Citation Nr: A25035396 Decision Date: 04/17/25 Archive Date: 04/17/25 DOCKET NO. 220114-212493 DATE: April 17, 2025 REMANDED Entitlement to eligibility for benefits under the Program of Comprehensive Assistance for Family Caregivers (PCAFC). REASONS FOR REMAND The Veteran served on active duty from January to June 1993, from September 2004 to March 2006, and from December 2007 to May 2009. He has been 100 percent disabled and in receipt of special monthly compensation (SMC) pursuant to 38 U.S.C. § 1114(k) since August 10, 2012. He and the Caregiver-Applicant (spouse) filed an application for PCAFC benefits dated November 2020. In April 2021, the Veterans Health Administration (VHA), the agency of original jurisdiction (AOJ), denied the claim. In the January 2022, the Veteran appealed to the Board via a VA Form 10182 and elected the Direct Review docket. Therefore, the Board may only consider the evidence of record at the time of the AOJ decision on appeal. 38 C.F.R. § 20.301. 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). The April 2021 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 March 2021 Centralized Eligibility and Appeals Team (CEAT) decision which found that he 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. 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 AOJ 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 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 April 2021 denial letter is insufficient, in that it does not comply with 38 U.S.C. § 5104(b) and include all required elements such as a summary of the evidence considered, a summary of the applicable laws and regulations, and identification of favorable findings. For these reasons, 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. 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 March 2021 CEAT Review Consultation found that the Veteran did not meet the eligibility requirements under the program. 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. For example, the opinion does not consider the January 2021 Veteran Functional Assessment during which the Veteran reported he required assistance with bathing, dressing, and medication management. He reported he needed his medication set up for medication management. For dressing, he reported supervision or touching assistance for upper body dressing and partial/moderate assistance for lower body dressing. For bathing, he reported partial/moderate assistance was required, noting that his wife will wash his back, lower extremities, and feet due to his low back pain, left shoulder range of motion, and becoming dizzy when bending over. Simply put, 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 action: 1. Obtain a current medical opinion from the CEAT as to whether the Veteran: a. Requires personal care services each time he completes one or more of the following: i. Dressing or undressing oneself; ii. Bathing; iii. Grooming oneself in order to keep oneself clean and presentable; iv. Adjusting any special prosthetic or orthopedic appliance, that by reason of the particular disability, cannot be done without assistance (this does not include the adjustment of appliances that nondisabled persons would be unable to adjust without aid, such as supports, belts, lacing at the back, etc.); v. Toileting or attending to toileting; vi. Feeding oneself due to loss of coordination of upper extremities, extreme weakness, inability to swallow, or the need for a non-oral means of nutrition; or vii. Mobility (walking, going up stairs, transferring from bed to chair, etc.). b. Has a need for supervision or protection based on symptoms or residuals of neurological or other impairment or injury; or c. Has a need for regular or extensive instruction or supervision without which the ability of the Veteran to function in daily life would be seriously impaired. In answering all questions, the medical facts and reasons underpinning every conclusion must be articulated. 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, and the Caregiver-Applicant. L. HOWELL Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Oettle, Teresa I. 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.