MYOCARDIAL INFARCTION

REBECCA N. POULSON · 2026 · Case ID: A26037433

MIXED

Summary

The veteran, who served from March 1964 to March 1966, appeals decisions concerning his service-connected heart disability, psychiatric disability, erectile dysfunction, and special monthly compensation (SMC) benefits. The Board granted a 100 percent disability rating for his myocardial infarction with congestive heart failure, finding that the evidence supported this rating for the entire period on appeal based on the established workload METs level and reported symptoms. The Board also granted service connection for adjustment disorder with mixed anxiety and depressed mood as secondary to his service-connected artery dissection, establishing an effective date of July 2, 2018, based on the intent to file date and the examiner's opinion that the psychiatric condition was a direct result of the artery dissection. Similarly, service connection for erectile dysfunction was granted as secondary to the psychiatric disability with the same effective date, supported by treatment records and a VA examination noting a 2014 onset. Entitlement to SMC for loss of use of a creative organ was also granted effective July 2, 2018, due to the established service connection for erectile dysfunction. Furthermore, the Board granted entitlement to SMC based on the need for regular aid and attendance, finding the veteran requires significant assistance with daily living activities due to his service-connected heart and psychiatric conditions. However, the Board remanded claims for an earlier effective date for SMC based on housebound criteria and for SMC at the r(1) level, pending the assignment of disability ratings for the psychiatric and erectile dysfunction conditions.

Rationale

Evidence supports 100% rating criteria for heart disability; August 2022 VA exam indicated 1-3 METs workload with symptoms; Consistent with prior reports of angina and shortness of breath

Special Benefit

SMC - AID & ATTENDANCE; SMC - HOUSEBOUND; EARLIER EFFECTIVE DATE

Diagnostic Code

7006

Docket No.

260221-628386

Full Decision Text

Citation Nr: A26037433
Decision Date: 04/22/26 Archive Date: 04/22/26

DOCKET NO. 260221-628386
DATE: April 22, 2026

ORDER

Entitlement to an initial rating of 100 percent for myocardial infarction with congestive heart failure (heart disability) is granted.

Entitlement to an effective date of July 2, 2018, but no earlier, for the grant of service connection for adjustment disorder with mixed anxiety and depressed mood (psychiatric disability) as secondary to service-connected left anterior descending artery dissection is granted.

Entitlement to an effective date of July 2, 2018, but no earlier, for the grant of service connection for erectile dysfunction as secondary to service-connected psychiatric disability is granted.

Entitlement to an effective date of July 2, 2018, but no earlier, for the grant of special monthly compensation based on loss of use of a creative organ is granted.

Entitlement to special monthly compensation (SMC) pursuant to 38 U.S.C. § 1114(l) based on the need for aid and attendance is granted.

REMANDED

Entitlement to an earlier effective date than October 3, 2025, for the grant of special monthly compensation based on housebound criteria is remanded.

Entitlement to special monthly compensation at the r(1) level is remanded.

FINDINGS OF FACT

1. For the entire period on appeal, the evidence is at least in approximate balance that the Veteran's heart disability was manifested by heart failure symptoms with workload less than 3 METs.

2. The Veteran filed an intent to file a claim on July 2, 2018; followed by a timely fully developed claim for compensation for his left anterior descending artery dissection; the Veteran's secondary psychiatric disability developed at the time of the primary service-connected disability.

3. The Veteran filed an intent to file a claim on July 2, 2018; followed by a timely fully developed claim for compensation for his left anterior descending artery dissection; the Veteran's secondary erectile dysfunction developed at the time of the primary service-connected disability.

4. Upon implementation of this decision, an earlier effective date of July 2, 2018, for service connection for erectile dysfunction is established; entitlement to SMC based on loss of use of a creative organ is warranted when service connection for erectile dysfunction is established.

5. The evidence is in approximate balance that the Veteran is in need of the regular aid and attendance of another person as a result of his service-connected heart disability and psychiatric disability.

CONCLUSIONS OF LAW

1. For the entire period on appeal, the criteria for a 100 percent rating for the Veteran's heart disability have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.104, Diagnostic Code 7006.

2. The criteria for an effective date of July 2, 2018, for service connection for a psychiatric disability as secondary to left anterior descending artery dissection have been met. 38 U.S.C. § 5107, 5110; 38 C.F.R. §§ 3.400, 3.1, 3.2500, 3.2501.

3. The criteria for an effective date of July 2, 2018, for service connection for erectile dysfunction as secondary to a psychiatric disability have been met. 38 U.S.C. § 5107, 5110; 38 C.F.R. §§ 3.400, 3.1, 3.2500, 3.2501.

4. The criteria for entitlement to an effective date of July 2, 2018, for the award of SMC based on loss of use of a creative organ have been met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. §§ 3.102, 38 C.F.R. § 3.114(a)(3), 3.400.

5. Resolving reasonable doubt in the Veteran's favor, the criteria for entitlement to SMC based on aid and attendance have been met. 38 U.S.C. § 1114(l); 38 C.F.R. §§ 3.102, 3.159, 3.350.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran had active duty service from March 1964 to March 1966.

The rating decisions on appeal were issued in October 2025, December 2025, and January 2026, and constitute initial decisions; therefore, the modernized review system, also known as
.R. § 3.114(a)(3), 3.400.

5. Resolving reasonable doubt in the Veteran's favor, the criteria for entitlement to SMC based on aid and attendance have been met. 38 U.S.C. § 1114(l); 38 C.F.R. §§ 3.102, 3.159, 3.350.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran had active duty service from March 1964 to March 1966.

In the February 2026 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Evidence Submission docket.

Therefore, the Board may only consider the evidence of record at the time of the October 2025, December 2025, and January 2026, agency of original jurisdiction (AOJ) decisions on appeal, as well as any evidence submitted by the Veteran or representative with, or within 90 days from receipt of, the VA Form 10182. 38 C.F.R. § 20.303. If evidence was submitted either (1) during the period after the AOJ issued the decision on appeal and prior to the date the Board received the VA Form 10182, or (2) more than 90 days following the date the Board received the VA Form 10182, the Board did not consider it in its decision. 38 C.F.R. §§ 20.300, 20.303, 20.801.

If the Veteran would like VA to consider any evidence that was submitted that the Board could not consider, the Veteran may file a Supplemental Claim (VA Form 20-0995) and submit or identify this evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the claim[s], considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision.

As a preliminary matter, in adjudicating the Veteran's appeal, the Board acknowledges the United States Court of Appeals for Veterans Claims (Court) decision in Williams v. McDonough, 37 Vet. App. 305 (2024), which found that under 38 C.F.R. § 20.202(c)(2), the Board generally may not decide an appeal before the deadline for requesting an AMA docket switch has elapsed. 38 C.F.R. § 20.202(c) allows appellants to switch AMA dockets by completing and submitting a new VA Form 10182 within 60 days from when the Board receives the original VA Form 10182, or one year from the date the AOJ mails notice of the decision on appeal, whichever is later, unless: (1) an appellant has already submitted evidence or testimony as described in 38 C.F.R. §§ 20.302 and 20.303, or (2) the appellant or representative has requested a waiver of the ability to request to switch dockets during this timeframe. See Williams, 37 Vet. App. 305. In this case, the Veteran submitted new evidence with the February 2026 VA Form 10182, including pertinent private medical examinations. Therefore, the Board may proceed with adjudication pursuant to 38 C.F.R. § 20.303.

Increased Ratings

Disability evaluations are determined by evaluating the extent to which a veteran's service connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Schedule). 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify various disabilities and the criteria for specific ratings. Pertinent regulations do not require that all cases show all findings specified by the Schedule, but that findings sufficient to identify the disease and the resulting disability and above all, coordination of the rating with impairment of function will be expected in all cases. 38 C.F.R. §§ 4.7 and 4.21; see also Mauerhan v. Principi, 16 Vet. App. 436 (2002).

If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining will be resolved in favor of the veteran
that all cases show all findings specified by the Schedule, but that findings sufficient to identify the disease and the resulting disability and above all, coordination of the rating with impairment of function will be expected in all cases. 38 C.F.R. §§ 4.7 and 4.21; see also Mauerhan v. Principi, 16 Vet. App. 436 (2002).

Evidence to be considered in the appeal of an initial assignment of a disability rating is not limited to that reflecting the then-current severity of the disorder. Fenderson v. West, 12 Vet. App. 119 (1999). In cases where an initially assigned disability evaluation has been disagreed with; it is possible for a veteran to receive a staged rating. That is, it is possible to be awarded separate percentage evaluations for separate periods, based on the facts found during the appeal period. Id. at 126-28; see also Hart v. Mansfield, 21 Vet. App. 505 (2007) (in determining the present level of a disability for any increased evaluation claim, the Board must consider staged ratings).

1. Entitlement to an initial rating in excess of 60 percent for myocardial infarction with congestive heart failure (heart disability)

The Veteran's myocardial infarction with congestive heart failure is currently rated as 60 percent disabling for the period prior to November 14, 2021, and as 100 percent disabling thereafter pursuant to 38 C.F.R. § 4.104, Diagnostic Code 7006. The Veteran contends that he is entitled to a 100 percent evaluation for the entire period on appeal (prior to November 14, 2021).

This disability is rated under Diagnostic Code (DC) 7006 pertaining to myocardial infarction. 38 C.F.R. § 4.104, DC 7006.

The Board notes that since the Veteran filed his claim, the rating criteria pertaining to cardiovascular conditions were revised effective November 14, 2021. Claims pending prior to the effective date will be considered under both the pre- and post-amendment rating criteria, and whichever is more favorable to the Veteran will be applied. However, the Board may not apply the post-amendment rating criteria to a period prior to its effective date, unless the regulation explicitly provides otherwise.

Prior to November 14, 2021, DC 7006 (myocardial infarction) warranted a 60 percent rating when there was more than one episode of CHF in the past year; or a workload of greater than 3 METs but not greater than 5 resulted in dyspnea, fatigue, angina, dizziness, or syncope; or there was left ventricular dysfunction with an ejection fraction of 30 to 50 percent. A 100 percent rating was warranted when there was chronic CHF; or workload of 3 METs or less resulted in dyspnea, fatigue, angina, dizziness, or syncope; or left ventricular dysfunction with an ejection fraction of less than 30 percent. 38 C.F.R. § 4.104, DC 7006.

Effective November 14, 2021, DC 7006 is governed by the rating criteria under the General Rating Formula for diseases of the heart. A 60 percent evaluation is assigned where a workload of 3.1 to 5.0 METs results in heart failure symptoms. A 100 percent evaluation is assigned where a workload of 3.0 METs or less results in heart failure symptoms.

For purposes of the General Rating Formula for Diseases of the Heart, heart failure symptoms include, but are not limited to, breathlessness, fatigue, angina, dizziness, arrhythmia, palpitations, or syncope. 38 C.F.R. § 4.104, Note (3).

Turning to the record, ongoing VA treatment records show an extensive history of complaints and treatment for his heart prior to and following a February 2014 heart surgery performed by the VA resulting in his service-connected left anterior descending artery dissection. During the period on appeal, the Veteran reported a history of angina, shortness of breath on exertion, chest pain, arrhythmia, and congestive heart failure.

The Veteran was afforded a VA examination for heart conditions in August 2022 whereby the examiner noted diagnoses of myocardial infarction and congestive heart failure. The examiner noted that the Veteran required continuous medication for his heart disorders. The examination also indicated supraventricular arrhythmia and stable angina. The examiner indicated that a June 2013 exercise-based stress test was attempted but terminated due to the cardiac symptoms. He noted that the test did show ischemia. Interview based METs testing on the date of the examination revealed breathlessness and fatigue and a workload level of 1 to 3 METs.

Based on a full review of the evidence of record, the Board finds the August 2022 examination report is adequate because it fully addressed rating criteria, included file review, and is fully responsive to the question at issue. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008).

In light of the evidence as discussed above, the Board finds that an initial evaluation of 100 percent for the Veteran's heart disability is warranted. During the period on appeal, the Veteran consistently reported symptoms of chest pain, angina, and shortness of breath. The August 2022 VA examination that determined the Veteran's workload METs level was between 1 and 3 is consistent with the Veteran's reports of breathlessness, fatigue, and angina reported previously in the record.

The Board notes that in the January 2026 rating decision, the AOJ granted an initial 60 percent rating from July 2, 2018, and increased the rating to 100 percent from November 14, 2021, the date that the rating criteria pertaining to cardiovascular conditions were revised. The Board acknowledges that the Board may not apply the post-amendment rating criteria to a period prior to its effective date, unless the regulation explicitly provides otherwise. However, the Board notes that under the rating criteria in effect prior to November 14, 2021, a 100 percent rating was warranted when there was chronic CHF; or workload of 3 METs or less resulted in dyspnea, fatigue, angina, dizziness, or syncope; or left ventricular dysfunction with an ejection fraction of less than 30 percent. See 38 C.F.R. § 4.104, DC 7006. Therefore, the Board finds that the Veteran met the rating criteria for a 100 percent rating under the criteria in effect prior to November 14, 2021, for the entire period on appeal.

Thus, an initial 100 percent evaluation for the Veteran's heart disability is granted from July 2, 2018, which is the effective date of service connection.

Effective Dates

Generally, the effective date of service connection based on an original claim will be the date of receipt of the claim or the date entitlement arose, whichever is the later. 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400. An exception is that the day following the date of separation from active service, or the date entitlement arose controls if the claim is received within one year after separation from active service; otherwise, the general rule applies. See 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400(b)(2)(i). Claim means a written or electronic communication requesting a determination of entitlement or evidencing a belief in entitlement, to a specific benefit under the laws administered by the Department of Veterans Affairs submitted on an application form prescribed by the Secretary. 38 C.F.R. § 3.1(p). An initial claim is any complete claim, other than a supplemental claim, for a benefit on a form prescribed by the Secretary. The first initial claim for one or more benefits received by VA is further defined as an original claim. 38 C.F.R. § 3.1(p)(1)(i). Initial claims include a new claim requesting service connection for a disability. Id.

Except as specifically provided, the effective date of a rating and award for pension, compensation, or dependency and indemnity compensation based on an original claim, a claim reopened after a final disallowance, or a claim for increase will be the date of receipt of the claim or the date entitlement arose, whichever is the
.F.R. § 3.1(p). An initial claim is any complete claim, other than a supplemental claim, for a benefit on a form prescribed by the Secretary. The first initial claim for one or more benefits received by VA is further defined as an original claim. 38 C.F.R. § 3.1(p)(1)(i). Initial claims include a new claim requesting service connection for a disability. Id.

Except as specifically provided, the effective date of a rating and award for pension, compensation, or dependency and indemnity compensation based on an original claim, a claim reopened after a final disallowance, or a claim for increase will be the date of receipt of the claim or the date entitlement arose, whichever is the later. 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400. For continuously pursued or supplemental claims, the effective dates are governed by 38 C.F.R. § 3.2500(h).

A claim, for VA compensation purposes, is broadly defined to include a formal or informal communication in writing requesting a determination of entitlement or evidencing a belief in entitlement to a benefit. 38 C.F.R. § 3.1(p); Brannon v. West, 12 Vet. App. 32, 34-5 (1998). Effective March 24, 2015, VA amended its regulations to require that all claims governed by VA's adjudication regulations be filed on a standard form.

There was an attempt to eliminate ITFs during AMA; however, the United States Court of Appeals for the Federal Circuit invalidated this elimination and ITFs are still in operation. See Military Veterans Advocacy v. McDonough, 7 F.4th 1110 (Fed. Cir. 2021), (invalidating § 3.155 in part to the extent it excludes AMA supplemental claims from the intent to file framework).

The VA is required to develop and adjudicate related claims for secondary service connection for disabilities that are reasonably raised during the adjudication of a formally initiated claim for the proper evaluation level for the primary service-connected disability. Bailey v. Wilkie, 33 Vet. App. 188, 203 (2021). An example of an issue "reasonably raised" by the record may be a statement or assertion of causation. Id.

2. Entitlement to an effective date of July 2, 2018, but no earlier, for the grant of service connection for adjustment disorder with mixed anxiety and depressed mood (psychiatric disability) as secondary to service-connected left anterior descending artery dissection

The Veteran contends that he is entitled to an effective date prior to October 3, 2025, for the grant of service connection for a psychiatric disability as secondary to service-connected left anterior descending artery dissection (artery dissection).

Historically, on July 2, 2018, the Veteran submitted an intent to file, followed by a VA Form 21-526EZ, fully developed claim seeking compensation for the artery dissection. In a May 2025 rating decision, the Veteran was granted service connection for the artery dissection effective October 17, 2018 (amended to July 2, 2018, the date of receipt of the ITF). In an October 2025 rating decision, the Veteran was granted service connection for a psychiatric disability as secondary to the artery dissection, with an effective date of October 3, 2025, the date of the VA examination for mental disorders.

After careful consideration, the Board concludes that the Veteran is entitled to an effective date of July 2, 2018, but no earlier, for the award of service connection for a psychiatric disability as secondary to service-connected artery dissection.

Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131. Establishing service connection generally requires competent evidence of three elements: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after separation when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d).

In this case, VA treatment records reveal that the Veteran has a current diagnosis of a psychiatric disability from at least July 2018. While there was no treatment or VA examination prior to October 2025, the October 2025 VA examination rendered a diagnosis of adjustment disorder with mixed anxiety and depressed mood with a noted onset following his February 2014 heart procedure
, i.e., a nexus, between the claimed in-service disease or injury and the current disability. 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after separation when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d).

In this case, VA treatment records reveal that the Veteran has a current diagnosis of a psychiatric disability from at least July 2018. While there was no treatment or VA examination prior to October 2025, the October 2025 VA examination rendered a diagnosis of adjustment disorder with mixed anxiety and depressed mood with a noted onset following his February 2014 heart procedure. Specifically, the examiner stated that the February 2014 procedure caused significant psychological consequences which have been continually present since the onset. The examiner noted that, although the Veteran has not received treatment for his mental health symptoms, they are a direct result of the July 2014 procedure resulting in the artery dissection. The examiner also noted an August 2022 private opinion noting that the Veteran suffered from "emotional and psychological distress" as a result of the procedure and ensuing conditions.

The Board finds that an effective date of July 2, 2018, but no earlier, for the grant of service connection for a psychiatric disability as secondary to service-connected artery dissection is warranted. The issue of a psychiatric disability was raised by the record as being within the scope of the initial claim for compensation for the artery dissection by the August 2022 private clinician indicating that the Veteran suffered from emotional and psychological distress as a result of the February 2014 procedure resulting in the service-connected artery dissection. The October 2025 VA examiner also indicated that the psychiatric diagnoses occurred as a direct result of the February 2014 procedure and began at the time of the service-connected artery dissection. See Morgan v. Wilkie, 31 Vet. App. 162, 167-168 (2019); Bailey v. Wilkie, 33 Vet. App. 188, 203 (2021).

Moreover, prior to July 2, 2018, there is no indication of a claim or an intent to file a claim for service connection for a psychiatric disability. Rather, the Veteran filed an intent to file on July 2, 2018 which is the date of the claim for the primary service-connected disability; during the pendency of that claim entitlement to service connection for a psychiatric disability was reasonably raised by the record.

As such, the claim for entitlement to an effective date of July 2, 2018, but no earlier, for the grant of service connection for a psychiatric disability as secondary to service-connected artery dissection is granted.

3. Entitlement to an effective date of July 2, 2018, but no earlier, for the grant of service connection for erectile dysfunction as secondary to service-connected psychiatric disability

The Veteran contends that he is entitled to an effective date prior to October 3, 2025, for the grant of service connection for erectile dysfunction as secondary to service-connected psychiatric disability.

Procedurally, as noted in the prior section, on July 2, 2018, the Veteran submitted an intent to file, followed by a VA Form 21-526EZ, fully developed claim seeking compensation for the artery dissection. In a May 2025 rating decision, the Veteran was granted service connection for the artery dissection effective October 17, 2018 (amended to July 2, 2018, the date of receipt of the ITF). In a December 2025 rating decision, the Veteran was granted service connection for erectile dysfunction as secondary to the service-connected psychiatric disability, with an effective date of October 3, 2025, the date service connection was granted for the primary disability.

After careful consideration, the Board thus concludes that the Veteran is entitled to an effective date of July 2, 2018, but no earlier, for the award of service connection for erectile dysfunction as secondary to service-connected psychiatric disability.

In this case, VA treatment records reveal that the Veteran has a current diagnosis of erectile dysfunction from at least July 2018. The Veteran's VA treatment records indicate a diagnosis of male erectile disorder from as early as April 2014, following the Veteran's heart procedure and ongoing to present. See April 2014 CAPRI record. The Veteran was also afforded a VA examination for male reproductive organ conditions in November 2025. The examiner confirmed the diagnosis of erectile dysfunction as secondary to his psychiatric disability and noted an onset of 2014. During the examination, the Veteran reported that it began after complications of his February 2014 procedure.

The Board finds that an effective date of July 2, 2018, but no earlier, for the grant of
VA treatment records reveal that the Veteran has a current diagnosis of erectile dysfunction from at least July 2018. The Veteran's VA treatment records indicate a diagnosis of male erectile disorder from as early as April 2014, following the Veteran's heart procedure and ongoing to present. See April 2014 CAPRI record. The Veteran was also afforded a VA examination for male reproductive organ conditions in November 2025. The examiner confirmed the diagnosis of erectile dysfunction as secondary to his psychiatric disability and noted an onset of 2014. During the examination, the Veteran reported that it began after complications of his February 2014 procedure.

The Board finds that an effective date of July 2, 2018, but no earlier, for the grant of service connection for erectile dysfunction as secondary to service-connected psychiatric disability is warranted. The issue of erectile dysfunction was raised by the record as being within the scope of the initial claim for compensation for the artery dissection. The treatment records indicate a diagnosis of erectile disorder as early as 2014 and the November 2025 VA examiner noted a 2014 onset of the condition as a result of the psychiatric disability secondary to the artery dissection. See Morgan, 31 Vet. App. at 167-168; Bailey, 33 Vet. App. at 203. Moreover, prior to July 2, 2018, there is no indication of a claim or an intent to file a claim for service connection for erectile dysfunction. Rather, the Veteran filed an intent to file on July 2, 2018, which is the date of the claim for the primary service-connected disability as granted in this decision; during the pendency of that claim entitlement to service connection for erectile dysfunction was reasonably raised by the record. As such, the claim for entitlement to an effective date of July 2, 2018, but no earlier, for the grant of service connection for erectile dysfunction as secondary to service-connected psychiatric disability is granted.

4. Entitlement to an effective date of July 2, 2018, but no earlier, for the grant of special monthly compensation based on loss of use of a creative organ

The Board finds that the Veteran is also entitled to an effective date of July 2, 2018, for entitlement to special monthly compensation (SMC) based on loss of use of a creative organ. Entitlement to SMC based on loss of use of a creative organ is warranted when service connection for erectile dysfunction is established. See 38 CFR § 4.115b, Diagnostic Code 7522. As service connection for erectile dysfunction is now established from July 2, 2018, the Board finds that the Veteran meets the criteria for an award for SMC based on loss of use of a creative organ from that date, and that an award of an effective date from July 2, 2018, for that benefit is also warranted.

5. Entitlement to special monthly compensation based on aid and attendance

SMC is available when, as the result of service-connected disability, a veteran suffers additional hardships above and beyond those contemplated by VA's schedule for rating disabilities. Breniser v. Shinseki, 25 Vet. App. 64, 68 (2011) (citing 38 U.S.C. § 1114 (k)-(s)).

Here, the Veteran seeks entitlement to SMC based on his need for the regular aid and attendance of another person.

Generally, with respect to claims of entitlement to SMC based on the need for the regular aid and attendance of another person, such claims will be granted when a veteran, due to a service-connected disability, has the anatomical loss or loss of use of both feet or one hand and one foot, or is blind in both eyes, or is permanently bedridden or so helpless as to be in need of regular aid and attendance. See 38 U.S.C.§ 1114(l); 38 C.F.R. § 3.350(b).

Determinations as to the need for aid and attendance must be based on actual requirements of personal assistance from others. In making such determinations, consideration is given to the following: inability of a veteran to dress or undress himself/herself or to keep himself/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; inability of a veteran to feed himself/herself through loss of coordination of 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 veteran from the hazards or dangers inherent in his/her daily environment. Bedridden will be a proper basis for the determination, and is defined as that condition which, through its essential character, actually requires that the veteran remain
inability of a veteran to dress or undress himself/herself or to keep himself/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; inability of a veteran to feed himself/herself through loss of coordination of 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 veteran from the hazards or dangers inherent in his/her daily environment. Bedridden will be a proper basis for the determination, and is defined as that condition which, through its essential character, actually requires that the veteran remain in bed. It is not required that all of the disabling conditions listed above be found to exist before a favorable rating may be made. The particular personal functions that a veteran is unable to perform should be considered in connection with his/her condition as a whole. It is only necessary that the evidence establish that a veteran is so helpless as to need regular aid and attendance, not that there be a constant need. 38 C.F.R. § 3.352(a).

For the following reasons, the Board finds that entitlement to SMC based on the need for aid and attendance is warranted.

Turning to the evidence, ongoing VA treatment records show an extensive history of complaints and treatment for his heart prior to and following a February 2014 heart surgery performed by the VA resulting in his service-connected left anterior descending artery dissection. During the period on appeal, the Veteran reported a history of angina, shortness of breath on exertion, chest pain, arrhythmia, and congestive heart failure.

In a July 2021 private opinion regarding the February 2014 heart surgery and subsequent service-connected heart conditions, including myocardial infarction with congestive heart failure, supraventricular arrythmia, and left anterior descending artery dissection, the clinician stated that "[t]hese disabilities have imposed very significant burdens and functional deficits."

The Veteran was afforded a VA examination for heart conditions in August 2022 whereby the examiner noted diagnoses of myocardial infarction and congestive heart failure. The examination also indicated supraventricular arrhythmia and stable angina. The examiner noted that the Veteran required continuous medication for his heart disorders. Interview based METs testing on the date of the examination revealed breathlessness and fatigue and a workload level of 1 to 3 METs. In terms of functional impairment, the examiner stated that the Veteran is "significantly limited in any activity that requires even mild exertion." He stated that this included walking and standing for below average time periods.

The Veteran was afforded a VA examination for mental disorders in October 2025 which indicated a diagnosis of adjustment disorder with mixed anxiety and depressed mood secondary to his service-connected artery dissection. In terms of functional impairment, the examiner described occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and/or mood.

Importantly, during the applicable evidentiary window, the Veteran submitted a VA 21-2680 completed by private clinician, Dr. W.H. (dated February 2026). Dr. W.H. noted that the service-connected conditions of myocardial infarction with congestive heart failure (heart disability) and adjustment disorder with mixed anxiety and depressed mood (psychiatric disability) are considered permanent and totally disabling. At the time, the Veteran was 79 years old, weighed 175 pounds, and was 5 feet 8 inches tall. Dr. W.H. indicated that the Veteran needs assistance with bathing/showering, eating/self-feeding, dressing, ambulating within the home, tending to hygiene needs, toileting, and additional activities including housekeeping, laundering, and meal preparation. He also needs assistance with medication management and use of assistive devices. The clinician indicated "yes" to whether the Veteran requires nursing home care. He noted that the Veteran is not currently in specialized residential care; however, if his wife were not available, he would require the services of an assisted living facility or a long-term care facility for survival, as he is not capable of living independently.

According to Dr. W.H., related to his upper extremities, the Veteran's primary limitations stem from cardiac condition causing fatigue with sustained arm activity, noting that the Veteran cannot carry groceries or lift objects due to exertional dyspnea and that his wife assists with compression sock application. Related to his lower extremities, the Veteran has chronic edema, weakness, limited weight bearing tolerance and occasional muscle spasms. For propulsion, he requires a cane for all ambulation and he cannot ambulate more than 100 yards without profound fatigue, dizziness, and dyspnea. He has a history of falls and near-syncope, is unable to climb stairs, and experiences balance impairment with positional changes. Dr. W.H. also noted cognitive factors including memory impairment, poor concentration, and confusion affecting medication management and daily task completion. He noted profound fatigue with minimal exertion requiring frequent rest periods, complex cardiac medication regimen requiring caregiver oversight to prevent errors, nocturnal dyspnea requiring sleep in upright chair position, and insomnia from anxiety. He also indicated safety concerns, specifically fall risk, due to the Veteran's near-syncope with positional changes, noting that he needs monitoring for cardiac decompensation. See February 2026 VA 21-2680 Examination for Housebound Status or Permanent Need for Regular Aid and Attendance.

The Veteran also included a private report from Dr. W.H. (dated February 2026) that essentially confirmed the above VA 21-2680. The clinician concluded that the Veteran requires regular hands-on assistance from another person for basic activities of daily living. He noted that the Veteran has a diagnosis of myocardial infarction with congestive heart failure and adjustment disorder with mixed anxiety and depressed mood associated with left anterior descending artery dissection which result in significant functional limitations requiring assistance. In sum, he opined that the Veteran requires regular aid and attendance due to his heart disability and psychiatric disability. See February 2026 Medical Treatment Record, Non-Government Facility.

Given the above, the Board finds that entitlement to SMC by reason of the need for regular aid and attendance from another person is warranted. The evidence of record demonstrates that the Veteran needs assistance with activities of daily living including tending to personal hygiene, feeding, toileting, preparing meals, being a fall risk, and managing medication due to his service-connected heart and psychiatric disabilities.

Overall, the evidence of record supports the Veteran's contentions that his service-connected heart disability and psychiatric disability render him unable to perform daily activities of living without the assistance of another. Accordingly, the claim for SMC for aid and attendance pursuant to 38 U.S.C. § 1114(l) is granted.

To avoid prejudice to the Veteran, the Board will allow the AOJ to assign the effective date of this benefit in the first instance. See Urban v. Principi, 18 Vet. App. 143 (2004). If the Veteran disagrees with the effective date assigned by the AOJ, he may seek review of that decision by filing an appropriate VA form.

REASONS FOR REMAND

1. Entitlement to an earlier effective date than October 3, 2025, for the grant of special monthly compensation based on housebound criteria

2. Entitlement to special monthly compensation at the r(1) level

Notably, the Veteran is currently in receipt of a 100 percent disability rating for his service-connected myocardial infarction with congestive heart failure (heart disability) effective July 2, 2018, and his award for SMC based on housebound criteria is, primarily, due to this award.

SMC at the housebound rate is payable when a Veteran has a single service-connected disability rated 100 percent and (1) has additional service-connected disability or disabilities independently ratable at 60 percent, separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems; or, (2) is permanently housebound by reason of service-connected disability or disabilities. 38 U.S.C. §1114(s); 38 C.F.R. § 3.350(i)(1).

SMC provided by 38 U.S.C. § 1114(r)(1) is payable when a claimant receiving the maximum rate under § 1114(o) or (p) is in need of regular aid and attendance or a higher level of care, whether or not the need for regular aid and attendance or a higher level of care was a partial basis for the entitlement to the maximum rate under § 1114(o) or (p). 38 C.F.R. § 3.350(h)(1).

In certain circumstances, benefits are payable at the intermediate or next higher rate of SMC. See 38 U.S.C. §
(s); 38 C.F.R. § 3.350(i)(1).

In certain circumstances, benefits are payable at the intermediate or next higher rate of SMC. See 38 U.S.C. § 1114(p). One of the circumstances where benefits may be paid at the intermediate or next higher rate is where, in addition to a disability or combination of disabilities that render a veteran so helpless as to require regular aid and attendance, a veteran is in receipt of service connection for a single additional permanent disability or combination of permanent disabilities that are independently ratable at 50 percent or more and the additional disability or disabilities are separate and distinct and involve different anatomical segments or body systems from the disability or combination of disabilities that render a veteran so helpless as to require regular aid and attendance. 38 C.F.R. § 3.350(f)(3).

Notably, earlier effective dates have been awarded for the Veteran's psychiatric disability and erectile dysfunction in this Board decision, but disability ratings have not yet been assigned prior to October 2025. Entitlement to SMC pursuant to 38 U.S.C. § 1114(l) based on the need for aid and attendance has also been granted herein. The outcome of the future rating assignments directly impacts the effective dates for the award of SMC at the housebound rate (s) and at the r(1) level. As the Federal Circuit has held in Smith v. Gober, 236 F.3d 1370, 1373 (Fed. Cir. 2001), where the facts underlying separate claims are "intimately connected," considerations of judicial economy and avoidance of piecemeal litigation require that the claims be adjudicated together. Here, the assignment of ratings for the Veteran's psychiatric disability and erectile dysfunction prior to October 2025 will determine whether the Veteran meets the criteria for SMC housebound prior to October 3, 2025, and/or SMC at the r(1) level throughout the appeal. Further, the Board has not assigned an effective date for the award of SMC pursuant to 38 U.S.C. § 1114(l) based on the need for aid and attendance; the effective date of this SMC award will impact whether the Veteran is entitled to SMC at the housebound rate prior to October 3, 2025, or if he is entitled to a higher benefit.

While there was not a pre-decisional duty to assist error in this case, the Board finds that the SMC issues should be deferred pending assigment of ratings for the Veteran's psychiatric disability and erectile dysfunction prior to October 2025. This remand is necessary to fulfill a statutory and regulatory duty, as it has a reasonable possibility of substantiating the claim. 38 C.F.R. § 20.802(a).

The matter is REMANDED for the following action:

Assign disability ratings for the Veteran's psychiatric disability and erectile dysfunction prior to October 3, 2025, to include consideration of SMC benefits.

Rebecca N. Poulson

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board Daniels, Leslie, 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.

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