Citation Nr: A25038136 Decision Date: 04/25/25 Archive Date: 04/25/25 DOCKET NO. 220204-218632 DATE: April 25, 2025 REMANDED Entitlement to eligibility for benefits under the Program of Comprehensive Assistance for Family Caregivers (PCAFC) is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1995 to April 1996, from February 2003 to March 2009, and from September 2005 to December 2009. In the February 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 September 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. The PCAFC requires VA to notify individuals who apply for the program of decisions affecting the furnishing of assistance with notice as described in 38 U.S.C. § 5104. 38 U.S.C. § 1720G(a)(12). Generally, notice under 38 U.S.C. § 5104 must include the following: 1) Identification of the issues adjudicated; 2) A summary of the evidence considered by the Secretary; 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; 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). Based on the available information of record, including that contained in the September 2021 VA denial note, there is no indication that any written denial notice met the criteria outlined in 38 U.S.C. § 5104(b) and as directed in 38 U.S.C. § 1720G(a)(12). Specifically, there is no indication that such notice provided a summary of the evidence, the applicable laws and regulations, any favorable findings or other elements that were not satisfied leading to the denial, or an explanation of how to obtain or access the evidence used in making the decision. 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 September 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 September 2021 Veteran Functional Assessment during which it was noted that the Veteran required "set-up or clean-up assistance" when eating. He was also noted to require, "partial/moderate assistance" with bathing, lower body dressing, toileting, and "substantial/maximal assistance" when moving from a lying to sitting position. "Supervision or touching assistance" was also required for upper body dressing, removing or applying footwear, applying his knee and wrist brace, and walking on uneven surfaces. The Veteran primarily ambulated with a rollator walker/cane and could only manage 1-3 steps. The Veteran was noted to have a "grabber" to pick up objects from the floor. Based on these findings, the CEAT opinion does not adequately explain why the Veteran does not require 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. It was further determined that participation in the Program of Comprehensive Assistance for Family Caregivers was deemed not in the Veteran's best interest. A rationale in support of these determinations was not provided. 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: 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 (if applicable), and the 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.