Citation Nr: 1335255 Decision Date: 11/01/13 Archive Date: 11/13/13 DOCKET NO. 08-22 648 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Newark, New Jersey THE ISSUES 1. Entitlement to a rating in excess of 10 percent for sinusitis. 2. Entitlement to service connection for posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: National Association of County Veterans Service Officers WITNESSES AT HEARING ON APPEAL Appellant and spouse ATTORNEY FOR THE BOARD T. S. Kelly, Counsel INTRODUCTION The Veteran had active service from May 1989 to May 1993 and from February 1994 to February 1998. This matter comes before the Board of Veterans' Appeals (Board) on appeal from November 2006 and January 2008 rating determinations of the Department of Veterans Affairs (VA) Regional Office (RO) in Augusta, Maine, and Newark, New Jersey. Thereafter, the Newark, New Jersey, Office assumed jurisdiction. In June 2012, the Veteran appeared at a Travel Board hearing before the undersigned Veterans Law Judge (VLJ) at the RO. A transcript of the hearing is of record. In May 2013, the Board remanded this matter for additional development. The directives set forth in the in the May 2013 Board remand have been complied with. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (noting the Board's duty to "insure [the RO's] compliance" with the terms of its remand orders. The matters are now ready for appellate review. The Board has not only reviewed the Veteran's physical claims file but also the file on the Virtual VA and VBMS system to insure a complete review of the evidence. FINDINGS OF FACT 1. Sinusitis is manifested by itchy watery eyes, postnasal drainage, congestion, discharge, pain, and intermittent headaches, along with intermittent use of antibiotics, resulting in more than six non-incapacitating episodes per year. 2. The Veteran did not engage in combat with the enemy; a diagnosis of PTSD has not been found by the appropriate health care provider to be based on a stressor adequate to support the diagnosis and his symptoms have not been related to the claimed stressor. CONCLUSIONS OF LAW 1. The criteria for a rating of 30 percent, but no higher, for sinusitis have been met. 38 U.S.C.A. §§ 1155, 5013(a), 5103A (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.321(b)(1), 4.1, 4.3, 4.7, 4.10, 4.97, Diagnostic Code (DC) 6513 (2013). 2. PTSD was not incurred in or aggravated by the Veteran's active duty service. 38 U.S.C.A. §§ 1110, 1131, 5103(a), 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.304(f) (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has reviewed all of the evidence in the Veteran's claims folder. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed, the Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, his claim. Sinusitis Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1 (2013). Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2013). However, the Board has been directed to consider only those factors contained wholly in the rating criteria. See Massey v. Brown, 7 Vet. App. 204, 208 (1994); but see Mauerhan v. Principi, 16 Vet. App. 436 (2002) (finding it appropriate to consider factors outside the specific rating criteria in determining level of occupational and social impairment). Where there is a question as to which of two separate evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria required for that particular rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in favor of the veteran. 38 C.F.R. § 4.3. While a veteran's entire history is reviewed when assigning a disability evaluation, where service connection has already been established and an increase in the rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). In determining the present level of a disability for any increased evaluation claim, the Board must consider the application of staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In other words, where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings would be necessary. Under DC 6513, a 10 percent 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 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. A 50 percent disability rating is awarded for sinusitis following radical surgery with chronic osteomyelitis, or manifested by near constant sinusitis characterized by headaches, pain, and tenderness of affected sinus, and purulent discharge or crusting after repeated surgeries. An incapacitating episode of sinusitis is specifically defined in the regulations as one requiring bed rest and treatment by a physician. 38 C.F.R. § 4.97 (2013). In July 2006, the Veteran requested an increased rating for sinusitis. In a September 2006 VA examination, he complained of recurrent nasal catarrh and postnasal drip with a persistent frontal headache. He had difficulty breathing from the nose. He stated that the headache had been persistent and the postnasal drip was interfering with his breathing. Physical examination showed congestion of the nasal mucosa, deflection of the nasal septum to the left with obstruction more than 50 percent of the nasal airway. There was tenderness over the right maxillary sinus indicating active nasal sinus disease. Congested mucosa of the larynx and pharynx was also present. CT scan of the sinuses confirmed the presence of a polyp in the right maxillary sinus due to chronic nasal sinus disease. The examiner diagnosed chronic nasal sinus disease under treatment and deflection of the nasal septum with obstruction of more than 50 percent of the nasal airway. In that same month, the Veteran underwent sinus surgery. He was noted to have averaged 5-6 episodes of sinusitis per year with multiple antibiotic treatment as well as multiple allergy medicines. Congestion has also been reported on numerous occasions as well as frontal headaches. In a June 2008 VA examination, the Veteran complained of persistent, recurrent nasal congestion with persistent postnasal drip and difficulty breathing. He was noted to have had nasal surgery in 2006 with no clinical improvement. He was diagnosed with residual of chronic sinusitis. Moreover, his sinus problems have been described as being year round as opposed to seasonal, with the use of Flonase and Allegra on a regular basis. At the June 2012 hearing, the Veteran credibly testified as to having six or more non-incapacitating episodes of sinusitis per year with headaches, pain, running nose, and crusting. He indicated that he was receiving treatment for his sinusitis in the form of Flonase and Allegra. He testified that the 2006 surgery had not helped. Most recently, in February 2013, he was treated with Cefdinir, an antibiotic, for acute and chronic sinusitis, with the CT scan showing moderate mucosal disease in the right maxillary sinus and minimal ethmoid mucosal disease. Based on the evidence showing symptoms of headache, pain, purulent discharge, and crusting and antibiotic treatment on multiple occasions, the criteria for a 30 percent rating have been met throughout the course of the appeal. Nonetheless, the criteria for a 50 percent rating have not been met. Although the Veteran underwent surgery in 2006, chronic osteomyelitis has not been shown. Further, while he has reported multiple episodes of sinusitis requiring treatment, he has not undergone repeated surgeries. Therefore, a rating in excess of 30 percent is not warranted. The Board has applied Mittleider v. West, 11 Vet. App. 181 (1998) and has attributed all the Veteran's sinus symptoms to his service-connected disability. With that in mind, the Board has considered whether referral for extra-schedular consideration is warranted. In exceptional cases where schedular evaluations are found to be inadequate, consideration of an extra-schedular evaluation is made. 38 C.F.R. § 3.321(b)(1). There is a three-step analysis for determining whether an extra-schedular evaluation is appropriate. Thun v. Peake, 22 Vet. App. 111 (2008). First, there must be a comparison between the level of severity and symptomatology of a veteran's service-connected disability and the established criteria found in the rating schedule to determine whether a veteran's disability picture is adequately contemplated by the rating schedule. If not, the second step is to determine whether the claimants exceptional disability picture exhibits other related factors identified in the regulations as "governing norms." See also 38 C.F.R. § 3.321(b)(1) (governing norms include marked interference with employment and frequent periods of hospitalization). If the factors of step two are found to exist, the third step is to refer the case to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for a determination whether, to accord justice, the claimant's disability picture requires the assignment of an extra-schedular rating. The record does not establish that the rating criteria are inadequate. To the contrary, the very symptoms that the Veteran describes and the findings made by the various medical professionals, such as antibiotic treatment, headaches, pain, discharge, and crusting, are the symptoms included in the criteria found in the rating schedule for his disability. For these reasons, the Board finds that the schedular rating criteria in this case is adequate to rate the Veteran's sinus disability. In the absence of evidence that the schedular rating criteria is inadequate to rate the disability, the Board is not required to remand this case to the RO for the procedural actions outlined in 38 C.F.R. § 3.321(b)(1). See also Bagwell v. Brown, 9 Vet. App. 237, 238-9 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). PTSD Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131. If a chronic disease is shown in service, subsequent manifestations of the same chronic disease at any later date, however remote, may be service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). However, continuity of symptoms is required where a condition in service is noted but is not, in fact, chronic or where a diagnosis of chronicity may be legitimately questioned. 38 C.F.R. § 3.303(b). Further, service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 U.S.C.A. § 1113(b); 38 C.F.R. § 3.303(d). In addition to the laws and regulations outlined above, service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a), a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. The provisions of 38 C.F.R. § 4.125(a) require that a diagnosis of a mental disorder conform to the Diagnostic and Statistical Manual, Fourth Edition (DSM-IV). A diagnosis of PTSD which is based on an examination which relied upon an unverified history is inadequate. See West v. Brown, 7 Vet. App. 70, 77-78 (1994). During the pendency of the appeal, VA amended its regulations governing service connection for PTSD by liberalizing, in certain circumstances, the evidentiary standard to establishing the required in-service stressor. Specifically, 38 C.F.R. § 3.304 was amended to include a paragraph which, in pertinent part, states that, if a stressor claimed by a veteran was related to his or her fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of PTSD and that his or her symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of service, lay testimony alone may establish the occurrence of the claimed in-service stressor. See 38 C.F.R. § 3.303(f)(3) (2013). The amended regulation applies to this appeal. With disability compensation claims, VA adjudicators are directed to assess both medical and lay evidence. As a general matter, a layperson is not capable of opining on matters requiring medical knowledge. See 38 C.F.R. § 3.159(a) (2); see also Routen v. Brown, 10 Vet. App. 183, 186 (1997) ("a layperson is generally not capable of opining on matters requiring medical knowledge"). In certain circumstances, however, lay evidence may be sufficient to establish a medical diagnosis or nexus. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). In addressing lay evidence and determining its probative value, if any, attention is directed to both competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted"). See Layno v. Brown, 6 Vet. App. 465, 469 (1994). In terms of competency, lay evidence has been found to be competent with regard to a disease with "unique and readily identifiable features" that is "capable of lay observation." See Barr v. Nicholson, 21 Vet. App. 303, 308-09 (2007) (concerning varicose veins); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (a dislocated shoulder); Charles v. Principi, 16 Vet. App. 370, 374 (2002) (tinnitus); Falzone v. Brown, 8 Vet. App. 398, 405 (1995) (flatfoot). That notwithstanding, a veteran is not competent to provide evidence as to more complex medical questions and, specifically, is not competent to provide an opinion as to etiology in such cases. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (concerning rheumatic fever.) In weighing credibility, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self-interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. See generally Caluza v. Brown, 7 Vet. App. 498 (1995). The Board may weigh the absence of contemporaneous medical evidence against the lay evidence in determining credibility, but the Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence. See Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006); but see Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000) (evidence of a prolonged period without medical complaint after service can be considered along with other factors in the analysis of a service connection claim). At the outset, the Board notes that service connection is currently in effect for a psychiatric disability, characterized as a mood disorder with depressive features, currently rated as 50 percent disabling. The Veteran applied for service connection for PTSD in August 2006. The Veteran's military occupational specialty (MOS) for his service in the Gulf War during Operation Desert Storm was that of a light wheel vehicle mechanic. He is in receipt of the Army Commendation Medal, the Army Service Ribbon, the Good Conduct Medal, the Kuwait Liberation Medal, the National Defense Service Medal, the Overseas Service Ribbon, and the Southwest Asia Medal with 3 Bronze Stars. None of these awards denote combat and he has denied direct combat experience. As an initial matter, the service treatment records do not show complaints of, treatment for, or a diagnosis of a psychiatric disorder. Symptoms related to a psychiatric disorder were not continuous since service and the first post service evidence of treatment for psychiatric treatment is shown many years later. When the Veteran filed a claim for PTSD, he initially asserted two stressors in support of his claim. First, he indicated that he woke up with the noises of sirens and fellow soldiers screaming that the war was on. He stated that he rushed to the bunker carrying his military gear, including his rifle and NBC suit. He submitted an additional statement indicating that that his company commander tried to kill another soldier. He did not indicate and, as noted above, subsequently acknowledged that he was not involved in combat. In January 2008, a formal finding of lack of information required to verify stressors in connection with the PTSD claim was made. A finding was made that the information required to verify stressful events described by the Veteran was insufficient to send to the U.S. Army and Joint Services Records Research Center (JSRRC) and/or insufficient to research the cases for the Air Force and Navy records. The RO listed all the efforts which were made for obtain information necessary to verify the stressful events for the PTSD claim. In a February 2008 stressor statement, the Veteran expanded on the initial stressor statement that the day Desert Storm started a sergeant came in to the tent screaming: "The war is on we are all going to die." He indicated that he did not know if he was just saying that to scare them or he was scared. He also submitted a statement saying that a Major had threatened to kill another soldier. In a July 2008 stressor statement, the Veteran added another stressor that around March 1991, after a cease fire was ordered by the President, his unit was catered by a Saudi Arabia catering service, where they were poisoned. He stated that about 75 percent of the Company became ill and most went to the field station. He also reported that an Iraq POW landed by helicopter in front of his guard point, with no specific date being listed. VA treatment records associated with the claims folder contain multiple psychiatric diagnoses including PTSD, mood disorder with depressive features, and major depressive disorder. The Board specifically notes that in a November 2009 VA outpatient treatment record, a diagnosis of PTSD was rendered, with the stressor being listed generally as war trauma. In a January 2011 VA examination, the Veteran described experiences in the Persian Gulf, but the examiner questioned whether these experiences met the criteria for fear of hostile military activity. The examiner noted that the Veteran talked about becoming very nervous when he was told the war was starting, discussed that the company commander threatened to kill one of his buddies, and worried about friendly fire. The Veteran further noted being near Kuwait, several miles away, when both he and his buddy were on the road and saw burning people in a car, which shocked them. He stated that he also still thought about wearing gas masks and the burning people in the car. The examiner indicated that it was unclear from the Veteran's description as to whether he generally experienced a fear of hostile military activity. The examiner opined that the Veteran failed to meet the diagnostic criteria for PTSD. The examiner found that the Veteran met the diagnostic criteria for depression considered to be secondary to his service-connected back pain. This evidence does not support the claim. First, the VA examiner questioned whether the Veteran's stressors (including a previously-unreported stressor of burning people in a car) were fear of hostile military or terrorist activity. Further, the examiner did not find that the Veteran's symptoms supported a diagnosis of PTSD. As he did not have a diagnosis of PTSD, a reasonable reading of the opinion is that the stressors were not adequate to support a diagnosis of PTSD. Moreover, the examiner concluded that the Veteran's psychiatric symptoms (depression) were related to a service-connected back disability, not to the claimed stressors. It is again noted that the Veteran is already service-connected for depression. In a June 2012 hearing, the Veteran testified that his duties during Desert Storm were mostly pulling guard duty. He noted that his MOS was a labor vehicle mechanic. He reported doing more than 100 convoys and indicated that he was stationed about 20 miles from Kuwait. He raised another stressor that the convoys entered the combat zone outside of base camps. He further testified that he feared for his life as a result of enemy attacks and friendly fire, also a new stressor. He stated that one person was either killed or injured in his unit from a motor vehicle accident but he could not remember the name. In conjunction with his claim for Social Security disability benefits, the Veteran was afforded a psychiatric examination in November 2012. At the time of the examination, he reported that he had been treated since 2005 for his PTSD and depression. The examiner noted that when asked what his PTSD was related to, the Veteran said it was Desert Storm. He reported that he was close to a combat zone and that he did not now sleep. As to military history, the Veteran indicated that he was never in active combat but said that he was close to the war zone during Desert Storm. The examiner noted that the mental health history treatment report by the Veteran was not consistent with a diagnosis of PTSD. The examiner indicated that the Veteran stated that he was not exposed to combat and he provided inadequate evidence to make this diagnosis. The examiner rendered Axis I diagnoses of alcohol dependence and depressive disorder, NOS. In a February 2013 VA psychiatric examination, an Axis I diagnosis of depression, secondary to service-connected back pain was rendered. There were no other Axis I diagnoses rendered. This evidence does not support the claim because neither the SSA examiner nor the February 2013 examiner diagnosed PTSD; therefore, the examiners did not address whether the stressors were adequate to support a diagnosis or whether the Veteran's symptoms were related to the stressors. While the weight of evidence does not support even a diagnosis of PTSD, the diagnosis has been recorded in the outpatient clinical records and the claim is not denied on the basis of no current diagnosis. Nonetheless, the claim is denied because the clinician who diagnosed PTSD did not confirm that stressors were adequate to support the diagnosis. The basis of the diagnosis was war trauma which is too vague to establish the criteria on which it was rendered. On the other hand, the examiners who reviewed the file and interviewed the Veteran specifically concluded that he did not have a diagnosis of PTSD. By implication, this means that they did not confirm that the claimed stressors (which he described during the examination) were adequate to support the diagnosis because there was no diagnosis. In addition, one examiner who evaluated the psychiatric symptoms diagnosed depression (for which the Veteran is already service-connected). The Board has also considered the Veteran's statements that he has PTSD caused by traumatic experiences while in service. He is competent to describe his experiences and express that they were traumatic to him; however, he is not competent to diagnose himself with PTSD or to determine whether his stressors were adequate to support a diagnosis of PTSD or relate his symptoms to the stressor. As such, the Veteran's statements alone are insufficient to support a grant of service connection in this case. The Veteran's stressors are not related to combat and his stressors are unverified. Moreover, to the extent that he claims that the stressors are related to fear of hostile military or terrorist activity (questioned by one examiner), an appropriate health care provider has not confirmed that the claimed stressor was adequate to support a diagnosis of PTSD and that his symptoms were related to the claimed stressor. Therefore, his lay statements alone do not establish the claimed in-service stressor. As such, even assuming that the medical evidence supports a diagnosis of PTSD and the reference to war trauma is enough to establish a link between current symptoms and in-service stressor, there is no credible supporting evidence that the claimed in-service stressor occurred and the Veteran's lay statements are not enough to establish such a relationship. Therefore, service connection for PTSD is denied. The preponderance of the evidence is against the claim and the benefit of the doubt doctrine is not applicable. Finally, as provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a 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. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). Proper notice from VA must inform the claimant of any information and medical or lay 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. Quartuccio v. Principi, 16 Vet. App. 183 (2002). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). When VCAA notice is delinquent or erroneous, the "rule of prejudicial error" applies. See 38 U.S.C.A. § 7261(b)(2) (West 2002). In addition, the notice requirements of the VCAA apply to all five elements of a service-connection claim, including: (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. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. Here, the VCAA duty to notify was satisfied by way of letters sent to the Veteran in August 2006 (sinusitis) and September 2007 (PTSD) that fully addressed all notice elements and were sent prior to the initial RO decisions in these matters. The letters informed him of what evidence was required to substantiate the claims and of his and VA's respective duties for obtaining evidence. Under these circumstances, the Board finds that the notification requirements of the VCAA have been satisfied as to both timing and content. With respect to the Dingess requirements, in the same letters, the RO provided the Veteran with notice of what type of information and evidence was needed to establish disability ratings, as well as notice of the type of evidence necessary to establish an effective date. With that letter, the RO effectively satisfied the remaining notice requirements with respect to the issues on appeal. Therefore, adequate notice was provided to the Veteran prior to the transfer and certification of his case to the Board and complied with the requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b). Next, VA has a duty to assist a veteran in the development of the claim. This duty includes assisting him or her in the procurement of service treatment records and other pertinent records, and providing an examination when necessary. See 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2013). In determining whether a medical examination be provided or medical opinion obtained, there are four factors to consider: (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) evidence establishing an in-service event, injury, or disease, or manifestations during the presumptive period; (3) an indication that the disability or symptoms may be associated with service; and (4) whether there otherwise is sufficient competent medical evidence of record to make a decision on the claim. With respect to the third factor, the types of evidence that "indicate" that a current disorder "may be associated" with service include, but are not limited to, medical evidence that suggests a nexus but is too equivocal or lacking in specificity to support a decision on the merits, or credible evidence of continuity of symptomatology such as pain or other symptoms capable of lay observation. McLendon v. Nicholson, 20 Vet. App. 79 (2006). After a careful review of the file, the Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). First, the record includes service treatment records, VA treatment records, private treatment records, VA examination reports, and lay evidence, to include testimony from the Veteran. No additional pertinent evidence has been identified by the claimant. The Board further notes that the directives of the May 2013 Board remand were complied with. The Veteran was afforded several VA examinations during the course of the appeal, including psychiatric and for evaluation of his sinuses. Given that the examination reports set forth detailed examination findings in a manner which allows for informed appellate review under applicable VA laws and regulations, the Board finds the examinations to be adequate for rating purposes. The examination reports provided a history supplied by the Veteran and detailed examination results and provided sufficient information to properly address the claims. Additionally, in June 2012, the Veteran was provided an opportunity to set forth his contentions during the hearing before the undersigned VLJ who explained the issues and suggested the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488 (2010). Moreover, following the hearing, the matter was remanded and additional evidence was obtained. The Veteran has been afforded a meaningful opportunity to participate effectively in the processing of the claim, including by submission of statements and by being afforded the opportunity to appear at a hearing if so desired. For these reasons, it is not prejudicial to the Veteran for the Board to proceed to finally decide the appeal. Based upon the foregoing, the duties to notify and assist the Veteran have been met, and no further action is necessary to assist the Veteran in substantiating this claim. ORDER A 30 percent rating, but no more, for sinusitis is granted, subject to the law and regulations governing the payment of monetary benefits. Service connection for PTSD is denied. ____________________________________________ L. HOWELL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs