Citation Nr: 1324101 Decision Date: 07/29/13 Archive Date: 08/07/13 DOCKET NO. 04-16 767A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for a right shoulder disability, to include as secondary to service-connected intervertebral disc disease of the cervical spine with cervical radiculopathy of the upper extremities. 2. Entitlement to a higher initial rating for chronic sinusitis, rated 10 percent disabling prior to March 12, 2012 and 30 percent disabling since that date. REPRESENTATION Appellant represented by: Paralyzed Veterans of America, Inc. WITNESSES AT HEARINGS ON APPEAL The Veteran and his wife ATTORNEY FOR THE BOARD B. Elwood, Associate Counsel INTRODUCTION The Veteran served on active duty from June 1973 to March 1981. These matters initially came before the Board of Veterans' Appeals (Board) from May 2002 and May 2003 decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. In the May 2002 decision, the RO denied entitlement to service connection for a right shoulder disability. In the May 2003 decision, a Decision Review Officer (DRO) granted service connection for chronic sinusitis and assigned an initial 10 percent disability rating, effective October 2, 2000. In May 2003 and February 2009, the Veteran testified at hearings before a DRO and the undersigned at the RO, respectively. Transcripts of these hearing have been associated with his claims folder. In April 2009, the Board remanded these matters for further development. In December 2010, the Board denied the claims of service connection for a right shoulder disability and for a higher initial rating for chronic sinusitis. The Veteran appealed the Board's denials to the United States Court of Appeals for Veterans Claims (Court). In August 2011, the Court set aside the Board's December 2010 decision and remanded the case for readjudication in compliance with directives specified in an August 2011 Joint Motion filed by counsel for the Veteran and VA. In February 2012, the Board remanded these matters for further development in compliance with the Joint Motion. In May 2013, a DRO assigned an initial 30 percent disability rating for chronic sinusitis, effective March 12, 2012. In addition to the paper claims file, there is a Virtual VA paperless claims file associated with the Veteran's claims. The documents in this file have been reviewed and considered as part of this appeal. The issue of entitlement to service connection for a right shoulder disability is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDING OF FACT Since October 2, 2000, the Veteran's chronic sinusitis has been manifested by near constant non-incapacitating episodes associated with sinus congestion, pain, purulent discharge, and headaches; the Veteran has not undergone any sinus surgeries. CONCLUSION OF LAW The criteria for an initial 30 percent rating for chronic sinusitis have been met since October 2, 2000. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.321(b)(1), 4.1, 4.2, 4.7, 4.10, 4.21, 4.97, Diagnostic Code (DC) 6510 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION The Veterans Claims Assistance Act of 2000 as amended (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). The appeal for a higher initial rating for chronic sinusitis arises from the Veteran's disagreement with the initial rating assigned after the grant of service connection. The courts have held, and VA's General Counsel has agreed, that where an underlying claim of service connection has been granted and there is disagreement as to "downstream" questions, the claim has been substantiated and there is no need to provide additional VCAA notice or address prejudice from absent VCAA notice. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007); VAOPGCPREC 8-2003 (2003). The Court has elaborated that filing a notice of disagreement begins the appellate process, and any remaining concerns regarding evidence necessary to establish a more favorable decision with respect to downstream elements (such as initial rating) are appropriately addressed under the notice provisions of 38 U.S.C.A. §§ 5104 and 7105. Goodwin v. Peake, 22 Vet. App. 128 (2008). Where a claim has been substantiated after the enactment of the VCAA, the appellant bears the burden of demonstrating any prejudice from defective VCAA notice with respect to the downstream elements. Id. There has been no allegation of such error in this case. The VCAA also requires VA to make reasonable efforts to help a claimant obtain evidence necessary to substantiate his claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c), (d). This "duty to assist" contemplates that VA will help a claimant obtain records relevant to his claim, whether or not the records are in Federal custody, and that VA will provide a medical examination or obtain an opinion when necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4). The Court has held that the provisions of 38 C.F.R. § 3.103(c)(2) (2012) impose two distinct duties on VA employees, including Board personnel, in conducting hearings: the duty to explain fully the issues and the duty to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488 (2010) (per curiam). At the Veteran's May 2003 DRO hearing and February 2009 Board hearing, the DRO and the undersigned identified the issues on appeal (including entitlement to a higher initial rating for chronic sinusitis) and asked the Veteran about the symptoms and history of his sinusitis as well as the treatment received for the disability. Further, the Veteran provided testimony as to the symptoms and history of his sinusitis and the treatment provided for the disability and has submitted evidence throughout the claim period, thereby demonstrating actual knowledge of the ability to identify and submit additional relevant evidence. The duties imposed by Bryant were thereby met. VA obtained the Veteran's service treatment records and all of the identified relevant post-service VA treatment records and private medical records. In addition, the Veteran was afforded VA examinations to assess the severity of his service-connected chronic sinusitis. In its April 2009 and February 2012 remands, the Board instructed the agency of original jurisdiction (AOJ) to, among other things: obtain all relevant VA treatment records from the VA Medical Center in Miami, Florida (VAMC Miami) and the VA outpatient clinic in Homestead, Florida (CBOC Homestead) dated since July 2005 and afford the Veteran VA examinations to assess the severity of his chronic sinusitis. As explained above, all relevant VA treatment records have been obtained and associated with the claims file (including records from VAMC Miami and CBOC Homestead dated since July 2005). Also, VA examinations were conducted in January 2010 and March 2012 to assess the severity of the service-connected chronic sinusitis. These examinations were thorough, contained all pertinent findings, and were responsive to the questions posed by the Board. Thus, the AOJ substantially complied with all of the Board's relevant April 2009 and February 2012 remand instructions and VA has no further duty to attempt to obtain any additional records or conduct additional examinations with respect to the claim being decided herein. See Dyment v. West, 13 Vet. App. 141, 146- 47 (1999); Stegall v. West, 11 Vet. App. 268 (1998). Analysis Disability evaluations are determined by the application of rating criteria set forth in the VA Schedule for Rating Disabilities (38 C.F.R. Part 4) based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155. Where service connection has been granted and the assignment of an initial evaluation is disputed, separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be "staged." Fenderson v. West, 12 Vet. App. 119, 125-126 (1999). 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. See 38 C.F.R. § 4.7. In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21. The medical as well as industrial history is to be considered, and a full description of the effects of the disability upon ordinary activity is also required. 38 C.F.R. §§ 4.1, 4.2, 4.10. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The Veteran's sinusitis is currently rated under 38 C.F.R. § 4.97, DC 6510 as chronic pansinusitis. Sinusitis is rated according to the General Rating Formula for Sinusitis. Under the General Rating Formula, a 10 percent disability rating is warranted for one or two incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or three to six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. A 30 percent disability rating is warranted for three or more incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or more than six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. Also, a 50 percent disability rating is warranted for chronic sinusitis following radical surgery with chronic osteomyelitis, or; near constant sinusitis characterized by headaches, pain and tenderness of the affected sinus, and purulent discharge or crusting after repeated surgeries. 38 C.F.R. § 4.97, DC 6510. A note accompanying DC 6510 states that an incapacitating episode is defined as one requiring bed rest and treatment by a physician. In this case, VA treatment records dated from December 1999 to October 2002 include reports of exacerbations of acute sinusitis episodes which lasted for weeks at a time and were difficult to alleviate. The Veteran had experienced 2 to 3 exacerbations at the time of a June 2000 VA ear, nose, and throat (ENT) outpatient evaluation and 4 exacerbations at the time of an April 2004 VA primary care evaluation. The symptoms associated with the sinusitis included headaches in the frontal and parietal areas, fatigue, weakness, congestion, peri-sinus pain, pressure, nasal obstruction, rhinnorhea (occasionally yielding yellow-green mucus), occasional purulent nasal discharge, and constant clearing of the throat. The Veteran took various medications to treat his sinus symptoms (e.g. Vancenase and Zyrtec), occasionally used antibiotics during periods of exacerbation, and had just finished a 3 week course of antibiotics at the time of the June 2000 VA ENT outpatient evaluation. Examinations revealed boggy and occasionally mildly enlarged turbinates, red/moist/edamatous nasal mucosa, clear secretion, a deviated septum, and tenderness of the maxillary and frontal sinuses upon palpation. There was no pus/purulence, masses, polyps, or ulcerations and the pharynx were without erythema or exudate. A CT scan revealed bilateral anterior ethmoid air cells, left frontal sinus and bilateral maxillary sinus inflammatory changes, and an abnormality of the osteomeatal complex bilaterally. The Veteran was diagnosed as having, among other things, sinusitis, allergic rhinitis, and post nasal drip. During the May 2003 DRO hearing the Veteran reported that sinus infections lasted for approximately one month, were associated with headaches and congestion, and were occasionally treated with antibiotics and other medications (e.g. Sudafed, saline solution, Flonase, and Activin). He also experienced a constant need to clear his throat. The symptoms of his sinusitis would subside with medication use for approximately one month before once again flaring up. He had not experienced a bad flare up "in awhile" at the time of the hearing (although he had reportedly been prescribed antibiotics within the previous 6 months) and had been taking medications other than antibiotics for approximately 6 months to a year. In an October 2003 statement, the Veteran's wife reported that the Veteran had experienced daily sinus problems ever since their relationship began. Such problems included headaches, nose bleeds, and constant throat clearing due to thick mucus. Also, the Veteran reported in his October 2003 notice of disagreement that he had been experiencing more than 6 non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. VA treatment records dated from December 2003 to December 2004 reveal that the Veteran reported occasional exacerbations of sinusitis which required the use of antibiotics (reported as more than 5 exacerbations a year at the time of an October 2004 VA primary care evaluation). The Veteran also used other over the counter medications to treat his chronic sinus symptoms. Such symptoms included nasal congestion, rhinorrhea with an occasionally thick and foul smelling discharge, frontal headaches, sinus pain, sneezing, different colored sputum, and occasional fever and chills. He also experienced an episode of bleeding from the sinuses in May 2004. Examinations revealed occasional tenderness upon palpation of the frontal/maxillary sinuses, erythema, swelling, and inflammation of the nasal turbinates with mucus, and an occasionally erythematous pharynx with no exudates. Diagnoses of chronic sinusitis were provided. An April 2005 VA examination report indicates that the Veteran reported nasal congestion, drainage, and postnasal drip which required frequent throat clearing and caused his voice to become hoarse. He also experienced headaches behind his eyes on most days. He had been treated with antibiotics for a sinus infection approximately 4 months prior to the examination, but there were no more recent sinus infections. He also took other medications on a regular basis to treat his sinus symptoms, including Zyrtec and Flonase. A nasal examination revealed a nasoseptal deviation to the right, but open airways bilaterally, no external deformities, and no pus, polyps, or blood. Also, the oral cavity and oropharynx were clear. The Veteran was diagnosed as having chronic rhinosinusitis. The physician who conducted the examination reported that although the Veteran was prescribed a course of antibiotics approximately 3 to 4 months prior to the examination, he did not require frequent antibiotics. VA treatment records dated from March 2006 to March 2008 include reports of daily and persistent frontal headaches, nasal congestion, post nasal drip, and sinus fullness. Examinations revealed that the nasal turbinates were slightly swollen and erythematous and that there was occasional post nasal drip, but that the oral mucosa was moist, the pharynx was without erythema and exudates, and there was no sinus tenderness. Diagnoses of chronic sinusitis and allergic rhinitis were provided and the Veteran was prescribed various medications (e.g. antihistamines and corticosteroid nasal sprays). The Veteran reported during the February 2009 Board hearing that he experienced constant headaches and yellowish nasal discharge as well as a consistent need to clear his throat. He visited a physician for his sinusitis approximately every six months and had been advised that surgery was possible to treat the sinusitis. However, he did not wish to undergo such surgery and there was little else that could be done to treat the disability other than to take medications (e.g. allergy medications). He was unable to remember the last time that he had been prescribed antibiotics and he had not lost any time from work during the previous 12 months due to his sinusitis. His wife reported that there was a constant bloody discharge visible when the Veteran blew his nose as well as constant daily headaches. A March 2009 VA attending physician treatment note reveals that the Veteran experienced yellow/green mucus due to sinusitis. Examination revealed congested nares and a possible polyp on the right. The Veteran was prescribed various medications and a 3 week course of antibiotics was recommended. A report of a VA examination dated in June 2009 reflects that the Veteran reported sinus headaches and pressure, post nasal drip, green/dark yellow sputum, and occasional fevers. He treated such symptoms with medications as needed and did not experience flare ups of symptoms because he immediately treated any increased headaches, nasal congestion, and post nasal drip. Such increases in symptomatology occurred once a month to every other month. Also, he experienced blood streaked nasal mucus for 2 to 3 days every other month. During a VA examination dated in January 2010, the Veteran reported persistent nasal congestion, headaches, productive cough, breathing difficulties, and postnasal drip. He had been prescribed antihistamines, nasal sprays, and decongestants, but he had stopped taking such medications because they were not effective. The examination report initially notes that he had experienced one episode of sinusitis which required 3 weeks of antibiotic use during the previous 12 months. However, the report subsequently states that there was one incapacitating episode of sinusitis which required 4 to 6 weeks of antibiotic treatment in March 2009. There were also near constant non-incapacitating episodes involving headaches, purulent discharge, and sinus pain. Such episodes lasted greater than 14 days in duration. Moreover, the Veteran experienced nasal congestion and excess nasal mucous as a result of rhinitis, as well as purulent nasal discharge, headaches (at least monthly, but less than weekly), and sinus pain and tenderness as a result of sinusitis. However, there was no history of any hospitalization, surgery, trauma, neoplasm, nasal allergy, osteomyelitis, or speech impairment. Examination revealed that there was no evidence of sinus disease or soft palate abnormality. Also, there were no signs of nasal obstruction and no nasal polyps, septal deviation, permanent hypertrophy of turbinates from bacterial rhinitis, rhinoscleroma, tissue loss, scarring, deformity of the nose, or evidence of Wegener's granulomatosis or granulomatous infection. The Veteran had not undergone a laryngectomy and there were no residuals of any injury to the pharynx. X-rays revealed normal paranasal sinuses. A diagnosis of chronic sinusitis was provided. This disability did not have any significant effects on the Veteran's occupation or usual daily activities. VA treatment records dated from March 2010 to November 2011 and an October 2010 statement by the Veteran (VA Form 21-4138) reflect that he reported nasal congestion/obstruction, facial pressure retro-orbitally, occasionally green/brown sputum, headaches, pain, post nasal drip, frequent nose bleeds, and occasional purulent discharge. Examinations of the nose revealed mild mucosal erythema/edema on the right of the inferior turbinate, but no lesions, masses, or bleeding. A CT scan revealed mild mucosal thickening of the ethmoids, but no significant evidence of sinusitis. The Veteran was diagnosed as having allergic rhinitis/bronchitis and was advised in March 2010 to have a treatment with antibiotics and a medrodose pack and to avoid decongestants on a chronic basis. A report of a VA examination dated on March 12, 2012 indicates that the Veteran reported chronic runny nose, post nasal drip, nasal congestion, headaches, and nasal bleeding of unknown origin. Such symptoms were treated with nasal sprays and Naproxen. There was near constant sinusitis with associated headaches, but the nurse practitioner who conducted the examination indicated that there were no non-incapacitating episodes of sinusitis characterized by headaches, pain, and purulent discharge during the previous 12 months and no incapacitating episodes of sinusitis requiring prolonged (4 to 6 weeks) of antibiotic treatment over the previous 12 months. Also, the Veteran had not undergone any sinus surgeries. With respect to rhinitis, there was permanent hypertrophy of the nasal turbinates, but there was not greater than a 50 percent obstruction of the nasal passage on both sides, there was no complete obstruction on one side, and there were no nasal polyps or granulomatous conditions. Also, the Veteran did not experience any larynx or pharynx conditions, there was not at least a 50 percent obstruction of the nasal passages on both sides or complete obstruction on one side due to traumatic septal deviation, he did not have any benign or malignant neoplasms or metastases, and he did not have any other problems related to his diagnosed disabilities. A CT scan revealed minimal ethmoid sinus mucosal thickening. Diagnoses of chronic sinusitis, non-allergic rhinitis, and epistaxis were provided. The Veteran was employed with the Postal Service and his diagnosed sinusitis did not impact his ability to work. In February 2013, the examiner who had conducted the March 2012 VA examination re-reviewed the Veteran's claims file and contacted him by telephone. The examiner opined that the Veteran's headaches were likely ("at least as likely as not") caused by or aggravated by his diagnosed sinusitis. This opinion was based on the fact that the most recent eye consultation dated in December 2012 included diagnoses of pterygium of the left eye and pinguecula of the right eye, which are benign growths of the conjunctiva that can result from chronic actinic irritation. Such eye conditions do not cause eye pain and there was no abnormality shown during the Veteran's eye examination which would result in headaches. Also, the ophthalmology report made no mention of any eye condition causing headaches. Thus, the Veteran's headaches were not secondary to any eye condition. Rather, they were associated with his chronic sinusitis, as substantiated by an otolaryngology outpatient treatment note dated in May 2011. Furthermore, medical literature reflected that sinusitis could cause headaches and pain behind and between the eyes. The March 2012 examiner additionally indicated that the Veteran had experienced 7 or more non-incapacitating episodes of sinusitis during the previous 12 months. These episodes were characterized by headaches, pain, and purulent discharge or crusting. The above evidence reflects that the Veteran has reported near constant sinusitis, associated with such symptoms as sinus congestion, pressure, and tenderness, purulent nasal discharge, and headaches since the effective date of service connection. He reported on numerous occasions that he experienced headaches, sinus pain, and occasional purulent nasal discharge consisting of green or yellow discharge that was occasionally thick and foul smelling. Also, he reported in his October 2003 notice of disagreement that he had been experiencing more than 6 non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. Examinations revealed sinus tenderness. The January 2010 VA examination report indicates that there were near constant non-incapacitating episodes involving headaches, purulent discharge, and sinus pain and that these episodes lasted greater than 14 days in duration. Moreover, the examiner who conducted the March 2012 VA examination indicated that the Veteran had experienced 7 or more non-incapacitating episodes of sinusitis during the previous 12 months and that these episodes were characterized by headaches, pain, and purulent discharge or crusting. Although various examinations during the claim period did not explicitly note the absence or presence of sinus pain or purulent discharge and some such symptoms were not specifically found at the time of the examinations, the Veteran is competent to report the symptoms of his sinusitis, such as headaches, sinus pain, and purulent nasal discharge. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006). Also, there is no evidence to explicitly contradict his reports of such symptoms at times during the claim period and his reports are otherwise consistent with the evidence of record. Thus, his reports are deemed credible. The Veteran's reports of near constant headaches, sinus pain, and nasal discharge and the reported frequency of non-incapacitating episodes most closely approximate the criteria for a 30 percent rating under DC 6510. In light of the frequency of the above reported symptoms and resolving reasonable doubt in the Veteran's favor, an initial 30 percent rating for chronic sinusitis under DC 6510 is warranted since the effective date of service connection. 38 U.S.C.A. §§ 1155, 5107(b); 38 C.F.R. § 4.7, 4.97, DC 6510. An initial rating higher than 30 percent is not warranted at any time during the claim period as there is no evidence that the Veteran has undergone surgery due to his sinusitis. He has specifically reported that although he was advised of the benefits of sinus surgery, he did not wish to undergo any such procedure. Extraschedular Pursuant to 38 C.F.R. § 3.321(b)(1), the Under Secretary for Benefits or the Director, Compensation and Pension Service, is authorized to approve an extraschedular evaluation if the case "presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards." 38 C.F.R. § 3.321(b)(1). The question of an extraschedular rating is a component of a claim for an increased rating. See Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). The Board must specifically address whether to refer a case for extraschedular evaluation when the issue either is raised by the claimant or is reasonably raised by the evidence of record. Barringer v. Peake, 22 Vet. App. 242, 244 (2008). If the evidence raises the question of entitlement to an extraschedular rating, the threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of a claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd sub nom, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). There is no allegation or evidence of exceptional factors in this appeal with regard to the Veteran's service-connected chronic sinusitis. All of the symptoms experienced by the Veteran described above are contemplated by the appropriate diagnostic criteria as set forth above. Thus, referral for consideration of an extraschedular evaluation is not warranted. 38 C.F.R. § 3.321(b)(1). Total Rating for Compensation Purposes Based on Individual Unemployability (TDIU) The Court has held that entitlement to a TDIU is an element of all appeals for a higher initial rating. Rice v. Shinseki, 22 Vet. App. 447 (2009). Entitlement to a TDIU is raised where a veteran: (1) submits evidence of a medical disability; (2) makes a claim for the highest rating possible; and (3) submits evidence of unemployability. Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001); see Jackson v. Shinseki, 587 F.3d 1106, 1109-10 (2009) (holding that an inferred claim for a TDIU is raised as part of an increased rating claim only when the Roberson requirements are met). The evidence reflects that the Veteran was employed full time for the majority of the claim period with the Postal Service. Although an August 2012 VA physical medicine rehabilitation consultation note indicates that he was retiring from the Postal Service, he has not reported, and the evidence does not otherwise reflect, that he retired due to any service-connected disability or that he is prevented from securing and following gainful employment due to any such disability. As there is no evidence of unemployability, the question of entitlement to a TDIU is not raised under Roberson and Rice in this instance. ORDER Entitlement to an initial 30 percent rating for chronic sinusitis, effective October 2, 2000, is granted. Entitlement to an initial rating higher than 30 percent for chronic sinusitis is denied. REMAND Once the Secretary undertakes the effort to provide an examination when developing a service connection claim, even if not statutorily obligated to do so, he must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Medical records reveal that the Veteran has been diagnosed as having various right shoulder disabilities. For example, a March 2012 VA examination report includes diagnoses of degenerative arthritis and rotator cuff bursitis of the right shoulder. Thus, a current right shoulder disability has been demonstrated. The Veteran contends that his current right shoulder disability is related to shoulder problems that he experienced in service. In the alternative, he claims that the right shoulder disability is related to his now service-connected intervertebral disc disease of the cervical spine with cervical radiculopathy of the upper extremities. Service treatment records include an April 1974 report of an examination during which the Veteran reported right shoulder pain. He was treated for right shoulder pain in May 1974, at which time he reported that he had experienced such pain for the previous 2 to 3 years following a sports injury prior to service. Examination and X-rays revealed no significant functional disability or pathological findings relating to the right shoulder joint. Moreover, the Veteran was involved in a motor vehicle accident in service in March 1975. Although there is no clinical evidence of a right shoulder injury at the time of the accident, the Veteran claims that he experienced shoulder problems as a result of the accident and that shoulder symptoms (including pain) have continued in the years since that time. However, there is some evidence to the contrary. For example, his January 1981 separation examination was normal and he reported on a January 1981 report of medical history for purposes of separation from service that he was not experiencing, nor had he ever experienced, any "painful or trick shoulder" or any other orthopedic problems. The nurse practitioner who conducted the March 2012 VA examination opined that the Veteran's diagnosed chronic bursitis and degenerative arthritis of the right shoulder were "not believed to be related" to his chronic cervical spine disability, but were rather due to injuries sustained while employed with the Postal Service. The March 2012 opinion is inadequate because it is not accompanied by any specific explanation or reasoning and does not address whether the Veteran's current right shoulder disability is directly related to his shoulder symptoms in service. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning; threshold considerations are whether the person opining is suitably qualified and sufficiently informed; an adequate medical opinion must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two). Additionally, the March 2012 opinion only addressed whether the Veteran's current right shoulder disability was caused by his now service-connected cervical spine disability. However, service connection may also be granted for a disability that is "aggravated" by a service-connected disability and no opinion has been provided as to any possible aggravation. 38 C.F.R. § 3.310 (2012). VA regulations provide that where an examination report does not contain sufficient detail, it is incumbent upon the rating board to return the report as inadequate for evaluation purposes. 38 C.F.R. § 4.2 (2012); see 38 C.F.R. § 19.9 (2012). Where the Board makes a decision based on an examination report which does not contain sufficient detail, remand is required "for compliance with the duty to assist by conducting a thorough and contemporaneous medical examination." Goss v. Brown, 9 Vet. App 109, 114 (1996); Stanton v. Brown, 5 Vet. App. 563, 569 (1993). Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for a VA examination to determine the etiology of his current right shoulder disability. All indicated tests and studies shall be conducted. The claims folder, including this remand and any relevant records contained in the Virtual VA system, must be sent to the examiner for review; consideration of such shall be reflected in the completed examination report or in an addendum. For each current right shoulder disability identified (i.e. any right shoulder disability diagnosed since October 2001), the examiner shall indicate whether it is at least as likely as not (50 percent probability or more) that the current right shoulder disability had its clinical onset in service, had its clinical onset in the year immediately following service (with respect to any arthritis), is related to the Veteran's right shoulder complaints in service, is related to the motor vehicle accident in service, or is otherwise the result of a disease or injury in service. The examiner shall also indicate whether it is at least as likely as not (50 percent probability or more) that the current right shoulder disability was caused or aggravated by the Veteran's service-connected intervertebral disc disease of the cervical spine with cervical radiculopathy of the upper extremities. If aggravated, specify the baseline level of disability prior to aggravation, and the permanent, measurable increase in disability resulting from the aggravation. In formulating the above opinions, the examiner shall specifically acknowledge and comment on all right shoulder disabilities diagnosed since October 2001, all instances of treatment for right shoulder problems in the Veteran's service treatment records, and his reported right shoulder injury in service due to a motor vehicle accident. The examiner is advised that despite the Veteran's reports of right shoulder problems prior to service, he was presumed to be in sound condition at the time of entrance into service. The absence of evidence of treatment for a right shoulder injury in the Veteran's service treatment records or of treatment for right shoulder problems for years after service cannot, standing alone, serve as the basis for a negative opinion. However, the examiner must also consider the inconsistent information concerning a continuity of right shoulder symptomatology in the years since service. The examiner must provide reasons for each opinion given. 2. If the benefit on appeal remains denied, the AOJ shall issue a supplemental statement of the case. After the Veteran is given an opportunity to respond, the case shall be returned to the Board. No action is required of the Veteran until he is notified by the RO; however, the Veteran is advised that failure to report for any scheduled examination may result in the denial of his claim. 38 C.F.R. § 3.655 (2012). The Veteran has the right to submit additional evidence and argument on the matter 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. 2012). ______________________________________________ THOMAS J. DANNAHER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs