Citation Nr: A25035278 Decision Date: 04/16/25 Archive Date: 04/16/25 DOCKET NO. 220127-215797 DATE: April 16, 2025 REMANDED Entitlement to eligibility for benefits under the Program of Comprehensive Assistance for Family Caregivers (PCAFC) is remanded. REASONS FOR REMAND The Veteran had active military service from September 2000 to September 2004. In the January 2022 VA Form 10182, Decision Review Request: Board Appeal, Notice of Disagreement, the Veteran elected the Direct Review docket. Therefore, the Board may only consider the evidence of record at the time of the May 2021 agency of original jurisdiction (AOJ), here the Veterans Health Administration (VHA), decision on appeal. 38 C.F.R. § 20.301. Any evidence submitted after the AOJ decision on appeal cannot be considered by the Board. 38 C.F.R. §§ 20.300, 20.301, 20.801. However, because the Board is remanding the claim, any evidence the Board could not consider will be considered by the AOJ in the adjudication of the claim. 38 C.F.R. § 3.103(c)(2)(ii). PCAFC eligibility is remanded. The Veteran has been evaluated at a 100 percent disability rating since January 2020, with a total disability rating for posttraumatic stress disorder with major depressive disorder and schizoaffective disorder. He and the Caregiver-Applicant (significant other) filed an application for PCAFC benefits dated February 2021. His mother was also listed as a secondary family caregiver applicant. The claim was denied in a May 2021 decision. Specifically, the decision on appeal found that the Veteran was not entitled to eligibility for participation in VA's PCAFC. The decision relied in part on a May 2021 Centralized Eligibility and Appeals Team (CEAT) decision which found that the Veteran was not in need of personal care services for a minimum of 6 continuous months based on an inability to perform an activity of daily living (ADL) and/or a need for supervision, protection, or instruction. Remand is necessary for several reasons. First, a remand is necessary to satisfy a statutory duty under 38 U.S.C. § 5104. Under 38 C.F.R. § 20.802(a), the Board may remand for correction of any error by the Agency of Original Jurisdiction in satisfying a regulatory or statutory duty if correction of the error would have a reasonable possibility of aiding in substantiating the claim. 38 U.S.C. § 1720G(a)(12). PCAFC requires the Department of Veterans Affairs (VA) to notify individuals who submit an application for the program of decisions affecting the furnishing of assistance with notice as described within 38 U.S.C. § 5104. Generally, notice under 38 U.S.C. § 5104(b) must include the following: (1) identification of the issues adjudicated; (2) a summary of the evidence considered by VA; (3) a summary of the applicable laws and regulations; (4) identification of findings favorable to the claimant; (5) in the case of a denial, identification of elements not satisfied leading to the denial; (6) an explanation of how to obtain or access evidence used in making the decision; and (7) if applicable, identification of the criteria that must be satisfied to grant service connection or the next higher level of compensation. 38 U.S.C. § 5104(b). Notice must also set forth the right to a hearing, the right of representation, and the right, as well as the necessary procedures and time limits to initiate a higher-level review, supplemental claim, or appeal to the Board of Veterans' Appeals. 38 C.F.R. § 3.102(b)(1). Claimants and their representatives are entitled to notice of any decision made by VA affecting the payment of benefits or the granting of relief. 38 C.F.R. § 3.103(b)(1). Notification will be in writing. See 38 C.F.R. § 3.103(f). In this case, the May 2021 denial letter was not sent to the Veteran's mother (i.e., the secondary family caregiver applicant) nor to the Veteran's representative. In addition, the letter does not comply with all requirements of 38 U.S.C. § 5104(b). Thus, notice is insufficient in this case. This is a pre-decisional duty to notify error and failure to satisfy a statutory duty under 38 U.S.C. § 5104. As such, on remand, the AOJ must provide complete notice of the decision as required by 38 U.S.C. § 5104 and 38 U.S.C. § 1720G(a)(12), including identification of whether or not the claim meets the criteria under 38 U.S.C. § 1720G and 38 C.F.R. § 71.15-71.25. Remand is also needed for an adequate decision. The May 2021 VHA decision indicates that the Veteran's application was being denied because the CEAT determination had found that the Veteran was not in need of personal care services for a minimum of 6 continuous months based on an inability to perform an ADL and/or a need for supervision, protection, or instruction. However, when reviewing the actual CEAT determination, the Veteran was found ineligible for the program because participation in the PCAFC program "was not in the Veteran's best interest." In other words, the reasons for the denial in the May 2021 decision seem to contradict the findings made by CEAT in its March 2021 review consultation. As such, proper identification of the elements not satisfied leading to the denial were not provided to the Veteran and the appellants. Moreover, the Board finds that the CEAT medical review is legally inadequate to support the decision made. As a general matter, a decision by VA affecting the furnishing of assistance or support under the Caregiver Program shall be considered a medical determination. 38 U.S.C. § 1720G. The issue turns on the medical judgment of VHA and the CEAT in determining whether the Veteran met the basic medical eligibility criteria under PCAFC. However, decisions as to eligibility under a Caregiver Program have been held to be subject to Board review. See Beaudette v. McDonough, 34 Vet. App. 95, 105 (2021). To this end, it is within the Board's jurisdictional authority to review the adequacy of all medical opinions upon which eligibility decisions are made. See Owens v. Brown, 7 Vet. App. 429, 433 (1995); Wilson v. Derwinski, 2 Vet. App. 614 (1992). This includes the CEAT's medical determination upon which the instant eligibility decision was based. A VA opinion is adequate if it "sufficiently inform[s] the Board of the medical expert's judgment on a medical question and the essential rationale for that opinion." A non-exhaustive list of factors that, depending on the case, may be relevant considerations in determining the adequacy and probative value of a medical opinion include: (1) whether there was personal examination of the patient; (2) the expert's knowledge and skill in analyzing the data; (3) whether the opinion contains clear conclusions with supporting data and a reasoned medical explanation connecting the two; (4) whether the opinion is clear and susceptible of only one meaning; (5) the expert's familiarity with pertinent medical history; (6) whether there is any inconsistency in the expert's statements; (7) whether the expert has provided a thorough and detailed opinion about an area within his or her expertise; (8) whether the expert has provided factually accurate, fully articulated, and sound reasoning for his or her conclusion; (9) whether the expert relied on sufficient facts or data; (10) whether the opinion is the product of reliable principles and methods; (11) whether the opinion is the result of principles and methods reliably applied to facts; and (12) whether medical text evidence that a medical opinion relies on contains qualifying or contradictory aspects where the text is entered into the record, at least in part. See McCray v. Wilkie, 31 Vet. App. 243, 257 (2019). In short, a medical opinion will be considered probative if it includes clear conclusions and supporting data with a reasoned analysis connecting the data and conclusions. A medical opinion that is a factually accurate, fully articulated, and based on sound reasoning carries significant weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Here, the CEAT's review does not meet these requirements. The medical opinion is conclusory and unexplained. In this regard, the opinion indicates that participation in the program was not in the Veteran's best interest, but failed to explain the medical basis for this conclusion. It simply answered, "No" to this question and indicated that "It has been determined that participation in the Program for Comprehensive Assistance for Family Caregivers (PCAFC) does not significantly enhance the Veteran's ability to live safely in a home setting, support potential progress in rehabilitation, increase potential independence, and/or and create an environment that supports Veteran health and well-being." The Board notes, however, that there was no explanation of how or why PCAFC participation would not enhance the Veteran's ability to live safely at home, increase his potential for independence, or support his overall well-being. In essence, without an adequate supporting explanation, the Board has no way to know how or why the decision here was reached, to include what specific medical facts in this Veteran's case justified the denial. Thus, remand is necessary for a new medical determination considering all medical information of record. Correction of these errors by the AOJ is necessary to satisfy a statutory duty under 38 U.S.C. § 5104 and a duty-to-assist error that occurred prior to the decision on appeal. See 38 C.F.R. § 20.802(a); see also 38 U.S.C. § 1720G(a)(12). The matters are REMANDED for the following actions: 1. Obtain an opinion from an appropriate clinician as to whether it is in the best interest of the Veteran to participate in the PCAFC. The Board defers to the discretion of the examiner to determine whether an evaluation is required. The examiner should provide any additional opinion(s) necessary to determine whether the Veteran is eligible for participation in the PCAFC. A complete rationale for all opinions expressed should be set forth by the examiner. 2. Issue a notice of the decision on the issue of entitlement to eligibility for PCAFC benefits as described in 38 U.S.C. § 5104. The notice shall include but is not limited to, a summary of the evidence; a summary of the applicable laws and regulations; identification of findings favorable to the claimant; and identification of the elements not satisfied but necessary for establishing eligibility for PCAFC benefits under 38 C.F.R. § 71.15-71.25. Notice must be sent to the Veteran, his representative, the Caregiver-Applicant, and the secondary family caregiver applicant. M. HYLAND Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. Casadei, 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.