Citation Nr: 22040129 Decision Date: 07/13/22 Archive Date: 07/13/22 DOCKET NO. 16-56 884 DATE: July 13, 2022 ORDER Entitlement to service connection for residuals of a stroke is granted. Entitlement to a rating in excess of 20 percent for service-connected diabetes mellitus is denied. Entitlement to a rating in excess of 20 percent for service-connected left lower extremity peripheral neuropathy is denied. Entitlement to a rating in excess of 20 percent for service-connected right lower extremity peripheral neuropathy is denied. Entitlement to a rating in excess of 60 percent for service-connected coronary artery disease (CAD) is denied. Entitlement to automobile or other conveyance and adaptive equipment, or for adaptive equipment only, is denied. Entitlement to special monthly compensation (SMC) based on aid and attendance is denied. FINDINGS OF FACT 1. The Veteran's stroke was caused by his service-connected diabetes mellitus, type II. 2. During the period on appeal, the Veteran's diabetes mellitus, type II, has not required a regulation of activities with the intention of avoiding hypoglycemic episodes. 3. During the period on appeal, the Veteran's diabetic peripheral neuropathy of the right lower extremity was manifested by no more than moderate incomplete paralysis of the right sciatic nerve. 4. During the period on appeal, the Veteran's diabetic peripheral neuropathy of the left lower extremity was manifested by no more than moderate incomplete paralysis of the left sciatic nerve. 5. During the period on appeal, the Veteran's CAD was manifested by relevant symptoms resulting from a workload of greater than 3 METs, and ejection fractions 50 percent or above; chronic congestive heart failure has not been shown. 6. The Veteran's service-connected disabilities do not result in the physical loss or permanent loss of use of one or both hands or feet, permanent impairment of vision in both eyes with corrected central visual acuity of 20/200 or less in the better eye or central visual acuity of more than 20/200 with a visual field defect of a degree specified by regulation, severe burn injury, amyotrophic lateral sclerosis, or ankylosis of one or both knees or hips. 7. The Veteran's service-connected disabilities, by themselves, do not render him so helpless as to require the regular aid and attendance of another person to perform personal care functions of everyday living or to protect him from the hazards and dangers incident to the daily environment. CONCLUSIONS OF LAW 1. The criteria for service connection for residuals of a stroke have been satisfied. 38 U.S.C. §§ 1110 5107; 38 C.F.R. §§ 3.102, 3.310. 2. The criteria for a disability rating in excess of 20 percent for service-connected diabetes mellitus, type II, have not been satisfied. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.119, Diagnostic Code 7913. 3. The criteria for entitlement to a disability rating in excess of 20 percent for diabetic peripheral neuropathy of the right lower extremity have not been satisfied. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.124a, Diagnostic Code 8520. 4. The criteria for entitlement to a disability rating in excess of 20 percent for diabetic peripheral neuropathy of the left lower extremity have not been satisfied. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.124a, Diagnostic Code 8520. 5. The criteria for a disability rating in excess of 60 percent for coronary artery disease have not been satisfied. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.104, Diagnostic Code 7005-7017. 6. The criteria for establishing eligibility for financial assistance for the purchase of an automobile or other conveyance and/or automobile adaptive equipment have not been satisfied. 38 U.S.C. §§ 3901, 3902, 5107; 38 C.F.R. §§ 3.102, 3.808. 7. The criteria for SMC based on the need for regular aid and attendance or being housebound have not been satisfied. 38 U.S.C. §§ 1114; 38 C.F.R. §§ 3.350, 3.352. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Air Force from May 1967 to April 1971, to include service in the Republic of Vietnam. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in December 2014 and January 2015. It was previously before the Board in November 2021, where the issues were remanded for additional development. They now return for further appellate review. Service Connection Generally, to establish service connection, a claimant must show: (1) a present disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service, the so-called "nexus" requirement. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303; see also Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). A disability that is proximately due to, the result of, or aggravated by a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310. VA has established certain rules and presumptions for chronic diseases. See 38 C.F.R. §§ 3.303(b), 3.307, 3.309(a); Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). With chronic diseases shown as such in service so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless attributable to intercurrent causes. 38 C.F.R. § 3.303(b). If chronicity in service is not established, a showing of continuity of symptoms after discharge may support the claim. 38 C.F.R. § 3.303(b). In addition, for veterans who have served 90 days or more of active service during a war period or after December 31, 1946, chronic diseases are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 C.F.R. §§ 3.307(a)(3), 3.309(a). 1. Service connection for a stroke is granted. The Veteran seeks service connection for stroke, which he asserts is proximately due to or the result of his service-connected diabetes mellitus or heart disability. In January 2015, the Veteran was provided a VA examination to ascertain the nature and etiology of his claimed stroke. In the report, the examiner noted that private treatment records show that the Veteran was admitted for possible transient ischemic attack (TIA) from March 2014 to April 2014, and that CT scans of the brain were negative, and his echocardiogram did not show any anatomical deficits for causing stroke. The report further notes that a May 16, 2014, VA neurology note shows that the Veteran was prescribed clopidogrel bisulphate for secondary stroke prevention. In the remarks section, the examiner concluded that the Veteran experienced a self-reported transient ischemic attack on March 29, 2014, which resolved without residuals. The examiner did not address the etiology of the Veteran's TIA. It has been held that the requirement for service connection that a current disability be present is satisfied when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim even though the disability resolves prior to the Secretary's adjudication of the claim. See McClain v. Nicholson, 21 Vet. App. 319, 321(2007). This can also be in close proximity to the date of claim. See Romanowsky v. Shinseki, 26 Vet. App. 289, 293-94(2013). Thus, in light of McClain and Romanowsky, the Board remanded the Veteran's claim in November 2021 for a new VA examination to address the etiology of the Veteran's transient ischemic attack. In an etiological opinion provided in January 2021, a VA examiner opined that it was at least as likely as not that the Veteran's stroke was proximately due to or the result of his service-connected diabetes. The examiner explained that the Veteran was diagnosed with diabetes in or around 1998 and suffered what appears to have been a TIA in 2014, for which he was prescribed Plavix, ans it is well established that diabetes increases one's risk of cardiovascular disease, peripheral vascular disease, and cerebrovascular disease two fold or more, which is a "statistically significant" risk factor. There are no other medical opinions in significant conflict with the above. As such, resolving all doubt in his favor, the evidence is in favor of a grant of service connection for the Veteran's 2014 TIA as caused by his diabetes on a secondary basis. 38 C.F.R. §§ 3.102, 3.310. Increased Ratings Disability ratings are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Different ratings may be assigned for different periods of time for the same disorder if the facts show distinct time periods with different levels of disability. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). If two ratings are potentially applicable, the higher rating will be assigned if the disability more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. See 38 C.F.R. § 4.3. The evidentiary record does not reasonably raise the prospect that the Veteran's disability is not and cannot be adequately rated under the Rating Schedule. 2. A disability rating in excess of 20 percent for diabetes mellitus. The Veteran is currently rated at 20 percent disabling for his diabetes mellitus under 38 C.F.R. § 4.119, Diagnostic Code 7913. Under Diagnostic Code 7913, a 20 percent rating is warranted when diabetes requires one or more daily injections of insulin or an oral hypoglycemic agent, and a restricted diet. 38 C.F.R. § 4.119, Diagnostic Code 7913. A 40 percent rating is warranted for diabetes that requires one or more daily injections of insulin, a restricted diet, and regulation of activities. Id. A 60 percent rating is warranted when diabetes mellitus requires more than one daily injection of insulin, a restricted diet, and a regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if separately evaluated. Id. For VA benefits purposes the term "regulation of activities" contained in Diagnostic Code 7913 means that a Veteran must have a medical need, caused by the Veteran's diabetes mellitus, to avoid strenuous occupational or recreational activities with the intention of avoiding hypoglycemic episodes, and thus, medical evidence of limitation of activities required by a physician must be shown. Camacho v. Nicholson, 21 Vet. App. 360, 363-364 (2007). The criteria for rating diabetes mellitus are conjunctive, and each element of the criteria is needed to meet the requirements for the specified evaluation. Id. For the reasons that follow, the Board finds the record against a finding that his service-connected diabetes warrants a rating higher than 20 percent, as the record is against a finding that his treatment required a regulation of activities at any point during the appeal. The Veteran filed a claim for an increased rating for his service-connected diabetes in September 2013. As such, a VA diabetes mellitus examination was afforded to the Veteran in November 2014 to determine the nature and severity of his diabetes. While the examiner noted that the Veteran's diabetes was managed by a restricted diet and prescribed insulin injections once per day, he specifically noted that the Veteran did not require a regulation of activities for VA purposes. The Veteran was noted to visit his diabetic care provider for episodes of ketoacidosis or hypoglycemic reactions less than two times per month, with no hospitalizations. Other than the peripheral neuropathy for which service connection has been awarded, the examiner further noted that the Veteran had no other complications of diabetes mellitus, including diabetic nephropathy or diabetic retinopathy, nor did he have any other condition due to diabetes mellitus. Based on the foregoing examination, the RO continued the Veteran's 20 percent rating for diabetes mellitus in the rating decision on appeal. As the Board noted in its previous remand, VA medical records generated since the most recent November 2014 VA diabetes mellitus examination suggested that the Veteran has developed diabetic retinopathy and that his peripheral neuropathy has resulted in increased falls, to the point of necessitating home modifications. Indeed, a February 25, 2019, VA treatment note shows that the Veteran applied for housing modification after experiencing more than six falls during the first two months of 2019. Thus, an additional VA diabetes mellitus examination was scheduled for the Veteran in December 2021. The record reflects, however, that the Veteran cancelled the examination. While VA has a duty to assist the Veteran in developing evidence pertinent to his claim, the Veteran also has a duty to assist and cooperate with VA in developing this evidence. 38 C.F.R. § 3.159(c). The duty to assist is not a one-way street. See Wood v. Derwinski, 1 Vet. App. 190 (1991). When a veteran fails to report for an examination scheduled in conjunction with an original compensation claim, the claim shall be rated based on the evidence of record. When the examination was scheduled in conjunction with any other original claim, a supplemental claim for a benefit which was previously disallowed, or a claim for increase, the claim shall be denied. See 38 C.F.R. § 3.655(b). When a veteran misses a scheduled VA examination, the Board must consider (1) whether the examination was necessary to establish entitlement to the benefit sought, and (2) whether the veteran lacked good cause to miss the scheduled examination. Turk v. Peake, 21 Vet. App. 565, 569 (2008). Examples of "good cause" for failure to report for a VA examination include illness or hospitalization of the claimant and death of an immediate family member. See 38 C.F.R. § 3.655(a). In this case, the Veteran failed to report for the VA examinations in December 2021 and neither he nor his representative provided any explanation for his failure to report to those examinations. While correspondence confirming the cancelled examinations were subsequently sent to the Veteran and his representative, no reply was received. Even if the Board were to determine that the scheduled examination was not entirely necessary to decide the claim and consider the evidence of record, such as the Veteran's initial VA examination and any medical treatment records, the record does not reflect that any regulation in activity is due to changes in blood sugar levels or hypoglycemia with increased activity where activity needs to be restricted to avoid sudden drops in blood sugar. 38 C.F.R. § 4.119, Diagnostic Code 7913. As such, entitlement to the next higher, 40 percent rating for the Veteran's diabetes is denied. 38 C.F.R. §§ 4.1, 4.3. 3. Disability ratings in excess of 20 percent for diabetic peripheral neuropathy of the bilateral lower extremities. The Veteran is currently assigned 20 percent disability ratings in each lower extremity for peripheral neuropathy associated with service-connected diabetes mellitus pursuant to 38 C.F.R. § 4.124a, Diagnostic Code 8520, for incomplete paralysis of the sciatic nerve. Under that regulation, moderate incomplete paralysis of the sciatic nerve warrants a 20 percent disability rating. Moderately severe incomplete paralysis of the sciatic nerve warrants a 40 percent disability rating. Severe incomplete paralysis of the sciatic nerve with marked muscular atrophy warrants a 60 percent disability rating. Finally, complete paralysis of the sciatic nerve where the foot dangles and drops, with no active movement possible of muscles below the knee, and with flexion of the knee weakened or (very rarely) lost warrants an 80 percent disability rating. 38 C.F.R. § 4.124a. Regulations provide that the ratings for peripheral neurological disorders are to be assigned based upon the relative impairment of motor function, trophic changes, or sensory disturbance. 38 C.F.R. § 4.120. Consideration is also given for loss of reflexes, pain, and muscle atrophy. See 38 C.F.R. §§ 4.123, 4.124. The term "incomplete paralysis" for peripheral nerve injuries indicates a degree of lost or impaired function which is substantially less than that which results from complete paralysis of these nerve groups, whether the loss is due to the varied level of the nerve lesion or to partial nerve regeneration. In rating the peripheral nerve injuries and their residuals, attention should be given to the site and character of the injury, the relative impairment in motor function, trophic changes, or sensory disturbances. 38 C.F.R. § 4.120. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a. The words "mild," "moderate," and "severe" as used in the various Diagnostic Codes are not defined in the Rating Schedule. Regulations provide that the ratings for peripheral neurological disorders are to be assigned based the relative impairment of motor function, trophic changes, or sensory disturbance. 38 C.F.R. § 4.120. Consideration is also given for loss of reflexes, pain, and muscle atrophy. See 38 C.F.R. §§ 4.123, 4.124. The Board does note that "Mild," as relevant to a physical condition, is defined as "not severe" or temperate; with "Temperate" being defined as "keeping or held within limits" and "not extreme or excessive." Merriam-Webster's Dictionary (merriam-webster.com/dictionary, accessed May 10, 2021). "Moderate" is defined as "tending toward the mean or average amount," "not violent, severe, or intense," and "limited in scope or effect." Id. "Severe" is defined as "very painful or harmful" or "of a great degree." Id. The term "severe" is used throughout the rating schedule, including in Diagnostic Code 8520, to indicate a very great degree of the specific listed disability, in order to differentiate between lesser (or sometimes greater) cases of that same disability within the specific diagnostic code. Within the context of Diagnostic Code 8520, which establishes a successive, tiered rating structure, it represents the highest or most extreme level of incomplete paralysis. As with the Veteran's diabetes claim, the Veteran filed an increase rating claim for his service-connected diabetic peripheral neuropathy in September 2013, and a VA examination was afforded the following November 2014. The examiner noted the Veteran's subjective reports of moderate constant and intermittent pain, moderate paresthesias and/or dysesthesias, and mild numbness, bilaterally. Physical examination revealed normal muscle strength and reflexes, but decreased sensation from the ankle to the toes. There was no muscle atrophy or any trophic changes. The examiner opined that the Veteran's bilateral lower extremity neuropathy manifested no more than moderate incomplete paralysis of the sciatic nerve. The Board notes that, in support of his increased rating claim, the record also reflects a VA disability benefits questionnaire (DBQ) completed by a private physician in 2014 but submitted by the Veteran in 2016. While the DBQ notes the veteran reporting severe symptoms, with absent reflexes and sensation, when asked to describe the overall severity of the Veteran's neuropathy the physician noted that that the Veteran's nerves were normal, i.e., there was neither incomplete nor complete paralysis in any lower extremity nerve. Further, while the Veteran checked "yes" in the portion of the DBQ asking if there were any tropic changes in the Veteran's extremities, no description of any trophic changes was provided as required. As such, the Board finds this conflicting, incomplete DBQ to be of no probative value. Pursuant to the Board's last remand, an additional VA examination was scheduled for the Veteran in December 2021. The record reflects, however, and as with the above diabetes claim, that the Veteran cancelled the examination without good cause. Even if the Board were to consider the available evidence of record, such as the Veteran's initial VA examination and any medical treatment records, the available record reflects Veteran's bilateral peripheral neuropathy is primarily manifested by sensory disturbance and pain. The record does not support a finding that the Veteran's disability has resulted in moderately severe incomplete paralysis of the sciatic nerve, as required for the next higher schedular evaluation under Diagnostic Code 8520. 38 C.F.R. § 4.124a. The Board has considered all other potentially applicable Diagnostic Codes, but there is no evidence showing the Veteran has neurological impairment associated with any other peripheral nerves that have not already been service-connected. As such, entitlement to a higher rating for the Veteran's peripheral neuropathy is denied. 38 C.F.R. §§ 4.1, 4.3. 4. CAD The Veteran's CAD is rated as 60 percent disabling during the entire appeal period under Diagnostic Code 7005-7017. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires the use of an additional diagnostic code to identify the basis for the rating assigned. 38 C.F.R. § 4.27. Here, Diagnostic Code 7005 provides rating criteria for CAD, and Diagnostic Code 7017 applies to the Veteran's history of coronary bypass surgery. Prior to November 14, 2021, under Diagnostic Code 7017, a 100 percent rating is assigned for three months following hospital admission for coronary bypass surgery. 38 C.F.R. § 4.104. Thereafter (or if there is no coronary bypass surgery), a 100 percent rating is warranted under Diagnostic Code 7005 for chronic congestive heart failure, or when a workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope, or left ventricular dysfunction with an ejection fraction of less than 30 percent. A 60 percent rating is warranted for more than one episode of acute congestive heart failure in the past year, or; workload of greater than 3 METs but not greater than 5 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope; or for left ventricular ejection fraction (LVEF) of 30 to 50 percent. Id. One MET (metabolic equivalent) is the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute. When the level of METs at which dyspnea, fatigue, angina, dizziness, or syncope develops is required for evaluation, and a laboratory determination of METs by exercise testing cannot be done for medical reasons, an estimation by a medical examiner of the level of activity (expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow) that results in dyspnea, fatigue, angina, dizziness, or syncope may be used. 38 C.F.R. § 4.104, Note (2). Effective November 14, 2021, VA revised the criteria for evaluating cardiovascular disorders. See Schedule for Rating Disabilities: The Cardiovascular System, 38 C.F.R. § 4.104 (Nov. 14, 2021). VA's General Counsel has held that where a law or regulation changes during the pendency of a claim for a higher rating, the Board must first determine whether the revised version is more favorable to the veteran. In so doing, it may be necessary for the Board to apply both the old and new versions of the regulation. If the revised version of the regulation is more favorable, the retroactive reach of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. The Board must generally apply both the former and the revised versions of the regulation for the period prior and subsequent to the regulatory change, but an effective date based on the revised criteria may be no earlier than the date of the change. VA thus must consider the claim for a higher rating pursuant to the former and revised regulations during the latter part of this appeal. See VAOPGCPREC 3 2000, 65 Fed. Reg. 33,422 (2000); DeSousa v. Gober, 10 Vet. App. 461, 467 (1997). Therefore, the Board will consider the Veteran's claim under the old criteria prior to November 14, 2021, and both the old and new rating criteria from November 14, 2021. The criteria that is more favorable to the Veteran will be applied. In this regard, the Board observes that former regulation 38 C.F.R. § 19.9(b)(2) (now renumbered as 38 C.F.R. § 20.904(d)(2)) provided that the Board has the authority to consider appeals in light of laws, including but not limited to statutes, regulations and court decisions that were not previously considered by the agency of original jurisdiction. In Disabled American Veterans v. Sec of Veterans Affairs, 327 F.3d 1339 (Fed. Cir. 2003), the United States Court of Appeals for the Federal Circuit (Federal Circuit) specifically upheld the validity of 38 C.F.R. § 19.9(b)(2) (now as noted renumbered as 38 C.F.R. § 20.904(d)(2)). Id. at 1349. As such, pursuant to 38 C.F.R. § 20.904(d)(2), the Board will proceed to adjudicate the Veteran's claim. Since November 14, 2021, the Veteran's service-connected IHD may be rated under the General Formula. Such provides that a 60 percent rating contemplates a workload of greater than 3 METs, but not greater than 5 METs, which results in heart failure symptoms. A 100 percent rating contemplates a workload of 3 METs or less, resulting in heart failure symptoms. 38 C.F.R. § 4.104, General Rating Formula. Turning to the evidence, the RO afforded the Veteran VA examinations in May 2014 and again in November 2014. Both examiners noted that the Veteran's diagnosis of CAD, status post coronary artery bypass grafts surgery in 2007, that manifested as symptoms of dyspnea (shortness of breath). The November 2014 examiner also noted the Veteran's report of rare incidents of angina alleviated with nitroglycerin. No other heart condition was indicated, to include congestive heart failure. Interview-based METs on each occasion were >5-7, consistent with activities such as walking 1 flight of stairs, golfing (without cart), mowing lawn (push mower), heavy yard work (digging). He was noted to have mild left ventricular hypertrophy, and LVEF via an echocardiogram was noted as 50 percent in May 2014 and 51 percent in November 2014. The Veteran's treatment records are not in significant conflict with the above findings, with the Veteran reporting fatigue and dyspnea. As with the Veteran's diabetes and neuropathy claims, the Board previously remanded his claim for a new VA examination to determine the current nature and severity of his CAD, which was scheduled in December 2021. Again, however, and as with the Veteran's diabetes claim, that record reflects the Veteran cancelled the examination without good cause. Even if the Board were to consider the remaining evidence of record, such as the Veteran's VA examinations and any medical treatment records, the evidence is against a finding that the Veteran meets the criteria for a higher, 100 percent rating. Chronic congestive heart failure, a workload of 3 METs or less resulting in relevant symptoms, or LVEF of less than 30 percent are not shown by the lay or medical evidence. At worst, the Veteran's disability was productive of a workload greater than 3 METs resulting in angina, dyspnea, and fatigue, and with LVEF results well over 30 percent. 38 C.F.R. § 4.104, Diagnostic Codes 7005, 7017. The Board has considered whether a higher rating is warranted under any other diagnostic code pertaining to diseases of the heart (Diagnostic Codes 7000-7020) but has found none. Thus, the claim for a disability rating in excess of 60 percent for the Veteran's service-connected CAD must be denied. 38 C.F.R. §§ 4.3, 4.7, As to all of the above increased rating claims, the Board is sympathetic to the Veteran's lay statements that his disabilities are worse than currently evaluated and those statements have been considered. The Veteran is competent to report symptoms because this requires only personal knowledge as it comes to him through his senses. Layno v. Brown, 6 Vet. App. 465 (1994). He is not, however, competent to identify a specific level of disability according to the appropriate diagnostic codes. Such competent evidence concerning the nature and extent of the Veteran's disabilities have been provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the examination reports and the clinical records) directly address the criteria under which the disabilities are evaluated. The medical and lay evidence has been assessed by the Board in determining the overall disability ratings. 5. Entitlement to automobile or other conveyance and adaptive equipment, or for adaptive equipment only. 6. Entitlement to SMC based on aid and attendance. The Veteran seeks entitlement to an automobile or other conveyance and adaptive equipment, or adaptive equipment only, as well as SMC based on the need for regular aid and attendance of another. Financial assistance may be provided to an "eligible person" in acquiring an automobile or other conveyance and adaptive equipment, or automotive adaptive equipment only. 38 U.S.C. § 3902 (a)(b). Eligibility for assistance to purchase a vehicle and adaptive equipment is warranted where one of the following exists as the result of injury or disease incurred or aggravated during active service: (1) loss or permanent loss of use of one or both feet; (2) loss or permanent loss of use of one or both hands; (3) permanent impairment of vision of both eyes, meaning central visual acuity of 20/200 or less in the better eye, with corrective glasses, or central visual acuity of more than 20/200 if there is a field defect in which the peripheral field has contracted to such an extent that the widest diameter of visual field subtends an angular distance no greater than 20 degrees in the better eye; (4) severe burn injury precluding effective operation of an automobile; (5) amyotrophic lateral sclerosis (ALS); or, (6) for adaptive equipment only, ankylosis of one or both knees or one or both hips. 38 C.F.R. § 3.808. At the outset, the Board notes that the Veteran has not asserted, nor does the record suggest, that he has permanent loss of an upper extremity, loss of vision, severe burn injury, ALS, or ankylosis. Rather, the veteran asserts that his diabetic neuropathy has amounts to loss of use of the feet. As to the SMC claim, increased monthly compensation at the aid and attendance rate is payable when the veteran, due to service-connected disability, has suffered the anatomical loss of use of both feet, or one hand and one foot, or is blind in both eyes, or is permanently bedridden or so helpless as to be in need of regular aid and attendance. 38 U.S.C. § 1114(l); 38 C.F.R. § 3.350(b). Determinations as to the need for regular aid and attendance are factual and must be based upon the actual requirements for personal assistance from others. In making such determinations, consideration is given to such conditions as: the inability of the veteran 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 veteran to feed himself or herself 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 veteran 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 veteran is unable to perform should be considered in connection with his or her condition as a whole. It is only necessary that the veteran 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 veteran 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, 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 veteran was so helpless as to be in need of regular aid and attendance will not be based solely upon an opinion that the veteran'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. The Veteran submitted a VA form 21-2680 Examination for Housebound Status or Permanent Need for Regular Aid and Attendance, completed by a private physician in May 2014. While unable to prepare his own meals, the Veteran was noted ot be able to feed himself, did not require assistance bathing and tending to other hygiene needs, was not legally blind, did not require nursing home care. Further, when asked to describe the restriction of each lower extremity, the physician responded with "none," and when asked if the Veteran required the aid of an assistive device, the physician marked both "yes" and "no." The Board does note that the aid and attendance examination report notes that the Veteran's daughter managed his medication and his financial affairs due ot a "cognitive dysfunction", which would suggest that the Veteran may have incapacity that requires assistance on a regular basis to protect him from hazards or dangers incident to his daily environment. The Board notes, however, that since the above aid and attendance examination and the RO's initial denial of the Veteran's SMC and auto adaptation claims, the Veteran has been granted service connection for an acquired psychiatric disorder, which was assigned a 30 percent rating based on occupational and social impairment due to mild or transient symptoms (such as anxiety, chronic sleep impairment, and depressed mood) which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress. See 38 C.F.R. § 4.130. The current record does not reflect that any cognitive disorder is the result of his newly-service-connected acquired psychiatric disorder, or any other service-connected disability. In that regard, available VA examinations and treatment records during the appeal note that his acquired psychiatric disorder manifests symptoms of anxiety, depressed mood, and chronic sleep impairment. No memory loss more than mild in severity or any cognitive issues are suggested. While the Board acknowledges that it is granting service connection for a stroke that occurred in close proximity to the Veteran's claim, the available record, including treatment records, does not reflect any current residuals of this disability. Moreover, as noted in the above claims for increased ratings, the evidence is against a finding that the Veteran's diabetes and its peripheral neuropathy, or his CAD, were so severe to result in loss of use of any extremity. As noted above, and pursuant to the Board's last remand, the Veteran failed to report to VA examinations scheduled to determine the nature and severity of his increased rating claims for diabetes, peripheral neuropathy, and CAD. Additionally, while the Board has granted the Veteran's service connection claim for a stroke based on an VA examiners opinion as an examination was deemed unnecessary to provide the opinion, a physical examination to determine current stroke residuals was nevertheless scheduled which was also cancelled by the Veteran. Again, under 38 C.F.R. § 3.655(b), if a claim for an increased disability rating cannot be determined without a new VA examination and the claimant, without good cause, fails to report to that scheduled examination, then the claim will be denied. When a veteran misses a scheduled VA examination, the Board must consider (1) whether the examination was necessary to establish entitlement to the benefit sought, and (2) whether the veteran lacked good cause to miss the scheduled examination." Turk, 21 Vet. App. at 569. As the Veteran failed to report for VA examinations scheduled in conjunction with his claims for increased ratings without good cause, the Board is limited to evidence of record. Based on the evidence noted above, the Veteran's service-connected disabilities do not result in loss of sue of the feet for the purposes of the Veteran's automobile/auto adaptation claim, nor does he the aid and attendance of another based on any service-connected physical or mental impairment. Thus, the claims for entitlement to entitlement to automobile or other conveyance and adaptive equipment, or for adaptive equipment only, as well as SMC based on the need for regular aid and attendance, must be denied. P.M. DILORENZO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. Scarduzio, 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.