Citation Nr: 1007685 Decision Date: 03/02/10 Archive Date: 03/11/10 DOCKET NO. 07-04 341 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUES 1. Entitlement to service connection for a bilateral wrist and hand disability. 2. Entitlement to service connection for an eating disorder. 3. Entitlement to service connection for a low back disability. 4. Entitlement to service connection for a heart disability. 5. Entitlement to an initial compensable evaluation for bilateral hearing loss disability. 6. Entitlement to an initial compensable evaluation for sinusitis. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD J. Barone, Counsel INTRODUCTION The Veteran had active service from December 1986 to December 2004. This matter comes before the Board of Veterans' Appeals (Board) from a rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The issues of entitlement to service connection for a bilateral wrist and hand disability and low back disability, as well as the evaluations of hearing loss and sinusitis are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. An eating disorder was not manifest in service and there is no credible or competent evidence of a current eating disorder. 2. A heart disability was not manifest in service or within one year of retirement from service; there is no credible or competent evidence of a current heart disability. 3. Bilateral hearing loss disability is manifested by Level III hearing loss in the right ear and Level III hearing loss in the left ear. CONCLUSIONS OF LAW 1. An eating disorder was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. § 3.303 (2009). 2. A heart disability was not incurred in or aggravated by service, and may not be presumed to have been incurred therein. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2009). 3. The criteria for a compensable rating for bilateral hearing loss disability have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.85, Tables VI, VIA, VII, Diagnostic Code 6100, 4.86 (2009). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act of 2000 (VCAA) describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2009). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2009); 38 C.F.R. § 3.159(b) (2009); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. VCAA notice should be provided to a claimant before the initial unfavorable RO decision on a claim. See Pelegrini v. Principi, 18 Vet. App. 112 (2004); Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). On March 3, 2006, the Court of Appeals for Veterans Claims (Court) issued a decision in the consolidated appeal of Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), which held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) Veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. The Court held that upon receipt of an application for a service-connection claim, 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating or is necessary to substantiate the elements of the claim as reasonably contemplated by the application. Id. at 486. In July 2004, prior to his retirement, the Veteran acknowledged that he had been advised of the provisions of the VCAA, and that he did not have or know of any other sources of evidence. At that time, he was advised of the evidence of record and told how VA would assist him in obtaining relevant evidence. The evidence necessary to support a claim for service connection was discussed. In December 2007, the Veteran was advised of the manner in which VA determines disability ratings and effective dates. Except as discussed below, the content of the notice provided to the Veteran fully complied with the requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) regarding VA's duty to notify. The Veteran has been provided with every opportunity to submit evidence and argument in support of his claims and to respond to VA notices. Further, the Board finds that the purpose behind the notice requirement has been satisfied because the Veteran has been afforded a meaningful opportunity to participate effectively in the processing of his claims. Therefore, the record reflects that he was provided with a meaningful opportunity during the pendency of his appeal such that the preadjudicatory notice error did not affect the essential fairness of the adjudication now on appeal. With respect to VA's duty to assist, VA examinations have been conducted, and the Board finds that the examinations were adequate in that they were performed by neutral, skilled providers who accurately recited the Veteran's history. Moreover, the report of the November 2006 audiometric examination provides the data required to appropriately rate the Veteran's hearing loss. The Board observes that in Martinak v. Nicholson, 21 Vet. App. 447 (2007), the Court, noted that VA had revised its hearing examination worksheets to include the effect of the Veteran's hearing loss disability on occupational functioning and daily activities. See Revised Disability Examination Worksheets, Fast Letter 07-10 (Dep't of Veterans Affairs Veterans Apr. 24, 2007); see also 38 C.F.R. § 4.10 (2009). The Court also noted, however, that even if an audiologist's description of the functional effects of the Veteran's hearing disability was somehow deficient, the Veteran bears the burden of demonstrating any prejudice caused by a deficiency in the examination. The Veteran has not asserted that there is any deficiency in the November 2006 VA examination. The Veteran has not otherwise identified any additional evidence or information which could be obtained to substantiate the claims. The Board is also unaware of any such outstanding evidence or information. Therefore, the Board is also satisfied that VA has complied with the duty to assist requirements of the VCAA and the implementing regulations. Finally, with respect to the Veteran's claim for a compensable evaluation for bilateral hearing loss disability, the Board observes that the Veteran is challenging the initial evaluation assigned following the grant of service connection. In Dingess, the Court of Appeals for Veterans Claims held that in cases where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service-connection claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Id. at 490-91. The notice provided in July 2004 predated the grant of service connection. Thus, because the notice that was provided before service connection was granted was legally sufficient, VA's duty to notify in this case has been satisfied. For the foregoing reasons, it is not prejudicial to the Veteran for the Board to proceed to a final decision in this appeal. Analysis Service Connection As an initial matter the Board notes that the Veteran has not alleged that his claimed disabilities result from combat service. Therefore, the combat provisions of 38 U.S.C.A. § 1154 are not applicable. Entitlement to VA compensation may be granted for disability resulting from disease or injury incurred in or aggravated by active duty. 38 U.S.C.A. §§ 1110 (wartime service), 1131 (peacetime service); 38 C.F.R. § 3.303. To establish a right to compensation for a present disability, a Veteran must show: "(1) the existence of a present disability; (2) in- service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service"-the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may be granted for any disease initially diagnosed after service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. 38 C.F.R. § 3.303(b). If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. Service connection may also be granted for any disease diagnosed after discharge when all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). In Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C.A. § 7104(a). Moreover, the Court has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b). Eating Disorder Service treatment records disclose that on examination in November 1985 and February 1986, the Veteran was assessed as psychiatrically normal. In July 1987 the Veteran complained of a weight problem and indicated that he induced vomiting. On mental health consult in August 1987 the provider determined that the Veteran did not meet the diagnostic criteria for bulimia. The provider indicated that the Veteran would be followed with behavioral counseling for weight loss and maintenance. On separation examination in May 2004, the Veteran denied nervous trouble of any sort. He also denied that he had received counseling of any type or having been evaluated or treated for a mental condition. In August 2004 the Veteran was seen for reported anxiety attacks. He reported a past history of bulimia from 1987 to 2000, resolved. The diagnosis was adjustment disorder with mixed anxious and depressed mood, mild. On VA psychiatric examination in September 2006, the Veteran reported problems with anxiety. He stated that his appetite was variable. Following mental status examination, the diagnosis was PTSD. In his December 2006 substantive appeal, the Veteran stated that he developed an eating disorder trying to maintain Army weight standards. Having carefully reviewed the record pertaining to this claim, the Board has determined that service connection for an eating disorder is not warranted. In this regard, the Board notes that while the Veteran reported self induced vomiting in service, mental health consultation in August 1987 resulted in no diagnosis of an eating disorder. On separation examination in May 2004, the Veteran specifically denied nervous trouble or having received counseling, evaluation, or treatment for a mental condition. At that time, he was noted to be psychiatrically normal. The Board has considered the Veteran's statements and acknowledges that the Veteran is competent to diagnose and report on simple conditions. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (explaining in footnote 4 that a Veteran is competent to provide a diagnosis of a simple condition such as a broken leg, but not competent to provide evidence as to more complex medical questions). However, competency must be distinguished from credibility, and, in this instance, the Board finds the Veteran's assertions that he developed an eating disorder in service not credible. In fact, the Veteran has neither produced nor identified evidence demonstrating an eating disorder during service or following discharge. Most significantly, at discharge the Veteran denied any history of nervous trouble, or having received treatment for a mental condition. The Board has considered the decision in Buchanan v. Nicholson, 451 F. 3d 1331, 1336-37 (Fed. Cir. 2006), wherein the Federal Circuit determined that the Board erred by finding that a claimant's report of in-service symptoms lacked credibility solely because there was no objective medical evidence corroborating those symptoms at the time. However, the Board believes the instant case is clearly distinguishable, as the Board does not rely solely upon a general absence of complaints during service. Rather, it relies on the fact that the Veteran specifically reported self induced vomiting on one occasion and was found not to meet the criteria for a diagnosis of bulimia. Following that instance of treatment, there are no further complaints, diagnoses, or treatment referable to any eating disorder. Moreover, there is no indication of a current eating disorder. The Veteran has not identified or produced any evidence, medical or otherwise, that would tend to show that he currently has an eating disorder that is related to service. See Sanchez-Benitez v. Principi, 259 F.3d 1356 (2001). Rather, he has stated only that he developed an eating disorder trying to maintain Army weight standards; however, as noted above, no such disorder was diagnosed during service, and there is no competent evidence reflecting a current diagnosis. Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. In the absence of proof of a present disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). In summary, there is no credible evidence of a chronic disability in service, no credible evidence of a continuity of symptomatology since service, and no medical evidence establishing any current eating disorder. As the preponderance of the evidence is against the claim, there is no doubt to be resolved. Consequently, the benefit sought on appeal is denied. Heart Review of the service treatment records indicates that EKG testing in November 1985 and February 1986 was normal. EKG was also normal in May 1987. In April 1997, the Veteran reported a history of palpitations and heart trouble. EKG revealed sinus bradycardia but was otherwise normal. EKG in September 1999 also revealed sinus bradycardia. In October 1999, the Veteran was seen for chest pain that came and went. EKG revealed normal sinus rhythm with occasional premature supraventricular complexes, and was otherwise normal. Borderline hypertension was noted on physical examination. On follow-up later that month, the assessment was atypical chest pain. The provider noted that myocardial infarction was ruled out. She noted that she had a lengthy discussion with the Veteran regarding other possible causes of chest pain, to include gastrointestinal symptoms, musculoskeletal causes such as costochondritis, and anxiety related symptoms. On medical board evaluation for his right knee in May 2004, the Veteran denied any significant medical problems. He did endorse a history of palpitation, pounding heart, or abnormal heart beat. The examiner noted that the Veteran had experienced premature ventricular contractions in 1993 and 1994, but that they had resolved. Physical examination revealed normal heart and chest. On VA examination in September 2006, the Veteran reported that he began having chest pain in 1991 and that he was worked up with negative results. He stated that his symptoms worsened in 1999, and he was diagnosed with Barrett's esophagus, gastroesophageal reflux, and hiatal hernia. He indicated that he had sharp, stabbing pain across his chest. Diagnoses did not include any finding referable to the Veteran's heart. Barrett's esophagus, hiatal hernia, and reflux were diagnosed. In December 2006 the Veteran stated that he suffered from chest pain during service. He argued that it was related to stress during active duty. Upon review of the record pertaining to this claim, the Board has determined that service connection for a heart disability is not warranted. In this regard, the Board notes that while the Veteran complained of chest pain during service, no cardiac diagnosis was made. Rather, atypical chest pain was noted in October 1999, and the provider discussed with the Veteran the possible causes of his symptoms, to include gastrointestinal, musculoskeletal, and anxiety related causes. On discharge examination in May 2004, the Veteran's heart and chest were normal. The Board has considered the Veteran's statements and acknowledges that the Veteran is competent to diagnose and report on simple conditions, to include chest pain. See Jandreau, supra. However, competency must be distinguished from credibility, and, in this instance, the Board finds his reports of developing a chronic disability related to his chest pain not credible. In fact, the Veteran has neither produced nor identified evidence demonstrating a heart disability. The Board again observes that while the May 2004 examiner noted a history of chest pain and premature ventricular contractions, the symptoms had resolved and the Veteran's heart and chest were normal. The Board has considered the decision in Buchanan, supra. However, the Board believes the instant case is clearly distinguishable, as the Board is not relying solely upon a general absence of complaints during service. Rather, it relies on the fact that the Veteran was worked up for chest pain and additionally underwent EKG testing during routine examinations, and no heart disability was diagnosed. Moreover, there is no indication of a current heart disability. The Veteran has not identified or produced any evidence, medical or otherwise, that would tend to show that he currently has a heart disability that is due to disease or injury in service. See Sanchez-Benitez v. Principi, 259 F.3d 1356 (2001). Rather, he has stated only that he experienced chest pain. Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. In the absence of proof of a present disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). In summary, there is no credible evidence of a chronic disability in service, no credible evidence of a continuity of symptomatology since service, and no medical evidence establishing any current disability of the heart. As the preponderance of the evidence is against the claim, there is no doubt to be resolved. Consequently, the benefit sought on appeal is denied. Evaluation of Bilateral Hearing Loss Disability Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule), found in 38 C.F.R. Part 4. The Board attempts to determine the extent to which the Veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, and the assigned rating is based, as far as practicable, upon the average impairment of earning capacity in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.10. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. The Board observes that in cases where the original rating assigned is appealed, consideration must be given to whether a higher rating is warranted at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119 (1999). The Board has considered whether staged ratings are warranted. However, the disability has not significantly changed and a uniform evaluation is warranted. Evaluations of hearing loss range from noncompensable to 100 percent, based upon organic impairment of hearing acuity as measured by the results of controlled speech discrimination tests, together with the average hearing threshold level as measured by pure tone audiometry tests in the frequencies 1000, 2000, 3000, and 4000 cycles per second. 38 C.F.R. § 4.85(a) and (d). To evaluate the degree of disability for service-connected bilateral hearing loss, the rating schedule establishes eleven (11) auditory acuity levels, designated from level I, for essentially normal acuity, through level XI, for profound deafness. 38 C.F.R. § 4.85, Diagnostic Code 6100. The assignment of disability ratings for hearing impairment is derived by a mechanical application of the rating schedule to the numeric designations assigned after audiometric evaluations are rendered. See Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). When the pure tone thresholds at the four specified frequencies (1000, 2000, 3000, and 4000 hertz) are 55 decibels or more, or when the pure tone thresholds are 30 decibels or less at 1000 Hz and 70 decibels or more at 2000 Hz, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIa, whichever results in the higher numeral. That numeral will then be elevated to the next highest Roman numeral. 38 C.F.R. § 4.86. The Board notes that the Veteran's hearing loss disability does not comport with either of these exceptional patterns of hearing impairment. Examinations are conducted using the controlled speech discrimination tests, together with the results of the puretone audiometry test. The horizontal lines in table VI, referenced in 38 C.F.R. § 4.85, represent nine categories of percent of discrimination based upon the controlled speech discrimination test. The vertical columns in table VI represent nine categories of decibel loss based upon the puretone audiometry test. The numeric designation of impaired efficiency (I through XI) will be determined for each ear by intersecting the horizontal row appropriate for the percentage of discrimination and the vertical column appropriate to puretone decibel loss; thus, for example, with a percent of discrimination of 70 and average puretone decibel loss of 64, the numeric designation is V for one ear. The same procedure will be followed for the other ear. The numeric designations are then applied to table VII, also referenced in 38 C.F.R. § 4.85, to determine the Veteran's disability rating. The Veteran submitted to a VA examination in November 2006. The examiner noted that audiometric testing in April 2004 revealed a mild notching hearing loss at 4000 Hz with all other test frequencies falling within normal to borderline normal limits. The Veteran indicated that he had noticed a significant worsening of his hearing in the previous two years. Diagnostic testing resulted in the following puretone thresholds: HERTZ Average 1000 2000 3000 4000 Right 20 20 30 45 29 Left 15 20 30 50 29 Speech recognition scores were 80 percent bilaterally. The Board observes that application of the regulation to the findings on the November 2006 audiometric evaluation results in a numeric designation of III for the right ear and III for the left. A noncompensable evaluation is warranted when those values are applied to Table VII. 38 C.F.R. § 4.85, Diagnostic Code 6100. Thus, the record demonstrates that the schedular rating assigned by the RO is correct. The Board has also considered whether the Veteran has an exceptional pattern of hearing impairment. 38 C.F.R. § 4.86. However, the evidence demonstrates that the Veteran did not have a threshold of 55 decibels or more at the indicated frequencies or a puretone threshold of 30 or less at 1000 Hertz and 70 or more at 2000 Hertz. Therefore, the provisions of 38 C.F.R. § 4.86 are not applicable in this case. The potential application of various provisions of Title 38 of the Code of Federal Regulations has also been considered but the record does not present such "an exceptional or unusual disability picture as to render impractical the application of the regular rating schedule standards." 38 C.F.R. § 3.321(b)(1). In this regard, the Board finds that there has been no showing by the Veteran that the service- connected hearing loss disability has resulted in marked interference with employment or necessitated frequent periods of hospitalization, or otherwise rendered impractical the application of the regular rating schedule standards. Furthermore, with regard to whether the schedular criteria for hearing loss are adequate in this case, although the assignment of disability evaluations is based on a mechanical application of numerical tables to the numerical findings upon audiological evaluation, the Board finds that the numerical criteria in the rating schedule contemplate the impairment of function that is experienced by the Veteran. Specifically, the Board determines that the decibel loss and speech discrimination ranges designated for each level of hearing impairment in Tables VI and VIA were chosen in relation to clinical findings of the impairment experienced by Veterans with certain degrees and types of hearing disability. In support of this finding, the Board points to the regulatory history of 38 C.F.R. §§ 4.85 and 4.86. The rating criteria for hearing loss were last revised, effective June 10, 1999. See 64 Fed. Reg. 25,200 (May 11, 1999). In forming these revisions, VA sought the assistance of the Veteran's Health Administration (VHA) in developing criteria that contemplated situations in which a Veteran's hearing loss was of such a type that speech discrimination tests may not reflect the severity of communicative functioning these Veterans experienced or that was otherwise an extreme handicap in the presence of any environmental noise, even with the use of hearing aids. VHA had found through clinical studies of Veterans with hearing loss that when certain patterns of impairment are present, a speech discrimination test conducted in a quiet room with amplification of the sounds does not always reflect the extent of impairment experienced in the ordinary environment. Id. The decibel threshold requirements for application of Table VIA were based on the findings and recommendations of VHA. The intended effect of the revision was to fairly and accurately assess the hearing disabilities of Veterans as reflected in a real life industrial setting. 59 Fed. Reg. 17,295 (April 12, 1994). Accordingly, the Board finds that functional impairment due to hearing loss that is compounded by background or environmental noise is a disability picture that is considered in the current schedular rating criteria. Therefore, the simple fact that the Veteran's hearing disability does not satisfy the numerical criteria for a compensable rating under these criteria, to include the criteria specifically designed for the type of real-world impairment experienced by the Veteran, does not place his symptomatology outside of that contemplated by the rating schedule or make application of the rating schedule impracticable in this case. Accordingly, the Board determines that the Veteran's complaints of hearing difficulty, have been considered under the numerical criteria set forth in the rating schedule. Thus, the Board determines that the schedular rating criteria adequately contemplate the Veteran's symptomatology, and that the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet.App. 337 (1996); Shipwash v. Brown, 8 Vet.App. 218, 227 (1995). ORDER Entitlement to service connection for an eating disorder is denied. Entitlement to service connection for a heart disability is denied. Entitlement to an initial compensable evaluation for bilateral hearing loss is denied. REMAND The Veteran claims that he has a back disability and a bilateral wrist disability that are related to service. The Board observes that goniometer readings apparently taken in August 2004, prior to the Veteran's retirement from service, show some limitation of motion of the lumbar spine and wrists. As a full examination report is not of record, it is unclear whether any pertinent diagnoses were rendered. As functional impairment was noted prior to discharge, the Board has determined that a VA examination is necessary to determine whether there is any current disability, and if so, whether such are related to the findings in service. The Veteran is in receipt of a noncompensable evaluation for sinusitis. A higher evaluation requires evidence of one or two incapacitating episodes per year requiring prolonged (lasting four to six weeks) antibiotic treatment or more than six non-incapacitating episodes per year characterized by headaches, pain, and purulent discharge or crusting. 38 C.F.R. § 4.97, Diagnostic Code 6511 (2009). The September 2006 VA examination did not address whether the Veteran experiences purulent discharge or crusting. Moreover, in December 2006, the Veteran stated that he suffered from daily sinus headaches. He also stated that he was prescribed antibiotics on average two times per year. Based on this evidence, it is unclear whether the Veteran does in fact meet the criteria for a compensable evaluation for sinusitis. Therefore, an additional VA examination is warranted to assess the severity of this disability. In light of the above discussion, the Board has determined that additional development is required in this case. Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for a VA orthopedic examination to determine the extent and etiology of his claimed low back, and bilateral wrist and hand disabilities. All necessary testing should be carried out in conjunction with this examination, the results of which should be reported in detail. Additionally, a complete history should be elicited from the Veteran. The claims file and a copy of this remand should be provided to the examiner for review. Following examination, interview of the Veteran, and review of the claims file, the examiner should provide an opinion as to whether it is more likely than not (i.e., probability greater than 50 percent), at least as likely as not (i.e., probability of 50 percent), or less likely than not (i.e., probability less than 50 percent) that the Veteran's claimed low back disability, and bilateral wrist and hand disability is related to any disease or injury in service. A discussion of the complete rationale for all opinions expressed should be included in the examination report. 2. Schedule the Veteran for a VA otolaryngology examination to determine the severity of his service-connected sinusitis. All necessary testing should be carried out in conjunction with this examination, the results of which should be reported in detail. Additionally, a complete history should be elicited from the Veteran. The claims file and a copy of this remand should be provided to the examiner for review. Following examination, interview of the Veteran, and review of the claims file, the examiner should identify all current manifestations of the Veteran's sinusitis. The examiner should also discuss the history of this disability in terms of the number of incapacitating and non-incapacitating episodes the Veteran experiences per year. The examiner should be informed of the regulatory definitions of incapacitating and non- incapacitating episodes as they pertain to the evaluation of sinusitis. A discussion of the complete rationale for all opinions expressed should be included in a written report. 3. The Veteran is hereby notified that it is his responsibility to report for any examination, and to cooperate in the development of the claims. The consequences for failure to report for a VA examination without good cause may include denial of the claims. 38 C.F.R. §§ 3.158, 3.655 (2009). 4. Readjudicate the Veteran's claims, with application of all appropriate laws, regulations, and case law, and consideration of any additional information obtained as a result of this remand. If the decision remains adverse to the Veteran, he and his representative should be furnished a supplemental statement of the case and afforded an appropriate period of time within which to respond thereto. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2009). ______________________________________________ LANA K. JENG Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs