MAJOR DEPRESSIVE DISORDER

Summary

The Veteran, a Veteran who served from September 1965 to May 1968, including service in Vietnam, appeals a January 2026 rating decision that granted service connection for parkinsonism with a 30 percent evaluation. The Veteran sought higher disability ratings for several conditions secondary to parkinsonism, including dementia, depression, sleep disturbances, bilateral upper and lower extremity bradykinesia with tremors, balance impairment, muscle rigidity and stiffness, voiding dysfunction, difficulty chewing and swallowing, speech impairment, stooped posture, and loss of sense of smell. The Board reviewed the evidence of record as of the January 2026 decision date. The Board found that the Veteran's symptoms for dementia, depression, and sleep disturbances approximated total occupational and social impairment, warranting a 100 percent rating. For the upper extremity symptoms, the Board found they approximated severe incomplete paralysis, warranting a 50 percent rating for the right upper extremity and 40 percent for the left. The lower extremity symptoms approximated moderately severe incomplete paralysis, warranting a 40 percent rating for both. Voiding dysfunction approximated the need for absorbent materials changed more than four times daily, warranting a 60 percent rating. Difficulty chewing/swallowing and speech impairment approximated moderate incomplete paralysis, warranting 10 percent each for the right and left sides. Stooped posture also approximated moderate incomplete paralysis, warranting 10 percent for the right and left sides. Finally, complete loss of sense of smell warranted a 10 percent rating. All conditions were granted as secondary to service-connected parkinsonism.

Rationale

Symptoms approximated total occupational and social impairment; Secondary to service-connected parkinsonism; Criteria for 100 percent rating met

Full Decision Text

Citation Nr: A26022930
Decision Date: 03/13/26	Archive Date: 03/13/26

DOCKET NO. 260108-626395
DATE: March 13, 2026

ORDER

Entitlement to a separate 100 percent disability rating for dementia, depression, and sleep disturbances, as secondary to service-connected parkinsonism, is granted, subject to the laws and regulations governing the award of monetary benefits.

Entitlement to a separate 50 percent disability rating, but no higher, for right upper extremity bradykinesia with tremors, balance impairment, muscle rigidity and stiffness, as secondary to service-connected parkinsonism, is granted, subject to the laws and regulations governing the award of monetary benefits.

Entitlement to a separate 40 percent disability rating, but no higher, for left upper extremity bradykinesia with tremors, balance impairment, and muscle rigidity and stiffness, as secondary to service-connected parkinsonism, is granted, subject to the laws and regulations governing the award of monetary benefits.

Entitlement to a separate 40 percent disability rating, but no higher, for right lower extremity bradykinesia with tremors, balance impairment, and muscle rigidity and stiffness, as secondary to service-connected parkinsonism, is granted, subject to the laws and regulations governing the award of monetary benefits.

Entitlement to a separate 40 percent disability rating, but no higher, for left lower extremity bradykinesia with tremors, balance impairment, and muscle rigidity and stiffness, as secondary to service-connected parkinsonism, is granted, subject to the laws and regulations governing the award of monetary benefits.

Entitlement to a separate 60 percent rating for voiding dysfunction, as secondary to service-connected parkinsonism, is granted, subject to the laws and regulations governing the award of monetary benefits.

Entitlement to a separate 10 percent disability rating, but no higher, for right side difficulty chewing and swallowing, as secondary to service-connected parkinsonism, is granted, subject to the laws and regulations governing the award of monetary benefits.

Entitlement to a separate 10 percent disability rating, but no higher, for left side difficulty chewing and swallowing, as secondary to service-connected parkinsonism, is granted, subject to the laws and regulations governing the award of monetary benefits.

Entitlement to a separate 10 percent disability rating, but no higher, for right side speech impairment, as secondary to service-connected parkinsonism, is granted, subject to the laws and regulations governing the award of monetary benefits.

Entitlement to a separate 10 percent disability rating, but no higher, for left side speech impairment, as secondary to service-connected parkinsonism, is granted, subject to the laws and regulations governing the award of monetary benefits.

Entitlement to a separate 10 percent disability rating, but no higher, for right side stooped posture, as secondary to service-connected parkinsonism, is granted, subject to the laws and regulations governing the award of monetary benefits.

Entitlement to a separate 10 percent disability rating, but no higher, for left side stooped posture, as secondary to service-connected parkinsonism, is granted, subject to the laws and regulations governing the award of monetary benefits.

Entitlement to a separate 10 percent disability rating for complete loss of sense of smell, as secondary to service-connected parkinsonism, is granted, subject to the laws and regulations governing the award of monetary benefits.

Entitlement to a separate 30 percent disability rating for bowel dysfunction, as secondary to service-connected parkinsonism, is granted, subject to the laws and regulations governing the award of monetary benefits.

Entitlement to a separate noncompensable disability rating for right side loss of automatic movements, as secondary to service-connected parkinsonism, is granted, subject to the laws and regulations governing the award of monetary benefits.

Entitlement to a separate noncompensable disability rating for left side loss of automatic movements, as secondary to service-connected parkinsonism, is granted, subject to the laws and regulations governing the award of monetary benefits.

Entitlement to a separate noncompensable rating for erectile dysfunction, as secondary to service-connected parkinsonism, is granted, subject to the laws and regulations governing the award of monetary benefits.

Entitlement to special monthly compensation (SMC) based on the need for aid and attendance is granted, subject to the laws and regulations governing the award of monetary benefits.

FINDINGS OF FACT

1.  The symptoms of the Veteran's dementia, depression, and sleep disturbances, as secondary to his service-connected parkinsonism, more nearly approximated total occupational and social impairment throughout the entire appeal period.

2.  The symptoms of the Veteran's bilateral upper extremity bradykinesia with tremors, balance impairment, and muscle rigidity and stiffness, as secondary to his service
able rating for erectile dysfunction, as secondary to service-connected parkinsonism, is granted, subject to the laws and regulations governing the award of monetary benefits.

Entitlement to special monthly compensation (SMC) based on the need for aid and attendance is granted, subject to the laws and regulations governing the award of monetary benefits.

FINDINGS OF FACT

1.  The symptoms of the Veteran's dementia, depression, and sleep disturbances, as secondary to his service-connected parkinsonism, more nearly approximated total occupational and social impairment throughout the entire appeal period.

2.  The symptoms of the Veteran's bilateral upper extremity bradykinesia with tremors, balance impairment, and muscle rigidity and stiffness, as secondary to his service-connected parkinsonism, more nearly approximated symptoms of severe incomplete paralysis throughout the entire appeal period.  However, his symptoms have not more nearly approximated complete paralysis: drop of hand and fingers, wrist and fingers perpetually flexed, the thumb adducted falling within the line of the outer border of the index finger; cannot extend hand at wrist, extend proximal phalanges of fingers, extend thumb, or make lateral movement of wrist; supination of hand, extension and flexion of elbow weakened, the loss of synergic motion of extensors impairs the hand grip seriously; total paralysis of the triceps occurs only as the greatest rarity, at any point during the appeal period.

3.  The symptoms of the Veteran's bilateral lower extremity bradykinesia with tremors, balance impairment, and muscle rigidity and stiffness, as secondary to his service-connected parkinsonism, more nearly approximated symptoms of moderately severe incomplete paralysis throughout the entire appeal period.  However, his symptoms have not more nearly approximated severe incomplete paralysis with marked muscular atrophy at any point during the appeal period.

4.  The symptoms of the Veteran's voiding dysfunction, as secondary to his service-connected parkinsonism, more nearly approximated the wearing of absorbent materials which must be changed more than four times per day throughout the entire appeal period.

5.  The symptoms of the Veteran's right and left side difficulty chewing and swallowing, as secondary to his service-connected parkinsonism, more nearly approximated moderate incomplete paralysis throughout the entire appeal period.  However, his symptoms have not more nearly approximated severe incomplete paralysis at any point during the appeal period.

6.  The symptoms of the Veteran's right and left side speech impairment, as secondary to his service-connected parkinsonism, more nearly approximated moderate incomplete paralysis throughout the entire appeal period.  However, his symptoms have not more nearly approximated severe incomplete paralysis at any point during the appeal period.

7.  The symptoms of the Veteran's right and left side stooped posture, as secondary to his service-connected parkinsonism, more nearly approximated moderate incomplete paralysis throughout the entire appeal period.  However, his symptoms have not more nearly approximated severe incomplete paralysis at any point during the appeal period.

8.  The Veteran experiences complete loss of sense of smell as secondary to his service-connected parkinsonism throughout the entire appeal period.

9.  The symptoms of the Veteran's bowel dysfunction, as secondary to his service-connected parkinsonism, more nearly approximated abdominal pain related to defecation at least one day per week during the previous three months; and two or more of the following: (1) change in stool frequency, (2) change in stool form, (3) altered stool passage (straining and/or urgency), (4) mucorrhea, (5) abdominal bloating, or (6) subjective distension.

10.  The symptoms of the Veteran's right and left side loss of automatic movements, as secondary to his service-connected parkinsonism, more nearly approximated mild, and not moderate, incomplete paralysis throughout the entire appeal period.

11.  The Veteran experiences erectile dysfunction with or without penile deformity as secondary to his service-connected parkinsonism throughout the entire appeal period.

12.  The evidence of record establishes that, throughout the entire appeal period, the Veteran's service-connected disabilities rendered him so helpless that he was unable to perform self-care tasks or protect himself from the hazards incident to his daily environment without care or assistance of another person on a regular basis.

CONCLUSIONS OF LAW

1.  The criteria for a separate 100 percent disability rating for dementia, depression, and sleep disturbances, as secondary to service-connected parkinsonism, are met for the entire appeal period.  38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.10, 4.124a, 4.130, Diagnostic Codes (DCs) 8004, 9326.

2.  The criteria for a separate disability rating of 50 percent, but no higher, for right upper
 self-care tasks or protect himself from the hazards incident to his daily environment without care or assistance of another person on a regular basis.

CONCLUSIONS OF LAW

1.  The criteria for a separate 100 percent disability rating for dementia, depression, and sleep disturbances, as secondary to service-connected parkinsonism, are met for the entire appeal period.  38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.10, 4.124a, 4.130, Diagnostic Codes (DCs) 8004, 9326.

2.  The criteria for a separate disability rating of 50 percent, but no higher, for right upper extremity bradykinesia with tremors, balance impairment, and muscle rigidity and stiffness, as secondary to service-connected parkinsonism, are met for the entire appeal period.  38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.10, 4.124a, DCs 8004, 8514.

3.  The criteria for a separate disability rating of 40 percent, but no higher, for left upper extremity bradykinesia with tremors, balance impairment, and muscle rigidity and stiffness, as secondary to service-connected parkinsonism, are met for the entire appeal period.  38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.10, 4.124a, DCs 8004, 8514.

4.  The criteria for separate disability ratings of 40 percent, but no higher, for bilateral lower extremity bradykinesia with tremors, balance impairment, and muscle rigidity and stiffness, as secondary to service-connected parkinsonism, are met for the entire appeal period.  38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.10, 4.124a, DCs 8004, 8520.

5.  The criteria for a separate disability rating of 60 percent for voiding dysfunction, as secondary to service-connected parkinsonism, are met for the entire appeal period.  38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.10, 4.115a, 4.115b, 4.124a, DCs 8004, 7542.

6.  The criteria for separate disability ratings of 10 percent, but no higher, for right and left side difficulty chewing and swallowing, as secondary to service-connected parkinsonism, are met for the entire appeal period.  38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.10, 4.124a, DCs 8004, 8205.

7.  The criteria for separate disability ratings of 10 percent, but no higher, for right and left side speech impairment, as secondary to service-connected parkinsonism, are met for the entire appeal period.  38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.10, 4.124a, DCs 8004, 8210.

8.  The criteria for separate disability ratings of 10 percent, but no higher, for right and left side stooped posture, as secondary to service-connected parkinsonism, are met for the entire appeal period.  38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.10, 4.124a, DCs 8004, 8211.

9.  The criteria for a separate disability rating of 10 percent for complete loss of sense of smell, as secondary to service-connected parkinsonism, are met for the entire appeal period.  38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.10, 4.87a, 4.124a, DCs 8004, 6275.

10.  The criteria for a separate disability rating of 30 percent for bowel dysfunction, as secondary to service-connected parkinsonism, are met for the entire appeal period.  38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.10, 4.114, 4.124a, DCs 8004,
 parkinsonism, are met for the entire appeal period.  38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.10, 4.87a, 4.124a, DCs 8004, 6275.

10.  The criteria for a separate disability rating of 30 percent for bowel dysfunction, as secondary to service-connected parkinsonism, are met for the entire appeal period.  38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.10, 4.114, 4.124a, DCs 8004, 7319.

11.  The criteria for separate noncompensable disability ratings for right and left side loss of automatic movements, as secondary to service-connected parkinsonism, are met for the entire appeal period.  38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.10, 4.124a, DCs 8004, 8207.

12.  The criteria for a separate noncompensable disability rating for erectile dysfunction, as secondary to service-connected parkinsonism, are met for the entire appeal period.  38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.10, 4.115b, 4.124a, DCs 8004, 7522.

13.  The criteria for entitlement to SMC based on the need for aid and attendance are met for the entire appeal period.  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 from September 1965 to May 1968, to include service in Vietnam.

These matters come before the Board of Veterans' Appeals (Board) on appeal from a January 2026 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) that, among other things, awarded service connection for parkinsonism with an initial evaluation of 30 percent, effective March 24, 2025, the date of an Intent to File. 

Although the RO did not address whether the Veteran was entitled to SMC based on the need for aid and attendance in the January 2026 rating decision awarding service connection and a 30 percent evaluation for parkinsonism, the Court has held that VA has a "well-established" duty to maximize a claimant's benefits.  Buie v. Shinseki, 24 Vet. App. 242, 250 (2011).  This duty to maximize benefits requires VA to assess all of a claimant's disabilities to determine whether any combination of disabilities establishes entitlement to SMC under 38 U.S.C. § 1114.  Perciavalle v. Wilkie, 32 Vet. App. 117, 122 (SMC benefits are to be accorded when a Veteran becomes eligible without the need for a separate claim).  Thus, given the circumstances of this case, including the award of a 100 percent separate disability rating for dementia as secondary to parkinsonism, as well as a November 2024 physician's letter documenting the Veteran's need for 24/7 care, the Board will address whether SMC based on the need for aid and attendance is warranted during the appeal period.

The Veteran timely appealed the January 2026 rating decision in a January 2026 Decision Review Request: Board Appeal (Notice of Disagreement) (NOD) (VA Form 10182) and selected direct review by a Veterans Law Judge (VLJ).  38 C.F.R. § 20.202(b)(1).  Accordingly, the Board will review the evidence of record as of the date of the January 2026 rating decision.  38 U.S.C. § 7113(a); 38 C.F.R. § 20.301.  The Board will not consider evidence added to the record after the date of the Agency of Original Jurisdiction (AOJ) decision on appeal.  If evidence was added during this ineligible period, the Board did not consider it.  If the Veteran wishes to have VA consider any evidence that was not considered, he may at any time file a supplemental claim with the AOJ after receiving this decision and the additional evidence will be considered in connection with the supplemental claim.  38 U.S.C. §§ 5104C(a)(1)(B), (b); 5108; 38 C.F.R. §§ 3.2501, 
 § 7113(a); 38 C.F.R. § 20.301.  The Board will not consider evidence added to the record after the date of the Agency of Original Jurisdiction (AOJ) decision on appeal.  If evidence was added during this ineligible period, the Board did not consider it.  If the Veteran wishes to have VA consider any evidence that was not considered, he may at any time file a supplemental claim with the AOJ after receiving this decision and the additional evidence will be considered in connection with the supplemental claim.  38 U.S.C. §§ 5104C(a)(1)(B), (b); 5108; 38 C.F.R. §§ 3.2501, 20.1105(a).  If filed within one year, this supplemental claim will preserve the date of the claim denied herein as the effective date of the grant of the benefit or benefits sought.  38 U.S.C. § 5110(a)(2)(B); 38 C.F.R. § 3.2500(h).  

As a final preliminary matter, in a January 2026 Statement in Support of Claim (VA Form 21-4138), the Veteran, through his representative, indicated he waived any remaining period to modify the January 2026 VA Form 10182.  Williams v. McDonough, 37 Vet. App. 305, 307 (2024) ("because [38 C.F.R. § 20.202(c)(2)] gives a claimant the later of one year from the date that the AOJ mails notice of the decision or 60 days from when the Board receives the NOD to change the NOD and select a different lane, the Board ordinarily may not decide an appeal before this time period is up"); Clark v. O'Rourke, 30 Vet. App. 92, 97-98 (2018) (allowing waiver of a right to a particular time period for submission of evidence to be waived if there is "a voluntary, knowing, and intentional waiver of that right").  Thus, the Board will proceed with adjudication of the claims.

Disability ratings and parkinsonism

Disability evaluations are?determined?by the application of VA's Schedule?for Rating Disabilities, which is based on average impairment of earning capacity. ?38 U.S.C. § 1155;?38 C.F.R. Part 4.? 

Where an award of service connection for a disability has been granted and the assignment of an initial evaluation for that disability is disputed, separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be staged.  Fenderson v. West, 12 Vet. App. 119 (1999).

In evaluating a disability, the Board considers the current examination reports?in light of?the whole recorded history to ensure that the current rating accurately reflects the severity of the condition. ?The medical as well as industrial history is to be considered, and a full description of the effects of the disability upon ordinary activity is also?required. ?38 C.F.R. §§ 4.1, 4.2, 4.10.?? 

Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required?for?that rating. ?Otherwise, the lower rating will be assigned. ?38 C.F.R. § 4.7.?? 

Parkinsonism is rated under 38 C.F.R. § 4.124a, DC 8004, as "paralysis agitans." Under DC 8004, a minimum 30 percent disability rating is assigned when there are "ascertainable residuals" of the disability.  

In addition, the Court addressed the rating schedule for Parkinson's disease in the case of Duran v. McDonough, 36 Vet. App. 230 (2023) and held that, if a veteran has a diagnosis of Parkinson's disease with at least one ascertainable manifestation, that veteran is entitled to a minimum 30 percent rating under DC.  Even when ascertainable manifestation ratings under other DCs combine for a total rating in excess of 30 percent, the basis for the minimum rating under DC 8004 remains as long as there is at least one ascertainable manifestation of Parkinson's disease that is not compensable under any other Diagnostic Code.  Thus, when VA assigns compensable ratings for Parkinson's manifestations that total more than 30 percent under DCs other than DC 8004, those other ratings do not replace the minimum 30 percent rating under DC 8004 provided that some manifestations remain that are not rated as compensable.  Duran, 36 Vet. App. at 237.

Here, the AOJ
 to a minimum 30 percent rating under DC.  Even when ascertainable manifestation ratings under other DCs combine for a total rating in excess of 30 percent, the basis for the minimum rating under DC 8004 remains as long as there is at least one ascertainable manifestation of Parkinson's disease that is not compensable under any other Diagnostic Code.  Thus, when VA assigns compensable ratings for Parkinson's manifestations that total more than 30 percent under DCs other than DC 8004, those other ratings do not replace the minimum 30 percent rating under DC 8004 provided that some manifestations remain that are not rated as compensable.  Duran, 36 Vet. App. at 237.

Here, the AOJ awarded in a January 2026 rating decision service connection for parkinsonism with an initial evaluation of 30 percent.  As discussed in more detail below, separate noncompensable disability ratings for loss of automatic movements and erectile dysfunction are warranted as they are noncompensable manifestations of the Veteran's parkinsonism.  Thus, the evidence shows the Veteran has a current diagnosis of parkinsonism with at least one ascertainable manifestation not being compensated under another DC.

Entitlement to a separate 100 percent disability rating for dementia, depression, and sleep disturbances, as secondary to service-connected parkinsonism

In an April 2025 VA Parkinson's Disease Disability Benefits Questionnaire (DBQ), the Veteran's private physician noted that the Veteran experienced mental manifestations due to parkinsonism of moderate depression and severe cognitive impairment or dementia, as well as severe sleep disturbances (insomnia or daytime "sleep attacks").  In addition, in July 2025, a VA psychologist noted that the Veteran's sleep issues were subsumed under his mental disorder.  Also, in November 2024, the private physician indicated that the Veteran was unable to be left alone and needed 24/7 caregiver support as a result of his medical conditions and needed assistance with activities of daily living.

Thus, the evidence of record reflects that the Veteran has dementia, depression, and sleep disturbances associated with his service-connected parkinsonism.  Dementia, depression, and sleep disturbances are assigned a disability rating pursuant to the General Formula for Mental Disorders.  38 C.F.R. § 4.130.  Specifically, DC 9326 assigns a disability evaluation for major or mild neurocognitive disorder due to another medical condition.

Under the General Formula, the Board must conduct a "holistic analysis" that considers all associated symptoms, regardless of whether they are listed as criteria.  Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130.  The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages.  Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-118 (Fed. Cir. 2013).

A 100 percent disability rating is assigned when symptoms such as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; or memory loss for names of close relatives, own occupation or own name cause total occupational and social impairment.

The evidence of record here supports a separate 100 percent evaluation pursuant to DC 9326 given that the Veteran has severe dementia (a neurocognitive disorder) with depression and sleep disturbances as secondary to parkinsonism and requires 24/7 care and assistance with activities of daily living because of those conditions.

Thus, for the above reasons, throughout the appeal period, the Veteran's symptoms and impairment more nearly approximated the total occupational and social impairment required for a separate 100 percent disability rating.  A separate disability rating of 100 percent for dementia, depression, and sleep disturbances, as secondary to service-connected parkinsonism, is therefore warranted for the entire appeal period.

Entitlement to separate disability ratings for right and left upper and lower extremity bradykinesia with tremors, balance impairment, and muscle rigidity and stiffness, as secondary to service-connected parkinsonism

As will be discussed further below, based on the evidence of record, the Veteran's right and left upper and lower extremity bradykinesia with tremors, balance impairment, and muscle rigidity and stiffness will be rated under DCs 8514 for the musculospiral nerve (radial nerve) and 8520 for the sciatic nerve.  In this regard, the Board notes that
 depression, and sleep disturbances, as secondary to service-connected parkinsonism, is therefore warranted for the entire appeal period.

Entitlement to separate disability ratings for right and left upper and lower extremity bradykinesia with tremors, balance impairment, and muscle rigidity and stiffness, as secondary to service-connected parkinsonism

As will be discussed further below, based on the evidence of record, the Veteran's right and left upper and lower extremity bradykinesia with tremors, balance impairment, and muscle rigidity and stiffness will be rated under DCs 8514 for the musculospiral nerve (radial nerve) and 8520 for the sciatic nerve.  In this regard, the Board notes that the selection of a particular diagnostic code "is a determination that is completely dependent upon the facts of a particular case," and the Board has discretion in determining the appropriate diagnostic code. Butts v. Brown, 5 Vet. App. 532, 538 (1993) (en banc) (applying the more deferential "arbitrary, capricious" standard, rather than de novo review, to the Board's determination of the appropriate diagnostic code).

Diseases affecting the nerves are rated on the basis of degree of paralysis, neuritis, or neuralgia under 38 C.F.R. § 4.124a.

Under DC 8514, mild incomplete paralysis of the radial nerve is rated 20 percent disabling bilaterally; moderate incomplete paralysis is rated 30 percent disabling in the major extremity and 20 percent disabling in the minor extremity; and severe incomplete paralysis is rated 50 percent disabling in the major extremity and 40 percent disabling in the minor extremity.  Complete paralysis is rated 70 percent disabling in the major extremity and 60 percent disabling in the minor extremity and is described as "drop of hand and fingers, wrist and fingers perpetually flexed, the thumb adducted falling within the line of the outer border of the index finger; cannot extend hand at wrist, extend proximal phalanges of fingers, extend thumb, or make lateral movement of wrist; supination of hand, extension and flexion of elbow weakened, the loss of synergic motion of extensors impairs the hand grip seriously; total paralysis of the triceps occurs only as the greatest rarity.  38 C.F.R. § 4.124a.  

Under DC 8520, a 10 percent rating is warranted for mild incomplete paralysis.  A 20 percent rating is assigned for moderate incomplete paralysis of the sciatic nerve. A 40 percent rating is assigned for moderately severe incomplete paralysis of the sciatic nerve.  A 60 percent rating is assigned for severe incomplete paralysis of the sciatic nerve, with marked muscular atrophy.  A maximum 80 percent rating is assigned for complete paralysis of the sciatic nerve; the foot dangles and drops, no active movement possible of muscles below the knee, flexion of knee weakened or (very rarely) lost.  Id.

The term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree.  Id.

Neither the Rating Schedule nor the regulations provide definitions for descriptive words such as "mild," "moderate," "moderately severe," and "severe."  Spellers v. Wilkie, 30 Vet. App. 211, 219 (2018) ("DC 8520 does not define 'mild,' 'moderate,' 'moderately severe,' or 'severe,' or generally associate those terms with specific symptoms").  Although the Board has at times attempted to define these terms using dictionary definitions, those definitions are problematic because they "do little to explain the Board's understanding of these terms and do not 'disclos[e] that benchmark it employed to reach [its] conclusion.'" Casey v. McDonough, No. 21-7569, slip op. at 3 (Vet. App. Jan. 24, 2023) (mem dec) (Falvey, J.) (quoting Johnson v. Wilkie, 30 Vet. App. 245, 255 (2018) (discussing the Board's attempt to define the terms slight, mild, moderate, and severe in DC 8515); Bethea v. Derwinski, 2 Vet. App. 252, 254 (1992) (single judge decisions may be relied upon for any persuasiveness or reasoning they contain).

With regard to DCs 8514 and 8520, although 38 C.F.R. § 4.120
7569, slip op. at 3 (Vet. App. Jan. 24, 2023) (mem dec) (Falvey, J.) (quoting Johnson v. Wilkie, 30 Vet. App. 245, 255 (2018) (discussing the Board's attempt to define the terms slight, mild, moderate, and severe in DC 8515); Bethea v. Derwinski, 2 Vet. App. 252, 254 (1992) (single judge decisions may be relied upon for any persuasiveness or reasoning they contain).

With regard to DCs 8514 and 8520, although 38 C.F.R. § 4.120, 4.123, and 4.124 are "helpful in framing the analysis, [they] are not alone sufficient to explain the Board's decision absent an articulated connection to specific evidence." Lemon v. McDonough, No. 21-3949, 2022 U.S. App. Vet. Claims LEXIS 1998, *7 (Dec. 16, 2022) (mem dec) (Toth, J.).  As explained in Lemon, these regulations leave gaps in defining the relevant terms that are filled by VA's Adjudication Manual, M21-1:

The Board "is required to discuss any relevant provisions contained in the M21-1 as part of its duty to provide adequate reasons or bases." Overton v. Nicholson, 30 Vet. App. [257,] 264 [(2006)].  Clearly relevant to this case are M21-1 provisions regarding evaluations of paralysis of the sciatic nerve.  The M21-1 describes mild incomplete paralysis as a disability "limited to sensory deficits that are lower graded, less persistent, or affecting a smaller area." Part V, sbpt. iii, ch. 12, sec. A.2.c.  And moderate incomplete paralysis, per the M21-1, should be "reserved for the most significant cases of sensory-only impairment," where the sensory involvement covers "a larger area in the nerve distribution."  Id.  M21-1 examples of a moderate disability include "motor and/or reflex impairment such as weakness or diminished or hyperactive reflexes (with or without sensory impairment) graded as medically moderate."  Id.  And the M21-1 provides that a moderately severe evaluation (that is, a 40 percent rating) is available when there is "[m]otor and/or reflex impairment (for example, weakness or diminished or hyperactive reflexes) at a grade reflecting a higher level of limitation or disability."  Id.  Atrophy may, but need not, be present for a moderately severe rating.  In discussing severe incomplete paralysis, VA's Adjudication Manual, V.iii.12.A.2.c., indicates, "In general, expect motor and/or reflex impairment (for example, atrophy, weakness, or diminished or hyperactive reflexes) at a grade reflecting a very high level of limitation or disability.  Trophic changes may be seen in severe longstanding neuropathy cases."  The Manual also indicates, "For the sciatic nerve (38 CFR 4.124a, DC 8520), marked muscular atrophy is expected."  Moreover, according to the Manual, "[e]ven though severe incomplete paralysis cases should show findings substantially less than representative findings for complete impairment of the nerve, the disability picture for severe incomplete paralysis may contain signs/symptoms resembling some of those expected in cases of complete paralysis of the nerve."  Finally in this regard, the Manual states, "Neuritis characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain should be rated as high as severe incomplete paralysis of the nerve (38 CFR 4.123)."

As concluded by the Court in Lemon, given the relevance of these provisions to rating disabilities of the peripheral nerves, "the Board's failure to mention the M21-1's relevant guidance in this area constitutes clear error." Lemon, at *7-*8, Bethea, 2 Vet. App. at 254.  The Board will therefore mention, and apply, these definitions in the instant case.  Boothe v. McDonough, No. 21-4488, 2023 U.S. App. Vet. Claims LEXIS 121, *2 (Jan. 27, 2023) (Nonprecedential Panel Order) (granting a Joint Motion for Remand in which the parties "agree[d] that the Board erred when it refused to consider relevant portions of the VA Adjudication Procedures Manual).

For the following reasons, a separate disability rating of 50 percent, but no higher, for right upper extremity bradykinesia with tremors, balance impairment,
 Vet. App. at 254.  The Board will therefore mention, and apply, these definitions in the instant case.  Boothe v. McDonough, No. 21-4488, 2023 U.S. App. Vet. Claims LEXIS 121, *2 (Jan. 27, 2023) (Nonprecedential Panel Order) (granting a Joint Motion for Remand in which the parties "agree[d] that the Board erred when it refused to consider relevant portions of the VA Adjudication Procedures Manual).

For the following reasons, a separate disability rating of 50 percent, but no higher, for right upper extremity bradykinesia with tremors, balance impairment, and muscle rigidity and stiffness, and separate 40 percent disability ratings, but no higher, for left upper and bilateral lower extremity bradykinesia with tremors, balance impairment, and muscle rigidity and stiffness, are warranted for the entire appeal period.

In the April 2025 VA Parkinson's disease DBQ, the Veteran's private physician noted that the Veteran was right hand dominant and that his balance impairment and bradykinesia or slowed motion (difficulty initiating movement, "freezing," short shuffling steps) were severe.  The Veteran also experienced mild tremors and moderate muscle rigidity and stiffness of the bilateral upper and lower extremities.

The evidence of record therefore reflects that the severity of the Veteran's bilateral upper and lower extremity radiculopathy symptoms more nearly approximated severe and moderately severe incomplete paralysis, respectively, for the entire appeal period.  As noted in VA's Adjudication Manual, M21-1, "moderately severe" can be defined as "[m]otor and/or reflex impairment (for example, weakness or diminished or hyperactive reflexes) at a grade reflecting a higher level of limitation or disability," and "severe" can be defined as "motor and/or reflex impairment (for example, atrophy, weakness, or diminished or hyperactive reflexes) at a grade reflecting a very high level of limitation or disability."  Part V, sbpt. iii, ch. 12, sec. A.2.c.  

Here, the Veteran's symptoms of bilateral upper and lower extremity bradykinesia with tremors, balance impairment, and muscle rigidity and stiffness more nearly approximated moderately severe and severe incomplete paralysis throughout the entire appeal period, to include motor and/or reflex impairment at a very high level, given the Veteran's severe balance impairment and bradykinesia with tremors and muscle rigidity and stiffness.  

The evidence of record does not reflect symptoms such as muscular atrophy or complete paralysis more nearly approximating the severe incomplete and complete paralysis for higher disability ratings at any point during the appeal period.  Thus, the evidence of record reflects symptoms that more closely approximated moderately severe and severe incomplete paralysis for the entire appeal period.

For the above reasons, a separate disability rating of 50 percent, but no higher, for right upper extremity bradykinesia with tremors, balance impairment, and muscle rigidity and stiffness, and separate 40 percent disability ratings, but no higher, for left upper and bilateral lower extremity bradykinesia with tremors, balance impairment, and muscle rigidity and stiffness, are warranted for the entire appeal period.  The evidence is neither evenly balanced nor approximately so with regard to whether higher disability ratings are warranted at any point during the appeal period.  Rather, the evidence at this time weighs persuasively against the criteria required for disability ratings higher than 50 and 40 percent.  The benefit of the doubt doctrine is therefore not for application.  Lynch v. McDonough, 21 F.4th 776, 781-82 (Fed. Cir. 2021) (en banc) (only when the evidence persuasively favors one side or another is the benefit of the doubt doctrine not for application).  

Entitlement to a separate disability rating for voiding dysfunction, as secondary to service-connected parkinsonism

The Veteran is entitled to a separate disability rating for voiding dysfunction, as secondary to parkinsonism, rated by analogy under DC 7542 (neurogenic bladder).  Voiding dysfunction requires that the disability be rated as urine leakage, frequency, or obstructed voiding.

Continual urine leakage, post-surgical urinary diversion, urinary incontinence, or stress incontinence is rated as follows: a 20 percent rating is warranted for voiding dysfunction requiring the wearing of absorbent materials which must be changed less than two times per day, a 40 percent rating is warranted for voiding dysfunction requiring the wearing of absorbent materials which must be changed 2 to 4 times per day, and a maximum 60 percent rating is warranted for voiding dysfunction requiring the use of an appliance
 dysfunction, as secondary to parkinsonism, rated by analogy under DC 7542 (neurogenic bladder).  Voiding dysfunction requires that the disability be rated as urine leakage, frequency, or obstructed voiding.

Continual urine leakage, post-surgical urinary diversion, urinary incontinence, or stress incontinence is rated as follows: a 20 percent rating is warranted for voiding dysfunction requiring the wearing of absorbent materials which must be changed less than two times per day, a 40 percent rating is warranted for voiding dysfunction requiring the wearing of absorbent materials which must be changed 2 to 4 times per day, and a maximum 60 percent rating is warranted for voiding dysfunction requiring the use of an appliance or wearing of absorbent materials which must be changed more than four times per day.  38 C.F.R. § 4.115a.

Urinary frequency is rated as follows: a 10 percent rating is warranted for daytime voiding interval between two and three hours, or; awakening to void two times per night, a 20 percent rating is warranted for daytime voiding interval between one and two hours, or; awakening to void three to four times per night, and a 40 percent rating is warranted for daytime voiding interval less than one hour, or; awakening to void five or more times per night.  Id.

As for obstructed voiding, a 10 percent rating is warranted for marked obstructive symptomatology (hesitancy, slow or weak stream, decreased force of stream) with any one or combination of the following: post-void residuals greater than 150 cc; uroflowmetry; markedly diminished peak flow rate (less than 10 cc/sec); recurrent urinary tract infections secondary to obstruction; or stricture disease requiring periodic dilation every two to three months.  A 30 percent rating is for urinary retention requiring intermittent or continuous catheterization.  Id.

Considering the evidence of record, a separate 60 percent disability rating is warranted for urinary incontinence for the entire appeal period.  Notably, the Veteran's private physician indicated in the April 2025 DBQ that the Veteran experienced urinary problems as a result of his parkinsonism and changed absorbent materials more than four times per day.  This is the maximum disability rating allowed under DC 7542.

Entitlement to separate disability ratings for right and left side difficulty chewing and swallowing, speech impairment, and stooped posture, as secondary to service-connected parkinsonism

As will be discussed further below, based on the evidence of record, the Veteran's right and left side difficulty chewing and swallowing will be rated under DC 8205 for paralysis of the fifth (trigeminal) cranial nerve, speech impairment will be rated under DC 8210 for paralysis of the tenth (pneumogastric, vagus) cranial nerve, and stooped posture will be rated under DC 8211 for paralysis of the eleventh (spinal accessory, external branch) cranial nerve.  See Butts, 5 Vet. App. at 538.

Under DC 8205 and 8210, a 50 percent rating is warranted for complete paralysis, 30 percent for incomplete paralysis but severe, and 10 percent for incomplete paralysis but moderate.  

Under DC 8211, a 30 percent rating is warranted for complete paralysis, 20 percent for incomplete paralysis but severe, and 10 percent for incomplete paralysis but moderate.  

Considering the evidence of record, separate 10 percent disability ratings are warranted for right and left side difficulty chewing and swallowing, speech impairment, and stooped posture as the Veteran's private physician indicated in the April 2025 DBQ that the Veteran experienced moderate difficulty chewing and swallowing, moderate speech impairment, and moderate stooped posture.  As noted in the section discussing separate disability ratings for bilateral upper and lower extremity bradykinesia with tremors, balance impairment, and muscle rigidity and stiffness, M21-1 examples of a moderate disability include "motor and/or reflex impairment such as weakness or diminished or hyperactive reflexes (with or without sensory impairment) graded as medically moderate." Part V, sbpt. iii, ch. 12, sec. A.2.c.  

Therefore, the Veteran's right and left side difficulty chewing and swallowing, speech impairment, and stooped posture symptoms more nearly approximated moderate incomplete paralysis throughout the entire appeal period, to include motor and/or reflex impairment graded as medically moderate, as the private physician found that the Veteran experiences moderate difficulty chewing and swallowing, moderate speech impairment, and moderate stooped posture.  Moreover, with reasonable doubt resolved in favor of the Veteran, the Board finds that disability ratings for both the right and left sides are warranted given the private physician's lack of distinction in the April 2025 DBQ as to which cranial nerves were affected.

The evidence
 moderate." Part V, sbpt. iii, ch. 12, sec. A.2.c.  

Therefore, the Veteran's right and left side difficulty chewing and swallowing, speech impairment, and stooped posture symptoms more nearly approximated moderate incomplete paralysis throughout the entire appeal period, to include motor and/or reflex impairment graded as medically moderate, as the private physician found that the Veteran experiences moderate difficulty chewing and swallowing, moderate speech impairment, and moderate stooped posture.  Moreover, with reasonable doubt resolved in favor of the Veteran, the Board finds that disability ratings for both the right and left sides are warranted given the private physician's lack of distinction in the April 2025 DBQ as to which cranial nerves were affected.

The evidence of record does not reflect symptoms of severe incomplete paralysis for higher disability ratings at any point during the appeal period.  Thus, the evidence of record reflects symptoms that more closely approximated moderate incomplete paralysis for the entire appeal period.

For the above reasons, separate disability ratings of 10 percent, but no higher, for right and left side difficulty chewing and swallowing, speech impairment, and stooped posture are warranted for the entire appeal period.  The evidence is neither evenly balanced nor approximately so with regard to whether higher disability ratings are warranted at any point during the appeal period.  Rather, the evidence at this time weighs persuasively against the criteria required for disability ratings higher than 10 percent.  The benefit of the doubt doctrine is therefore not for application.  Lynch, 21 F.4th 776, 781-82.

Entitlement to a separate disability rating for complete loss of sense of smell, as secondary to service-connected parkinsonism

As will be discussed further below, based on the evidence of record, the Veteran's complete loss of smell will be rated under DC 6275.  See Butts, 5 Vet. App. at 538.  Under DC 6275, a 10 percent disability rating is warranted for complete loss of the sense of smell.  38 C.F.R. § 4.87a.

As the April 2025 private physician indicated that the Veteran experienced complete loss of sense of smell, a 10 percent disability rating is warranted for the entire appeal period.  This is the maximum schedular disability rating under DC 6275.

Entitlement to a separate disability rating for bowel dysfunction, as secondary to service-connected parkinsonism

As will be discussed further below, based on the evidence of record, the Veteran's bowel dysfunction, to include fecal incontinence and constipation, will be evaluated under DC 7319.  See Butts, 5 Vet. App. at 538.  Bowel dysfunction is rated by analogy pursuant to DC 7319 for irritable bowel syndrome.  

Under DC 7319, a 10 percent disability rating is warranted for abdominal pain related to defecation at least once during the previous three months; and two or more of the following: (1) change in stool frequency, (2) change in stool form, (3) altered stool passage (straining and/or urgency), (4) mucorrhea, (5) abdominal bloating, or (6) subjective distension.  A 20 percent disability rating is warranted for abdominal pain related to defecation for at least three days per month during the previous three months; and two or more of the following: (1) change in stool frequency, (2) change in stool form, (3) altered stool passage (straining and/or urgency), (4) mucorrhea, (5) abdominal bloating, or (6) subjective distension.  A 30 percent disability rating is warranted for abdominal pain related to defecation at least one day per week during the previous three months; and two or more of the following: (1) change in stool frequency, (2) change in stool form, (3) altered stool passage (straining and/or urgency), (4) mucorrhea, (5) abdominal bloating, or (6) subjective distension.  38 C.F.R. § 4.114.  

In addition, a note to DC 7319 provides that the DC may include functional digestive disorders such as dyspepsia, functional bloating and constipation, and diarrhea.  

The Veteran's private physician indicated in an April 2025 DBQ that the Veteran experienced mild constipation due to his parkinsonism, and he also noted in a November 2024 DBQ that the Veteran was fecally incontinent more than 50 percent of the time as a result of his parkinsonism.

Thus, the evidence is approximately evenly balanced as to whether the Veteran's bowel dysfunction symptoms more nearly approximated abdominal pain related to defecation at least one day per week during the previous three months; and two or more of the
.  

In addition, a note to DC 7319 provides that the DC may include functional digestive disorders such as dyspepsia, functional bloating and constipation, and diarrhea.  

The Veteran's private physician indicated in an April 2025 DBQ that the Veteran experienced mild constipation due to his parkinsonism, and he also noted in a November 2024 DBQ that the Veteran was fecally incontinent more than 50 percent of the time as a result of his parkinsonism.

Thus, the evidence is approximately evenly balanced as to whether the Veteran's bowel dysfunction symptoms more nearly approximated abdominal pain related to defecation at least one day per week during the previous three months; and two or more of the following: (1) change in stool frequency, (2) change in stool form, (3) altered stool passage (straining and/or urgency), (4) mucorrhea, (5) abdominal bloating, or (6) subjective distension, throughout the entire appeal period.  A separate disability rating of 30 percent is therefore warranted for the Veteran's bowel dysfunction, as secondary to service-connected parkinsonism, for the entire appeal period.  This is the maximum schedular disability rating under DC 7319.

Entitlement to separate disability ratings for right and left side loss of automatic movements, as secondary to service-connected parkinsonism

As will be discussed further below, based on the evidence of record, the Veteran's loss of automatic movements will be rated under DC 8207 for paralysis of the seventh (facial) cranial nerve.  See Butts, 5 Vet. App. at 538.

Under DC 8207, a 30 percent rating is warranted for complete paralysis, 20 percent for incomplete paralysis but severe, and 10 percent for incomplete paralysis but moderate.  

Considering the evidence of record, separate noncompensable disability ratings are warranted for right and left side loss of automatic movements as the Veteran's private physician indicated in the April 2025 DBQ that the Veteran experienced mild loss of automatic movements (such as blinking, leading to fixed gaze, typical Parkinson's facies).  However, in order to receive a compensable disability rating of 10 percent for loss of automatic movements, the schedular rating criteria require that the Veteran's symptoms more nearly approximate moderate incomplete paralysis.  As noted in the section discussing separate disability ratings for bilateral upper and lower extremity bradykinesia with tremors, balance impairment, and muscle rigidity and stiffness, M21-1 examples of a moderate disability include "motor and/or reflex impairment such as weakness or diminished or hyperactive reflexes (with or without sensory impairment) graded as medically moderate." Part V, sbpt. iii, ch. 12, sec. A.2.c.  

Here, the Veteran's right and left side loss of automatic movements symptoms did not more nearly approximate moderate incomplete paralysis at any point during the appeal period as the evidence of record shows that the Veteran's symptoms were mild and did not more nearly approximate motor and/or reflex impairment graded as medically moderate.  Moreover, with reasonable doubt resolved in favor of the Veteran, the Board finds that disability ratings for both the right and left sides are warranted given the private physician's lack of distinction in the April 2025 DBQ as to which cranial nerves were affected.

For the above reasons, separate noncompensable disability ratings for right and left side loss of automatic movements is warranted for the entire appeal period.  The evidence is neither evenly balanced nor approximately so with regard to whether compensable disability ratings are warranted at any point during the appeal period.  Rather, the evidence at this time weighs persuasively against the criteria required for compensable disability ratings.  The benefit of the doubt doctrine is therefore not for application.  Lynch, 21 F.4th 776, 781-82.

Entitlement to a separate disability rating for erectile dysfunction, as secondary to service-connected parkinsonism

The Veteran experiences sexual dysfunction, including erectile dysfunction, as secondary to his service-connected parkinsonism, as indicated in an April 2025 DBQ.

Under DC 7522, erectile dysfunction is noncompensable with or without penile deformity.  38 C.F.R. § 4.115b.

In this case, although the evidence of record shows that the Veteran has been diagnosed with erectile dysfunction, there is no evidence of record of a penile deformity at any time during the appeal period.  Further, a noncompensable rating, with or without penile deformity, is the highest schedular rating available under DC 7522.  Thus, a noncompensable disability rating for erectile dysfunction, as secondary to service-connected parkinsonism, is warranted for the entire appeal period.

Entitlement to SMC based on the need for aid and attendance

SMC
7522, erectile dysfunction is noncompensable with or without penile deformity.  38 C.F.R. § 4.115b.

In this case, although the evidence of record shows that the Veteran has been diagnosed with erectile dysfunction, there is no evidence of record of a penile deformity at any time during the appeal period.  Further, a noncompensable rating, with or without penile deformity, is the highest schedular rating available under DC 7522.  Thus, a noncompensable disability rating for erectile dysfunction, as secondary to service-connected parkinsonism, is warranted for the entire appeal period.

Entitlement to SMC based on the need for aid and attendance

SMC on a higher level under 38 U.S.C. § 1114(l) and 38 C.F.R. § 3.350(b) is payable as the result of service-connected disability if the Veteran has an anatomical loss or loss of use of both feet, or of one hand and one foot; has blindness in both eyes with visual acuity of 5/200 or less (or concentric contraction of the field of vision beyond 5 degrees in both eyes); is permanently bedridden; or is so helpless as to be in need of regular aid and attendance of another person.

Loss of use of a hand or foot is defined as no effective function remaining other than that which would be equally well served by an amputation stump at the site of election below the elbow or knee with use of a suitable prosthetic appliance.  The determination will be made on the basis of the actual remaining function, whether the acts of grasping, manipulation, etc., in the case of the hand, or of balance, propulsion, etc., in the case of a foot, could be accomplished equally well by an amputation stump with prosthesis.  38 C.F.R. §§ 3.350(a)(2)(i), 4.63.

The following will be accorded consideration in determining the need for regular aid and attendance of another person: inability of a claimant to dress or undress him or herself, or to keep him or herself 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 aid (this will not include the adjustment of appliances which normal persons would be unable to adjust without aid, such as supports, belts, lacing at the back, etc.); inability of a claimant to feed him or herself through loss of coordination of the upper extremities or through extreme weakness; inability to attend to the wants of nature; or incapacity, physical or mental, which requires care or assistance on a regular basis to protect a claimant from the hazards or dangers incident to his or her daily environment.  38 C.F.R. § 3.352(a).

Bedridden, i.e., the Veteran is actually required to remain in bed, will be a proper basis for the determination.  The fact that a Veteran has voluntarily taken to bed or that a physician has prescribed rest in bed for the greater or lesser part of the day to promote convalescence or cure will not suffice.  Id.

The evidence of record does not reveal anatomical loss or loss of use of both of the Veteran's feet, or of one hand and one foot; or blindness in both eyes with visual acuity of 5/200 or less (or concentric contraction of the field of vision beyond 5 degrees in both eyes); or that the Veteran was permanently bedridden at any point during the appeal period.  38 U.S.C. § 1114(l), 38 C.F.R. § 3.350(b).

It is not required that all of the disabling conditions enumerated be found to exist before a favorable rating may be made.  Turco v. Brown, 9 Vet. App. 222, 224 (1996) (providing that eligibility for special monthly compensation by reason of regular need for aid and attendance requires that at least one of the factors set forth in VA regulation is met, but not all).  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 evidence establish that the Veteran is so helpless as to need regular aid and attendance, not that there be a constant need.  Determinations that the Veteran is 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 requirements of personal assistance from others.  38 C.F.R. § 3.352(a).

As a result of this decision, the Veteran is in receipt of multiple separate disability ratings
 all).  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 evidence establish that the Veteran is so helpless as to need regular aid and attendance, not that there be a constant need.  Determinations that the Veteran is 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 requirements of personal assistance from others.  38 C.F.R. § 3.352(a).

As a result of this decision, the Veteran is in receipt of multiple separate disability ratings, to include a 100 percent disability rating for dementia, depression, and sleep disturbances, as secondary to his service-connected parkinsonism.

For the following reasons, SMC based on the need for aid and attendance pursuant to 38 U.S.C. § 1114(l) is warranted for the entire appeal period.  

The Veteran required assistance in accomplishing the activities of daily living and was unable to protect himself from the hazards and dangers of his daily environment due to his service-connected disabilities throughout the entire appeal period.  Specifically, a November 2024 DBQ from a private physician noted that as a result of his parkinsonism, the Veteran required assistance for bathing/showering, eating or self-feeding, dressing, ambulating with the home or living area, tending to hygiene needs, transferring in or out of bed/chair, toileting, and medication management.  The Veteran was also unable to stand or ambulate on his own and had poor balance.  Moreover, a November 2024 letter from the physician indicated that the Veteran was unable to be left alone and needed 24/7 caregiver support because of his underlying conditions.

Thus, the evidence reflects that that the Veteran required assistance for daily functions as a result of his service-connected parkinsonism and related disabilities, and that the Veteran required assistance for activities such as walking, bathing, dressing, grooming, toileting, fixing meals, eating, and taking medication.  Therefore, the evidence of record supports that the Veteran's mental and physical incapacities due to his service-connected disabilities required care or assistance on a regular basis to protect him from hazards or dangers incident to his daily environment.  

For the above reasons, the evidence of record reflects that SMC based on the need for aid and attendance is warranted for the entire appeal period.

The Board has considered the Veteran's claims and decided entitlement based on the evidence.  Neither the Veteran nor his representative have raised any other issues, nor have any other issues been reasonably raised by the record, to include entitlement to a separate disability rating, entitlement to an extraschedular disability rating, entitlement to a total rating based on individual unemployability due to service-connected disability (TDIU), or service connection secondary to disability.  Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record).

 

Jonathan Hager

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	H. Styer, 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.