### Section H. Special Monthly Compensation (SMC)

#### Overview

+------------+---------------------------------------------------------+
| #          | > This section contains the following topics:           |
| #### In th |                                                         |
| is Section |                                                         |
+------------+---------------------------------------------------------+

  ------------ ---------------------------------------------- ------------
  Topic        Topic Name                                     See Page

  36           General Information on SMC                     2-H-2

  37           Combining Disabilities When Entitlement to SMC 2-H-5
               is at Issue                                    

  38           Hospital Adjustments Under 38 CFR 3.552        2-H-8

  39           Entitlement to SMC Under 38 U.S.C. 1114(k)     2-H-10

  40           Additional SMC for Blindness Coupled With      2-H-16
               Hearing Loss or the Loss, or Loss of Use,      
               (L/LOU) of an Extremity Under 38 CFR           
               3.350(e)(1) and 38 CFR 3.350(f)(2)             

  41           SMC for Additional 50- and 100-Percent         2-H-24
               Evaluations Under 38 CFR 3.350(f)(3) and 38    
               CFR 3.350(f)(4)                                

  42           Additional SMC for L/LOU of Three Extremities  2-H-29
               Under 38 CFR 3.350(f)(5)                       

  43           Entitlement to Specially Adapted Housing Under 2-H-32
               38 U.S.C. 2101                                 

  44           Entitlement to SMC Based on the Need for Aid   2-H-33
               and Attendance (A&A)                           

  45           Entitlement to a Higher A&A Allowance Under 38 2-H-38
               U.S.C. 1114(r)(2)                              

  46           Entitlement to Housebound Benefits             2-H-41
  ------------ ---------------------------------------------- ------------

#### 36. General Information on SMC

+------------+---------------------------------------------------------+
| ##### In   | > This topic contains information on Special Monthly    |
| troduction | > Compensation (SMC), including                         |
|            |                                                         |
|            | -   the definition of ***Special Monthly                |
|            |     Compensation***                                     |
|            |                                                         |
|            | -   the responsibility for determining loss of use      |
|            |                                                         |
|            | -   the information to request from an examiner         |
|            |                                                         |
|            | -   determining the extent of examinations              |
|            |                                                         |
|            | -   considering amputation or loss of use of            |
|            |     extremities                                         |
|            |                                                         |
|            | -   showing entitlement to SMC in rating decisions, and |
|            |                                                         |
|            | -   showing the denial of SMC in rating decisions.      |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### C    | > December 13, 2005                                     |
| hange Date |                                                         |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ####       | > ***Special Monthly Compensation (SMC)*** is an        |
| # a. Defin | > additional level of compensation to veterans (above   |
| ition: SMC | > the basic levels of compensation payable based on     |
|            | > disability ratings of 0 to 100 percent) for various   |
|            | > types of anatomical losses or levels of impairment    |
|            | > due solely to service-connected (SC) disabilities.    |
|            | >                                                       |
|            | > ***Reference***: For more information on SMC, see the |
|            | > "SMC Training Guide" under "Training" on the          |
|            | > [Compensation and Pension Service\'s Intranet         |
|            | > website](http://vbaw.vba.va.gov/bl/21/).              |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| #          | > The responsibility for determining whether there is   |
| #### b. Re | > loss of use of an extremity                           |
| sponsibili |                                                         |
| ty for Det | -   rests with the rating activity, and                 |
| ermining L |                                                         |
| oss of Use | -   cannot be delegated to the examining physician.     |
+------------+---------------------------------------------------------+

Continued on next page

36\. General Information on SMC, Continued

+------------+---------------------------------------------------------+
| ##### c.   | > When requesting an examination to determine loss of   |
|  Informati | > use of an extremity, ask the examiner to furnish a    |
| on to Requ |                                                         |
| est From a | -   detailed objective description of remaining         |
| n Examiner |     function                                            |
|            |                                                         |
|            | -   quantitative assessment of strength for each        |
|            |     extremity involved, and                             |
|            |                                                         |
|            | -   description of any pain that affects use.           |
|            |                                                         |
|            | > Do not request that the examiner                      |
|            |                                                         |
|            | -   determine loss of use, or                           |
|            |                                                         |
|            | -   express an opinion as to whether there is, or is    |
|            |     not, loss of use of an extremity or extremities.    |
|            |                                                         |
|            | > ***Note***: If loss of use cannot be determined upon  |
|            | > review of an examination report, request an           |
|            | > appropriate specialized examination.                  |
|            | >                                                       |
|            | > ***References***: For more information on             |
|            |                                                         |
|            | -   considering functional loss due to pain in claims   |
|            |     for SMC, see *[Tucker v.                            |
|            |     West](h                                             |
|            | ttp://vbaw.vba.va.gov/bl/21/Advisory/CAVCDAD.htm#bmt),* |
|            |     96-1493, and                                        |
|            |                                                         |
|            | -   requesting a specialist examination, see [M21-1MR,  |
|            |     Part III, Subpart iv,                               |
|            |     3.A.8](../pt03_sp04_ch03_secA.xml#III.iv.3.A.8).    |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### d    | > Exercise considerable care when requesting            |
| . Determin | > examinations in connection with claims involving SMC  |
| ing the Ex | > under [38 U.S.C. 1114(1) through                      |
| tent of Ex | > (n)](http://straylight.law.cornell.edu/               |
| aminations | uscode/html/uscode38/usc_sec_38_00001114----000-.html). |
|            | >                                                       |
|            | > ***Example***: A prior examination clearly            |
|            | > established loss of use of both lower extremities at  |
|            | > a level preventing natural knee action. Do not        |
|            | > request a complete medical examination if the only    |
|            | > issue in question is the extent of involvement of one |
|            | > or both of the upper extremities. Instead, request an |
|            | > examination with a notation that the examination be   |
|            | > restricted to the degree of functional impairment of  |
|            | > the upper extremities.                                |
+------------+---------------------------------------------------------+

Continued on next page

36\. General Information on SMC, Continued

+------------+---------------------------------------------------------+
| ##         | > A determination as to loss of use of a hand or foot   |
| ### e. Con | > is not restricted to organic loss; it includes        |
| sidering A | > functional loss of use as well.                       |
| mputation  | >                                                       |
| or Loss of | > The relevant inquiry concerning entitlement to SMC is |
|  Use of an | > not whether amputation is warranted. Instead,         |
|  Extremity | > question whether the effective function remaining is  |
|            | > other than that which would be equally well served by |
|            | > an amputation with the use of a suitable prosthetic   |
|            | > appliance.                                            |
|            | >                                                       |
|            | > ***Reference***: For more information on determining  |
|            | > entitlement to SMC based on loss of use that is       |
|            | > tantamount to amputation, see *[Tucker v.             |
|            | > West](h                                               |
|            | ttp://vbaw.vba.va.gov/bl/21/Advisory/CAVCDAD.htm#bmt),* |
|            | > 96-1493.                                              |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| #####      | > Entitlement to SMC must be reflected in the *Coded    |
|  f. Showin | > Conclusion* section of the rating decision by         |
| g Entitlem |                                                         |
| ent to SMC | -   noting entitlement to SMC and statutory awards      |
|  in Rating |     immediately following citation of the combined      |
|  Decisions |     evaluation of all service-connected disabilities    |
|            |     (if more than one exists)                           |
|            |                                                         |
|            | -   listing any anatomical loss as the first            |
|            |     entitlement in order of preference over all losses  |
|            |     of use, and                                         |
|            |                                                         |
|            | -   citing separately each additional specific          |
|            |     disability if entitlement under [38 U.S.C.          |
|            |     1114(k)](http://www4.law.cornell.edu                |
|            | /uscode/html/uscode38/usc_sec_38_00001114----000-.html) |
|            |     is shown for more than one anatomical loss, or loss |
|            |     of use.                                             |
|            |                                                         |
|            | > ***Reference***: For more information on the          |
|            | > appropriate codes and phrases to use in the rating    |
|            | > decision, see [M21-1, Part I, Appendix                |
|            | > A](htt                                                |
|            | p://www.warms.vba.va.gov/admin21/m21_1/part1/appa.doc). |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ####       | > The denial of SMC, whether specifically claimed by    |
| # g. Showi | > the veteran or inferred by the rating activity, must  |
| ng the Den | > be addressed in the *Reasons for Decision* section of |
| ial of SMC | > the rating decision.                                  |
|  in Rating |                                                         |
|  Decisions |                                                         |
+------------+---------------------------------------------------------+

#### 37. Combining Disabilities When Entitlement to SMC Is at Issue

+------------+---------------------------------------------------------+
| ##### In   | > This topic contains information on combining          |
| troduction | > disabilities when entitlement to SMC is at issue,     |
|            | > including information on                              |
|            |                                                         |
|            | -   when multiple disabilities should not be rated as a |
|            |     single disability                                   |
|            |                                                         |
|            | -   rating a multisystemic disorder                     |
|            |                                                         |
|            | -   an example of a rating decision involving a         |
|            |     multisystemic disorder, and                         |
|            |                                                         |
|            | -   cases involving loss of anal and bladder sphincter  |
|            |     control.                                            |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### C    | > December 13, 2005                                     |
| hange Date |                                                         |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### a.   | > Do *not* rate multiple disabilities as a single       |
|  When Mult | > disability if there is a possibility of entitlement   |
| iple Disab | > to                                                    |
| ilities Sh |                                                         |
| ould Not B | -   SMC under [38 U.S.C.                                |
| e Rated as |     1114(s)](http://straylight.law.cornell.edu/         |
|  a Single  | uscode/html/uscode38/usc_sec_38_00001114----000-.html), |
| Disability |     or                                                  |
|            |                                                         |
|            | -   an intermediate or next higher rate of SMC under    |
|            |                                                         |
|            | ```{=html}                                              |
|            | <!-- -->                                                |
|            | ```                                                     |
|            | -   [38 CFR                                             |
|            |     3.350(f)(3)](http://w                               |
|            | ww.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_350.DOC), |
|            |     or                                                  |
|            |                                                         |
|            | -   [38 CFR                                             |
|            |     3.350(f)(4)](http://w                               |
|            | ww.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_350.DOC). |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### b. R | > The assignment of a single evaluation of 100 percent  |
| ating a Mu | > for a multisystemic disorder, based on loss of use of |
| ltisystemi | > two extremities, may overlook the disorder's          |
| c Disorder | > involvement in other body systems. This involvement   |
|            | > might meet requirements for                           |
|            |                                                         |
|            | -   an intermediate rate under [38 CFR                  |
|            |     3.350(f)(3)](http://w                               |
|            | ww.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_350.DOC), |
|            |     or                                                  |
|            |                                                         |
|            | -   the next higher rate under [38 CFR                  |
|            |     3.350(f)(4)](http://w                               |
|            | ww.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_350.DOC). |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### c.   | > ***Situation***: A veteran has lost the use of both   |
|  Example:  | > lower extremities due to SC multiple sclerosis.       |
| Rating Mul | >                                                       |
| tisystemic | > ***Result***: Assign                                  |
|  Disorders |                                                         |
|            | -   a 100-percent evaluation for the loss of use of     |
|            |     both lower extremities under hyphenated diagnostic  |
|            |     code (DC) 8018-5110, and                            |
|            |                                                         |
|            | -   separate evaluations under the appropriate DCs for  |
|            |     the involvement of any other body system so that    |
|            |     possible entitlement to a higher level of SMC will  |
|            |     not be overlooked.                                  |
+------------+---------------------------------------------------------+

Continued on next page

37\. Combining Disabilities When Entitlement to SMC Is at Issue,
Continued

+------------+---------------------------------------------------------+
| c\.        | > ***Coded Conclusion***: Assume the disabilities shown |
| Example:   | > below are all related to multiple sclerosis.          |
| Rating     | >                                                       |
| Mul        | > SUBJECT TO COMPENSATION (1.SC)                        |
| tisystemic | >                                                       |
| Disorders  | > 8018-5110 MULTIPLE SCLEROSIS, WITH LOSS OF USE BOTH   |
| (          | > LOWER EXTREMITIES                                     |
| continued) | >                                                       |
|            | > 100 percent from 06/14/1996.                          |
|            | >                                                       |
|            | > 6516 DYSARTHRIA, DUE TO MULTIPLE SCLEROSIS            |
|            | >                                                       |
|            | > 30 percent from 06/14/1996.                           |
|            | >                                                       |
|            | > 7332 IMPAIRMENT OF ANAL SPHINCTER CONTROL DUE TO      |
|            | > MULTIPLE SCLEROSIS                                    |
|            | >                                                       |
|            | > 10 percent from 06/14/1996.                           |
|            | >                                                       |
|            | > 7512 LOSS OF BLADDER CONTROL, MODERATE, DUE TO        |
|            | > MULTIPLE SCLEROSIS                                    |
|            | >                                                       |
|            | > 10 percent from 06/14/1996.                           |
|            | >                                                       |
|            | > 6016 NYSTAGMUS DUE TO MULTIPLE SCLEROSIS              |
|            | >                                                       |
|            | > 10 percent from 06/14/1996.                           |
|            | >                                                       |
|            | > *COMBINED EVALUATION FOR COMPENSATION*:               |
|            | >                                                       |
|            | > 100 percent from 06/14/1996.                          |
|            | >                                                       |
|            | > *SPECIAL MONTHLY COMPENSATION*                        |
|            | >                                                       |
|            | > L-1 Entitled to SMC under 38 U.S.C. 1114(1) and 38    |
|            | > CFR 3.350(b) on account of loss of use of both feet   |
|            | > from 06/14/1996.                                      |
|            | >                                                       |
|            | > P-1 Entitled to SMC under 38 U.S.C. 1114(p) and 38    |
|            | > CFR 3.350(f)(3) at the rate intermediate between 38   |
|            | > U.S.C. 1114(l) and 38 U.S.C. 1114(m) on account of    |
|            | > loss of use of both feet with additional              |
|            | > disabilities, dysarthria, loss of bladder control,    |
|            | > impairment of anal sphincter control and nystagmus    |
|            | > independently ratable at 50 percent or more disabling |
|            | > from 06/14/1996.                                      |
+------------+---------------------------------------------------------+

Continued on next page

37\. Combining Disabilities When Entitlement to SMC Is at Issue,
Continued

+------------+---------------------------------------------------------+
| c\.        | > SMC coding is shown in the table below.               |
| Example:   |                                                         |
| Rating     |                                                         |
| Mul        |                                                         |
| tisystemic |                                                         |
| Disorders  |                                                         |
| (          |                                                         |
| continued) |                                                         |
+------------+---------------------------------------------------------+

  -------------- --------- ----------- ----------- ----------- -----------
  EFFECTIVE DATE BASIC     HOSPITAL    LOSS OF USE ANAT. LOSS  OTHER LOSS

  06/14/1996     18        18          24          00          0
  -------------- --------- ----------- ----------- ----------- -----------

+------------+---------------------------------------------------------+
| ##### d    | > Under certain circumstances, loss of use of both      |
| . Cases In | > lower extremities, together with loss of anal and     |
| volving Lo | > bladder sphincter control, satisfies the requirements |
| ss of Anal | > of [38 CFR                                            |
|  and Bladd | > 3.350(e)(2)](http://                                  |
| er Sphinct | www.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_350.DOC) |
| er Control | > for entitlement to SMC under [38 U.S.C.               |
|            | > 1114(o)](http://straylight.law.cornell.edu/           |
|            | uscode/html/uscode38/usc_sec_38_00001114----000-.html). |
|            | >                                                       |
|            | > In such cases, separate ratings for loss of anal and  |
|            | > bladder sphincter control are not required. Use SMC   |
|            | > code 55 as shown in [M21-1, Part I, Appendix          |
|            | > A](htt                                                |
|            | p://www.warms.vba.va.gov/admin21/m21_1/part1/appa.doc). |
+------------+---------------------------------------------------------+

#### 38. Hospital Adjustments Under 38 CFR 3.552

+------------+---------------------------------------------------------+
| ##### In   | > This topic contains information on hospital           |
| troduction | > adjustments under 38 CFR 3.552, including information |
|            | > on                                                    |
|            |                                                         |
|            | -   specifying the basis of entitlement under 38 CFR    |
|            |     3.552 in the rating decision                        |
|            |                                                         |
|            | -   the consequences of an improperly assigned SMC      |
|            |     code, and                                           |
|            |                                                         |
|            | -   two examples of rating decisions with properly      |
|            |     assigned SMC hospital codes.                        |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### C    | > December 13, 2005                                     |
| hange Date |                                                         |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### a.   | > The rating decision must specify the basis of the     |
| Specifying | > veteran's entitlement to a hospital adjustment in     |
|  Basis of  | > order to ensure the proper application of [38 CFR     |
| Entitlemen | > 3.552](http://w                                       |
| t Under 38 | ww.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_552.DOC). |
|  CFR 3.552 | >                                                       |
|            | > The SMC allowance for aid and attendance (A&A) must   |
|            | > be discontinued during hospitalization at government  |
|            | > expense, *unless* the need for A&A is due to          |
|            |                                                         |
|            | -   paraplegia involving                                |
|            |                                                         |
|            | ```{=html}                                              |
|            | <!-- -->                                                |
|            | ```                                                     |
|            | -   paralysis of both lower extremities, together with  |
|            |                                                         |
|            | -   loss of anal and bladder sphincter control, or      |
|            |                                                         |
|            | ```{=html}                                              |
|            | <!-- -->                                                |
|            | ```                                                     |
|            | -   Hansen's disease.                                   |
|            |                                                         |
|            | > ***Exception***: The SMC allowance for A&A must be    |
|            | > discontinued during hospitalization, regardless of    |
|            | > the disability involved, if entitlement is            |
|            | > established under                                     |
|            |                                                         |
|            | -   [38 U.S.C.                                          |
|            |     1114(r)(1)](http://straylight.law.cornell.edu/      |
|            | uscode/html/uscode38/usc_sec_38_00001114----000-.html), |
|            |     or                                                  |
|            |                                                         |
|            | -   [38 U.S.C.                                          |
|            |     1114(r)(2)](http://straylight.law.cornell.edu/      |
|            | uscode/html/uscode38/usc_sec_38_00001114----000-.html). |
|            |                                                         |
|            | > ***Reference***: For more information on entitlement  |
|            | > to a higher A&A allowance under [38 U.S.C.            |
|            | > 1114(r)](http://straylight.law.cornell.edu/           |
|            | uscode/html/uscode38/usc_sec_38_00001114----000-.html), |
|            | > see [M21-1MR, Part IV, Subpart ii,                    |
|            | > 2.H.45](../pt04_sp02_ch02_secH#IV.ii.2.H.45).         |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| #####      | > The assignment of an improper SMC hospital code may   |
| b. Consequ | > result in erroneous adjustment of the veteran's award |
| ences of a | > upon hospitalization.                                 |
| n Improper |                                                         |
| ly Assigne |                                                         |
| d SMC Code |                                                         |
+------------+---------------------------------------------------------+

Continued on next page

38\. Hospital Adjustments Under 38 CFR 3.552, Continued

+------------+---------------------------------------------------------+
| ##### c.   | > ***Situation***: The veteran has                      |
|  Example 1 |                                                         |
| : Rating D | -   a 100-percent disabling heart condition so severe   |
| ecision Wi |     as to require the Aid and Attendance (A&A) of       |
| th a Prope |     another person, and                                 |
| rly Assign |                                                         |
| ed SMC Hos | -   bilateral, below-knee amputations.                  |
| pital Code |                                                         |
|            | > ***Result***: Entitlement under [38 U.S.C.            |
|            | > 1114(r)(1)](http://straylight.law.cornell.edu         |
|            | /uscode/html/uscode38/usc_sec_38_00001114----000-.html) |
|            | > is warranted based upon the need for A&A; entitlement |
|            | > under [38 U.S.C.                                      |
|            | > 1114(l)](http://straylight.law.cornell.edu            |
|            | /uscode/html/uscode38/usc_sec_38_00001114----000-.html) |
|            | > is also warranted for the bilateral amputations.      |
|            | >                                                       |
|            | > ***Coded Conclusion***: The proper                    |
|            |                                                         |
|            | -   SMC code is 51, and                                 |
|            |                                                         |
|            | -   SMC hospital code is 07 for SMC under [38 U.S.C.    |
|            |     1114(m)](http://straylight.law.cornell.edu/         |
|            | uscode/html/uscode38/usc_sec_38_00001114----000-.html). |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### d.   | > ***Situation***: The veteran has a                    |
|  Example 2 |                                                         |
| : Rating D | -   100-percent disabling psychiatric condition that    |
| ecision Wi |     does not require A&A, and                           |
| th a Prope |                                                         |
| rly Assign | -   100-percent disabling heart condition that does     |
| ed SMC Hos |     require A&A.                                        |
| pital Code |                                                         |
|            | > ***Result***: Entitlement under [38 U.S.C.            |
|            | > 1114(m)](http://straylight.law.cornell.edu            |
|            | /uscode/html/uscode38/usc_sec_38_00001114----000-.html) |
|            | > is warranted based upon the need for A&A plus an      |
|            | > additional 100-percent disability.                    |
|            | >                                                       |
|            | > ***Coded Conclusion***: The proper                    |
|            |                                                         |
|            | -   basic SMC code is 19, and                           |
|            |                                                         |
|            | -   SMC hospital code is 48 for SMC under [38 U.S.C.    |
|            |     1114(s)](http://straylight.law.cornell.edu/         |
|            | uscode/html/uscode38/usc_sec_38_00001114----000-.html). |
+------------+---------------------------------------------------------+

#### 39. Entitlement to SMC Under 38 U.S.C. 1114(k)

+------------+---------------------------------------------------------+
| ##### In   | > This topic contains information on entitlement to SMC |
| troduction | > under 38 U.S.C. 1114(k), including information on     |
|            |                                                         |
|            | -   the eligibility criteria for SMC under 38 U.S.C.    |
|            |     1114(k)                                             |
|            |                                                         |
|            | -   the history of SMC for loss, or loss (L/LOU) of     |
|            |     use, of creative organ, and                         |
|            |                                                         |
|            | -   awarding SMC for L/LOU of a creative organ          |
|            |                                                         |
|            | -   the basis for considering entitlement to SMC for    |
|            |     L/LOU of a creative organ                           |
|            |                                                         |
|            | -   awarding SMC for L/LOU of a hand or foot            |
|            |                                                         |
|            | -   other medical indications of loss of use of the     |
|            |     foot, and                                           |
|            |                                                         |
|            | -   awarding SMC for                                    |
|            |                                                         |
|            | ```{=html}                                              |
|            | <!-- -->                                                |
|            | ```                                                     |
|            | -   loss of use of both buttocks                        |
|            |                                                         |
|            | -   deafness                                            |
|            |                                                         |
|            | -   aphonia                                             |
|            |                                                         |
|            | -   blindness, and                                      |
|            |                                                         |
|            | -   loss of breast tissue.                              |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### C    | > September 29, 2006                                    |
| hange Date |                                                         |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| #          | > SMC under [38 U.S.C.                                  |
| #### a. El | > 1114(k)](http://straylight.law.cornell.edu            |
| igibility  | /uscode/html/uscode38/usc_sec_38_00001114----000-.html) |
| Criteria f | > is payable for the following levels of impairment:    |
| or SMC Und |                                                         |
| er 38 U.S. | -   loss, or loss (L/LOU) of use, of a creative organ   |
| C. 1114(k) |                                                         |
|            | -   L/LOU of a hand                                     |
|            |                                                         |
|            | -   L/LOU of a foot                                     |
|            |                                                         |
|            | -   loss of use of both buttocks                        |
|            |                                                         |
|            | -   deafness of both ears                               |
|            |                                                         |
|            | -   complete organic aphonia                            |
|            |                                                         |
|            | -   blindness in one eye, having only light perception, |
|            |     and                                                 |
|            |                                                         |
|            | -   loss of tissue from one or both breasts.            |
+------------+---------------------------------------------------------+

Continued on next page

39\. Entitlement to SMC Under 38 U.S.C. 1114(k), Continued

+------------+---------------------------------------------------------+
| ###        | > *Public Law (PL) 82-427*, which went into effect      |
| ## b. Hist | > August 1, 1952, provided for the payment of SMC under |
| ory of SMC | > [38 U.S.C.                                            |
|  for L/LOU | > 1114(k)](http://straylight.law.cornell.edu            |
|  of a Crea | /uscode/html/uscode38/usc_sec_38_00001114----000-.html) |
| tive Organ | > for L/LOU of a creative organ.                        |
|            | >                                                       |
|            | > [38 CFR                                               |
|            | > 3.114(a)](http://w                                    |
|            | ww.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_114.DOC), |
|            | > which provides instructions for assigning effective   |
|            | > dates pursuant to liberalizing law or VA policy,      |
|            | > became effective December 01, 1962. Accordingly, the  |
|            | > proper effective date for granting entitlement to a   |
|            | > veteran who was otherwise eligible for SMC on August  |
|            | > 1, 1952, based on L/LOU of a creative organ, is the   |
|            | > earlier of the following two dates, but no earlier    |
|            | > than December 01, 1962:                               |
|            |                                                         |
|            | -   one year before the date VA received a claim, or    |
|            |                                                         |
|            | -   one year before the date of an administrative       |
|            |     determination of entitlement.                       |
|            |                                                         |
|            | > ***Reference***: For more information on the history  |
|            | > of SMC under [38 U.S.C.                               |
|            | > 1114(k)](http://straylight.law.cornell.edu/           |
|            | uscode/html/uscode38/usc_sec_38_00001114----000-.html), |
|            | > see [M21-1MR, Part IV, Subpart ii,                    |
|            | > 2.I](../pt04_sp02_ch02_secI.xml#IV.ii.2.I).           |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| #          | > Award SMC based on L/LOU of a creative organ, if      |
| #### c. Aw | > medical evidence of records shows                     |
| arding SMC |                                                         |
|  for L/LOU | -   the acquired absence of one or both testicles,      |
|  of a Crea |     ovaries or other creative organs                    |
| tive Organ |                                                         |
|            | -   a condition of the reproductive tract which results |
|            |     in loss of use of a creative organ, such as         |
|            |     retrograde ejaculation or spermatozoa dumping into  |
|            |     the bladder in a male veteran, or                   |
|            |                                                         |
|            | -   the loss of erectile power secondary to a disease   |
|            |     process, such as diabetes or multiple sclerosis, in |
|            |     a male veteran.                                     |
|            |                                                         |
|            | > ***References***: For more information on loss or     |
|            | > loss of use of a creative organ, see                  |
|            |                                                         |
|            | -   [38 CFR                                             |
|            |     3.350(a)(1)](http://                                |
|            | www.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_350.DOC) |
|            |                                                         |
|            | -   [38 CFR 4.115b,                                     |
|            |     Note](http://ww                                     |
|            | w.warms.vba.va.gov/regs/38CFR/BOOKC/PART4/S4_115b.DOC), |
|            |     and                                                 |
|            |                                                         |
|            | -   [38 CFR 4.116, Note                                 |
|            |     2](http://w                                         |
|            | ww.warms.vba.va.gov/regs/38CFR/BOOKC/PART4/S4_116.DOC). |
+------------+---------------------------------------------------------+

Continued on next page

39\. Entitlement to SMC Under 38 U.S.C. 1114(k), Continued

+------------+---------------------------------------------------------+
| ##### d.   | > The issue of entitlement to SMC for L/LOU of a        |
| Basis for  | > creative organ may be                                 |
| Considerin |                                                         |
| g Entitlem | -   based on a specific claim, or                       |
| ent to SMC |                                                         |
|  for L/LOU | -   inferred from the evidence of record, such as a     |
|  of a Crea |     Department of Veterans Affairs (VA) examination or  |
| tive Organ |     hospitalization report.                             |
|            |                                                         |
|            | > Undertake any development necessary, including        |
|            | > submission of a request for a special examination, if |
|            | > there is a reasonable probability of entitlement.     |
|            | >                                                       |
|            | > ***Note***: There is no bar to the payment of         |
|            | > compensation or establishment of SC for anatomical    |
|            | > loss of a creative organ, when a nonservice-connected |
|            | > (NSC) loss of use of a creative organ existed prior   |
|            | > to anatomical loss resulting from service.            |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| #####      | > Award SMC for loss of use of a hand or a foot when    |
|  e. Awardi | > function is no better than if the hand or foot were   |
| ng SMC for | > amputated and replaced by prosthesis.                 |
|  Loss of U | >                                                       |
| se of a Ha | > When considering loss of use, determine whether the   |
| nd or Foot | > following activities could be accomplished equally    |
|            | > well by a prosthesis:                                 |
|            |                                                         |
|            | -   grasping or manipulation (for a hand), and          |
|            |                                                         |
|            | -   balancing, propulsion, or ambulation (for a foot).  |
|            |                                                         |
|            | > ***References***: For more information on L/LOU of a  |
|            | > hand or foot, see                                     |
|            |                                                         |
|            | -   [38 CFR                                             |
|            |     3.350(a)(2)](http://w                               |
|            | ww.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_350.DOC), |
|            |     and                                                 |
|            |                                                         |
|            | -   [38 CFR                                             |
|            |     4.63](http://                                       |
|            | www.warms.vba.va.gov/regs/38CFR/BOOKC/PART4/S4_63.DOC). |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| #          | > Other medical indications of loss of use of the foot  |
| #### f. Ot | > include                                               |
| her Medica |                                                         |
| l Indicati | -   extremely unfavorable complete ankylosis of the     |
| ons of Los |     knee                                                |
| s of Use o |                                                         |
| f the Foot | -   complete ankylosis of two major joints of a lower   |
|            |     extremity                                           |
|            |                                                         |
|            | -   shortening of the lower extremity three and         |
|            |     one-half inches or more, and                        |
|            |                                                         |
|            | -   complete paralysis of the external popliteal        |
|            |     (common peroneal) nerve and consequent foot drop,   |
|            |     accompanied by characteristic organic changes.      |
+------------+---------------------------------------------------------+

Continued on next page

39\. Entitlement to SMC Under 38 U.S.C. 1114(k), Continued

+------------+---------------------------------------------------------+
| ####       | > Award SMC for loss of use of both buttocks when there |
| # g. Award | > is severe damage by disease or injury to muscle group |
| ing SMC fo | > XVII, bilaterally, which renders the veteran unable,  |
| r Loss of  | > without assistance, to                                |
| Use of Bot |                                                         |
| h Buttocks | -   rise from a seated or stooped position, and         |
|            |                                                         |
|            | -   maintain postural stability.                        |
|            |                                                         |
|            | > ***Note***: The "assistance" referred to above        |
|            | > includes the person's own hands or arms, and, for     |
|            | > postural stability, a special appliance.              |
|            | >                                                       |
|            | > ***References***: For more information on loss of use |
|            | > of the buttocks, see                                  |
|            | >                                                       |
|            | > [38 CFR                                               |
|            | > 3.350(a)(3)](http://w                                 |
|            | ww.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_350.DOC). |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ####       | > Award SMC for deafness of both ears, having absence   |
| # h. Award | > of air and bone conduction, if the SC, bilateral      |
| ing SMC fo | > hearing loss warrants a 100-percent evaluation under  |
| r Deafness | > the rating schedule for hearing impairment.           |
|            | >                                                       |
|            | > A veteran with bilateral, service-connected hearing   |
|            | > impairment, numerically designated as XI, is entitled |
|            | > to SMC, regardless of whether or not measurable       |
|            | > hearing impairment was noted on entrance into service |
|            | > and service connection was granted based on           |
|            | > aggravation of a pre-existing disability.             |
|            | >                                                       |
|            | > ***Notes***:                                          |
|            |                                                         |
|            | -   A numeric designation of hearing impairment of      |
|            |                                                         |
|            | ```{=html}                                              |
|            | <!-- -->                                                |
|            | ```                                                     |
|            | -   XI in both ears entitles the veteran to SMC, and    |
|            |                                                         |
|            | -   less than XI in either ear precludes entitlement to |
|            |     SMC.                                                |
|            |                                                         |
|            | ```{=html}                                              |
|            | <!-- -->                                                |
|            | ```                                                     |
|            | -   Base disability ratings *only* on an examination    |
|            |     conducted in a VA-authorized audiology clinic using |
|            |     current testing criteria.                           |
|            |                                                         |
|            | -   Hearing loss justifying an award of SMC must be     |
|            |     permanent in nature.                                |
+------------+---------------------------------------------------------+

Continued on next page

39\. Entitlement to SMC Under 38 U.S.C. 1114(k), Continued

+------------+---------------------------------------------------------+
| ###        | > Award SMC for complete organic aphonia if a           |
| ## i. Awar | > disability of the organs of speech exists that        |
| ding SMC f | > constantly precludes communication by speech and      |
| or Aphonia |                                                         |
|            | -   the veteran is unable to communicate by voice or    |
|            |     whisper through the normal organs of speech, and    |
|            |                                                         |
|            | -   the disability is constant and of organic origin.   |
|            |                                                         |
|            | > ***Notes***:                                          |
|            |                                                         |
|            | -   Complete organic aphonia most frequently results    |
|            |     from loss or paralysis of an organ of speech such   |
|            |     as the tongue or larynx.                            |
|            |                                                         |
|            | -   The use of other organs of the body or prosthetic   |
|            |     devices to provide voice sounds does not preclude   |
|            |     entitlement to SMC.                                 |
|            |                                                         |
|            | -   The assignment of total schedular ratings under DCs |
|            |     6518, 6519, 6520, and 7202 generally entitles the   |
|            |     veteran to SMC.                                     |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| #####      | > Award SMC for loss of use or blindness of one eye,    |
|  j. Awardi | > having light perception only (LPO), when the veteran  |
| ng SMC for | > is unable to                                          |
|  Blindness |                                                         |
|            | -   recognize test letters at one foot, and             |
|            |                                                         |
|            | -   recognize objects, hand movements, or count fingers |
|            |     at a distance of three feet.                        |
|            |                                                         |
|            | > ***Note***: SMC is also payable for the anatomical    |
|            | > loss of an eye.                                       |
+------------+---------------------------------------------------------+

Continued on next page

39\. Entitlement to SMC Under 38 U.S.C. 1114(k), Continued

+------------+---------------------------------------------------------+
| ##### k    | > Entitlement to SMC for loss of tissue from one or     |
| . Awarding | > both breasts is limited to women veterans.            |
|  SMC for L | >                                                       |
| oss of Bre | > *PL 107-330*, enacted December 6, 2002, provides for  |
| ast Tissue | > the payment of SMC                                    |
|            |                                                         |
|            | -   for loss of 25 percent or more of the tissue from a |
|            |     single breast or both breasts in combination        |
|            |     (including loss by mastectomy or partial            |
|            |     mastectomy), or                                     |
|            |                                                         |
|            | -   when breast tissue has been subjected to radiation  |
|            |     treatment.                                          |
|            |                                                         |
|            | > ***Note***: Before enactment of *PL 107-330*,         |
|            | > entitlement to SMC existed only upon complete         |
|            | > surgical removal of breast tissue (or the equivalent  |
|            | > loss of breast tissue due to injury), in which        |
|            | > includes radical mastectomy, modified radical         |
|            | > mastectomy and simple (or total) mastectomy.          |
|            | >                                                       |
|            | > ***Reference***: For more information on entitlement  |
|            | > to SMC for loss of breast tissue, see [38 CFR         |
|            | > 4.116](http://w                                       |
|            | ww.warms.vba.va.gov/regs/38CFR/BOOKC/PART4/S4_116.DOC). |
+------------+---------------------------------------------------------+

#### 40. Additional SMC for Blindness Coupled With Hearing Loss or the Loss, or Loss of Use, (L/LOU) of an Extremity Under 38 CFR 3.350(e)(1) and 38 CFR 3.350(f)(2)

+------------+---------------------------------------------------------+
| ##### In   | > This topic contains information on SMC for blindness  |
| troduction | > and hearing loss under 38 CFR 3.350(e)(1) and 38 CFR  |
|            | > 3.350(f)(2), including information on                 |
|            |                                                         |
|            | -   additional SMC payable for blindness coupled with   |
|            |     hearing loss or the L/LOU of an extremity           |
|            |                                                         |
|            | -   SMC for bilateral blindness and total SC deafness   |
|            |     in one ear                                          |
|            |                                                         |
|            | -   examples of rating decisions involving SMC for      |
|            |     bilateral blindness and total SC deafness in one    |
|            |     ear                                                 |
|            |                                                         |
|            | -   SMC for bilateral blindness with bilateral hearing  |
|            |     loss considered 10- or 20-percent disabling         |
|            |                                                         |
|            | -   examples of rating decisions involving SMC for      |
|            |     bilateral blindness with bilateral hearing loss     |
|            |     considered 10- or 20-percent disabling              |
|            |                                                         |
|            | -   SMC for bilateral blindness with bilateral hearing  |
|            |     loss considered 30-percent disabling                |
|            |                                                         |
|            | -   an example of a rating decision involving SMC for   |
|            |     bilateral blindness with bilateral hearing loss     |
|            |     considered 30-percent disabling                     |
|            |                                                         |
|            | -   SMC for bilateral blindness with bilateral hearing  |
|            |     loss considered 40-percent disabling                |
|            |                                                         |
|            | -   examples of rating decisions involving SMC for      |
|            |     bilateral blindness with bilateral hearing loss     |
|            |     considered 40-percent disabling                     |
|            |                                                         |
|            | -   SMC for bilateral blindness with bilateral hearing  |
|            |     loss considered 60-percent disabling                |
|            |                                                         |
|            | -   an example of a rating decision involving SMC for   |
|            |     bilateral blindness with bilateral hearing loss     |
|            |     considered 60-percent disabling                     |
|            |                                                         |
|            | -   SMC for bilateral blindness with L/LOU of any       |
|            |     extremity considered at least 50 percent disabling  |
|            |                                                         |
|            | -   an example of a rating decision involving SMC for   |
|            |     bilateral blindness with L/LOU of any extremity     |
|            |     considered at least 50 percent disabling.           |
|            |                                                         |
|            | -   SMC for bilateral blindness with L/LOU of a lower   |
|            |     extremity considered less than 50 percent           |
|            |     disabling, and                                      |
|            |                                                         |
|            | -   an example of a rating decision involving SMC for   |
|            |     bilateral blindness with L/LOU of a lower extremity |
|            |     considered less than 50 percent disabling.          |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### C    | > December 13, 2005                                     |
| hange Date |                                                         |
+------------+---------------------------------------------------------+

Continued on next page

40\. Additional SMC for Blindness Coupled With Hearing Loss or the Loss,
or Loss of Use, (L/LOU) of an Extremity Under 38 CFR 3.350(e)(1) and 38
CFR 3.350(f)(2), Continued

+------------+---------------------------------------------------------+
| ####       | > Additional SMC is payable to veterans with bilateral  |
| # a. Gener | > blindness who are already entitled to SMC under [38   |
| al Criteri | > U.S.C. 1114(1) through                                |
| a for Enti | > (n)](http://straylight.law.cornell.edu                |
| tlement to | /uscode/html/uscode38/usc_sec_38_00001114----000-.html) |
|  Additiona | > who also have varying degrees of SC hearing loss or   |
| l SMC for  | > SC L/LOU of an extremity.                             |
| Blindness  |                                                         |
| Coupled Wi |                                                         |
| th Hearing |                                                         |
|  Loss or L |                                                         |
| /LOU of an |                                                         |
|  Extremity |                                                         |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| #          | > A veteran with total SC deafness in one ear, such as  |
| #### b. To | > that numerically designated as "XI," and SC blindness |
| tal SC Dea | > with                                                  |
| fness in O |                                                         |
| ne Ear and | -   LPO or less, bilaterally, is entitled to SMC under  |
|  Bilateral |     [38                                                 |
|  Blindness |     U.S.C.1114(o)](http://straylight.law.cornell.edu    |
|            | /uscode/html/uscode38/usc_sec_38_00001114----000-.html) |
|            |     and [38 CFR                                         |
|            |     3.350(e)(1)(iv)](http://w                           |
|            | ww.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_350.DOC), |
|            |     or                                                  |
|            |                                                         |
|            | -   visual acuity of 5/200 (1.5/60) or less             |
|            |     bilaterally, is entitled to an additional half-step |
|            |     in the level of SMC, under the provisions of [38    |
|            |     CFR                                                 |
|            |     3.350(f)(2)(iv)](http://w                           |
|            | ww.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_350.DOC). |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| #####      | > ***Situation***: The veteran has                      |
| c. Example |                                                         |
|  1: Rating | -   bilateral SC blindness with LPO, and                |
|  for Total |                                                         |
|  SC Deafne | -   total SC hearing loss in the left ear.              |
| ss in One  |                                                         |
| Ear and SC | > ***Result***: Since the veteran has LPO bilaterally,  |
|  Blindness | > and total SC loss of hearing in the left ear,         |
|            | > entitlement to SMC is warranted under                 |
|            |                                                         |
|            | -   [38 U.S.C.                                          |
|            |     1114(o)](http://straylight.law.cornell.edu          |
|            | /uscode/html/uscode38/usc_sec_38_00001114----000-.html) |
|            |                                                         |
|            | -   [38 CFR                                             |
|            |     3.350(e)(1)(iv)](http://w                           |
|            | ww.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_350.DOC), |
|            |     and                                                 |
|            |                                                         |
|            | -   [38 U.S.C. 1114                                     |
|            |     (r)(1)](http://straylight.law.cornell.edu/          |
|            | uscode/html/uscode38/usc_sec_38_00001114----000-.html). |
|            |                                                         |
|            | > ***Coded Conclusion***:                               |
|            |                                                         |
|            | -   The appropriate SMC paragraph code is OB-2.         |
|            |                                                         |
|            | -   The appropriate SMC coding is 55-37-22-00-0.        |
+------------+---------------------------------------------------------+

Continued on next page

40\. Additional SMC for Blindness Coupled With Hearing Loss or the Loss,
or Loss of Use, (L/LOU) of an Extremity Under 38 CFR 3.350(e)(1) and 38
CFR 3.350(f)(2), Continued

+------------+---------------------------------------------------------+
| ##         | > ***Situation***: The veteran has                      |
| ### d. Exa |                                                         |
| mple 2: Ra | -   bilateral SC blindness with                         |
| ting Total |                                                         |
|  SC Deafne | ```{=html}                                              |
| ss in One  | <!-- -->                                                |
| Ear and SC | ```                                                     |
|  Blindness | -   no light perception in the left eye, and            |
|            |                                                         |
|            | -   visual acuity of 5/200 (1.5/60) in the right eye,   |
|            |     and                                                 |
|            |                                                         |
|            | ```{=html}                                              |
|            | <!-- -->                                                |
|            | ```                                                     |
|            | -   total SC hearing loss in the left ear.              |
|            |                                                         |
|            | > ***Result***: The veteran is entitled to SMC under    |
|            | > [38 U.S.C.                                            |
|            | > 1114(m)](http://straylight.law.cornell.edu            |
|            | /uscode/html/uscode38/usc_sec_38_00001114----000-.html) |
|            | > for the degree of bilateral blindness alone, but an   |
|            | > additional one-half step in the level of SMC ("m½")   |
|            | > is warranted, based on the degree of hearing loss,    |
|            | > under the provisions of [38 CFR                       |
|            | > 3.350(f)(2)(iv)](http://w                             |
|            | ww.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_350.DOC). |
|            | >                                                       |
|            | > ***Coded Conclusion***:                               |
|            |                                                         |
|            | -   The appropriate SMC paragraph code is PB-1.         |
|            |                                                         |
|            | -   The appropriate SMC coding is 20-20-22-00-0.        |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| #####      | > A veteran is entitled to an additional one-half step  |
|  e. Bilate | > in the level of SMC under [38 CFR                     |
| ral Blindn | > 3.350(f)(2)(v)](http://                               |
| ess with B | www.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_350.DOC) |
| ilateral H | > if he/she has                                         |
| earing Los |                                                         |
| s Consider | -   SC bilateral blindness with LPO or less             |
| ed 10- or  |                                                         |
| 20-Percent | -   bilateral hearing loss, considered 10-or 20-percent |
|  Disabling |     disabling, and                                      |
|            |                                                         |
|            | -   SC hearing loss in at least one ear.                |
|            |                                                         |
|            | > ***Note***: If visual acuity in either of the eyes is |
|            | > better than LPO, entitlement to the additional        |
|            | > one-half step does not exist.                         |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ###        | > ***Situation***: The veteran has                      |
| ## f. Exam |                                                         |
| ple 1: Rat | -   anatomical loss of the left eye                     |
| ing Bilate |                                                         |
| ral Blindn | -   LPO in the right eye                                |
| ess with B |                                                         |
| ilateral H | -   bilateral hearing loss, considered 20-percent       |
| earing Los |     disabling, and                                      |
| s Consider |                                                         |
| ed 10- or  | -   SC hearing loss in the right ear.                   |
| 20-Percent |                                                         |
|  Disabling | > ***Result***: The appropriate level of SMC for the    |
|            | > degree of blindness alone is "m½." However, an        |
|            | > additional one-half step is warranted based on the    |
|            | > degree of hearing loss, making the veteran entitled   |
|            | > to SMC under [38 U.S.C.                               |
|            | > 1114(n)](http://straylight.law.cornell.edu/           |
|            | uscode/html/uscode38/usc_sec_38_00001114----000-.html). |
|            | >                                                       |
|            | > ***Coded Conclusion***:                               |
|            |                                                         |
|            | -   The appropriate SMC paragraph code is PB-2.         |
|            |                                                         |
|            | -   The appropriate SMC coding is 21-21-11-11-0.        |
+------------+---------------------------------------------------------+

Continued on next page

40\. Additional SMC for Blindness Coupled With Hearing Loss or the Loss,
or Loss of Use, (L/LOU) of an Extremity Under 38 CFR 3.350(e)(1) and 38
CFR 3.350(f)(2), Continued

+------------+---------------------------------------------------------+
| ###        | > ***Situation***: The veteran has                      |
| ## g. Exam |                                                         |
| ple 2: Rat | -   anatomical loss of the left eye                     |
| ing Blindn |                                                         |
| ess With B | -   visual acuity of 5/200 (1.5/60) in the right eye    |
| ilateral H |                                                         |
| earing Los | -   bilateral hearing loss, considered 20-percent       |
| s Consider |     disabling, and                                      |
| ed 10- or  |                                                         |
| 20-Percent | -   SC hearing loss in the right ear.                   |
|  Disabling |                                                         |
|            | > ***Result***: Since visual acuity in the right eye is |
|            | > better than LPO, do not apply [38 CFR                 |
|            | > 3.350(f)(2)(v)](http://w                              |
|            | ww.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_350.DOC). |
|            | > The veteran is entitled to SMC under [38 U.S.C.       |
|            | > 1114(m)](http://straylight.law.cornell.edu/           |
|            | uscode/html/uscode38/usc_sec_38_00001114----000-.html). |
|            | >                                                       |
|            | > ***Coded Conclusion***:                               |
|            |                                                         |
|            | -   The appropriate SMC paragraph code is MB-2.         |
|            |                                                         |
|            | -   The appropriate SMC coding is 19-19-11-11-0.        |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### h.   | > A veteran is entitled to an additional full step in   |
|  Bilateral | > the level of SMC, not to exceed that provided by [38  |
|  Blindness | > U.S.C.                                                |
|  With Hear | > 1114(o)](http://straylight.law.cornell.edu            |
| ing Loss C | /uscode/html/uscode38/usc_sec_38_00001114----000-.html) |
| onsidered  | > and [38 CFR                                           |
| 30-Percent | > 3.350(f)(2)(vi)](http://w                             |
|  Disabling | ww.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_350.DOC), |
|            | > if he/she has                                         |
|            |                                                         |
|            | -   visual acuity of 5/200 (1.5/60) or less,            |
|            |     bilaterally                                         |
|            |                                                         |
|            | -   bilateral hearing loss, considered 30 percent       |
|            |     disabling, and                                      |
|            |                                                         |
|            | -   SC hearing loss in one ear.                         |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ####       | > ***Situation***: The veteran has                      |
| # i. Examp |                                                         |
| le: Rating | -   anatomical loss of the left eye                     |
|  Bilateral |                                                         |
|  Blindness | -   visual acuity of 5/200 (1.5/60) in the right eye    |
|  With Hear |                                                         |
| ing Loss C | -   bilateral hearing loss, considered 30 percent       |
| onsidered  |     disabling, and                                      |
| 30-Percent |                                                         |
|  Disabling | -   SC hearing loss in the right ear.                   |
|            |                                                         |
|            | > ***Result***: The veteran is entitled to SMC under    |
|            | > the provisions of [38 U.S.C.                          |
|            | > 1114(m)](http://straylight.law.cornell.edu            |
|            | /uscode/html/uscode38/usc_sec_38_00001114----000-.html) |
|            | > for the degree of blindness alone. However, an        |
|            | > additional full step is warranted under the           |
|            | > provisions of [38 CFR                                 |
|            | > 3.350(f)(2)(vi)](http://w                             |
|            | ww.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_350.DOC), |
|            | > thereby entitling the veteran to SMC under [38 U.S.C. |
|            | > 1114(n)](http://straylight.law.cornell.edu/           |
|            | uscode/html/uscode38/usc_sec_38_00001114----000-.html). |
|            | >                                                       |
|            | > ***Coded Conclusion***:                               |
|            |                                                         |
|            | -   The appropriate SMC paragraph code is PB-3.         |
|            |                                                         |
|            | -   The appropriate SMC coding is 21-21-11-11-0.        |
+------------+---------------------------------------------------------+

Continued on next page

40\. Additional SMC for Blindness Coupled With Hearing Loss or the Loss,
or Loss of Use, (L/LOU) of an Extremity Under 38 CFR 3.350(e)(1) and 38
CFR 3.350(f)(2), Continued

+------------+---------------------------------------------------------+
| ##### j.   | > A veteran is entitled to SMC under [38 U.S.C.         |
| Bilateral  | > 1114(o)](http://straylight.law.cornell.edu            |
| Blindness  | /uscode/html/uscode38/usc_sec_38_00001114----000-.html) |
| With Hearl | > and [38 CFR                                           |
| ing Loss C | > 3.350(e)(1)(iv)](http://                              |
| onsidered  | www.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_350.DOC) |
| 40-Percent | > if he/she has                                         |
|  Disabling |                                                         |
|            | -   blindness with LPO or less in both eyes             |
|            |                                                         |
|            | -   bilateral hearing, considered 40 percent disabling, |
|            |     and                                                 |
|            |                                                         |
|            | -   SC hearing loss in one ear.                         |
|            |                                                         |
|            | > ***Note***: If bilateral blindness is present, but    |
|            | > visual acuity in either eye is better than LPO, the   |
|            | > veteran is entitled to an additional full step only   |
|            | > in the level of SMC, not to exceed that provided by   |
|            | > [38 U.S.C.                                            |
|            | > 1114(o)](http://straylight.law.cornell.edu/           |
|            | uscode/html/uscode38/usc_sec_38_00001114----000-.html), |
|            | > per [38 CFR                                           |
|            | > 3.350(f)(2)(vi)](http://w                             |
|            | ww.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_350.DOC). |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| #####      | > ***Situation***: The veteran has                      |
| k. Example |                                                         |
|  1: Rating | -   no light perception in the right eye                |
|  Bilateral |                                                         |
|  Blindness | -   LPO in the left eye                                 |
|  with Bila |                                                         |
| teral Hear | -   bilateral hearing loss, considered 40 percent       |
| ing Loss C |     disabling, and                                      |
| onsidered  |                                                         |
| 40-Percent | -   SC hearing loss in the right ear.                   |
|  Disabling |                                                         |
|            | > ***Result***: The appropriate level of SMC for the    |
|            | > degree of bilateral blindness alone is "m½." However, |
|            | > apply [38 CFR                                         |
|            | > 3.350(e)(1)(iv)](http://                              |
|            | www.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_350.DOC) |
|            | > because of the coexisting hearing loss. The veteran   |
|            | > is accordingly entitled to SMC under [38 U.S.C.       |
|            | > 1114(o)](http://straylight.law.cornell.edu            |
|            | /uscode/html/uscode38/usc_sec_38_00001114----000-.html) |
|            | > and [38 U.S.C.                                        |
|            | > 1114(r)(1)](http://straylight.law.cornell.edu/        |
|            | uscode/html/uscode38/usc_sec_38_00001114----000-.html). |
|            | >                                                       |
|            | > ***Coded Conclusion***:                               |
|            |                                                         |
|            | -   The appropriate SMC paragraph code is OB-2.         |
|            |                                                         |
|            | -   The appropriate SMC coding is 55-37-22-00-0.        |
+------------+---------------------------------------------------------+

Continued on next page

40\. Additional SMC for Blindness Coupled With Hearing Loss or the Loss,
or Loss of Use, (L/LOU) of an Extremity Under 38 CFR 3.350(e)(1) and 38
CFR 3.350(f)(2), Continued

+------------+---------------------------------------------------------+
| #####      | > ***Situation***: The veteran has                      |
| l. Example |                                                         |
|  2: Rating | -   no light perception in the right eye                |
|  Bilateral |                                                         |
|  Blindness | -   visual acuity of 5/200 (1.5/60) in the left eye     |
|  with Bila |                                                         |
| teral Hear | -   bilateral hearing loss, considered 40 percent       |
| ing Loss C |     disabling, and                                      |
| onsidered  |                                                         |
| 40-Percent | -   SC hearing loss in one ear.                         |
|  Disabling |                                                         |
|            | > ***Result***: The veteran is entitled to SMC under    |
|            | > [38 U.S.C.                                            |
|            | > 1114(m)](http://straylight.law.cornell.edu            |
|            | /uscode/html/uscode38/usc_sec_38_00001114----000-.html) |
|            | > for the degree of bilateral blindness alone. However, |
|            | > because of the degree of hearing loss present,        |
|            | > increase the level of SMC by a full step under the    |
|            | > provisions of [38 CFR                                 |
|            | > 3.350(f)(2)(vi)](http://                              |
|            | www.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_350.DOC) |
|            | > and award SMC under [38 U.S.C.                        |
|            | > 1114(n)](http://straylight.law.cornell.edu/           |
|            | uscode/html/uscode38/usc_sec_38_00001114----000-.html). |
|            | >                                                       |
|            | > ***Coded Conclusion***:                               |
|            |                                                         |
|            | -   The appropriate SMC paragraph code is PB-3.         |
|            |                                                         |
|            | -   The appropriate SMC coding is 21-21-22-00-0.        |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### m.   | > A veteran is entitled to SMC under [38 U.S.C.         |
|  Bilateral | > 1114(o)](http://straylight.law.cornell.edu            |
|  Blindness | /uscode/html/uscode38/usc_sec_38_00001114----000-.html) |
|  With Hear | > and [38 CFR                                           |
| ing Loss C | > 3.350(e)(1)(iii)](http://                             |
| onsidered  | www.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_350.DOC) |
| 60-Percent | > if he/she has                                         |
|  Disabling |                                                         |
|            | -   visual acuity of 5/200 (1.5/60), bilaterally, or    |
|            |                                                         |
|            | -   visual acuity of 5/200 (1.5/60) in one eye and LPO  |
|            |     or less in the other eye LPO, and                   |
|            |                                                         |
|            | -   bilateral hearing loss, considered 60 percent       |
|            |     disabling, and                                      |
|            |                                                         |
|            | -   SC hearing loss in one ear.                         |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ####       | > ***Situation***: The veteran has                      |
| # n. Examp |                                                         |
| le: Rating | -   LPO in the right eye                                |
|  Bilateral |                                                         |
|  Blindness | -   visual acuity of 5/200 (1.5/60) in the left eye     |
|  With Bila |                                                         |
| teral Hear | -   bilateral hearing loss, considered 60 percent       |
| ing Loss C |     disabling, and                                      |
| onsidered  |                                                         |
| 60-Percent | -   SC hearing loss in one ear.                         |
|  Disabling |                                                         |
|            | > ***Result***: Due to the coexisting blindness and     |
|            | > hearing loss, the veteran is entitled to SMC under    |
|            | > [38 U.S.C.                                            |
|            | > 1114(o)](http://straylight.law.cornell.edu            |
|            | /uscode/html/uscode38/usc_sec_38_00001114----000-.html) |
|            | > and [38 U.S.C.                                        |
|            | > 1114(r)(1).](http://straylight.law.cornell.edu        |
|            | /uscode/html/uscode38/usc_sec_38_00001114----000-.html) |
|            | >                                                       |
|            | > ***Coded Conclusion***:                               |
|            |                                                         |
|            | -   The appropriate SMC paragraph code is OB-1.         |
|            |                                                         |
|            | -   The appropriate SMC coding is 55-37-22-00-0.        |
+------------+---------------------------------------------------------+

Continued on next page

40\. Additional SMC for Blindness Coupled With Hearing Loss or the Loss,
or Loss of Use, (L/LOU) of an Extremity Under 38 CFR 3.350(e)(1) and 38
CFR 3.350(f)(2), Continued

+------------+---------------------------------------------------------+
| ##### o    | > The provisions of [38 CFR                             |
| . Bilatera | > 3.350(f)(2)(vii)(A)](http://                          |
| l Blindnes | www.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_350.DOC) |
| s With L/L | > and                                                   |
| OU of Any  | >                                                       |
| Extremity  | > [38 CFR                                               |
| Considered | > 3.350(f)(2)(vii)(B)](http://                          |
|  at Least  | www.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_350.DOC) |
| 50 Percent | > allow for an additional full step of SMC, not to      |
|  Disabling | > exceed entitlement under [38 U.S.C.                   |
|            | > 1114(o)](http://straylight.law.cornell.edu/           |
|            | uscode/html/uscode38/usc_sec_38_00001114----000-.html), |
|            | > if the veteran has                                    |
|            |                                                         |
|            | -   visual acuity of 5/200 (1.5/60) or less,            |
|            |     bilaterally, and                                    |
|            |                                                         |
|            | -   SC L/LOU of an upper or lower extremity, which by   |
|            |     itself or in combination with another compensable   |
|            |     disability is considered at least 50 percent        |
|            |     disabling.                                          |
|            |                                                         |
|            | > ***Note***: Payment of this additional full step of   |
|            | > SMC is in addition to the SMC payable under [38 CFR   |
|            | > 3.350(a)](http://w                                    |
|            | ww.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_350.DOC). |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##         | > ***Situation***: The veteran has                      |
| ### p. Exa |                                                         |
| mple: Rati | -   SC bilateral blindness with visual acuity of 5/200  |
| ng Bilater |     (1.5/60), and                                       |
| al Blindne |                                                         |
| ss With L/ | -   loss of use of the right hand.                      |
| LOU of an  |                                                         |
| Extremity  | > ***Result***: The veteran is entitled to SMCunder [38 |
| Considered | > U.S.C.                                                |
|  at Least  | > 1114(1)](http://straylight.law.cornell.edu            |
| 50 Percent | /uscode/html/uscode38/usc_sec_38_00001114----000-.html) |
|  Disabling | > for the degree of blindness alone. The veteran is     |
|            | > also entitled to an additional full step of SMC, plus |
|            | > SMC under [38 CFR                                     |
|            | > 3.350(a)](http://w                                    |
|            | ww.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_350.DOC), |
|            | > for loss of use of the right hand. Accordingly, the   |
|            | > appropriate level of SMC is "m+k."                    |
|            | >                                                       |
|            | > ***Coded Conclusion***:                               |
|            |                                                         |
|            | -   The appropriate SMC paragraph code is PB-4.         |
|            |                                                         |
|            | -   The appropriate SMC coding is 25-25-35-00-0.        |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##         | > A veteran is entitled to an additional one-half step  |
| ### q. Bil | > of SMC under [38 CFR                                  |
| ateral Bli | > 3.350(f)(2)(vii)(C)](http://                          |
| ndness Wit | www.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_350.DOC) |
| h L/LOU of | > if he/she has                                         |
|  a Lower E |                                                         |
| xtremity C | -   visual acuity of 5/200 (1.5/60) or less,            |
| onsidered  |     bilaterally                                         |
| Less Than  |                                                         |
| 50 Percent | -   L/LOU of a foot, considered less than 50 percent    |
|  Disabling |     disabling, and                                      |
|            |                                                         |
|            | -   no other compensable SC disability.                 |
|            |                                                         |
|            | > ***Note***: The level of SMC may not exceed that      |
|            | > provided by [38 U.S.C.                                |
|            | > 1114(o)](http://straylight.law.cornell.edu/           |
|            | uscode/html/uscode38/usc_sec_38_00001114----000-.html). |
+------------+---------------------------------------------------------+

Continued on next page

40\. Additional SMC for Blindness Coupled With Hearing Loss or the Loss,
or Loss of Use, (L/LOU) of an Extremity Under 38 CFR 3.350(e)(1) and 38
CFR 3.350(f)(2), Continued

+------------+---------------------------------------------------------+
| ##### r.   | > ***Situation***: The veteran has                      |
|  Example:  |                                                         |
| Rating Bil | -   visual acuity of 5/200 (1.5/60), bilaterally,       |
| ateral Bli |                                                         |
| ndness Wit | -   a below-the-knee amputation of the right foot       |
| h L/LOU of |     considered 40 percent disabling, and                |
|  a Lower E |                                                         |
| xtremity C | -   no other compensable disabilities.                  |
| onsidered  |                                                         |
| Less Than  | > ***Result***: The veteran is entitled to SMC under    |
| 50 Percent | > [38 U.S.C.                                            |
|  Disabling | > 1114(l)](http://straylight.law.cornell.edu            |
|            | /uscode/html/uscode38/usc_sec_38_00001114----000-.html) |
|            | > based on the degree of blindness alone. The veteran   |
|            | > is also entitled to SMC under [38 U.S.C.              |
|            | > 1114(k)](http://straylight.law.cornell.edu            |
|            | /uscode/html/uscode38/usc_sec_38_00001114----000-.html) |
|            | > for loss of the right foot. The appropriate level of  |
|            | > SMC, therefore, is "l+k." Award an additional         |
|            | > one-half step of SMC (l½+k) under the provisions of   |
|            | > [38 CFR                                               |
|            | > 3.350(f)(2)(vii)(C)](http://w                         |
|            | ww.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_350.DOC). |
|            | >                                                       |
|            | > ***Coded Conclusion***:                               |
|            |                                                         |
|            | -   The appropriate SMC paragraph code is PB-6.         |
|            |                                                         |
|            | -   The appropriate SMC coding is 18-18-21-13-0.        |
+------------+---------------------------------------------------------+

#### 41. SMC for Additional 50- and 100-Percent Evaluations Under 38 CFR 3.350(f)(3) and 38 CFR 3.350(f)(4)

+------------+---------------------------------------------------------+
| ##### In   | > This topic contains information on SMC for additional |
| troduction | > 50- and 100-percent evaluations under 38 CFR          |
|            | > 3.350(f)(3) and 38 CFR 3.350(f)(4), including         |
|            | > information on                                        |
|            |                                                         |
|            | -   the proper application of 38 CFR 3.350(f)(3) and 38 |
|            |     CFR 3.350(f)(4)                                     |
|            |                                                         |
|            | -   SMC under 38 CFR 3.350(f)(3)                        |
|            |                                                         |
|            | -   SMC under 38 CFR 3.350(f)(4), and                   |
|            |                                                         |
|            | -   examples of rating decisions addressing the issue   |
|            |     of entitlement to SMC under 38 CFR 3.350(f)(3) and  |
|            |     38 CFR 3.350(f)(4).                                 |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### C    | > September 29, 2006                                    |
| hange Date |                                                         |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##         | > Apply the provisions of [38 CFR                       |
| ### a. Pro | > 3.350(f)(3)](http://                                  |
| per Applic | www.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_350.DOC) |
| ation of 3 | > or [38 CFR                                            |
| 8 CFR 3.35 | > 3.350(f)(4)](http://w                                 |
| 0(f)(3) an | ww.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_350.DOC), |
| d 38 CFR 3 | > whichever is appropriate, only once in a rating       |
| .350(f)(4) | > decision.                                             |
|            | >                                                       |
|            | > ***Important***: Concurrent entitlement to SMC under  |
|            | > both [38 CFR                                          |
|            | > 3.350(f)(3)](http://                                  |
|            | www.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_350.DOC) |
|            | > and [38 CFR                                           |
|            | > 3.350(f)(4)](http://                                  |
|            | www.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_350.DOC) |
|            | > is prohibited.                                        |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### b    | > A veteran entitled to SMC under [38 U.S.C. 1114(l)    |
| . SMC Unde | > through                                               |
| r 38 CFR 3 | > (n)](http://straylight.law.cornell.edu                |
| .350(f)(3) | /uscode/html/uscode38/usc_sec_38_00001114----000-.html) |
|            | > is entitled to the next higher intermediate rate of   |
|            | > SMC under the provisions of [38 CFR                   |
|            | > 3.350(f)(3)](http://                                  |
|            | www.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_350.DOC) |
|            | > if he/she has an additional single disability, or a   |
|            | > combination of disabilities, that is independently    |
|            | > ratable as 50 percent or more disabling.              |
|            | >                                                       |
|            | > ***Note***: For the purpose of [38 CFR                |
|            | > 3.350(f)(3)](http://w                                 |
|            | ww.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_350.DOC), |
|            | > define a single disability in accordance with [38 CFR |
|            | > 4.16](http://                                         |
|            | www.warms.vba.va.gov/regs/38CFR/BOOKC/PART4/S4_16.DOC). |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### c    | > A veteran who is entitled to SMC under [38 U.S.C.     |
| . SMC Unde | > 1114(l) through                                       |
| r 38 CFR 3 | > (n)](http://straylight.law.cornell.edu/               |
| .350(f)(4) | uscode/html/uscode38/usc_sec_38_00001114----000-.html), |
|            | > is entitled to the next higher statutory rate if      |
|            | > he/she has an additional single permanent disability  |
|            | > that is independently ratable as 100 percent          |
|            | > disabling, apart from any consideration of individual |
|            | > unemployability.                                      |
|            | >                                                       |
|            | > ***Note***: For the purpose of [38 CFR                |
|            | > 3.350(f)(4)](http://w                                 |
|            | ww.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_350.DOC), |
|            | > define a single disability in accordance with [38 CFR |
|            | > 4.16](http://                                         |
|            | www.warms.vba.va.gov/regs/38CFR/BOOKC/PART4/S4_16.DOC). |
+------------+---------------------------------------------------------+

Continued on next page

41\. SMC for Additional 50- and 100-Percent Evaluations Under 38 CFR
3.350(f)(3) and 38 CFR 3.350(f)(4), Continued

+------------+---------------------------------------------------------+
| ##### d    | > ***Situation***: The veteran has SC disabilities as   |
| . Example  | > shown below and qualifies for                         |
| 1: Rating  |                                                         |
| Decision I | -   SMC under [38 U.S.C.                                |
| nvolving S |     1114(m)](http://straylight.law.cornell.edu          |
| MC Under 3 | /uscode/html/uscode38/usc_sec_38_00001114----000-.html) |
| 8 CFR 3.35 |     on account of the anatomical loss of both hands,    |
| 0(f)(3) an |     and                                                 |
| d 38 CFR 3 |                                                         |
| .350(f)(4) | -   two disabilities (anatomical loss of one eye and    |
|            |     loss of a creative organ) that each qualify for SMC |
|            |     under [38 U.S.C.                                    |
|            |     1114(k)](http://straylight.law.cornell.edu/         |
|            | uscode/html/uscode38/usc_sec_38_00001114----000-.html). |
|            |                                                         |
|            | > ***Result***: As provided in [38 CFR                  |
|            | > 3.350(f)(3)](http://w                                 |
|            | ww.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_350.DOC), |
|            | > in addition to and independent of the disability for  |
|            | > which SMC is payable under [38 U.S.C.                 |
|            | > 1114(m)](http://straylight.law.cornell.edu/           |
|            | uscode/html/uscode38/usc_sec_38_00001114----000-.html), |
|            | > the following permanent disabilities (considered a    |
|            | > single disability under the provisions of [38 CFR     |
|            | > 4.16](http://                                         |
|            | www.warms.vba.va.gov/regs/38CFR/BOOKC/PART4/S4_16.DOC)) |
|            | > exist that are independently ratable as 50 percent    |
|            | > disabling:                                            |
|            |                                                         |
|            | -   enucleation of the right eye, considered 40 percent |
|            |     disabling, and                                      |
|            |                                                         |
|            | -   loss of the left testis, considered 10 percent      |
|            |     disabling.                                          |
|            |                                                         |
|            | > Accordingly, the requirements of [38 CFR              |
|            | > 3.350(f)(3)](http://                                  |
|            | www.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_350.DOC) |
|            | > are met for the rate intermediate between [38 U.S.C.  |
|            | > 1114(m)](http://straylight.law.cornell.edu            |
|            | /uscode/html/uscode38/usc_sec_38_00001114----000-.html) |
|            | > and [38 U.S.C.                                        |
|            | > 1114(n)](http://straylight.law.cornell.edu/           |
|            | uscode/html/uscode38/usc_sec_38_00001114----000-.html), |
|            | > plus two rates under [38 U.S.C.                       |
|            | > 1114(k)](http://straylight.law.cornell.edu/           |
|            | uscode/html/uscode38/usc_sec_38_00001114----000-.html). |
|            | >                                                       |
|            | > ***Coded Conclusion***:                               |
|            |                                                         |
|            | 5016. AMPUTATION, BOTH HANDS AT WRIST                   |
|            |                                                         |
|            | > 100 percent from 02/01/1996.                          |
|            |                                                         |
|            | 6066. ENUCLEATION, RIGHT EYE, LEFT 20/20                |
|            |                                                         |
|            | > 40 percent from 02/01/1996.                           |
|            |                                                         |
|            | 7524. REMOVAL OF LEFT TESTIS                            |
|            |                                                         |
|            | > 10 percent from 02/01/1996.                           |
|            | >                                                       |
|            | > *COMBINED EVALUATION FOR COMPENSATION*:               |
|            | >                                                       |
|            | > 100 percent from 02/01/1996.                          |
|            | >                                                       |
|            | > K-1 Entitled to SMC under 38 U.S.C. 1114(k) and 38    |
|            | > CFR 3.350(a) on account of anatomical loss of one eye |
|            | > from 02/01/1996.                                      |
|            | >                                                       |
|            | > K-1 Entitled to SMC under 38 U.S.C. 1114(k) and 38    |
|            | > CFR 3.350(a) on account of anatomical loss of a       |
|            | > creative organ from 02/01/1996.                       |
|            | >                                                       |
|            | > M-2 Entitled to SMC under 38 U.S.C. 1114(m) and 38    |
|            | > CFR 3.350(c) on account of anatomical loss of both    |
|            | > hands from 02/01/1996.                                |
+------------+---------------------------------------------------------+

Continued on next page

41\. SMC for Additional 50- and 100-Percent Evaluations Under 38 CFR
3.350(f)(3) and 38 CFR 3.350(f)(4), Continued

+------------+---------------------------------------------------------+
| d\.        | > P-1 Entitled to SMC under 38 U.S.C. 1114(p) and 38    |
| Example 1: | > CFR 3.350(f)(3) at the rate intermediate between 38   |
| Rating     | > U.S.C. 1114(m) and 38 U.S.C. 1114(n) on account of    |
| Decision   | > anatomical loss of both hands with additional         |
| Involving  | > disabilities of enucleation, right eye, and removal   |
| SMC Under  | > of left testis independently ratable as 50 percent    |
| 38 CFR     | > disablingor more from 02/01/1996.                     |
| 3          | >                                                       |
| .350(f)(3) | > ***Note***: The appropriate SMC coding is             |
| and 38 CFR | > 31-31-00-33-1.                                        |
| 3          |                                                         |
| .350(f)(4) |                                                         |
| (          |                                                         |
| continued) |                                                         |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| #####      | > ***Situation***: The veteran has the SC disabilities  |
| e. Example | > shown below and loss of use of both lower extremities |
|  2: Rating | > that meet the requirements for SMC under [38 U.S.C.   |
|  Decision  | > 1114(m)](http://straylight.law.cornell.edu/           |
| Involving  | uscode/html/uscode38/usc_sec_38_00001114----000-.html). |
| SMC Under  | > Completely independent of the loss of use of both     |
| 38 CFR 3.3 | > lower extremities, the combined evaluation for the    |
| 50(f)(3) a | > remaining disabilities is 100 percent.                |
| nd 38 CFR  | >                                                       |
| 3.350(f)(4 | > ***Result***: As provided in [38 CFR                  |
|            | > 4.16](http:/                                          |
|            | /www.warms.vba.va.gov/regs/38CFR/BOOKC/PART4/S4_16.DOC) |
|            | > of the rating schedule, the latter disabilities       |
|            | > result from a common etiology (rheumatoid arthritis)  |
|            | > and meet the requirement of [38 CFR                   |
|            | > 3.350(f)(4)](http://                                  |
|            | www.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_350.DOC) |
|            | > for an additional, single, permanent disability that  |
|            | > is independently ratable as 100 percent disabling.    |
|            | > There is no prohibition against using the 40 percent  |
|            | > evaluation for enucleation of the left eye in         |
|            | > combination with the other disabilities to justify    |
|            | > awarding                                              |
|            |                                                         |
|            | -   the next higher rate of SMC under [38 CFR           |
|            |     3.350(f)(4)](http://w                               |
|            | ww.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_350.DOC), |
|            |     and                                                 |
|            |                                                         |
|            | -   SMC under [38 U.S.C.                                |
|            |     1114(k)](http://straylight.law.cornell.edu/         |
|            | uscode/html/uscode38/usc_sec_38_00001114----000-.html). |
|            |                                                         |
|            | > ***Coded Conclusion***:                               |
|            | >                                                       |
|            | > SUBJECT TO COMPENSATION (1. SC)                       |
|            | >                                                       |
|            | > 5002-5110 LOSS OF USE OF BOTH FEET WITH SEVERE        |
|            | > INVOLVEMENT OF BOTH KNEES, DUE TO RHEUMATOID          |
|            | > ARTHRITIS                                             |
|            | >                                                       |
|            | > 100 percent from 12/01/1994.                          |
|            | >                                                       |
|            | > 5286 FAVORABLE ANKYLOSIS OF SPINE DUE TO RHEUMATOID   |
|            | > ARTHRITIS                                             |
|            | >                                                       |
|            | > 60 percent from 12/01/1994.                           |
+------------+---------------------------------------------------------+

Continued on next page

41\. SMC for Additional 50- and 100-Percent Evaluations Under 38 CFR
3.350(f)(3) and 38 CFR 3.350(f)(4), Continued

+------------+---------------------------------------------------------+
| e\.        | > 5201 LIMITATION OF MOTION RIGHT ARM (MAJOR), TO 25    |
| Example 2: | > DEGREES FROM SIDE DUE TO RHEUMATOID ARTHRITIS         |
| Rating     | >                                                       |
| Decision   | > 40 percent from 12/01/1994.                           |
| Involving  | >                                                       |
| SMC Under  | > 5201 LIMITATION OF MOTION, LEFT ARM, AT SHOULDER      |
| 38 CFR     | > LEVEL DUE TO RHEUMATOID ARTHRITIS                     |
| 3          | >                                                       |
| .350(f)(3) | > 20 percent from 12/01/1994.                           |
| and 38 CFR | >                                                       |
| 3.350(f)(4 | > 37\. Disability directly due to or proximately the    |
| (          | > result of SC disability coded 5002.                   |
| continued) | >                                                       |
|            | > 7308 POSTGASTRECTOMY SYNDROME, SEVERE                 |
|            | >                                                       |
|            | > 60 percent from 02/01/1996.                           |
|            | >                                                       |
|            | > 6003-6066 IRITIS WITH ENUCLEATION, LEFT EYE, RIGHT    |
|            | > 20/20                                                 |
|            | >                                                       |
|            | > 40 percent from 02/01/1996.                           |
|            | >                                                       |
|            | > Bilateral factor of 5.2 percent added for DCs 5201,   |
|            | > 5201.                                                 |
|            | >                                                       |
|            | > *COMBINED EVALUATION FOR COMPENSATION*:               |
|            | >                                                       |
|            | > 100 percent from 12/01/1994.                          |
|            | >                                                       |
|            | > *SPECIAL MONTHLY COMPENSATION*                        |
|            | >                                                       |
|            | > K-1 Entitled to SMC under 38 U.S.C. 1114(k) and 38    |
|            | > CFR 3.350(a) on account of anatomical loss of one eye |
|            | > from 02/01/1996.                                      |
|            | >                                                       |
|            | > M-2 Entitled to SMC under 38 U.S.C. 1114(m) and 38    |
|            | > CFR 3.350(c) from 02/01/1996 on account of loss of    |
|            | > use of one leg at a level or with complications       |
|            | > preventing natural knee action with prosthesis in     |
|            | > place, and loss of use of the other leg at a level    |
|            | > with complications preventing natural knee action     |
|            | > with prosthesis in place.                             |
+------------+---------------------------------------------------------+

Continued on next page

41\. SMC for Additional 50- and 100-Percent Evaluations Under 38 CFR
3.350(f)(3) and 38 CFR 3.350(f)(4), Continued

+------------+---------------------------------------------------------+
| e\.        | > P-2 Entitled to SMC under 38 U.S.C. 1114 (p) and 38   |
| Example 2: | > CFR 3.350(f)(4) equal to 38 U.S.C. 1114 (n) from      |
| Rating     | > 02/01/1996 on account of entitlement to SMC under 38  |
| Decision   | > U.S.C. 1114(m) with additional disability, favorable  |
| Involving  | > ankylosis of spine, loss of movement (LOM) of right   |
| SMC Under  | > arm, LOM of left arm, postgastrectomy syndrome and    |
| 38 CFR     | > iritis with enucleation of the left eye independently |
| 3          | > ratable as 100 percent disabling.                     |
| .350(f)(3) | >                                                       |
| and 38 CFR | > The appropriate SMC coding is shown in the table      |
| 3.350(f)(4 | > below.                                                |
| (          |                                                         |
| continued) |                                                         |
+------------+---------------------------------------------------------+

  -------------- --------- ----------- ----------- ----------- -----------
  EFFECTIVE DATE BASIC     HOSPITAL    LOSS OF USE ANAT. LOSS  OTHER LOSS

  02/01/1996     27        27          24          11          0
  -------------- --------- ----------- ----------- ----------- -----------

#### 42. Additional SMC for L/LOU of Three Extremities Under 38 CFR 3.350(f)(5)

+------------+---------------------------------------------------------+
| ##### In   | > This topic contains information on additional SMC for |
| troduction | > loss or loss of use of three extremities under 38 CFR |
|            | > 3.350(f)(5), including                                |
|            |                                                         |
|            | -   determining the correct rate of payment under this  |
|            |     provision, and                                      |
|            |                                                         |
|            | -   an example of a rating decision involving           |
|            |     additional SMC for the loss or loss of use of three |
|            |     extremities.                                        |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### C    | > September 29, 2006                                    |
| hange Date |                                                         |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### a    | > A veteran with L/LOU of three extremities is entitled |
| . Consider | > to additional SMC under [38 CFR                       |
| ing L/LOU  | > 3.350(f)(5)](http://w                                 |
| of Three E | ww.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_350.DOC). |
| xtremities | >                                                       |
|            | > To determine the correct rate of SMC payable to a     |
|            | > veteran with the requisite degree of disability,      |
|            |                                                         |
|            | -   decide the rate of SMC payable without regard to    |
|            |     [38 CFR                                             |
|            |     3.350(f)(5)](http://w                               |
|            | ww.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_350.DOC), |
|            |     and                                                 |
|            |                                                         |
|            | -   increase this rate to the next higher rate          |
|            |     authorized under [38 U.S.C. 1114(1) through         |
|            |     (n)](http://straylight.law.cornell.edu/             |
|            | uscode/html/uscode38/usc_sec_38_00001114----000-.html), |
|            |     without loss of any entitlement under [38 U.S.C.    |
|            |     1114(k)](http://straylight.law.cornell.edu/         |
|            | uscode/html/uscode38/usc_sec_38_00001114----000-.html). |
|            |                                                         |
|            | > ***Notes***:                                          |
|            |                                                         |
|            | -   The term "next higher rate" is intended to include  |
|            |     the intermediate rates authorized under [38 U.S.C.  |
|            |     1114(p)](http://straylight.law.cornell.edu/         |
|            | uscode/html/uscode38/usc_sec_38_00001114----000-.html). |
|            |                                                         |
|            | -   The total monthly amount payable (minus any         |
|            |     additional amount for dependents) must not exceed   |
|            |     the rate payable under [38 U.S.C.                   |
|            |     1114(p)](http://straylight.law.cornell.edu/         |
|            | uscode/html/uscode38/usc_sec_38_00001114----000-.html). |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### b.   | > ***Situation***: The veteran has the SC disabilities  |
| Example: R | > shown below and qualifies for SMC at the rate under   |
| ating Deci | > [38 U.S.C.                                            |
| sion Invol | > 1114(m)](http://straylight.law.cornell.edu            |
| ving Addit | /uscode/html/uscode38/usc_sec_38_00001114----000-.html) |
| ional SMC  | > on account of the anatomical loss of both hands.      |
| for L/LOU  | > Entitlement to SMC under [38 U.S.C.                   |
| of Three E | > 1114(k)](http://straylight.law.cornell.edu            |
| xtremities | /uscode/html/uscode38/usc_sec_38_00001114----000-.html) |
|            | > for an amputation of the left foot also exists. In    |
|            | > addition, the veteran is entitled to an additional    |
|            | > one-half step in the level of SMC, under [38 CFR      |
|            | > 3.350(f)(3)](http://w                                 |
|            | ww.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_350.DOC), |
|            | > due to the separate disabilities ratable as 50        |
|            | > percent or more disabling.                            |
|            | >                                                       |
|            | > ***Result***: The rate of SMC payable without regard  |
|            | > to [38 CFR                                            |
|            | > 3.350(f)(5)](http://                                  |
|            | www.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_350.DOC) |
|            | > is "m½+k." Elevate this rate to the next higher rate  |
|            | > authorized under [38 U.S.C. 1114(l) through           |
|            | > (n)](http://straylight.law.cornell.edu/               |
|            | uscode/html/uscode38/usc_sec_38_00001114----000-.html), |
|            | > without loss of entitlement under [38 U.S.C.          |
|            | > 1114(k)](http://straylight.law.cornell.edu/           |
|            | uscode/html/uscode38/usc_sec_38_00001114----000-.html). |
|            | > Accordingly, the rate of SMC payable in this case is  |
|            | > "n+k."                                                |
+------------+---------------------------------------------------------+

Continued on next page

42\. Additional SMC for L/LOU of Three Extremities Under 38 CFR
3.350(f)(5), Continued

+------------+---------------------------------------------------------+
| b\.        | > ***Coded Conclusion***:                               |
| Example:   | >                                                       |
| Rating     | > SUBJECT TO COMPENSATION (1. SC)                       |
| Decision   | >                                                       |
| Involving  | > 5106 AMPUTATION, BOTH HANDS AT WRIST                  |
| Additional | >                                                       |
| SMC for    | > 100 percent from 06/01/1996.                          |
| L/LOU of   | >                                                       |
| Three      | > 5165 AMPUTATION, LEFT FOOT, BELOW KNEE                |
| E          | >                                                       |
| xtremities | > 40 percent from 06/01/1996.                           |
| (          | >                                                       |
| continued) | > 7101 HYPERTENSION                                     |
|            | >                                                       |
|            | > 20 percent from 06/01/1996.                           |
|            | >                                                       |
|            | > *COMBINED EVALUTION FOR COMPENSATION*:                |
|            | >                                                       |
|            | > 100 percent from 06/01/1996.                          |
|            | >                                                       |
|            | > *SPECIAL MONTHLY COMPENSATION*                        |
|            | >                                                       |
|            | > K-1 Entitled to SMC under 38 U.S.C. 1114 (k) and 38   |
|            | > CFR 3.350(a) on account of anatomical loss of one     |
|            | > foot from 06/01/1996.                                 |
|            | >                                                       |
|            | > M-1 Entitled to SMC under 38 U.S.C. 1114(m) and 38    |
|            | > CFR 3.350(c) on account of anatomical loss of both    |
|            | > hands from 06/01/1996.                                |
|            | >                                                       |
|            | > P-1 Entitled to SMC under 38 U.S.C. 1114(p) and 38    |
|            | > CFR 3.350(f)(3) at the rate intermediate between 38   |
|            | > U.S.C. 1114(m) and 38 U.S.C. 1114(n) on account of    |
|            | > anatomical loss of both hands with additional         |
|            | > disabilities of amputation of the left foot and       |
|            | > hypertension independently ratable as 50 percent or   |
|            | > more disabling from 06/01/1996.                       |
|            | >                                                       |
|            | > P-3 Entitled to SMC under 38 U.S.C. 1114(p) and 38    |
|            | > CFR 3.350(f)(5) at the next higher rate or            |
|            | > intermediate rate of 38 U.S.C. 1114(n) due to loss of |
|            | > three extremities from 06/01/1996.                    |
+------------+---------------------------------------------------------+

Continued on next page

42\. Additional SMC for L/LOU of Three Extremities Under 38 CFR
3.350(f)(5), Continued

+------------+---------------------------------------------------------+
| b\.        | > The appropriate SMC coding is shown in the table      |
| Example:   | > below.                                                |
| Rating     |                                                         |
| Decision   |                                                         |
| Involving  |                                                         |
| Additional |                                                         |
| SMC for    |                                                         |
| L/LOU of   |                                                         |
| Three      |                                                         |
| E          |                                                         |
| xtremities |                                                         |
| (          |                                                         |
| continued) |                                                         |
+------------+---------------------------------------------------------+

  -------------- --------- ----------- ----------- ----------- -----------
  EFFECTIVE DATE BASIC     HOSPITAL    LOSS OF USE ANAT. LOSS  OTHER LOSS

  06/01/1996     27        27          00          32          0
  -------------- --------- ----------- ----------- ----------- -----------

#### 43. Entitlement to Specially Adapted Housing Under 38 U.S.C. 2101

+------------+---------------------------------------------------------+
| ##### In   | > This topic contains information about specially       |
| troduction | > adapted housing under 38 U.S.C. 2101, including       |
|            |                                                         |
|            | -   the eligibility requirements for specially adapted  |
|            |     housing                                             |
|            |                                                         |
|            | -   loss of use of a lower extremity, and               |
|            |                                                         |
|            | -   circumstances under which specially adapted housing |
|            |     may be awarded without entitlement to SMC.          |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### C    | > December 13, 2005                                     |
| hange Date |                                                         |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ###        | > If the veteran is entitled to SMC under [38 U.S.C.    |
| ## a. Elig | > 1114](http://straylight.law.cornell.edu               |
| ibility Re | /uscode/html/uscode38/usc_sec_38_00001114----000-.html) |
| quirements | > based on the L/LOU of both lower extremities, the     |
|  for Speci | > veteran also meets the requirements for specially     |
| ally Adapt | > adapted housing under [38 U.S.C.                      |
| ed Housing | > 2101](http://straylight.law.cornell.edu/              |
|            | uscode/html/uscode38/usc_sec_38_00002101----000-.html). |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| #          | > In order to establish entitlement to SMC under [38    |
| #### b. Lo | > U.S.C.                                                |
| ss of Use  | > 1114](http://straylight.law.cornell.edu               |
| of a Lower | /uscode/html/uscode38/usc_sec_38_00001114----000-.html) |
|  Extremity | > based on the loss of use of both lower extremities,   |
|            | > loss of use of each lower extremity, as defined in    |
|            | > [38 CFR                                               |
|            | > 3.350(a)(2)](http://w                                 |
|            | ww.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_350.DOC), |
|            | > must be demonstrated.                                 |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### c    | > In some cases, a veteran's inability to walk is due   |
| . Circumst | > solely to loss of use of                              |
| ances Unde |                                                         |
| r Which Sp | -   only one lower extremity, not improvable by         |
| ecially Ad |     prosthesis, and                                     |
| apted Hous |                                                         |
| ing May Be | -   a paired upper extremity, which precludes           |
|  Awarded W |     locomotion without prosthetic assistance.           |
| ithout SMC |                                                         |
|            | > In such cases,                                        |
|            |                                                         |
|            | -   do not award SMC for loss of use of an apparently   |
|            |     normal lower extremity, but                         |
|            |                                                         |
|            | -   grant entitlement to specially adapted housing      |
|            |     under [38 U.S.C.                                    |
|            |     2101](http://straylight.law.cornell.edu             |
|            | /uscode/html/uscode38/usc_sec_38_00002101----000-.html) |
|            |     and [38 CFR                                         |
|            |     3.809(b)(3)](http://w                               |
|            | ww.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_809.DOC). |
+------------+---------------------------------------------------------+

#### 44. Entitlement to SMC Based on the Need for Aid and Attendance (A&A)

+------------+---------------------------------------------------------+
| ##### In   | > This topic contains information on entitlement to SMC |
| troduction | > based on a demonstrated need for the aid and          |
|            | > attendance (A&A) of another person, including         |
|            | > information on                                        |
|            |                                                         |
|            | -   the criteria for entitlement to A&A under 38 CFR    |
|            |     3.352(a)                                            |
|            |                                                         |
|            | -   considering                                         |
|            |                                                         |
|            | ```{=html}                                              |
|            | <!-- -->                                                |
|            | ```                                                     |
|            | -   the level of disability required for entitlement to |
|            |     A&A                                                 |
|            |                                                         |
|            | -   entitlement to A&A when the evaluation is less than |
|            |     100 percent                                         |
|            |                                                         |
|            | -   entitlement to A&A as an inferred issue             |
|            |                                                         |
|            | -   entitlement to A&A, with L/LOU of two extremities,  |
|            |     and                                                 |
|            |                                                         |
|            | -   entitlement to A&A under 38 U.S.C. 1114(o)          |
|            |                                                         |
|            | ```{=html}                                              |
|            | <!-- -->                                                |
|            | ```                                                     |
|            | -   denying entitlement to A&A                          |
|            |                                                         |
|            | -   coding the rating decision to reflect entitlement   |
|            |     to A&A                                              |
|            |                                                         |
|            | -   entitlement to A&A under the provisions of *PL      |
|            |     96-128*, and                                        |
|            |                                                         |
|            | -   drafting and coding the rating decision granting    |
|            |     entitlement to A&A under *PL 96-128*.               |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### C    | > September 5, 2008                                     |
| hange Date |                                                         |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ###        | > The criteria for entitlement to A&A, which appear in  |
| ## a. Crit | > [38 CFR                                               |
| eria for E | > 3.352(a)](http://w                                    |
| ntitlement | ww.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_352.DOC), |
|  to A&A Un | > require that the veteran be so helpless that he/she   |
| der 38 CFR | > requires the aid of another person to perform the     |
|  3.352(a)  | > personal functions required in everyday living.       |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| #####      | > A greater level of disability is required for         |
| b. Conside | > entitlement to the additional allowance for A&A than  |
| ring the L | > for                                                   |
| evel of Di |                                                         |
| sability R | -   entitlement to SMC at the Housebound rate, or       |
| equired fo |                                                         |
| r Entitlem | -   a 100-percent schedular evaluation.                 |
| ent to A&A |                                                         |
|            | > A single disability rated as 100-percent disabling    |
|            | > under a schedular evaluation is generally a           |
|            | > prerequisite for entitlement to A&A. Any lesser       |
|            | > disability would be incompatible with the             |
|            | > requirements of [38 CFR                               |
|            | > 3.352(a)](http://w                                    |
|            | ww.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_352.DOC). |
|            | >                                                       |
|            | > ***Note***: For the purpose of [38 CFR                |
|            | > 3.352(a)](http://w                                    |
|            | ww.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_352.DOC), |
|            | > define a single disability in accordance with [38 CFR |
|            | > 4.16](http://                                         |
|            | www.warms.vba.va.gov/regs/38CFR/BOOKC/PART4/S4_16.DOC). |
+------------+---------------------------------------------------------+

Continued on next page

44\. Entitlement to SMC Based on the Need for Aid and Attendance (A&A),
Continued

+------------+---------------------------------------------------------+
| ####       | > The table below shows the procedures to follow when   |
| # c. Consi |                                                         |
| dering Ent | -   entitlement to A&A is at issue, and                 |
| itlement t |                                                         |
| o A&A When | -   a veteran's evaluation is less than 100 percent.    |
|  the Evalu |                                                         |
| ation is L | > ***Important***: The evidence in the case must        |
| ess Than 1 | > include the report from a current examination or its  |
| 00 Percent | > equivalent.                                           |
+------------+---------------------------------------------------------+

+-----------------------+-----------------------+-----------------------+
| If ...                | And ...               | Then ...              |
+-----------------------+-----------------------+-----------------------+
| The evaluation is     | the disability is so  | refer the case to     |
| less than 100 percent | severe as to          | Compensation and      |
|                       | demonstrate a need    | Pension (C&P) Service |
|                       | for A&A               | (211B) for an         |
|                       |                       | advisory opinion.     |
|                       |                       |                       |
|                       |                       | ***Reference***: For  |
|                       |                       | more information on   |
|                       |                       | requesting an         |
|                       |                       | advisory opinion, see |
|                       |                       | [M21-1MR, Part III,   |
|                       |                       | Subpart vi,           |
|                       |                       | 1.A.2]                |
|                       |                       | (http://10.220.1.4/bl |
|                       |                       | /21/M21-1MR/index.asp |
|                       |                       | ?id=pt03_sp06_ch01_se |
|                       |                       | cA.xml#III.vi.1.A.2). |
+-----------------------+-----------------------+-----------------------+
| The evaluation is     | the disability does   | dispose of the issue  |
| less than 100 percent | *not* demonstrate a   | by explaining how     |
|                       | need for A&A          | this conclusion was   |
|                       |                       | reached in the        |
|                       |                       | *Reasons for          |
|                       |                       | Decision* section of  |
|                       |                       | the rating decision.  |
+-----------------------+-----------------------+-----------------------+

+------------+---------------------------------------------------------+
| #####      | > If a single disability is rated 100-percent           |
| d. Conside | > disabling, consider entitlement to A&A.               |
| ring Infer | >                                                       |
| red Issues | > If entitlement to A&A does not exist, consider        |
|            | > entitlement to SMC at the Housebound rate.            |
|            | >                                                       |
|            | > ***Important***: If the evidence does not show        |
|            | > entitlement or probable entitlement to SMC at the A&A |
|            | > or the Housebound rate, do not raise either issue     |
|            | > merely to deny it.                                    |
+------------+---------------------------------------------------------+

Continued on next page

44\. Entitlement to SMC Based on the Need for Aid and Attendance (A&A),
Continued

+------------+---------------------------------------------------------+
| #####      | > Show entitlement to SMC, based on the need for A&A or |
|  e. Coding | > evidence showing the veteran is housebound, by        |
|  the Ratin |                                                         |
| g Decision | -   using the appropriate narrative rating code on the  |
|  to Reflec |     code sheet, immediately following statement of the  |
| t Entitlem |     combined degree of disability, and                  |
| ent to SMC |                                                         |
|            | -   entering the necessary SMC codes in the data table. |
|            |                                                         |
|            | > ***Reference***: For more information on proper SMC   |
|            | > coding to ensure the veteran's rate is correctly      |
|            | > adjusted during hospitalization, see [M21-1MR, Part   |
|            | > III, Subpart v,                                       |
|            | > 6.B](../pt03_sp05_ch06_secB.xml#III.v.6.B).           |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### f.   | > Do not designate [38 U.S.C. 1114                      |
|  Entitleme | > (l)](http://straylight.law.cornell.edu                |
| nt to A&A, | /uscode/html/uscode38/usc_sec_38_00001114----000-.html) |
|  With L/LO | > as the statute under which entitlement to SMC based   |
| U of Two E | > on the need for A&A is established if the veteran     |
| xtremities | > also has L/LOU of two extremities.                    |
|            | >                                                       |
|            | > ***Rationale***: The rate payable for A&A under [38   |
|            | > U.S.C. 1114                                           |
|            | > (l)](http://straylight.law.cornell.edu                |
|            | /uscode/html/uscode38/usc_sec_38_00001114----000-.html) |
|            | > is subject to reduction if the veteran is             |
|            | > hospitalized, while the rate payable under [38 U.S.C. |
|            | > 1114                                                  |
|            | > (l)](http://straylight.law.cornell.edu                |
|            | /uscode/html/uscode38/usc_sec_38_00001114----000-.html) |
|            | > for L/LOU of two extremities is not.                  |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ###        | > Make determinations of entitlement to SMC under [38   |
| ## g. Cons | > U.S.C.                                                |
| idering En | > 1114(1)](http://straylight.law.cornell.edu            |
| titlement  | /uscode/html/uscode38/usc_sec_38_00001114----000-.html) |
| to A&A Und | > on the basis of need of regular A&A in light of the   |
| er 38 U.S. | > criteria contained in [38 CFR                         |
| C. 1114(o) | > 3.352(a)](http://w                                    |
|            | ww.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_352.DOC). |
|            | > Fully explain the reasoning in the *Reasons for       |
|            | > Decision* section of the rating decision.             |
|            | >                                                       |
|            | > ***Notes***:                                          |
|            |                                                         |
|            | -   The need to explain the reasoning is especially     |
|            |     important in situations in which, under [38 CFR     |
|            |     3.350(c)](http://w                                  |
|            | ww.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_350.DOC), |
|            |     the rate under [38 U.S.C.                           |
|            |     1114(1)](http://straylight.law.cornell.edu          |
|            | /uscode/html/uscode38/usc_sec_38_00001114----000-.html) |
|            |     based on the need for A&A is to be used as one of   |
|            |     the conditions that entitles the claimant to two or |
|            |     more of the rates (no condition being considered    |
|            |     twice) that are provided in [38 U.S.C. 1114(1)      |
|            |     through                                             |
|            |     (n)](http://straylight.law.cornell.edu              |
|            | /uscode/html/uscode38/usc_sec_38_00001114----000-.html) |
|            |     for the purpose of establishing entitlement under   |
|            |     [38 U.S.C.                                          |
|            |     1114(o)](http://straylight.law.cornell.edu/         |
|            | uscode/html/uscode38/usc_sec_38_00001114----000-.html). |
+------------+---------------------------------------------------------+

Continued on next page

44\. Entitlement to SMC Based on the Need for Aid and Attendance (A&A),
Continued

+------------+---------------------------------------------------------+
| g\.        | -   Base the determination of need for A&A on separate  |
| C          |     and distinct disabilities if the rate under [38     |
| onsidering |     U.S.C.                                              |
| E          |     1114(1)](http://straylight.law.cornell.edu          |
| ntitlement | /uscode/html/uscode38/usc_sec_38_00001114----000-.html) |
| to A&A     |     on account of need for A&A is used to establish     |
| Under 38   |     entitlement under [38 U.S.C.                        |
| U.S.C.     |     1114(o)](http://straylight.law.cornell.edu/         |
| 1114(o)    | uscode/html/uscode38/usc_sec_38_00001114----000-.html). |
| (          |                                                         |
| continued) | > ***Example***: If a veteran has loss of use of both   |
|            | > feet and is also being considered for the maximum     |
|            | > rate under [38 U.S.C.                                 |
|            | > 1114(o)](http://straylight.law.cornell.edu            |
|            | /uscode/html/uscode38/usc_sec_38_00001114----000-.html) |
|            | > because of his/her need for A&A, the need for A&A     |
|            | > must be due to SC disabilities, completely            |
|            | > independent of the loss of use of both feet. In other |
|            | > words, when determining whether the veteran needs     |
|            | > A&A, disregard the disabling effects of the loss of   |
|            | > both feet. Show the need for A&A as due to a separate |
|            | > SC disability rated 100 percent disabling.            |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| #####      | > If there is no need for A&A, dispose of the issue by  |
|  h. Denyin | > explaining how this conclusion was reached in the     |
| g Entitlem | > *Reasons for Decision* section of the rating          |
| ent to A&A | > decision.                                             |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##         | > *PL 96-128* amended [38 U.S.C.                        |
| ### i. Pro | > 1114(r)](http://straylight.law.cornell.edu            |
| visions of | /uscode/html/uscode38/usc_sec_38_00001114----000-.html) |
|  PL 96-128 | > concerning the awarding of A&A in cases where the SMC |
|            | > level is "n½+k," so that the SC disabilities used to  |
|            | > establish entitlement to SMC at this level may also   |
|            | > be used to establish entitlement to A&A if factual    |
|            | > need is shown.                                        |
|            | >                                                       |
|            | > Under *PL 96-128*, entitlement to SMC under           |
|            |                                                         |
|            | -   [38 U.S.C.                                          |
|            |     1114(r)(1)](http://straylight.law.cornell.edu       |
|            | /uscode/html/uscode38/usc_sec_38_00001114----000-.html) |
|            |     exists if the basic criteria contained in [38 CFR   |
|            |     3.352(a)](http://                                   |
|            | www.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_352.DOC) |
|            |     is met, and                                         |
|            |                                                         |
|            | -   [38 U.S.C.                                          |
|            |     1114(r)(2)](http://straylight.law.cornell.edu       |
|            | /uscode/html/uscode38/usc_sec_38_00001114----000-.html) |
|            |     exists if the basic criteria contained in [38 CFR   |
|            |     3.352(b)](http://                                   |
|            | www.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_352.DOC) |
|            |     is met.                                             |
|            |                                                         |
|            | > ***Note***: Prior to enactment of *PL 96-12*, a       |
|            | > veteran had to be entitled to SMC under [38 U.S.C.    |
|            | > 1114(o)](http://straylight.law.cornell.edu            |
|            | /uscode/html/uscode38/usc_sec_38_00001114----000-.html) |
|            | > in order to establish entitlement to SMC under [38    |
|            | > U.S.C.                                                |
|            | > 1114(r)(1)](http://straylight.law.cornell.edu         |
|            | /uscode/html/uscode38/usc_sec_38_00001114----000-.html) |
|            | > and [38 U.S.C.                                        |
|            | > 1114(r)(2)](http://straylight.law.cornell.edu/        |
|            | uscode/html/uscode38/usc_sec_38_00001114----000-.html). |
+------------+---------------------------------------------------------+

Continued on next page

44\. Entitlement to SMC Based on the Need for Aid and Attendance (A&A),
Continued

+------------+---------------------------------------------------------+
| ##         | > If entitlement to A&A is established under the        |
| ### j. Dra | > provisions of *PL 96-128*, then                       |
| fting and  |                                                         |
| Coding the | -   cite relevant evidence and information in the       |
|  Rating De |     *Reasons for Decision* to fully justify awarding or |
| cision Gra |     denying A&A, and                                    |
| nting Enti |                                                         |
| tlement to | -   use SMC code 43 or 44 in higher level care claims.  |
|  A&A Under |                                                         |
|  PL 96-128 | > ***Note***: Pay the rate allowed for SMC at the       |
|            | > "n½+k" level, plus the additional amount allowed      |
|            | > under [38 U.S.C.                                      |
|            | > 1114(r)(1)](http://straylight.law.cornell.edu         |
|            | /uscode/html/uscode38/usc_sec_38_00001114----000-.html) |
|            | > or [38 U.S.C.                                         |
|            | > 1114(r)(2)](http://straylight.law.cornell.edu/        |
|            | uscode/html/uscode38/usc_sec_38_00001114----000-.html), |
|            | > whichever is appropriate.                             |
|            | >                                                       |
|            | > ***Reference***: For more information on entitlement  |
|            | > to a higher A&A allowance under [38 U.S.C.            |
|            | > 1114(r)](http://straylight.law.cornell.edu/           |
|            | uscode/html/uscode38/usc_sec_38_00001114----000-.html), |
|            | > see [M21-1MR, Part IV, Subpart ii,                    |
|            | > 2.H.45](http://vbaw.vba.va.gov/bl/21/M2               |
|            | 1-1MR/pt04/sp02/ch02/pt04_sp02_ch02_secH#IV.ii.2.H.45). |
+------------+---------------------------------------------------------+

#### 45. Entitlement to a Higher A&A Allowance Under 38 U.S.C. 1114(r)(2)

+------------+---------------------------------------------------------+
| ##### In   | > This topic contains information the statutory         |
| troduction | > provisions for a higher A&A allowance , including     |
|            | > information on                                        |
|            |                                                         |
|            | -   considering entitlement to a higher A&A allowance   |
|            |     under 38 U.S.C. 1114(r)(2)                          |
|            |                                                         |
|            | -   when to award a higher A&A allowance under 38       |
|            |     U.S.C. 1114(r)(2)                                   |
|            |                                                         |
|            | -   the requirement for a statement from a treating or  |
|            |     supervising licensed health care professional       |
|            |                                                         |
|            | -   handling claims for entitlement to a higher A&A     |
|            |     allowance under 38 U.S.C. 1114(r)(2), and           |
|            |                                                         |
|            | -   possible hospitalization adjustment under 38 CFR    |
|            |     3.552(b)(2).                                        |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### C    | > December 13, 2005                                     |
| hange Date |                                                         |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| #####      | > A veteran entitled to the A&A allowance under [38     |
|  a. Consid | > U.S.C.                                                |
| ering Enti | > 1114(r)](http://straylight.law.cornell.edu            |
| tlement to | /uscode/html/uscode38/usc_sec_38_00001114----000-.html) |
|  a Higher  | > is entitled to receive, in lieu of that allowance, a  |
| A&A Allowa | > higher A&A allowance if the veteran is found to be in |
| nce Under  | > need of, and receiving, a higher level of care.       |
| 38 U.S.C.  |                                                         |
| 1114(r)(2) |                                                         |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##         | > Award the higher A&A allowance under [38 U.S.C.       |
| ### b. Whe | > 1114(r)(2)](http://straylight.law.cornell.edu         |
| n to Award | /uscode/html/uscode38/usc_sec_38_00001114----000-.html) |
|  a Higher  | > *only* when the                                       |
| A&A Allowa |                                                         |
| nce Under  | -   need is clearly established, and                    |
| 38 U.S.C.  |                                                         |
| 1114(r)(2) | -   amount of skilled service required by the veteran   |
|            |     is substantial.                                     |
|            |                                                         |
|            | > Base eligibility to the higher allowance on medical   |
|            | > certification that the veteran meets the criteria set |
|            | > forth in [38 CFR                                      |
|            | > 3.352(a)](http://w                                    |
|            | ww.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_352.DOC). |
|            | >                                                       |
|            | > ***Note***: This allowance is payable even if VA or   |
|            | > another entity is furnishing such skilled service at  |
|            | > no expense to the veteran.                            |
+------------+---------------------------------------------------------+

Continued on next page

45\. Entitlement to a Higher A&A Allowance Under 38 U.S.C. 1114(r)(2),
Continued

+------------+---------------------------------------------------------+
| ##         | > A statement from a licensed health care professional, |
| ### c. Req | > who provides or supervises daily skilled health care  |
| uired Stat | > on a continuing basis in the veteran's home, is a     |
| ement From | > prerequisite to establishing entitlement to a higher  |
|  a Treatin | > A&A allowance.                                        |
| g or Super | >                                                       |
| vising Lic | > The statement must indicate the                       |
| ensed Heal |                                                         |
| th Care Pr | -   conditions justifying the need for this level of    |
| ofessional |     care                                                |
|            |                                                         |
|            | -   nature, extent, and frequency of the services       |
|            |     provided, and                                       |
|            |                                                         |
|            | -   nature and extent of the supervision being          |
|            |     provided, if the services are actually provided by  |
|            |     a nonprofessional.                                  |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ####       | > Follow the steps below to process claims for          |
| # d. Proce | > entitlement to a higher A&A allowance under [38       |
| ssing Clai | > U.S.C.                                                |
| ms for Ent | > 1114(r)(2)](http://straylight.law.cornell.edu/        |
| itlement t | uscode/html/uscode38/usc_sec_38_00001114----000-.html). |
| o a Higher |                                                         |
|  Level of  |                                                         |
| A&A Under  |                                                         |
| 38 U.S.C.  |                                                         |
| 1114(r)(2) |                                                         |
+------------+---------------------------------------------------------+

+-------+--------------------------------------------------------------+
| Step  | Action                                                       |
+-------+--------------------------------------------------------------+
| 1     | Does the claim include the statement from a treating or      |
|       | supervising licensed healthcare professional?                |
|       |                                                              |
|       | -   If *yes*, go to Step 3.                                  |
|       |                                                              |
|       | -   If *no*                                                  |
|       |                                                              |
|       | ```{=html}                                                   |
|       | <!-- -->                                                     |
|       | ```                                                          |
|       | -   ask the veteran to furnish the statement, and            |
|       |                                                              |
|       | -   go to Step 2.                                            |
+-------+--------------------------------------------------------------+
| 2     | Did the veteran submit the statement from the treating or    |
|       | supervising healthcare professional?                         |
|       |                                                              |
|       | -   If *yes*, go to Step 3.                                  |
|       |                                                              |
|       | -   If *no*, prepare a rating decision, denying the claim.   |
+-------+--------------------------------------------------------------+

Continued on next page

45\. Entitlement to a Higher A&A Allowance Under 38 U.S.C. 1114(r)(2),
Continued

  -----------------------------------------------------------------------
  d\. Processing Claims for Entitlement to a Higher Level of A&A Under 38
  U.S.C. 1114(r)(2) (continued)

  -----------------------------------------------------------------------

+-------+--------------------------------------------------------------+
| Step  | Action                                                       |
+-------+--------------------------------------------------------------+
| 3     | Does the statement from the treating or supervising          |
|       | healthcare professional show that qualifying skilled         |
|       | services are being provided on a continuing basis?           |
|       |                                                              |
|       | -   If *yes*, go to Step 4.                                  |
|       |                                                              |
|       | -   If *no*, dispose of the issue by appropriate rating      |
|       |     action.                                                  |
+-------+--------------------------------------------------------------+
| 4     | Request an immediate examination via the Automated Medical   |
|       | Information Exchange (AMIE)/Compensation and Pension Records |
|       | Interchange (CAPRI) or Veterans Examination Request          |
|       | Information System (VERIS).                                  |
|       |                                                              |
|       | *VA Form 21-2680, Examination for Housebound Status or       |
|       | Permanent Need for Regular Aid and Attendance*, should be    |
|       | completed in response to the examination request.            |
|       |                                                              |
|       | The examiner will certify whether an ongoing daily need for  |
|       | skilled personal care is indicated by completing Item 32 of  |
|       | the form.                                                    |
|       |                                                              |
|       | ***Note***: Provide a copy of the statement submitted by the |
|       | licensed healthcare provider to the examiner.                |
+-------+--------------------------------------------------------------+
| 5     | Does the examination report show an ongoing need for skilled |
|       | personal care?                                               |
|       |                                                              |
|       | -   If *yes*, grant entitlement to the higher A&A allowance  |
|       |     under [38 U.S.C.                                         |
|       |     1114(r)(2)](http://straylight.law.cornell                |
|       | .edu/uscode/html/uscode38/usc_sec_38_00001114----000-.html). |
|       |                                                              |
|       | -   If *no*, prepare a rating decision, denying the claim.   |
+-------+--------------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### e.   | > The A&A allowance, including that payable under [38   |
| Possible H | > U.S.C.                                                |
| ospitaliza | > 1114(r)(2)](http://straylight.law.cornell.edu/        |
| tion Adjus | uscode/html/uscode38/usc_sec_38_00001114----000-.html), |
| tment Unde | > is subject to reduction under [38 CFR                 |
| r 38 CFR 3 | > 3.552(b)(2)](http://w                                 |
| .552(b)(2) | ww.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_352.DOC). |
+------------+---------------------------------------------------------+

#### 46. Entitlement to Housebound Benefits

+------------+---------------------------------------------------------+
| ##### In   | > This topic contains information about entitlement to  |
| troduction | > Housebound benefits, including information on         |
|            |                                                         |
|            | -   statutory entitlement to Housebound benefits        |
|            |                                                         |
|            | -   determining whether the veteran is permanently      |
|            |     housebound in fact, and                             |
|            |                                                         |
|            | -   protected evaluations.                              |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### C    | > September 5, 2008                                     |
| hange Date |                                                         |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ###        | > The Housebound benefit is payable under [38 U.S.C.    |
| ## a. Stat | > 1114(s)](http://straylight.law.cornell.edu            |
| utory Enti | /uscode/html/uscode38/usc_sec_38_00001114----000-.html) |
| tlement to | > ([38 CFR                                              |
|  Houseboun | > 3.350(i)](http://w                                    |
| d Benefits | ww.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_350.DOC)) |
|            | > to a veteran who has a single, SC disability rated as |
|            | > totally disabling and                                 |
|            |                                                         |
|            | -   has an additional SC disability, or combination of  |
|            |     disabilities, independently ratable as 60 percent   |
|            |     or more disabling, or                               |
|            |                                                         |
|            | -   is permanently housebound due to SC disability.     |
|            |                                                         |
|            | > If the veteran is entitled to Housebound benefits by  |
|            | > statute (without demonstrating need, under [38 U.S.C. |
|            | > 1114(s)](http://straylight.law.cornell.edu/u          |
|            | scode/html/uscode38/usc_sec_38_00001114----000-.html)), |
|            | > the additional disability(ies), rated 60 percent or   |
|            | > more disabling, must                                  |
|            |                                                         |
|            | -   be separate and distinct from the single            |
|            |     disability, rated totally disabling, and            |
|            |                                                         |
|            | -   involve separate anatomical segments or body        |
|            |     systems.                                            |
|            |                                                         |
|            | > ***Notes***:                                          |
|            |                                                         |
|            | -   The principles regarding avoidance of pyramiding    |
|            |     contained in [38 CFR                                |
|            |     4.14](http:/                                        |
|            | /www.warms.vba.va.gov/regs/38CFR/BOOKC/PART4/S4_14.DOC) |
|            |     are applicable.                                     |
|            |                                                         |
|            | -   Within these limits, the fact that the single       |
|            |     disability, rated totally disabling, and additional |
|            |     disabilility(ies), independently ratable as 60      |
|            |     percent or more disabling, share a common etiology, |
|            |     does not preclude entitlement.                      |
|            |                                                         |
|            | -   Ratings of 100 percent under [38 CFR                |
|            |     4.28](http://                                       |
|            | www.warms.vba.va.gov/regs/38CFR/BOOKC/PART4/S4_28.DOC), |
|            |     [38 CFR                                             |
|            |     4.29](http://                                       |
|            | www.warms.vba.va.gov/regs/38CFR/BOOKC/PART4/S4_29.DOC), |
|            |     and [38 CFR                                         |
|            |     4.30](http:/                                        |
|            | /www.warms.vba.va.gov/regs/38CFR/BOOKC/PART4/S4_30.DOC) |
|            |     of the rating schedule may be used as a basis for   |
|            |     entitlement.                                        |
+------------+---------------------------------------------------------+

Continued on next page

46\. Entitlement to Housebound Benefits, Continued

+------------+---------------------------------------------------------+
| ####       | > If entitlement is based on the veteran being          |
| # b. Deter | > housebound in fact, the law requires the housebound   |
| mining Whe | > state to be permanent.                                |
| ther the V | >                                                       |
| eteran is  | > Consider a veteran permanently housebound if, as a    |
| Permanentl | > result of a single, total disability, by itself or in |
| y Housebou | > combination with other SC disabilities, the veteran   |
| nd in Fact | > is permanently and substantially confined to          |
|            |                                                         |
|            | -   his/her place of residence and immediate premises,  |
|            |     or                                                  |
|            |                                                         |
|            | -   ward or clinical areas, if institutionalized under  |
|            |     [38 CFR                                             |
|            |     3.350(i)(2)](http://w                               |
|            | ww.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_350.DOC). |
|            |                                                         |
|            | > ***Important***:                                      |
|            |                                                         |
|            | -   There is no requirement that either the single      |
|            |     disability, rated totally disabling, or the         |
|            |     additional disability(ies), independently ratable   |
|            |     as 60- percent or more disabling, be permanent in   |
|            |     nature.                                             |
|            |                                                         |
|            | -   Leaving home for medical purposes cannot, by        |
|            |     itself, serve as the basis for finding that a       |
|            |     veteran is not substantially confined for purposes  |
|            |     of SMC Housebound benefits.                         |
|            |                                                         |
|            | > ***Reference***: For more information on substantial  |
|            | > confinement to home, see *[Howell v.                  |
|            | > Nicholson](h                                          |
|            | ttp://vbaw.vba.va.gov/bl/21/Advisory/CAVCDAD.htm#bmh),* |
|            | > March 23, 2006, No. 04-0624.                          |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##         | > Consider any evaluation protected under [38 CFR       |
| ### c. Con | > 3.951](http://                                        |
| sidering P | www.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_950.DOC) |
| rotected E | > at its protected level.                               |
| valuations | >                                                       |
|            | > For the purpose of determining entitlement to         |
|            | > Housebound benefits only, utilize ratings under the   |
|            | > 1925 schedule, which are protected by [38 CFR         |
|            | > 3.952](http://                                        |
|            | www.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_952.DOC) |
|            | > with ratings under the current rating schedule for    |
|            | > separate and distinct disabilities.                   |
+------------+---------------------------------------------------------+