Welcome to
Special
Monthly
Compensation
11/16/2011 1
Objectives:
Clearly identify when the
application of Special Monthly
Compensation is appropriate for
levels of disability equivalent to S,
K and L
11/16/2011 2
SMC
Additional level of compensation to
veterans (above the basic levels of
compensation payable based on disability
ratings of 0 to 100 percent)
Various types of anatomical losses or
levels of impairment
Based solely on service connected
disabilities (also includes disabilities
service connected under paired organs
and/or extremities
11/16/2011 3
SMC
Should be inferred whenever there
is a severe level of disability
involving an extremity or sensory
organ or; whenever a 100 % service
connected disability is established.
11/16/2011 4
SMC
Rules for SMC include permanency
Disabilitiesat these levels should
for the most part be permanent
11/16/2011 5
SMC K 38 CFR 3.350 (a)
Loss, or loss (L/LOU) of use, of a creative organ
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; or
radiation of breast tissue.
11/16/2011 6
Loss, or Loss of Use, of a Creative Organ (1
or more-(K) 38 CFR 3.350 (a)(1)
Award SMC based on L/LOU of a creative
organ, if medical evidence of records shows
- the acquired absence of one or both testicles,
ovaries or other creative organs
- 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.
11/16/2011 7
L/LOU Creative Organ
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.
11/16/2011 8
L/LOU Creative Organ
SMC K may be considered for other
conditions which are part of the
reproductive tract, such as a male
veteran undergoing removal of the
epididymis or prostate gland, or a
female veteran who has her uterus
or a fallopian tube removed
11/16/2011 9
L/LOU Creative Organ
Note: SMC K can be assigned only once for
loss or loss of use of a creative organ even
though there may be more than one loss for a
creative organ
Example: anatomical loss of both testicles or
the removal of the uterus and ovaries will only
count as one K regardless of whether both losses
occur at the same time or separately.
11/16/2011 10
Question
The requirement for SMC K is met
whether there is absence of:
a. One testicle
b. Both testicles
c. One ovary
d. All of the above
11/16/2011 11
L/LOU Creative Organ
Elective surgery such as a
vasectomy or tubal ligation, would
not be considered loss or loss of use
of a creative organ.
11/16/2011 13
L/LOU Creative Organ
Loss of use of one testicle will be established
when:
The diameter of the affected testicle is reduced
to one-third of diameter of the paired testicle
The diameter of the affected testicle is reduced
to one-half of the corresponding normal testicle
and there is alteration of consistency so that the
affected testicle is harder or softer than the
corresponding normal testicle
Infertility is shown by biopsy.
11/16/2011 14
L/LOU Creative Organ
Atrophy due to mumps
Award SMC for loss of use of a creative organ
if loss of erectile power is shown, with or
without penile deformity. Must be factual
evidence must show the need for medication,
penile pump or the inability to obtain and
maintain an erection or to ejaculate. If evidence
is not sufficient to award SMC K we must ask
for an examination
11/16/2011 15
L/LOU Hand –K 38 CFR 3.350 (a)(2) and 38 CFR 4.63
L/LOU of a hand
- Exists when the function remaining would be no
better served than by amputation and
replacement by a prosthesis.
- Complete ankylosis of two major joints of an
upper extremity establishes loss of use of a
hand.
- Considerations-grasping or manipulation, fine
motor skills, weakness, requirements of braces
or splints.
11/16/2011 16
L/LOU Hand - K
In determining Loss the question
must be:
What can the person do with that extremity?
Is there any effective useful function remaining?
Can the hand hold things, button a shirt, or would
the veteran be equally well off with a
prosthesis?
11/16/2011 17
Question:
If a veteran could not pick up a coin
or hold a screwdriver, entitlement to
SMC K could be established due to
the inability to grasp and manipulate
tools.
A: True
B: False
11/16/2011 18
Question
Veteran is entitled to SMC K
because the shoulder is ankylosed
and in a position above his head.
He can manipulate his fingers and
grasp tools, but cannot reach his
mouth with his hand.
A: True B: False
11/16/2011 20
L/LOU Foot- K 38 CFR 3.350 (a)(2) and 38 CFR 4.63
Exists when the function is no better
than if the foot were to be amputated and
replaced by a prosthesis
It is unable to perform normal functions
such as balancing, propulsion, or
ambulation
11/16/2011 22
L/LOU of a foot
Consideration should be given to:
balancing, propulsion, or ambulation,
weakness, use of canes, braces etc.
Other Factors that establish LOU of a foot
includes:
11/16/2011 23
L/LOU of a foot
Extremely unfavorable complete ankylosis of
the knee.
Complete ankylosis of two major joints of an
extremity
Shortening of the lower extremity 3 ½ inches or
more.
Complete paralysis of the external popliteal
(common peroneal) nerve and consequent foot
drop, accompanied by characteristic organic
changes.
11/16/2011 24
L/LOU of a foot
Is there complete foot drop?
Can the veteran walk or is the foot
able to support the veterans weight?
If a veteran cannot balance on his
foot or push off from the foot in
walking entitlement to SMC K for
loss of use of a foot may be met.
11/16/2011 25
L/LOU of a foot
Tucker vs. West
The responsibility for determining
loss of use lies with the rating
specialist and not the examining
physician.
11/16/2011 26
L/LOU of a foot
Examinations should provide an
objective description of remaining
function, strength and pain.
11/16/2011 27
Loss/LOU of a hand or foot 38 CFR 3.383
If there is loss or loss of use of a hand or
foot which is service connected and the
veteran suffers loss or loss of use of the
other paired extremity as the result of non
service connected disability not due to
willful misconduct-Compensation will be
paid as if both extremities were service
connected
11/16/2011 28
•L/LOU both Buttocks 38 CFR 3.350 (a)(3) and 38 CFR
4.64
Loss or loss of use of both buttocks exists
when :
Severe damage by disease or injury to
muscle group XVII (DC 5317) bilateral
Inability to rise without assistance from a
seated or stooped position
Inability to maintain postural stability
(stand erect)
11/16/2011 29
L/LOU both Buttocks
Must be able to perform activities
without assistance
If hands or arms are used or, for
postural stability an appliance is
used …….
SMC will still be established !
11/16/2011 30
L/LOU both Buttocks
Watch as veteran stands from a seated
position in a chair
Is the veteran able to stand up straight
from a stooped position?
Is the veteran able to stand erect with
torso over legs?
11/16/2011 31
Blindness of one Eye-K 38 CFR 3.350 (a)(4), 38 CFR
4.79
SMC K for the loss of use or blindness of one
eye exists when there is light perception only
(LPO).
SMC K is also established when there is
anatomical loss of the eye
LPO exists when there is inability to recognize
test letters at a distance of one foot and when
further examination of the eye reveals that
perception of objects, hand movements, or
counting fingers cannot be accomplished at
three feet.
11/16/2011 32
Blindness of one Eye-K
For SMC purposes for each level of SMC the
degree of blindness is specified.
When there is total blindness in one eye which
is SC and the veteran has suffered a total
blindness in the other eye as a result of a NSC
disability not the result of willful misconduct,
compensation for total blindness in both eyes
will be established as though both eyes were
service connected. 38CFR 3.383
11/16/2011 33
SMC K for Deafness of both ears 38 CFR
3.350(a)(5)
Deafness of both ears exists when there is
absence of air and bone conduction.
Absence of air and bone conduction
exists when a licensed audiologist under
current testing criteria shows that
bilateral hearing los is equal to or greater
than the minimum bilateral hearing loss
required for a maximum rating evaluation
under the rating schedule
11/16/2011 34
SMC K for Deafness of both ears
A numerical designation of XI or 100 percent in
both ears meets this requirement, while a
designation of less than XI in either ear will
preclude entitlement.
If total deafness in one ear is SC and the veteran
suffered total deafness in the other ear as the
result of a NSC disability, not due to willful
misconduct, the total deafness in both ears will
be rated as if SC. 38 CFR 3.383 effective
December 1, 1965
11/16/2011 35
Question
A veteran is entitled to SMC K for
deafness if hearing is rated at:
a. Both ears 90%
b. Both ears 100%
c. One ear 10%
d. One ear 90%
11/16/2011 36
Complete Organic Aphonia 38 CFR 3.350 (a)(6)
Complete Organic Aphonia exists
when:
There is a disability of the organs of
speech that constantly precludes
communication by speech.
11/16/2011 38
Complete Organic Aphonia
Usually a result from the loss or paralysis
of an organ of speech, such as the tongue
or larynx.
The veteran must be unable to
communicate by voice or whisper
through normal speech. Example: a total
laryngectomy meets the requirement for
SMC K.
Stenosis of the larynx or loss of the
tongue may also result in aphonia
11/16/2011 39
Complete Organic Aphonia
The use of other organs of the body
or prosthetic devices to provide
voice sound will not preclude
entitlement to this benefit.
11/16/2011 40
Loss of tissue from one or both breasts
Entitlement to SMC for loss of tissue from one or both breasts is
limited to women veterans.
PL 107-330, enacted December 6, 2002, provides for 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.
11/16/2011 41
Loss of tissue from one or both breasts
Anatomical loss of a breast exists when
there is complete surgical removal of
breast tissue or the equivalent loss of
breast tissue due to injury.
Radical mastectomy, modified radical
mastectomy and simple (or total)
mastectomy result in anatomical loss of a
breast, but wide local excision, with or
without significant alteration of size or
form, does not
11/16/2011 42
Loss of tissue from one or
both breasts
Radical mastectomy- removal of the entire breast,
underlying pectoral muscles, and regional lymph nodes up
to the coracoclavicular ligament.
Modified radical mastectomy removal of entire breast and
axillary lymph nodes (pectoral muscles remain intact
Simple (or total) mastectomy removal of all breast tissue,
nipple and a small portion of the overlying skin (muscle
and lymph nodes remain intact)
Wide Local excision (including partial mastectomy,
lumpectomy, tylectomy, segmentectomy and
quadrantectomy) means removal of a portion of the breast
tissue.
Loss of tissue from one or both breasts
Fast Letter 09-25 dated June 4, 2009 Review of all female
veterans granted service connection for injury or disease of the
breast and/or reproductive system
A review showed many of these women did not receive the
SMC K benefit for loss of use of a creative organ or loss of use
of tissue from one or both breasts
11/16/2011 44
SMC “k” Based on Service Connection for Mastectomy,
Loss of Breast Tissue, or Radiation Treatment
Effective November 1, 2000, section 1114(k) of the
United States Code was amended to allow SMC for
Women Veterans who suffered service-connected loss of
one or both breasts, including loss by mastectomy.
If service connection was established for loss of one or
both breasts, including loss by mastectomy, before
November 1, 2000, and SMC “k” was not granted, grant
the benefit effective April 16, 2008 (one year prior to the
date of administrative review), in compliance with the
provisions of 38 C.F.R. § 3.114(a)(2).
Summary of SMC K
SMC K covers single losses of the hand, foot,
buttocks, creative organ, blindness, LPO
deafness, organic aphonia and anatomical loss
of one or both breasts (mastectomy and
radiation)
May be entitled to more than one K based on
combinations of loss or loss of use.
No more than three K’s are assignable and the
basic rate of compensation payable of the basis
of degree of disability may not exceed the
monthly rate under SMC L
11/16/2011 46
SMC L
When a veteran suffers multiple losses
such as the loss of both lower extremities
the level of loss is also important in
arriving at the correct rate of SMC
The upper extremities have three levels
which are the hand, elbow and shoulder
and the lower extremities consist of the
foot, knee and hip
11/16/2011 47
SMC L
Any loss or loss of use below the
elbow is considered at the hand
level
Any loss or loss of use below the
knee is considered a loss at the foot
level.
11/16/2011 48
SMC L 38 CFR 3.350(a),(f)
Entitlement to a level of Special
Monthly Compensation equivalent
to L exists when:
- anatomical loss or loss of use of both feet.
- anatomical loss or loss of use of one hand and one foot
- blindness in both eyes with vision 5/200 or less or the
visual field restricted to 5 degrees or less
- permanently bedridden or in need of aid and
attendance
11/16/2011 49
L/LOU both feet- L
Anatomical loss is met with a below knee
amputation of both lower extremities
A SC BKA of one extremity with BKA of the
NSC lower extremity not due to willful
misconduct 38 CFR 3.383
Loss of use is held to exist when there is no
better function than if the lower extremities
were amputated and replaced by a suitable
prosthesis. This means the feet are not capable
of functions such as balancing, propulsion or
ambulation
11/16/2011 50
Question
Vet is SC for a stroke he suffered
while on active duty, as a result of
the stroke he has a useless right
hand and foot drop on the right
lower extremity requiring a brace.
Does this veteran meet criteria for
entitlement to SMC L?
11/16/2011 51
Loss or loss of use of one hand and one
foot 38 CFR (b)(1)
The loss of use of a hand and foot is held to
exist when the function would be no better than
if it were amputated
These combinations should be evaluated under
one diagnostic code at 100 percent.
A common mistake of raters is to evaluate these
as separate disabilities which would result in an
evaluation less than 100%. DC’s for these
combinations are between 5104 and 5111
11/16/2011 53
Blindness of both eyes 38 CFR 3.350 (b)(2)
SMC L for vision exists if the
bilateral visual acuity is 5/200 or
less. This means:
Blindness in both eyes with visual acuity
of 5/200 or less; or concentric contraction
or visual field restriction is to 5 degrees
or less in both eyes (equivalent to 5/200)
11/16/2011 54
Blindness SMC L
An evaluation at 100 % based on
acuity less than 10/200 but not to
5/200 does not entitle a veteran to
SMC L. The actual disability must
be 5/200 or less.
11/16/2011 55
Aid and Attendance-L
Aid and attendance must be necessary
solely due to SC disabilities and because
of these disabilities the veteran requires
aid and attendance.
At least one of the service connected
disabilities must be rated at 100%
The need must be regular, but need not
constant.
11/16/2011 56
Aid and Attendance-L
If service connected for disabilities
which result in loss of both feet or a
hand and a foot or other
combinations of extremities aid and
attendance cannot be assigned due
to these losses as the veteran is
already getting the greater benefit.
11/16/2011 57
Aid and Attendance-L
Combinations of anatomical loss or loss of use
of an extremity will not be reduced on
hospitalization. They will continue to be
compensated at the basic rate. Please note: If
veteran is entitled to SMC based on aid and
attendance, the basic rate will be reduced on
hospitalization
Exception: No reduction will be made when
hospitalized if the veteran is bedridden due to
SC disabilities .
11/16/2011 58
Summary of SMC L
To Qualify for SMC L, one of the
following criteria must be met:
Anatomical loss or loss of use of both feet.
Anatomical loss or loss of use of one hand and one foot.
Blindness in both eyes with vision 5/200 or less
Permanently bedridden or in need of aid and attendance.
11/16/2011 59
Housebound (In fact ) S 38 CFR 3.350(i)(2)
Usually evaluated as 100 percent
disabled
Veteran must be permanently
housebound by reason of SC disability.
Substantially confined to immediate
dwelling or premises due to SC
disabilities and they are reasonably
certain to continue throughout his or her
lifetime. (Permanent)
If
11/16/2011 60
Statutory Housebound-S 38 CFR 3.350 (i)
Also referred to as total +60 or 100 +60.
If veteran has single disability which is rated as
100 percent and additional disabilities
independently ratable at 60 percent, separate and
distinct from the 100 percent SC disability and
involving different anatomical segments or
bodily systems
NOTE: If the total disability and independent 60
percent result from a common etiology
entitlement will not be precluded.
11/16/2011 61
Statutory Housebound-S
Total evaluations under 38 CFR
4.28, 4.29, and 4.30 satisfy the
requirements for a total evaluation
(O.G.C. Precedent Opinion 2-94)
11/16/2011 62
Entitlement to Housebound based on
Individual Unemployability
Fast Letter 09-33, dated July 22, 2009 in
response to the court case of Bradley v Peake
Allows SMC of S based on housebound in fact
and housebound (total +60) if
IU is based on a single disability and has
additional disabilities which combine to 60
percent, or; the veteran is permanently
housebound by reason of a service-connected
disability or disabilities.
11/16/2011 63
HB based on IU
The Court’s holding allows a TDIU
rating to serve as the “total” service-
connected disability, if the TDIU
entitlement was solely predicated
upon a single disability for the
purpose of considering entitlement
to SMC at the (s) rate.
HB based on IU
In applying the Court’s holding, if the medical
evidence is insufficient to render an adjudicative
determination as to whether the veteran’s TDIU
entitlement solely originates from a single
service-connected disability, and there is
potential entitlement to SMC at the (s) rate, the
veteran should be scheduled for a VA
examination to include an opinion as to the
cause of unemployability.
11/16/2011 65