Citation Nr: A25036331 Decision Date: 04/21/25 Archive Date: 04/21/25 DOCKET NO. 220127-215811 DATE: April 21, 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 April 1969 to January 1971. In the January 2021 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 December 2020 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. PCAFC eligibility is remanded. The Veteran has been evaluated at 80 percent from September 2002, with a total disability rating based upon individual unemployability since April 2, 2003. He and the Caregiver-Applicant (spouse) filed an application for PCAFC benefits in October 2020. The claim was denied in a December 2020 decision. The AOJ 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 November 2020 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 and participation in PCAFC was deemed not in the Veteran's best interest. 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 December 2020 denial letter was not sent to the Veteran's representative nor to the Caregiver-Appellant (spouse). 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. 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 November 2020 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 October 2020 Veteran Functional Assessment during which the Veteran reported he requires supervision when cooking due to leaving the stove on or unattended. It was also noted that the Veteran needed assistance during the time of the examination to get up from the exam table and required assistance from the nurse. The nurse also indicated that the Veteran was guarding himself when walking and indicated that he had "a close fall 2 months ago." Specifically, the Veteran reported that he had lost his balance, caught himself, but had injured his left arm and hand in the process. The Functional Assessment report also indicated that the Veteran was unable to drive and could not attend medical appointments on his own. The CEAT's review consultation opinion also does not provide any explanation as to why participation in PCAFC was deemed not in the Veteran's best interest. In sum, 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: (a.) Dressing or undressing oneself; (b.) Bathing; (c.) Grooming oneself in order to keep oneself clean and presentable; (d.) 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.); (e.) Toileting or attending to toileting; (f.) 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 (g.) Mobility (walking, going up stairs, transferring from bed to chair, etc.). (h.) Has a need for supervision or protection based on symptoms or residuals of neurological or other impairment or injury; or (i.) 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. M. HYLAND Veterans Law Judge Board of Veterans' Appeals Attorney for the Board 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.