profound deafness) for hearing impairment, based upon a combination of the percent of speech discrimination and the puretone threshold average, which is the sum of the puretone thresholds at 1000, 2000, 3000 and 4000 hertz, divided by four. 38 C.F.R. § 4.85, Diagnostic Code 6100. Table VII is then used to determine the percentage evaluation by intersecting the Roman numeral designations from Table VI for hearing impairment of each ear. The horizontal row represents the ear having the poorer hearing and the vertical column represents the ear having the better hearing. Id. Exceptional patterns of hearing impairment are evaluated under the provisions of 38 C.F.R. § 4.86. When the puretone threshold at each of the four specified frequencies (1000, 2000, 3000, and 4000 hertz) is 55 decibels or more, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIa, whichever results in the higher numeral. Each ear will be evaluated separately. 38 C.F.R. § 4.86(a). When the puretone threshold is 30 decibels or less at 1000 hertz, and 70 decibels or more at 2000 hertz, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIa, whichever results in the higher numeral. That numeral will then be elevated to the next higher Roman numeral. Each ear will be evaluated separately. 38 C.F.R. § 4.86(b). As an initial matter, the Board notes that the record contains an audiological examination that is not adequate for rating purposes. In November 2016, the Veteran submitted an ear conditions disability benefits questionnaire (DBQ) and accompanying audiometric testing performed by a private examiner. While word recognition testing was conducted, the examiner did not use the Maryland CNC speech discrimination test. Further, it is unclear whether the examiner is a state-licensed audiologist. As such, this evidence cannot be used to rate the Veteran's bilateral hearing loss disability. See 38 C.F.R. § 4.85(a). Nonetheless, the record contains ample medical evidence to properly assess the severity of the Veteran's disability during the appeal period. Turning to the relevant evidence, the Veteran underwent a VA audiology examination in March 2016. Upon examination, the Veteran reported that he has difficulty hearing people, especially his wife, which causes him to constantly ask people to repeat themselves. He also reported difficulty hearing the phone ringing. 38 C.F.R. § 4.10; Martinak v. Nicholson, 21 Vet. App. 447 (2007). Upon audiometric testing, the Veteran's Maryland CNC Word List speech recognition score and pure tone thresholds, in decibels, were as follows: HERTZ 1000 2000 3000 4000 Average CNC RIGHT 10 15 70 85 45 96 LEFT 15 40 80 85 55 94 The March 2016 audiology examination findings, applied to Table VI, yield a numeric designation of Roman numeral I in the right ear on the basis of a 45 decibel puretone threshold average and 96 percent speech discrimination, and a numeric designation of Roman numeral I in the left ear on the basis of a 55 decibel puretone threshold average, and 94 percent speech discrimination. The numeric designation for the right ear, I, along with the numeric designation for the left ear, I, entered into Table VII, corresponds to a noncompensable rating for hearing impairment. 38 C.F.R. § 4.85. Exceptional patterns of hearing impairment under 38 C.F.R. § 4.86 are not present. The Veteran underwent another VA examination in November 2017. Upon audiometric testing, the Veteran's Maryland CNC Word List speech recognition score and pure tone thresholds, in decibels, were as follows: HERTZ 1000 2000 3000 4000 Average CNC RIGHT 10 25 75 85 49 84 LEFT 10 50 85 90 59 86 The November 2017 audiology examination findings, applied to Table VI, yield a numeric designation of Roman numeral II in the right ear on the basis of a 49 decibel puretone threshold average and 84 percent speech discrimination, and a numeric designation of Roman numeral III in the left ear on the basis of a 59 decibel puretone threshold average, and 86 percent speech discrimination. The numeric designation for the right ear, II, along with the numeric designation for the left ear, III, entered into Table VII, corresponds to a noncompensable rating for hearing impairment. 38 C.F.R. § 4.85. Exceptional patterns of hearing impairment under 38 C.F.R. § 4.86 are not present. The Veteran underwent a final VA examination in May 2021. Upon examination, the Veteran reported that he has difficulty understanding speech and that he has to use the captions when watching television. 38 C.F.R. § 4.10; Martinak v. Nicholson, 21 Vet. App. 447 (2007). Upon audiometric testing, the Veteran's Maryland CNC Word List speech recognition score and pure tone thresholds, in decibels, were as follows: HERTZ 1000 2000 3000 4000 Average CNC RIGHT 15 30 80 90 54 94 LEFT 20 65 95 100 70 84 The May 2021 audiology examination findings, applied to Table VI, yield a numeric designation of Roman numeral I in the right ear on the basis of a 54 decibel puretone threshold average and 94 percent speech discrimination, and a numeric designation of Roman numeral III in the left ear on the basis of a 70 decibel puretone threshold average, and 84 percent speech discrimination. The numeric designation for the right ear, I, along with the numeric designation for the left ear, III, entered into Table VII, corresponds to a noncompensable rating for hearing impairment. 38 C.F.R. § 4.85. Exceptional patterns of hearing impairment under 38 C.F.R. § 4.86 are not present. Based on the above evidence, the Board finds that an initial compensable rating for the Veteran's bilateral hearing loss is not warranted at any time. In making this finding, the Board is sympathetic to the Veteran's contention that he has difficulty hearing conversations, his cell phone, or the television due to his hearing loss disability. However, the Board must consider the Veteran's description of his service-connected disability in conjunction with the clinical evidence of record and the pertinent rating criteria. In this regard, the Board emphasizes that disability ratings for hearing loss are derived by a mechanical application of the rating schedule. Lendenmann, 3 Vet. App. at 349. Thus, the Board has no discretion in this matter and must predicate its determination on the basis of the results of the audiological testing of record. As described above, the three VA audiological testing results, which are the only (adequate) audiometric tests of record, when applied to the rating criteria, show that the Veteran's bilateral hearing loss disability did not rise to the level of severity required for the assignment of a compensable rating at any time. Furthermore, the Board notes that in addition to dictating objective test results, a VA audiologist must fully describe the functional effects caused by a hearing disability in the final report. See Martinak v. Nicholson, 21 Vet. App. 447 (2007). In this case, the VA examiners noted that the Veteran reported experiencing a functional impact due to difficulty hearing conversations and having to ask people to repeat themselves, as well as difficulty hearing the telephone and television. The Board finds that such functional impairment, in addition to the Veteran's other lay statements of record in which he described that he must wear hearing aids, has been appropriately considered. However, the overall evidence, as previously discussed, fails to support the assignment of an increased rating. The Board further notes that the Veteran's reported functional limitations are manifestations of decreased hearing acuity, which is already contemplated by the schedular rating criteria for hearing loss. A comparison between the level of severity and symptomatology of the Veteran's assigned rating with the established criteria found in the rating schedule shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology, including his difficulty hearing people or the television or telephone. The Board notes that this conclusion is consistent with the United States Court of Appeals for Veterans Claims' holding in Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017) ("[W]hen a claimant's hearing loss results in an inability to hear or understand speech or to hear other sounds in various contexts, those effects are contemplated by the schedular rating criteria."). The Board further finds that other than difficulty hearing or understanding speech, the record contains no evidence of other symptoms attributable to the service-connected hearing loss. Finally, the Board acknowledges the Veteran's sincere belief that his hearing loss is worse than reflected by his currently-assigned rating. The Veteran is competent to report symptoms of disability, such as difficulty hearing speech. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). However, he is not competent to report that his hearing acuity is of sufficient severity to warrant a higher rating under the rating schedule for hearing loss, as such an opinion requires specialized medical testing and expertise which falls outside the realm of the common knowledge of a layperson. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). For the above reasons, the evidence is neither evenly balanced nor approximately so with regard to whether an initial compensable rating for bilateral hearing loss is warranted. Rather, the evidence persuasively weighs against the claim. Therefore, the benefit of the doubt doctrine, see 38 U.S.C. § 5107(b), is not for application as to this claim. Lynch v. McDonough, 999 F.3d 1391 (Fed. Cir. 2021), affirmed en banc 2021 U.S. App. LEXIS 37307 (Dec. 17, 2021) (only when the evidence persuasively favors one side or another is the benefit of the doubt doctrine not for application). Accordingly, the Veteran's claim for entitlement to an initial compensable rating for bilateral hearing loss is denied. 2. Entitlement to an initial rating in excess of 10 percent for tinnitus The Veteran is in receipt of an initial 10 percent rating for service-connected tinnitus, effective December 21, 2015, pursuant to 38 C.F.R. § 4.87, Diagnostic Code 6260. The Veteran generally seeks entitlement to an increased rating for tinnitus; however, he has not made clear the basis for his claim. As such, the Board is required to interpret his claim broadly. To the extent the Veteran seeks a rating higher than 10 percent or separate 10 percent ratings for each ear, the Board notes such awards are precluded by VA regulation. Diagnostic Code 6260 assigns only a single evaluation of 10 percent for recurrent tinnitus, whether the sound is perceived as being in one ear, both ears, or in the head. 38 C.F.R. § 4.87, Diagnostic Code 6260, Note (2). The maximum schedular rating available for tinnitus is 10 percent. 38 U.S.C. § 1155; 38 C.F.R. § 4.87; Smith v. Nicholson, 451 F.3d 1344 (Fed. Cir. 2006). To the extent that the Veteran believes he is eligible for an increased rating for tinnitus on an extraschedular basis, the Board notes that the Veteran does not contend, and the evidence does not suggest, that his tinnitus presents such an exceptional or unusual disability picture as to render application of the schedule impractical. See 38 C.F.R. § 3.321(b)(1); Fisher v. Principi, 4 Vet. App. 57, 60 (1993). In this regard, the Veteran has only ever described experiencing ringing in his ears, which are symptoms already contemplated by his currently-assigned 10 percent rating. See Doucette, 28 Vet. App. at 369-70. As such, the Board finds that the Veteran's symptomatology is fully addressed by the rating criteria under which his disability is rated. As the maximum schedular rating for tinnitus under Diagnostic Code 6260 has already been assigned, and the Veteran's reported symptoms are reasonably contemplated by the rating criteria, a higher schedular rating is not available. The Veteran's claim for an initial rating in excess of 10 percent for tinnitus must be denied on the basis of a lack of entitlement under the law. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). Service Connection Service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). In general, service connection requires: (1) evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of an in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. See Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Service connection may be granted for any disease diagnosed after discharge when all evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection may also be established on a secondary basis for a disability that is shown to be proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires medical evidence sufficient to show that a current disability exists and that the current disability was either caused or aggravated by a service-connected disability. 38 C.F.R. § 3.310(a); Allen v. Brown, 7 Vet. App. 439 (1995). A finding of aggravation does not require that there be "permanent" worsening of the nonservice-connected disability. Any increase in disability is sufficient. Ward v. Wilkie, 31 Vet. App. 233, 239 (2019). Where 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(b); 38 C.F.R. § 3.102; Lynch v. McDonough, 999 F.3d 1391 (Fed. Cir. 2021), affirmed en banc 2021 U.S. App. LEXIS 37307 (Dec. 17, 2021). 3. Entitlement to service connection for hypertension and chronic kidney disease The Veteran seeks entitlement to service connection for hypertension and chronic kidney disease. The Veteran contends that his hypertension is proximately due to or caused by service-connected depressive disorder. He further contends that his chronic kidney disease is proximately due to or caused by his hypertension. As the resolution of these claims involved the application of similar facts to identical laws, the Board will address them together. The Veteran was afforded VA examinations in November 2017, which confirmed his current diagnoses of hypertension and chronic kidney disease. However, the VA examiner only provided opinions for direct service connection, opining that the claimed conditions are less likely than not incurred in or caused by military service, to include reported exposure to asbestos and lead paint. The examiner's rationale was that medical literature does not support medical/scientific evidence to support this contention. The Board finds the November 2017 opinions to be inadequate because the examiner did not provide sufficient rationale to support his negative findings, nor did he address the Veteran's theory of entitlement to service connection for hypertension and chronic kidney disease on a secondary basis. In September 2020, the Veteran submitted a May 2019 medical opinion provided by a private doctor, Dr. H.S. The doctor, upon review of the Veteran's claims file, including his military and medical history, and interview of the Veteran, opined that the Veteran's depressive disorder more likely than not aided in the development and permanent aggravation of his hypertension. To support this conclusion, the doctor explained Anxiety and depression cause overactive nerve activity, dysfunctional immune response, and activation of the hormone system that controls blood pressure. Just think of how your own heart races when you are scared or angry. This veteran had that type of stress on his heart daily and had this problem continuously since service... The relationship between stress, such as this veteran's depressive disorder, and hypertension is undisputed... This constant long-term stress damages the heart. Stress increases blood pressure by increasing the heart rate and constricting blood vessels. Thereafter, Dr. H.S. cited to, and provided a copy of, medical literature describing research which found the incidence rate of hypertension was higher in persons with high or intermediate depressive symptoms scores than in persons with low depressive symptom scores. He explained that research has also shown anxiety and depression are predictive of later incidence of hypertension and prescription treatment for hypertension. Dr. H.S. continued his medical opinion by discussing the Veteran's chronic kidney disease. He explained that medical research states that hypertension is one of the major risk factors for the development and progression of chronic kidney disease. According to the Merck Manual, high blood pressure damages the circulatory system and most susceptible to the effects of hypertension are the smaller vessels which are present in high concentration in the kidneys. The circulatory damage leads to blockages in parts of the kidney, which, over time, deprive oxygen rich blood and cause kidney tissue to die. This tissue loss decreases the kidney's ability to process and excrete waste products from the body leading to chronic kidney disease or renal insufficiency. The doctor provided a copy of the journal article which supports his above explanation. Based on the above, the doctor concluded that the Veteran's hypertension more likely than not led to the development of his kidney disease. In November 2020, VA obtained an addendum medical opinion to address whether the Veteran's hypertension is secondary to depressive disorder. The VA examiner, in providing a negative etiology opinion, concluded that there is no objective medical record or reputable medical literature evidence to indicate that hypertension is proximately due to or caused by depression. The examiner further stated that there is no mechanism of action for cause or permanent aggravation beyond natural progression of the Veteran's hypertension by depression. Finally, the examiner stated that the Veteran's hypertension is "essential," which means it is of unknown etiology. The Board finds the November 2020 opinion to be inadequate. First, the examiner ignored the current medical research provided, and cited to, by Dr. H.S., which supports a positive causative relationship between stress, depression, and the occurrence of hypertension. Next, the examiner only addressed permanent aggravation, which is not a requirement for a finding of secondary service connection, per Ward, 31 Vet. App. at 239. After a careful review of all the medical and lay evidence of record, the Board finds that the most probative evidence of record weighs in favor of service connection for both hypertension and chronic kidney disease. In the absence of an adequate VA medical opinion, the Board has based its finding on the only adequate medical opinion of record, the May 2019 private medical opinion provided by Dr. H.S. The Board finds this opinion to be highly probative as it was based on a review of the Veteran's clinical history and application of the doctor's medical expertise and knowledge as it is relates to the facts of the Veteran's case. Moreover, the doctor provided a detailed and plausible medical rationale for the conclusions reached, with citation to evidence-based medical literature that directly supports those conclusions. See 38 C.F.R. § 3.159 (a)(1); Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302 (2008) (holding that it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value of a medical opinion); see also Prejean v. West, 13 Vet. App. 444, 448-49 (2000); Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). In the absence of any other probative medical opinion to the contrary, the Board accepts Dr. H.S.'s conclusion that the Veteran's service-connected depressive disorder more likely than not caused or aggravated the Veteran's hypertension. Accordingly, service connection for hypertension, as secondary to service-connected depressive disorder, is granted. In light of the above grant of service connection, the Board also finds that service connection for chronic kidney disease, as secondary to now service-connected hypertension, is warranted. In this regard, the only medical opinion of record that addresses the claim under the theory of entitlement to secondary service connection is the May 2019 private medical opinion. This opinion persuasively explains the likely relationship between the Veteran's hypertension and the occurrence and ongoing aggravation of his chronic kidney disease. There is no medical evidence to the contrary and the Court of Appeals for Veterans Claims has cautioned VA against seeking a medical opinion where favorable evidence in the record is unrefuted. See Mariano v. Principi, 17 Vet. App. 305, 312 (2003). Accordingly, service connection for chronic kidney disease, as secondary to service-connected hypertension, is granted. For the above reasons, the evidence is neither evenly balanced nor approximately so with regard to whether service connection for hypertension and chronic kidney disease is warranted. Rather, the most probative medical evidence of record persuasively weighs in favor of finding that service connection is warranted for both disabilities on a secondary basis. The benefit of the doubt doctrine, see 38 U.S.C. § 5107(b), is therefore not for application as to these claims. Lynch v. McDonough, 999 F.3d 1391 (Fed. Cir. 2021), affirmed en banc 2021 U.S. App. LEXIS 37307 (Dec. 17, 2021) (only when the evidence persuasively favors one side or another is the benefit of the doubt doctrine not for application). The Veteran's claims are granted. REASONS FOR REMAND Although further delay is regrettable, the Board finds that additional development of the claim remaining on appeal is necessary prior to appellate review. Entitlement to SMC based on the need for regular aid and attendance and/or housebound status is remanded. The Board notes that although the Veteran filed a claim for SMC, it is not clear whether the Veteran seeks benefits based on being housebound or based on the need of regular aid and attendance of another person. In January 2017, the Veteran submitted VA Form 21-2680 Examination for Housebound Status or Permanent Need for Regular Aid and Attendance, which was completed by a private doctor. However, the Board notes that the examination report does not contain sufficiently detailed responses for the VA decisionmaker to determine whether the Veteran is eligible for SMC. In this regard, the examination report indicates that the Veteran is unable to stand long enough to prepare his own meals or bath himself due to dizziness and fall risks. However, it is unclear whether these limitations are the result of service-connected or nonservice-connected disability. In light of the above, the Board finds that remand is warranted to schedule the Veteran for the relevant VA examination with a qualified VA examiner to determine whether the Veteran, by reason of service-connected disability, requires the regular aid and attendance of another person and/or is housebound. Accordingly, the matter is REMANDED for the following action: Schedule the Veteran for a VA examination to determine whether he is entitled to SMC based on housebound status or the need for regular aid and attendance. The examiner is requested to provide responses to the following: (a) Whether the Veteran is blind or so nearly blind as to have corrected visual acuity of 5/200 or less in both eyes, or concentric contraction of the visual field to 5 degrees; (b) Whether the Veteran is a patient in a nursing home on account of mental or physical incapacity; (c) Whether the Veteran is so helpless or so nearly helpless so as to require the regular aid and attendance of another person. In making this determination, the examiner should specifically comment on whether the Veteran is unable to dress or undress himself, or to keep himself ordinarily clean and presentable; requires the frequent adjustment of any special prosthetic or orthopedic appliances which by reason of the particular disability cannot be done without such aid; is unable to cook for or feed himself; is unable to attend to the wants of nature; or has an incapacity, physical or mental, that requires care of assistance on a regular basis to protect him from the hazards or dangers incident to his daily environment; or is bedridden. In providing the above, the examiner must identify the medical condition(s) that contribute to any limitations the Veteran has in attending to activities of daily living. (d) Whether the Veteran is substantially confined to his dwelling and the immediate premises, or, if institutionalized, to the ward or clinical area and it is reasonably certain that the disability and resultant confinement will continue throughout his lifetime. The examiner must provide a detailed explanation and rationale for any conclusions reached. By law, the Board is not permitted to rely on any conclusion that is not supported by a thorough explanation. Providing an opinion or conclusion without a thorough explanation will delay processing of the claim and may also result in a clarification being requested. J. NICHOLS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Melissa Barbee, 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.