Citation Nr: 1339929 Decision Date: 12/04/13 Archive Date: 12/18/13 DOCKET NO. 12-13 988 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to an increased disability rating for chronic sinusitis/rhinitis associated with deviated nasal septum, fractured nose, currently evaluated at 10 percent. 2. Entitlement to service connection for obstructive sleep apnea. REPRESENTATION Appellant represented by: Military Order of the Purple Heart of the U.S.A. ATTORNEY FOR THE BOARD P. M. Johnson, Associate Counsel INTRODUCTION The Veteran had active service in the United States Air Force from September 1963 to December 1967. This matter comes before the Board of Veterans' Appeals (Board) as an appeal of a February 2011 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. The Veteran's entire claims file, to include the portion contained in the electronic "Virtual VA" system, was reviewed. FINDINGS OF FACT 1. The Veteran has had more than six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. 2. There is no evidence of sinusitis with chronic osteomyelitis following radical surgery, or; near constant sinusitis characterized by headaches, pain, and tenderness of affected sinus, and purulent discharge or crusting after repeated surgeries. 3. The Veteran's obstructive sleep apnea did not have onset in service and was not caused or aggravated by his service-connected sinusitis. CONCLUSIONS OF LAW 1. The criteria for a 30 percent rating for sinusitis, but no more than 30 percent, have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. Part 4, including §§ 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.97, Diagnostic Code 6514 (2013). 2. The criteria for service connection for sleep apnea, including as secondary to service-connected sinusitis, have not been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.310 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Increased Rating for Chronic Sinusitis Disability ratings are determined by applying criteria set forth in VA's Schedule for Rating Disabilities. Ratings are based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. See 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations should 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 determining the disability evaluation, VA has a duty to consider all possible regulations which may be potentially applicable based upon the assertions and issues raised in the record. After such a consideration, VA must explain to the Veteran the reasons and bases utilized in the government's decision. See Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). For claims for an increase that do not rise out of an initial grant of service connection, the Board must consider the application of "staged" ratings for different periods from the filing of the claim forward, if the evidence suggests that such a rating would be appropriate. See Hart v. Mansfield, 21 Vet. App 505 (2007). In the instant case, there is no evidence that the disability has significantly changed and a uniform evaluation is warranted. Sinusitis is evaluated under the General Rating Formula for Sinusitis (General Formula). Under these criteria, evaluations may be assigned ranging between 0 and 50 percent. The Veteran is currently assigned a 10 percent disability rating. This evaluation is warranted when the disability is manifested by 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. 38 C.F.R. § 4.97, Diagnostic Code 6510-14. 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 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, Diagnostic Codes 6510-14. A note accompanying the General Formula states that an incapacitating episode is defined as one requiring bed rest and treatment by a physician. Id. The Veteran's sinus disease has been rated under Code 6514, pertaining to sphenoid sinusitis; however, the service-connected disability picture, noted as "sinusitis," includes all of the Veteran's facial sinuses. The General Formula pertains to disablement in all sinus cavities, and its applicability to all sinus manifestations will be discussed together. The Veteran has a history of sinusitis dating back to 1967 and an in-service nasal septum deviation. In 1998, he underwent septoplasty in an attempt to help alleviate these symptoms. The Veteran contends, in essence, that he meets the criteria for a higher evaluation because he has three or more incapacitating episodes per year and more than six non-incapacitating episodes per year that manifest with headaches, pain, and purulent discharge or crusting. The Veteran asserts that his medical providers are given information regarding episodes regularly but they may not be regularly recorded as he has received treatment for this condition continuously since his deviated septum in 1967. The Veteran reports that he been on Zyrtec and nasal decongestants for over 5 years to treat his condition. Treatment records from July 2007 through July 2009 show multiple reports of active problems with allergies/sinusitis. The Veteran has reported symptoms that include: headaches, sore throats, runny nose, watery eyes, and sneezing. In a September 2010 VA examination, the examiner noted that the Veteran reported flu-like symptoms with sore throat and congestion. A sinus x-ray revealed abnormal findings of "left maxillary sinus with partial opacification without air-fluid level." The x-ray findings noted that the partial opacification could represent mucosal thickening, mucus retention cyst, or polyp. The Veteran was diagnosed with chronic sinusitis/rhinitis that had a mild effect on activities of daily living, providing evidence against this claim. No periods of physician prescribed bed rest were reported. With disability compensation claims, the Board is 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). 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 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). 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 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). The Board recognizes that the Veteran is competent to report some symptoms of his sinusitis (such as runny nose, headaches, and tenderness) because this requires only personal knowledge as it comes to him through his senses. See Jandreau at 1376. He is not, however, competent to identify a specific level of disability of this disorder according to the appropriate diagnostic code. Such competent evidence concerning the nature and extent of the Veteran's disability requires additional evidence provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The Veteran has stated that he has more than six non-incapacitating episodes per year that manifest with headaches, pain, and purulent discharge or crusting. The Veteran is competent to report these symptoms, and they are consistent with the evidence of record. While the current medical evidence of record does not contain more than six non-incapacitating episodes in a calendar year, the Board finds it the Veteran credible when he states that he has repeatedly reported these symptoms to his primary care physician since his condition began. In this regard, it is reasonable that certain flu-like symptoms may not be recorded each time a primary care physician is visited if the symptoms have persisted for over 30 years, or if other issues are the primary cause of concern. The Veteran has taken prescribed medication for his condition since 2007 and treated with over-the-counter medications prior to that time. Overall, his sinusitis has been reasonably consistent with non-incapacitating episodes criteria for a 30 percent rating, and accordingly such a rating will be assigned. See 38 C.F.R. § 4.97, Diagnostic Codes 6510-14. The Veteran's sinusitis has not met the rating schedule criteria for a rating higher than 30 percent, that is, a 50 percent rating. Neither the Veteran's accounts nor clinicians' observations have indicated that he has chronic osteomyelitis following radical surgery, or near constant sinusitis characterized by headaches, pain, and tenderness of affected sinus, and purulent discharge or crusting after repeated surgeries. Indeed, there is no evidence of record that the Veteran suffers from osteomyelitis and the current evidence indicates only one surgery has been performed to relieve his symptoms. Thus, a schedular rating above 30 percent is not warranted at this time. 38 C.F.R. § 4.97, Diagnostic Code 6510-14. Additionally, the Board notes that the symptoms exhibited by the Veteran are not so unique, in itself, as to take the service-connected disability picture outside of the norm. The Veteran's disability is manifested by recurrent congestion, headaches, flu-like symptoms, sore throats, upper respiratory infections, and periodic incapacitating episodes. While his condition has a mild effect on activities of daily living, there is nothing of record to suggest that this causes a frequent or marked interference with his activities of daily living or his ability to maintain employment. Indeed, as noted, above-referenced symptoms are fully contemplated by the rating schedule (without consideration of all problems, the current grant could not be justified as not all evidence in this case supports the grant, let alone a higher evaluation), and thus, the claim will not be remanded for a referral to the Director of VA's Compensation Service for consideration of an extraschedular rating for his sinusitis disability. See Thun v. Peake, 22 Vet. App. 111 (2008). In reaching this determination, the Board acknowledges that VA is statutorily required to resolve the benefit of the doubt in favor of the Veteran when there is an approximate balance of positive and negative evidence regarding the merits of an outstanding issue. 38 U.S.C.A. § 5107(b); see also, e.g., Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990); Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). As the evidence of record, at the very least, places the claim into relative equipoise, a 30 percent rating will be assigned. Service Connection for Sleep Apnea Applicable law provides that service connection will be granted if it is shown that the Veteran experiences a disability resulting from an injury or disease contracted in the line of duty, or for aggravation of a preexisting injury or disease contracted in the line of duty, in the active military, naval, or air service. 38 U.S.C.A. § 1110, 1131; 38 C.F.R. § 3.303. That an injury or disease occurred in service alone is not enough; there must be chronic disability resulting from that injury. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). In this regard, Congress has specifically limited entitlement to service connection for disease or injury to cases where such have resulted in a disability. 38 U.S.C.A. § 1110. Thus, in the absence of proof of a present disability (and, if so, of a nexus between that disability and service), there can be no valid claim for service connection. Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Service connection may also be established on a secondary basis for a disability that is shown to be proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. Id.; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc) (additional disability resulting from aggravation of a nonservice-connected disorder by a service-connected disorder is also compensable under 38 C.F.R. § 3.310). As noted in the decision above, 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. In certain circumstances, however, lay evidence may be sufficient to establish a medical diagnosis or nexus. See Davidson. 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. 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 Routen. A significant factor to be considered for any opinion is the accuracy of the factual predicate, regardless of whether the information supporting the opinion is obtained by review of medical records or lay reports of injury, symptoms and/or treatment. See Harris v. West, 203 F.3d 1347, 1350-51 (Fed. Cir. 2000) (examiner opinion based on accurate lay history deemed competent medical evidence in support of the claim); Kowalski v. Nicholson, 19 Vet. App. 171, 177 (2005) (holding that a medical opinion cannot be disregarded solely on the rationale that the medical opinion was based on history given by the veteran); Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that the Board may reject a medical opinion based on an inaccurate factual basis). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a Veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. The Board has reviewed all the evidence in the Veteran's claims file. The Veteran contends that his sleep apnea is the direct result of his military service or secondary to his service-connected sinusitis. In support of his claim, the Veteran has submitted his own statements, an informal brief through his representative, and private medical opinions with citations to medical articles. The Veteran's service treatment records (STR), VA medical records, and private treatment records have also been reviewed. Service treatment records are negative for any complaints or treatment for a sleep disorder. In the June 1967 service separation examination report, which includes a summary of the Veteran's significant in-service medical history, the service examiner's review of the history is negative for any reports by the Veteran of symptoms of sleeping problems. Moreover, many other conditions, even those asymptomatic at the time of the exam (gingivitis, measles, and chickenpox) were discussed. Review of the Veteran's STR from November 1967 forward demonstrates through his separation from service in December 1967 shows no indication of any sleeping problem or disorder. In his Notice of Disagreement of March 2011, the Veteran states that there isn't much information in his service medical records regarding his sinusitis and deviated septum because he broke his nose approximately one month before separating from service in 1967. Two physicians of record have opined as to whether the condition is related to his service-connected conditions. A private physician stated in a letter dated in July 2010 that, The Veteran was seen by me for evaluation of his chronic sinus disease and recently diagnosed sleep apnea. The patient states that he has used medications chronically for his sinus disease, which has included nasal steroid sprays as well as antihistamines. There are several studies which do support the correlation of chronic sinus disease and sleep apnea. This patient does receive compensation for his chronic sinus disease, as well as, a deviated septum. It is very likely that his sleep apnea is related to these aforementioned illnesses. The physician also sent an additional letter in October 2012 stating that after review of the Veteran's active duty medical records: that there was evidence of difficulty sleeping while on active duty and that sleep apnea was "likely undiagnosed during his active duty career." Several medical articles linking sleep apnea and other conditions were referenced. The Veteran also underwent a VA examination in January 2011. The examiner noted that he had reviewed the Veteran's claims file and the associated medical records. The examiner reported that the Veteran developed hoarseness and increased fatigue, and he was referred to sleep studies that were positive for sleep apnea. The veteran reported that his sleep apnea had resulted in different duties being assigned at work prior to his retirement, and that it caused a decrease in his ability to concentrate, lack of stamina, weakness, and fatigue. The Veteran reported that a CPAP machine had been helpful. The examiner diagnosed the Veteran with severe sleep apnea. However, the examiner reported that sleep apnea was not permanently aggravated by sinusitis, rhinitis, deviated septum, or fractured nose. The examiner stated as his rational for this conclusion that "there is no causal relationship between sleep apnea and sinusitis, rhinitis, deviated septum, and nasal fracture. The nasal condition can aggravate the treatment of sleep apnea by interfering with the CPAP; however, this does not appear to be the situation in this Veteran." It is the Board's responsibility to evaluate the evidence and to assign each report or opinion its due probative weight. Owens v. Brown, 7 Vet. App. 429, 433 (1995). In reviewing the evidence, the Board is free to favor one medical opinion over another if the Board provides an adequate statement of reasons or bases. Id.; see also 38 U.S.C. § 7104(d)(1). In rendering a decision on appeal the Board must also analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). Generally, the degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider takes into account such factors as its thoroughness and degree of detail, and whether there was review of the Veteran's claims file. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Also significant is whether the examining medical provider had a sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting clinical data. See Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005) (rejecting medical opinions that did not indicate whether the physicians actually examined the veteran, did not provide the extent of any examination, and did not provide any supporting clinical data). The Board finds the opinion of the private physician linking the Veteran's obstructive sleep apnea with the Veteran's service-connected sinusitis to be less persuasive than the opinion of the VA examiner. While the physician is competent to make his diagnosis, the private opinion is given substantially less weight as it discusses evidence that is factually inaccurate. The Board has found no evidence to support the physician's assertion that there was evidence of difficulty sleeping while on active duty. A careful review of the claims file and the associated STR do not indicate any reports of sleeping difficulty or sleep apnea (the Veteran's own statements on this point are not fully supportive of this finding). This inaccuracy calls into question how closely the physician reviewed the claims file or if the physician was reviewing the correct file when drawing his conclusions. Further, the statement that "there are several studies which do support the correlation of chronic sinus disease and sleep apnea" to be, at best, highly speculative that this Veteran has this problem. Accordingly, the private examiner's opinion is found to be less probative than the VA examiner's opinion that cited to facts recorded in the service records and post-service records or to history given by the Veteran. The Board finds that the VA examiner's opinion is better explained in terms of the accepted facts and history in this case than is the opinion of the private physician. The Veteran argues in his informal hearing that the VA examiner did not provide a reasoned opinion. It is acknowledged that the probative value of a medical opinion comes from when it is factually accurate, fully-articulated, and sound reasoning exists for the conclusion. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The court in Nieves-Rodriguez states that "neither a VA medical examination report nor a private medical opinion is entitled to any weight in a service-connection or rating context if it contains only data and conclusions." Id. at 304. However, the Board finds that the VA examiner's opinion fulfilled this requirement. The VA examiner's conclusion is that the Veteran's sleep apnea has not been permanently aggravated by the Veteran's service connected sinusitis. He clearly states that his rationale is that there is no causal relationship between sleep apnea and sinusitis or deviated septum. Thus, the service-connected condition would be incapable of causing the condition at issue. The examiner acknowledges that it would be possible for sinusitis to aggravate an otherwise present sleep apnea and possibly interfere with CPAP treatment, but that this did not appear to be the case in this instance, addressing this issue. This contention is supported by the report earlier in the exam that the CPAP was providing good results. Nieves-Rodriquez requires that a factually accurate, fully-articulated, and sound reasoning exists for the conclusion. Nieves-Rodriguez, at 295. In this instance, the conclusion is that the Veteran's sleep apnea wasn't being aggravated by his service-connected sinusitis. The medical provider does not need to provide a rationale for each medical fact that is cited in reaching that conclusion. Otherwise, it would be very difficult to reach any medical conclusions at all. Therefore, in light of the VA examiner's opinion, the Board finds that the Veteran's sleep apnea is not etiologically related to or permanently aggravated by the Veteran's service-connected sinusitis. Finally, the private physician's contention in the October 2012 letter that the Veteran's sleep apnea likely arose during service and has been undiagnosed must be addressed. Service connection generally requires evidence of a current disability with a relationship or connection to an injury or disease or some other manifestation of the disability during service. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); Mercado-Martinez v. West, 11 Vet. App. 415, 419 (1998) (citing Cuevas v. Principi, 3 Vet. App. 542, 548 (1992)). Establishing service connection generally requires evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). The condition at issue is not a regulatory-established "chronic disease." As such, it cannot be presumed to have been incurred in active service if manifest to a compensable degree within the first post-service year, and further, continuity of symptomatology, without an established nexus to service, in not enough to warrant service connection. 38 U.S.C.A. § 1112; 38 C.F.R. §§ 3.303(b), 3.307, 3.309 (2013); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Moreover, while the Veteran is competent to state that he had certain symptoms of sleep apnea (fatigue, restless sleep) at any time, the Board notes that the Veteran himself made no such assertions and has specifically alleged that his sleep apnea was a subsequent development due to his service-connected sinusitis. As noted above, while the private examiner stated that the Veteran likely had undiagnosed sleep apnea in service, such an opinion was based on an inaccurate reading of the service history, which did not, as noted, include any sleep-related complaints. As this is the case, and as there is no additional evidence supportive of a relationship between service and sleep apnea outside of the Veteran's unsubstantiated lay assertions, the Board finds that there is no direct basis for service connection. Even the Veteran's own statements on this point do not fully support this finding. In sum, the Veteran's obstructive sleep apnea is not causally related to service directly or related secondary to his service-connected sinusitis either causally or by aggravation. Therefore, service connection for obstructive sleep apnea is not warranted. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert, at 53-56. Duty to Assist Under applicable criteria, VA has certain notice and assistance obligations to claimants. See 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). When VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and his representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). VA 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. Quartuccio v. Principi, 16 Vet. App. 183 (2002). In this case, the Veteran was provided with notice with regard to his increased rating claim for sinusitis and service connection for sleep apnea. In both instances, he was informed of what evidence VA would provide and what evidence he should supply in support of his claim. The Veteran was specifically informed as to how disability ratings are assigned based on the severity of the service-connected disability and how service connection is established. Additionally, he was also informed as to how effective dates are assigned. See Dingess v. Nicholson, 19 Vet. App. 473, 490 (2006). It is pertinent to note that the Veteran is represented by the Military Order of the Purple Heart, and that organization is presumed to have knowledge of what is necessary to substantiate a claim for both a higher disability evaluation for sinusitis and for service connection for sleep apnea. Neither the Veteran nor his representative have pled prejudicial error with respect to the content or timing of VCAA notice. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009). Regarding VA's duty to assist the Veteran in obtaining evidence needed to substantiate his claim, the Board finds that all necessary assistance has been provided in this case. The evidence includes all relevant service treatment records and pertinent post-service medical records that address complaints of sinusitis or sleep apnea. Furthermore, the Veteran has been afforded comprehensive VA examinations, which addressed his complaints. The October 2008 and January 2011 examinations provide a current description of the disability picture. As the Veteran has not alleged or provided evidence of a worsening condition, they are adequate for rating purposes. The January 2011 examination addressed the Veteran's contentions with regard to etiology of sleep apnea, and is adequate to resolve that issue. See McClendon v. Nicholson, 20 Vet. App. 79 (2006). Accordingly, there is no indication of any additional relevant evidence that has not been obtained. There is no duty to provide another examination or a medical opinion. See 38 C.F.R. §§ 3.326, 3.327 (2013). ORDER Entitlement to a 30 percent rating for sinusitis, but no more than 30 percent, is warranted. Entitlement to service connection for sleep apnea, including as secondary to service-connected sinusitis, is denied. ____________________________________________ JOHN J. CROWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs