In This Section

Introduction

• definition of SMC
• responsibility for determining loss of use (LOU)
• information to request from an examiner to determine LOU
• determining the extent of examinations in claims involving SMC under 38 U.S.C. 1114(l) through (n)
• considering amputation or LOU of extremities
• showing
  • entitlement to SMC in rating decisions, and
  • the denial of SMC in rating decisions
• mandatory use of the SMC Calculator
• use of VA Form 21-2680, Examination for Housebound Status or Permanent Need for Regular Aid and Attendance, in SMC claims, and
• definition of anatomical segment.

Change Date

VIII.iv.4.A.1.a. Definition: SMC

• the SMC Training Guide located on the Compensation Service Intranet in Job Aids under the Training Materials Link
• 38 U.S.C. 1114, and
• 38 CFR 3.350.

VIII.iv.4.A.1.b.  Responsibility for Determining LOU

• rests with the rating activity, and
• cannot be delegated to the examining physician. 

VIII.iv.4.A.1.c.  Information to Request From an Examiner to Determine LOU

• detailed objective description of remaining function
• quantitative assessment of strength for each extremity involved, and
• description of any pain that affects use. 

• determine LOU, or
• express an opinion as to whether there is, or is not, LOU of an extremity or extremities.

• considering functional loss due to pain in claims for SMC, see Tucker v. West, 11 Vet.App 369, 374 (1998)
• requesting a specialist examination, see M21-1, Part IV, Subpart i, 2.A.6, and
• avoidance of asking for legal conclusions regarding LOU in a medical opinion request, see M21-1, Part IV, Subpart i, 2.A.7.j.

VIII.iv.4.A.1.d.  Determining the Extent of Examinations in Claims Involving SMC Under 38 U.S.C. 1114(l) Through (n)

VIII.iv.4.A.1.e.  Considering Amputation or LOU of Extremities

VIII.iv.4.A.1.f.  Showing Entitlement to SMC in Rating Decisions

• noting entitlement to SMC and statutory awards immediately following citation of the combined evaluation of all SC disabilities (if more than one exists)
• listing any anatomical loss as the first entitlement in order of preference over all LOUs, and
• citing separately each additional specific disability if entitlement under 38 U.S.C. 1114(k) is shown for more than one anatomical loss, or LOU.

• SMC codes, see historical M21-1, Part I, Appendix A, Section V-VIII
• SMC payment rates, see Rate Tables
• the Codesheet in SMC decisions, see M21-1, Part V, Subpart iv, 1.B.5.a
• two-signature requirements for SMC ratings, see M21-1, Part V, Subpart iv, 1.B.7.d, and
• protection of SMC ratings, see M21-1, Part X, Subpart ii, 1.B.1.g.

VIII.iv.4.A.1.g.  Showing the Denial of SMC in Rating Decisions

VIII.iv.4.A.1.h.  Mandatory Use of the SMC Calculator

• TYPE:  Worksheet: Rating Calculator Worksheets
• SOURCE:  VBMS
• SUBJECT:  SMC Calculator Worksheet

• Build the SMC rating narrative using system generated language, glossary fragments, and free text as appropriate.
• Consider any ancillary benefit information generated by the calculator and consider whether additional issues need to be decided.
• The calculator must be used anytime a decision addresses SMC and SMC is coded on the Codesheet, including for confirmed and continued decisions.

• using the legacy SMC Calculator, see the SMC Calculator User Guide
• using the SMC Calculator in VBMS-R, see the VBMS Rating User Guide
• generating the rating narrative, see M21-1, Part V, Subpart iv, 1.A, and
• considering subordinate issues and ancillary benefits, see M21-1, Part V, Subpart ii, 3.A.2.b

VIII.iv.4.A.1.i.  Use of VA Form 21-2680 in SMC Claims

• Statements by medical providers on VA Form 21-2680 which meet the requirements of 38 CFR 3.326(b) and 38 CFR 3.159(a)(1) are acceptable for rating purposes.
• Although VA Form 21-2680 may be accepted as a prescribed form adequate to claim entitlement to SMC, this form is not required to develop a claim for or grant entitlement to SMC.  Additional development for VA Form 21-2680 should not be routinely undertaken when the form is not received with a claim.

• accepting VA Form 21-2680 as a prescribed form in claims for SMC, see 
  • M21-1, Part II, Subpart iii, 1.A.1.a, and
  • M21-1, Part II, Subpart iii, 1.A.3.a
• issues that arise from consideration of VA Form 21-2680, including the potential for increased evaluation of an SC disability, see M21-1, Part II, Subpart iii, 1.A.3.c, and
• processing fully developed claims, see M21-1, Part X, Subpart i, 2.B.

Introduction

• when multiple disabilities should not be evaluated as a single disability
• evaluating a multisystem disorder
• an example of a rating decision involving a multisystem disorder
• cases involving loss of anal and bladder sphincter control, and
• avoiding separate SMC assignments for L/LOU of an extremity.

Change Date

VIII.iv.4.A.2.a.  When Multiple Disabilities Should Not Be Evaluated as a Single Disability

• SMC under 38 U.S.C. 1114(s), or
• an intermediate or next higher rate of SMC under
  • 38 CFR 3.350(f)(3), or
  • 38 CFR 3.350(f)(4).

VIII.iv.4.A.2.b.  Evaluating a Multisystem Disorder

• an intermediate rate under 38 CFR 3.350(f)(3), or
• the next higher rate under 38 CFR 3.350(f)(4).

VIII.iv.4.A.2.c.  Example:  Rating Decision Involving a Multisystem Disorder

• a 100-percent evaluation for the LOU 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.

VIII.iv.4.A.2.d.  Cases Involving Loss of Anal and Bladder Sphincter Control

VIII.iv.4.A.2.e.  Avoiding Separate SMC Assignments for L/LOU of an Extremity

• loss or loss of use (L/LOU) of a leg and L/LOU of the foot of the same leg, or
• L/LOU of an arm and L/LOU of the hand of the same arm.

Introduction

• specifying the basis of entitlement under 38 CFR 3.552 in the rating decision
• consequences of an improperly assigned SMC hospital code, and
• examples of rating decisions with properly assigned SMC hospital codes.

Change Date

VIII.iv.4.A.3.a.  Specifying the Basis of Entitlement Under 38 CFR 3.552 in the Rating Decision

• paraplegia involving
  • paralysis of both lower extremities, together with
  • loss of anal and bladder sphincter control, or
• Hansen’s disease.

• 38 U.S.C. 1114(r)(1)
• 38 U.S.C. 1114(r)(2), or
• 38 U.S.C. 1114(t).

• 38 U.S.C. 1114(r), see M21-1, Part VIII, Subpart iv, 4.A.9, and
• 38 U.S.C. 1114(t), see M21-1, Part VIII, Subpart iv, 4.A.11.

VIII.iv.4.A.3.b.  Consequences of an Improperly Assigned SMC Hospital Code

VIII.iv.4.A.3.c.  Example 1:  Rating Decision With a Properly Assigned SMC Hospital Code

• a 100-percent disabling heart condition so severe as to require A&A of another person, and
• bilateral, below-knee amputations. 

• basic SMC code is 51, and
• SMC hospital code is 19 for SMC under 38 U.S.C. 1114(m).

VIII.iv.4.A.3.d.  Example 2:  Rating Decision With a Properly Assigned SMC Hospital Code

• 100-percent disabling psychiatric condition that does not require A&A, and
• 100-percent disabling heart condition that does require A&A.

• basic SMC code is 19, and
• SMC hospital code is 48 for SMC under 38 U.S.C. 1114(s).

Introduction

• eligibility criteria for SMC under 38 U.S.C. 1114(k)
• history of SMC for L/LOU of a creative organ
• awarding SMC for L/LOU of a creative organ
• basis for considering entitlement to SMC for L/LOU of a creative organ
• awarding SMC for LOU of a hand or foot
• other medical indications of LOU of the foot, and
• awarding SMC for
  • LOU of both buttocks
  • deafness
  • complete organic aphonia
  • LOU or blindness of one eye, and
  • loss of breast tissue.

Change Date

VIII.iv.4.A.4.a.  Eligibility Criteria for SMC Under 38 U.S.C. 1114(k)

• L/LOU of a creative organ
• L/LOU of a hand
• L/LOU of a foot
• L/LOU of both buttocks
• deafness of both ears having absence of air and bone conduction
• complete organic aphonia with constant inability to communicate by speech
• blindness in one eye, having light perception only (LPO), and
• loss of 25-percent or more of tissue from one or both breasts or breast tissue has been subject to radiation treatment.

VIII.iv.4.A.4.b.  History of SMC for L/LOU of a Creative Organ

• one year before the date VA received the claim, or
• one year before the date of an administrative determination of entitlement.

• the history of SMC under 38 U.S.C. 1114(k), see M21-1, Part VIII, Subpart iv, 4.B.2
• SMC and radical prostatectomy, see M21-1, Part V, Subpart iii, 7.3.d
• SMC and erectile dysfunction, see
  • M21-1, Part V, Subpart iii, 7.4.b, and
  • M21-1, Part VIII, Subpart iv, 4.A.4.d, and
• SMC and FSAD, see M21-1, Part V, Subpart iii, 8.A.1.e.

VIII.iv.4.A.4.c.  Awarding SMC for L/LOU of a Creative Organ

• the acquired absence of one or both testicles, ovaries, or other creative organs
• a condition of the reproductive tract which results in LOU of a creative organ, such as retrograde ejaculation or spermatozoa dumping into the bladder in a male Veteran
• the loss of erectile power secondary to a disease process, such as diabetes or multiple sclerosis, in a male Veteran, or
• a diagnosis of FSAD.

• If the Veteran is SC for prostate cancer and the evidence of record includes a surgical report showing a radical prostatectomy was performed, award SMC (k) effective the date the radical prostatectomy was performed. 
• If the Veteran is SC for prostate cancer but the evidence of record does not show a radical prostatectomy was performed, clinical evidence of the LOU of a creative organ due to the SC prostate cancer is required to award SMC (k) for LOU of a creative organ due to prostate cancer.

• L/LOU of a creative organ, see
  • 38 CFR 3.350(a)(1)
  • 38 CFR 4.115b, Note, and
  • 38 CFR 4.116, Note 2
• erectile dysfunction associated with prostate cancer, see M21-1, Part V, Subpart iii, 7.3.d, and
• FSAD, see M21-1, Part V, Subpart iii, 8.A.1.e.

VIII.iv.4.A.4.d.  Basis for Considering Entitlement to SMC for L/LOU of a Creative Organ

• based on a specific claim, or
• raised within the scope of another claimed issue when entitlement is shown in the evidence of record, such as a VA examination or hospitalization report. 

• Entitlement to SMC (k) for one or more creative organs
  • may be based on a multi-link causal chain between an SC disability and the LOU or anatomical loss, and
  • is not limited to certain disabilities.
• There is no bar to the payment of compensation or establishment of SC for anatomical loss of a creative organ, when a non-service-connected (NSC) LOU of a creative organ existed prior to anatomical loss resulting from service.
• The successful use of medication or prosthetic implant to restore erectile ability does not preclude the award of SMC for LOU if the Veteran is unable to complete the act of procreation.

• providing SMC for anatomical loss of a creative organ when a pre-existing NSC functional loss was present, see VAOPGCPREC 5-1989
• restoring SMC for anatomical loss of a creative organ when eligibility was originally found to have existed, but was later found not to exist due to suffering a complete loss of procreative power prior to service through surgical removal of certain other organs, see VAOPGCPREC 93-1990, and
• considering entitlement to SMC as an ancillary benefit that is within scope of another claimed issue, see
  • 38 CFR 3.155(d)(2)
  • M21-1, Part V, Subpart ii, 3.A.2.b, and
  • Payne v. Wilkie, No. 17-3439, CAVC (2019).

VIII.iv.4.A.4.e.  Awarding SMC for LOU of a Hand or Foot

• grasping or manipulation (for a hand), and
• balancing, propulsion, or ambulation (for a foot).

• L/LOU of a hand or foot, see
  • 38 CFR 3.350(a)(2), and
  • 38 CFR 4.63, and
• avoiding separate SMC assignments for L/LOU of an extremity, see M21-1, Part VIII, Subpart iv, 4.A.2.e.

VIII.iv.4.A.4.f.  Other Medical Indications of LOU of the Foot

• extremely unfavorable complete ankylosis of the knee
• 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.

VIII.iv.4.A.4.g.  Awarding SMC for LOU of Both Buttocks

• rise from a seated or stooped position, and
• maintain postural stability.

VIII.iv.4.A.4.h.  Awarding SMC for Deafness

• A numeric designation of hearing impairment of
  • XI in both ears entitles the Veteran to SMC, and
  • less than XI in either ear precludes entitlement to SMC.
• 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. 

VIII.iv.4.A.4.i.  Awarding SMC for Complete Organic 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.

• 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 38 CFR 4.97, DCs 6518, 6519, and 6520, and 38 CFR 4.114, DC 7202, generally entitles the Veteran to SMC.

VIII.iv.4.A.4.j.  Awarding SMC for LOU or Blindness of One Eye

• recognize test letters at one foot, and
• recognize objects, hand movements, or count fingers at a distance of three feet.

VIII.iv.4.A.4.k.  Awarding SMC for Loss of Breast Tissue

• 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.

Introduction

• basic criteria for entitlement to
  • SMC (l), and
  • SMC (m)
• general criteria for entitlement to SMC for blindness with hearing loss or L/LOU of an extremity
• SMC for
  • bilateral deafness evaluated as 60 percent or more and bilateral visual acuity of 20/200 or less, and
  • total SC deafness in one ear and bilateral blindness
• example 1 of a rating decision involving SMC for total SC deafness in one ear and bilateral blindness
• example 2 of a rating decision involving SMC for total SC deafness in one ear and bilateral blindness
• SMC for bilateral blindness with bilateral hearing loss considered 10- or 20-percent disabling
• example 1 of a rating decision involving SMC for bilateral blindness with bilateral hearing loss considered 10- or 20-percent disabling
• example 2 of a rating decision 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
• example 1 of a rating decision involving SMC for bilateral blindness with bilateral hearing loss considered 40-percent disabling
• example 2 of a rating decision 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 an extremity considered at least 50-percent disabling
• an example of a rating decision involving SMC for bilateral blindness with L/LOU of an 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.

Change Date

VIII.iv.4.A.5.a.  Basic Criteria for Entitlement to SMC (l)

• anatomical L/LOU of both feet
• anatomical L/LOU of one hand and one foot
• blindness in both eyes with visual acuity of 5/200 or less
• being permanently bedridden, or
• being so helpless as to be in need of the regular A&A of another person.

VIII.iv.4.A.5.b.  Basic Criteria for Entitlement to SMC (m)

• anatomical L/LOU of both hands
• anatomical L/LOU of both legs at a level, or with complications, preventing natural knee action with prostheses in place
• anatomical L/LOU of one arm and one leg preventing natural elbow and knee action with prostheses in place, due to the level of involvement or with complications
• blindness in both eyes having LPO, or
• blindness in both eyes leaving the Veteran so significantly disabled as to be in need of regular A&A. 

VIII.iv.4.A.5.c.  General Criteria for Entitlement to SMC for Blindness With Hearing Loss or L/LOU of an Extremity

VIII.iv.4.A.5.d.  SMC for Bilateral Deafness Evaluated as 60 Percent or More and Bilateral Visual Acuity of 20/200 or Less

• bilateral deafness rated at 60 percent or more (and the hearing loss in either ear is SC), and
• SC blindness with bilateral visual acuity of 20/200 (6/60) or less.

VIII.iv.4.A.5.e.  SMC for Total SC Deafness in One Ear and Bilateral Blindness

• LPO or less, bilaterally, is entitled to SMC under 38 U.S.C.1114(o) and 38 CFR 3.350(e)(1)(iv), 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).

VIII.iv.4.A.5.f.  Example 1:  Rating Decision Involving SMC for Total SC Deafness in One Ear and Bilateral Blindness

• bilateral SC blindness with LPO, and
• total SC hearing loss in the left ear
• no separate and distinct disability evaluated as 100-percent disabling, and
• no separate and distinct disability evaluated as 50-percent disabling. 

• 38 U.S.C. 1114(o), and
• 38 CFR 3.350(e)(1)(iv).

• The appropriate SMC paragraph code is OB-2.
• The appropriate SMC coding is 37-37-21-00-0.

VIII.iv.4.A.5.g.  Example 2:  Rating Decision Involving SMC for Total SC Deafness in One Ear and Bilateral Blindness

• bilateral SC blindness with
  • no light perception (NLP) in the left eye, and
  • visual acuity of 5/200 (1.5/60) in the right eye
• total SC hearing loss in the left ear
• no separate and distinct disability evaluated as 100-percent disabling, and
• no separate and distinct disability evaluated as 50-percent disabling.

• The appropriate SMC paragraph code is PB-1.
• The appropriate SMC coding is 20-20-21-00-0.

VIII.iv.4.A.5.h.  SMC for Bilateral Blindness With Bilateral Hearing Loss Considered 10- or 20-Percent Disabling

• SC bilateral blindness with LPO or less
• bilateral hearing loss, considered 10-or 20-percent disabling, and
• SC hearing loss in at least one ear.

VIII.iv.4.A.5.i.  Example 1:  Rating Decision Involving SMC for Bilateral Blindness With Bilateral Hearing Loss Considered 10- or 20-Percent Disabling

• anatomical loss of the left eye
• LPO in the right eye
• SC bilateral hearing loss, evaluated as 20-percent disabling
• no total hearing loss in either ear
• no separate and distinct disability evaluated as 100-percent disabling, and
• no separate and distinct disability evaluated as 50-percent disabling. 

• The appropriate SMC paragraph code is PB-2.
• The appropriate SMC coding is 21-21-11-11-0.

VIII.iv.4.A.5.j.  Example 2: Rating Decision Involving SMC for Bilateral Blindness With Bilateral Hearing Loss Considered 10- or 20-Percent Disabling

• anatomical loss of the left eye
• visual acuity of 5/200 (1.5/60) in the right eye
• SC bilateral hearing loss, evaluated as 20-percent disabling
• no total hearing loss in either ear
• no separate and distinct disability evaluated as 100-percent disabling, and
• no separate and distinct disability evaluated as 50-percent disabling. 

• The appropriate SMC paragraph code is MB-2.
• The appropriate SMC coding is 19-19-11-11-0.

VIII.iv.4.A.5.k.  SMC for Bilateral Blindness With Bilateral Hearing Loss Considered 30-Percent Disabling

• 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.

VIII.iv.4.A.5.l.  Example:  Rating Decision Involving SMC for Bilateral Blindness With Bilateral Hearing Loss Considered 30-Percent Disabling

• anatomical loss of the left eye
• visual acuity of 5/200 (1.5/60) in the right eye
• SC bilateral hearing loss evaluated as 30-percent disabling  
• no total hearing loss in either ear
• no separate and distinct disability evaluated as 100-percent disabling, and
• no separate and distinct disability evaluated as 50-percent disabling.

• The appropriate SMC paragraph code is PB-3.
• The appropriate SMC coding is 21-21-11-11-0.

VIII.iv.4.A.5.m.  SMC for Bilateral Blindness With Bilateral Hearing Loss Considered 40-Percent Disabling

• blindness with LPO or less in both eyes, and
• bilateral hearing loss, considered at least 40-percent disabling, or SC hearing loss in at least one ear. 

VIII.iv.4.A.5.n.  Example 1:  Rating Decision Involving SMC for Bilateral Blindness With Bilateral Hearing Loss Considered 40-Percent Disabling

• NLP in the right eye
• LPO in the left eye
• SC bilateral hearing loss evaluated as 40-percent disabling 
• no total hearing loss in either ear
• no separate and distinct disability evaluated as 100-percent disabling, and
• no separate and distinct disability evaluated as 50-percent disabling.

• The appropriate SMC paragraph code is OB-2.
• The appropriate SMC coding is 37-37-21-00-0.

VIII.iv.4.A.5.o.  Example 2: Rating Decision Involving SMC for Bilateral Blindness With Bilateral Hearing Loss Considered 40-Percent Disabling

• NLP in the right eye
• visual acuity of 5/200 (1.5/60) in the left eye
• SC bilateral hearing loss, evaluated as 40-percent disabling
• no total hearing loss in either ear
• no separate and distinct disability evaluated as 100-percent disabling, and
• no separate and distinct disability evaluated as 50-percent disabling.

• The appropriate SMC paragraph code is PB-3.
• The appropriate SMC coding is 21-21-21-00-0.

VIII.iv.4.A.5.p.  SMC for Bilateral Blindness With Bilateral Hearing Loss Considered 60-Percent Disabling

• visual acuity of 20/200 (6/60), bilaterally
• visual acuity of 20/200 (6/60) in one eye and LPO or less in the other eye LPO
• bilateral hearing loss, considered at least 60-percent disabling, and
• SC hearing loss in one ear.

VIII.iv.4.A.5.q.  Example:  Rating Decision Involving SMC for Bilateral Blindness With Bilateral Hearing Loss Considered 60-Percent Disabling

• LPO in the right eye
• visual acuity of 20/200 (6/60) in the left eye
• SC bilateral hearing loss, evaluated as 60-percent disabling
• no total hearing loss in either ear
• no separate and distinct disability evaluated as 100-percent disabling
• no separate and distinct disability evaluated as 50-percent disabling, and
• no entitlement to A&A.

• The appropriate SMC paragraph code is OB-1.
• The appropriate SMC coding is 37-37-21-00-0.

VIII.iv.4.A.5.r.   SMC for Bilateral Blindness With L/LOU of an Extremity Considered at Least 50-Percent Disabling

• 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.

VIII.iv.4.A.5.s.  Example:  Rating Decision Involving SMC for Bilateral Blindness With L/LOU of an Extremity Considered at Least 50-Percent Disabling

• SC bilateral blindness with visual acuity of 5/200 (1.5/60)
• SC LOU of the dominant hand evaluated as 50-percent disabling
• no separate and distinct disability evaluated as 100-percent disabling, and
• no separate and distinct disability evaluated as 50-percent disabling. 

• The appropriate SMC paragraph code is PB-4.
• The appropriate SMC coding is 25-25-35-00-0.

VIII.iv.4.A.5.t.  SMC for Bilateral Blindness With L/LOU of a Lower Extremity Considered Less Than 50-Percent Disabling

• visual acuity of 5/200 (1.5/60) or less, bilaterally
• L/LOU of a foot, considered less than 50-percent disabling, and
• no other compensable SC disability.

VIII.iv.4.A.5.u.  Example:  Rating Decision Involving SMC for Bilateral Blindness With L/LOU of a Lower Extremity Considered Less Than 50-Percent Disabling

• visual acuity of 5/200 (1.5/60), bilaterally
• a below-the-knee amputation of the right foot evaluated as 40-percent disabling, and
• no other compensable disabilities. 

• The appropriate SMC paragraph code is P B-6.
• The appropriate SMC coding is 24-24-21-13-0.

Introduction

• proper application of 38 CFR 3.350(f)(3) and 38 CFR 3.350(f)(4)
• SMC under
  • 38 CFR 3.350(f)(3), and
  • 38 CFR 3.350(f)(4)
• permanence requirement for SMC under 38 CFR 3.350(f)(3) and 38 CFR 3.350(f)(4), and
• an example of a rating decision involving SMC under
  • 38 CFR 3.350(f)(3), and
  • 38 CFR 3.350(f)(4).

Change Date

VIII.iv.4.A.6.a.  Proper Application of 38 CFR 3.350(f)(3) and 38 CFR 3.350(f)(4)

VIII.iv.4.A.6.b.  SMC Under 38 CFR 3.350(f)(3)

VIII.iv.4.A.6.c.  SMC Under 38 CFR 3.350(f)(4)

VIII.iv.4.A.6.d.  Permanence Requirement for SMC Under 38 CFR 3.350(f)(3) and 38 CFR 3.350(f)(4)

VIII.iv.4.A.6.e.  Example 1:  Rating Decision Involving SMC Under 38 CFR 3.350(f)(3)

• SMC under 38 U.S.C. 1114(m) on account of the anatomical loss of both hands, and
• two disabilities (blindness of one eye, having LPO, and loss of a creative organ) that each qualify for SMC under 38 U.S.C. 1114(k).

• blindness of the right eye, having LPO, evaluated as 30-percent disabling, and
• loss of both testes, evaluated as 30-percent disabling. 

VIII.iv.4.A.6.f.  Example 2:  Rating Decision Involving SMC Under 38 CFR 3.350(f)(4)

Introduction

• considering L/LOU of three extremities, and
• an example of a rating decision involving additional SMC for L/LOU of three extremities.

Change Date

VIII.iv.4.A.7.a.  Considering L/LOU of Three Extremities

• decide the rate of SMC payable without regard to 38 CFR 3.350(f)(5), and
• increase this rate to the next higher rate authorized under 38 U.S.C. 1114(l) through (n), without loss of any entitlement under 38 U.S.C. 1114(k).

• The term “next higher rate” is intended to include the intermediate rates authorized under 38 U.S.C. 1114(p).
• The total monthly amount payable (minus any additional amount for dependents) must not exceed the rate payable under 38 U.S.C. 1114(p). 

VIII.iv.4.A.7.b.  Example:  Rating Decision Involving Additional SMC for L/LOU of Three Extremities

Introduction

• criteria for entitlement to A&A under 38 CFR 3.352(a)
• considering
  • the level of disability required for entitlement to A&A
  • entitlement to A&A when the evaluation for a single disability is less than 100 percent
  • permanence when evaluating claims for A&A
  • entitlement to A&A as an inferred issue, and
  • the importance of reasoning in awarding SMC under 38 U.S.C 1114(l) when considering entitlement to A&A under 38 U.S.C. 1114(o)
• coding the rating decision to reflect entitlement to A&A or housebound
• denying entitlement to A&A
• entitlement to A&A under the provisions of PL 96-128, and
• drafting and coding the rating decision awarding entitlement to A&A under PL 96-128.

Change Date

VIII.iv.4.A.8.a.  Criteria for Entitlement to A&A Under 38 CFR 3.352(a)

• considering permanence in A&A determinations, see M21-1, Part VIII, Subpart iv, 4.A.8.d, and
• entitlement to special monthly spouse’s compensation based on a spouse’s need for A&A, see M21-1, Part VIII, Subpart iv, 4.A.12.

VIII.iv.4.A.8.b.  Considering the Level of Disability Required for Entitlement to A&A

• entitlement to SMC at the housebound rate, or
• a 100-percent schedular evaluation.

• The single disability rated as totally disabling must be the sole or partial cause of the need for A&A.
• 38 CFR 4.16 applies only to IU determinations.  It does not permit decision makers to apply 38 CFR 4.16 guidelines on what constitutes a single disability to A&A determinations.
• Temporary 100-percent evaluations under 38 CFR 4.28, 4.29, and 4.30 qualify for the single schedular evaluation needed for entitlement to A&A.  However, grants of entitlement to A&A are not routine in these circumstances.
• To establish entitlement to SMC (t), the need for A&A must be due to traumatic brain injury (TBI) or multiple disabilities due to TBI that combine to a 100-percent evaluation.

• when evaluations of facets or multisystem effects of a single disease entity (including, but not limited to multiple sclerosis, Parkinson’s disease or diabetes mellitus) combine to 100 percent without regard to other conditions and A&A is required as a result of SC disability.  Multisystem diseases are rated under a primary DC or by separate ratings of residuals under multiple DCs when more advantageous to the claimant, or
• when evaluations of primary and secondary SC disabilities combine to 100 percent and A&A is required as a result of SC disability. 

• when the schedular rating is less than 100 percent, see M21-1, Part VIII, Subpart iv, 4.A.8.c, and
• for residuals of TBI, see
  • 38 CFR 3.350(j), and
  • M21-1, Part VIII, Subpart iv, 4.A.11.

VIII.iv.4.A.8.c.  Considering Entitlement to A&A When the Evaluation for a Single Disability Is Less Than 100 Percent

• entitlement to A&A is at issue, and
• a Veteran’s evaluation for a single disability is less than 100 percent.

VIII.iv.4.A.8.d.  Considering Permanence When Evaluating Claims for A&A

VIII.iv.4.A.8.e.  Considering Entitlement to A&A as an Inferred Issue

VIII.iv.4.A.8.f.  Importance of Reasoning in Awarding SMC Under 38 U.S.C 1114(l) When Considering Entitlement to A&A Under 38 U.S.C. 1114(o)

• The need to explain the reasoning is especially important in situations in which, under 38 CFR 3.350(c), the rate under 38 U.S.C. 1114(l) 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(l) through (n) for the purpose of establishing entitlement under 38 U.S.C. 1114(o).
• Base the determination of need for A&A on separate and distinct disabilities if the rate under 38 U.S.C. 1114(l) on account of need for A&A is used to establish entitlement under 38 U.S.C. 1114(o).

VIII.iv.4.A.8.g.  Coding the Rating Decision to Reflect Entitlement to A&A or Housebound

• using the appropriate narrative rating code on the Codesheet, immediately following statement of the combined degree of disability, and
• entering the necessary SMC codes in the data table.

VIII.iv.4.A.8.h.  Denying Entitlement to A&A

• When A&A and/or housebound are not specifically claimed, do not infer entitlement to A&A or housebound SMC rates to deny the benefit(s).
• When VA Form 21-2680 is received, follow the procedures at M21-1, Part II, Subpart iii, 1.A.3.c to determine which issues must be addressed in a rating.
• A&A should not be denied if evidence indicates that an SC disability worsened, which is alleged or reasonably raised as a contributing factor to A&A, until a decision is rendered concerning the evaluation for the SC disability. 

VIII.iv.4.A.8.i.  Entitlement to A&A Under the Provisions of PL 96-128

• 38 U.S.C. 1114(r)(1) exists if the basic criteria contained in 38 CFR 3.352(a) are met, and
• 38 U.S.C. 1114(r)(2) exists if the basic criteria contained in 38 CFR 3.352(b) are met.

VIII.iv.4.A.8.j.  Drafting and Coding the Rating Decision Awarding Entitlement to A&A Under PL 96-128

• cite relevant evidence and information in the Narrative to fully justify awarding or denying A&A, and
• use SMC code 43 or 44 in higher level care claims. 

Introduction

• 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)
• evidentiary considerations for higher level of care
• processing 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).

Change Date

VIII.iv.4.A.9.a.  Entitlement to a Higher A&A Allowance Under 38 U.S.C. 1114(r)(2)

VIII.iv.4.A.9.b.  When to Award a Higher A&A Allowance Under 38 U.S.C. 1114(r)(2)

• need is clearly established, and
• the amount of skilled service required by the Veteran is substantial.

• VAOPGCPREC 23-1992, and
• M21-1, Part VIII, Subpart iv, 4.A.9.e.

VIII.iv.4.A.9.c.  Evidentiary Considerations for Higher Level of Care

• an ongoing need for skilled personal care, and
• in the absence of such care, the Veteran would require hospitalization, nursing home care, or other residential institutional care.

• conditions justifying the need for this level of 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.

VIII.iv.4.A.9.d.  Processing Claims for Entitlement to a Higher A&A Allowance Under 38 U.S.C. 1114(r)(2)

VIII.iv.4.A.9.e.  Possible Hospitalization Adjustment Under 38 CFR 3.552(b)(2)

Introduction

• statutory entitlement to housebound benefits
• defining a single disability for housebound purposes
• extraschedular consideration on housebound claims involving IU
• temporary total ratings used to award SMC (s)
• determining whether the Veteran is
  • permanently housebound in fact, and
  • substantially confined for housebound in fact entitlement, and
• protected evaluations in determination of housebound entitlement.

Change Date

VIII.iv.4.A.10.a.  Statutory Entitlement to Housebound Benefits

• has an additional SC disability, or combination of disabilities, independently evaluated as 60-percent or more disabling, or
• is permanently housebound due to SC disability.

• be separate and distinct from the single disability evaluated as totally disabling, and
• involve separate anatomical segments or body systems. 

• The principles regarding avoidance of pyramiding contained in 38 CFR 4.14 are applicable.
• Within these limits, the fact that the single disability, evaluated as totally disabling, and additional disability(ies), independently evaluated as 60-percent or more disabling, share a common etiology, does not preclude entitlement.
• In determining the eligibility for SMC benefits pursuant to 38 U.S.C. 1114(s), an erroneous disability evaluation that is protected by the 20-year rule under 38 CFR 3.951(b) must be used in calculating the total percentage of disability to establish eligibility as indicated in VAOPGCPREC 16-1989.

VIII.iv.4.A.10.b.  Defining a Single Disability for Housebound Purposes

• A total rating based on IU when awarded for multiple disorders treated as one disability under the five options listed in 38 CFR 4.16(a) does not satisfy the regulatory requirement under 38 CFR 3.350(i) of, “a single SC disability rated as 100 percent.”
• The Court of Appeals for Veterans Claims (CAVC) noted in Bradley v. Peake, 22 Vet.App. 280 (2008) that restrictive language precluding an IU evaluation from satisfying the “total” requirement of 38 U.S.C. 1114(s) was dropped from the implementing regulation, 38 CFR 3.350(i), in 1995 following VAOPGCPREC 2-1994 that held that 38 U.S.C. 1114 did not authorize such a restriction.
  • CAVC only clarified in the Bradley decision that there was no restriction under 38 U.S.C. 1114(s) preventing the consideration of a “total” evaluation based on an SC disability used for IU. 
  • If IU was granted based on a single disability and the Veteran has additional disabilities combining to 60 percent, SMC (s) can be granted prior to November 26, 2008, the date of the Bradley holding. 
  • Follow the procedures at M21-1, Part V, Subpart ii, 4.A.6.n to determine the proper effective date for entitlement to SMC based on the Bradley holding.

• Bradley v. Peake, 22 Vet.App. 280 (2008)
• Guerra v. Shinseki, 642 F.3d 1046 (Fed. Cir., 2011)
• Youngblood v. Wilkie, 31 Vet.App. 412 (2019), and
• VAOPGCPREC 66-1991.

VIII.iv.4.A.10.c.  Extraschedular Consideration in Housebound Claims Involving IU

VIII.iv.4.A.10.d.  Temporary Total Ratings Used to Award SMC (s)

VIII.iv.4.A.10.e.  Determining Whether the Veteran Is Permanently Housebound in Fact

• the place of residence and immediate premises, or
• ward or clinical areas, if institutionalized under 38 CFR 3.350(i)(2). 

VIII.iv.4.A.10.f.  Determining Whether the Veteran Is Substantially Confined for Housebound in Fact Entitlement

VIII.iv.4.A.10.g.  Protected Evaluations in Determination of Housebound Entitlement

Introduction

• change in law establishing SMC (t)
• developing for SMC (t)
• establishing entitlement to A&A at the (l) rate prior to rating for SMC (t), and
• processing
  • awards for SMC (t), and
  • hospitalization rates for SMC (t).

Change Date

VIII.iv.4.A.11.a. Change in Law Establishing SMC (t)

• need regular A&A for residuals of TBI, but
• are not eligible for higher level of A&A under (r)(2), and
• would require hospitalization, nursing home care, or other residential institutional care in the absence of regular A&A.

• SMC (t) authorized by PL 111-275 is not the same historical SMC (t) rate that was discontinued in 1986.  The current benefit cannot be awarded or rated using that historical code.
• 38 CFR 3.350(j), 38 CFR 3.352(b)(2), and 38 CFR 3.552(b)(2) were updated to implement PL 111-275 on June 7, 2018.  These regulatory amendments do not change entitlement to benefits under SMC (t) as was previously established under PL 111-275 and associated non-regulatory implementing guidance.

VIII.iv.4.A.11.b.  Developing for SMC (t)

VIII.iv.4.A.11.c.  Establishing Entitlement to A&A at the (l) Rate Prior to Rating for SMC (t)

VIII.iv.4.A.11.d.  Processing Awards for SMC (t)

VIII.iv.4.A.11.e.  Processing Hospitalization Rates for SMC(t)

• use the SMC calculator in the Job Aids webpage to determine the highest rate(s) of SMC
• enter the calculated rates into the VBMS-R SMC PARAGRAPH and SMC CODES screens, and
• place the following notation in the free text Codesheet SPECIAL NOTATION box: SMC(t) = (r)(2).

• If a Veteran is entitled to a higher rate than SMC (l), but less than SMC (r)(2), the appropriate level of SMC should be determined without accounting for an elevation to SMC (t).  This action will generate the correct hospitalization code.
• Reduction for hospitalization will be made to the rate equal to SMC (s) in cases where there is no underlying SMC entitlement other than to A&A.  Otherwise, the hospitalization rate will be paid according to underlying entitlement. 

Introduction

Change Date

VIII.iv.4.A.12.a.  Spousal A&A Criteria

• is blind with corrected visual acuity of 5/200 or less, in both eyes, or concentric contraction of the visual field to 5 degrees or less
• is a patient in a nursing home because of mental or physical incapacity, or
• has disabilities causing a factual need for A&A as defined in 38 CFR 3.352(a).

• special monthly spouse’s compensation, see 38 CFR 3.351
• effective dates for special monthly spouse’s compensation, see
  • 38 CFR 3.401(a)(3), and
  • M21-1, Part V, Subpart ii, 4.A.5.g
• reviewing VA Form 21-2680 for claims for spousal A&A, see M21-1, Part II, Subpart iii, 1.A.3.a
• requesting examinations for non-Veteran claimants and beneficiaries, see M21-1, Part IV, Subpart i, 2.E.2.a, and
• entitlement to special monthly pension, Dependency Indemnity Compensation, or death compensation based on the need for A&A of a surviving spouse, see M21-1, Part IX, Subpart ii, 1.A.1.d.

VIII.iv.4.A.12.b.  Requirement for a 30-Percent Rating