Citation Nr: 1745538 Decision Date: 10/12/17 Archive Date: 10/19/17 DOCKET NO. 10-23 028 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Honolulu, Hawaii THE ISSUE Entitlement to a disability rating in excess of 10 percent prior to February 17, 2009, and rating in excess of 30 percent from that date for chronic sinusitis, to include on an extra-schedular basis pursuant to 38 C.F.R. § 3.321(b)(1). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant and his coworker ATTORNEY FOR THE BOARD N. Laroche, Associate Counsel INTRODUCTION The Veteran served on active duty with the United States Navy from July 2003 to December 2006. This appeal to the Board of Veterans' Appeals (Board) arose from a May 2009 rating decision in which the RO in Waco, Texas, inter alia, denied the Veteran's claim for a rating in excess of 10 percent for chronic sinusitis. In October 2009, the Veteran filed a notice of disagreement (NOD). A statement of the case (SOC) was issued in May 2010 and the Veteran filed a substantive appeal (via a VA Form 9, Appeal to the Board of Veterans' Appeals) in May 2010. Subsequently, jurisdiction in this case was transferred to the RO in Honolulu, Hawaii, which certified the appeal to the Board. In June 2013, the Veteran and a witness, a co-worker, testified during a hearing before the undersigned Veterans Law Judge at the Honolulu RO; a transcript of the hearing is of record. In January 2014, the Board remanded the claim on appeal to the RO, via the Appeals Management Center (AMC) in Washington, DC for further development. After accomplishing the requested action, the AMC awarded a 30 percent rating for chronic sinusitis from February 17, 2009, the date of the claim for increase (as reflected in the July 2014 rating decision), and has returned this matter to the Board for further appellate consideration. Although the AMC granted a higher rating during the pendency of the appeal for the Veteran's service-connected chronic sinusitis, inasmuch as a higher rating for this disability was available, and the Veteran is presumed to be seeking the maximum available benefit for a disability, a claim for increase remains viable on appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993). In July 2016, the Board remanded the claim on appeal to the RO, via the AMC in Washington, DC, for further development. After accomplishing the requested action, the AMC continued to deny a rating in excess of 30 percent (as reflected in the January 2017 SSOC) and returned the claim to the Board. While the Veteran previously had a paper claims file, this appeal is now being processed utilizing the paperless, electronic Veterans Benefits Management System (VBMS) and Virtual VA claims processing systems. All records have been reviewed. FINDINGS OF FACT 1. All notification and development actions needed to fairly adjudicate the claim on appeal have been accomplished. 2. Prior to February 17, 2009, the Veteran's sinusitis was manifested by no more than two non-incapacitating episodes annually; characterized by headaches, sinus pain, and purulent discharge. 3. Since February 17, 2009, the Veteran's sinusitis was manifested by more than six non-incapacitating episodes annually of sinusitis characterized by headaches, pain, and purulent discharge/crusting. 4. At no pertinent point has the Veteran's sinusitis been shown to be so exceptional or so unusual a picture as to warrant the assignment of any higher rating on an extra-schedular basis. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for sinusitis, to include on an extra-schedular basis, prior to February 17, 2009, are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1 -4.7, 4.96, 4.97, Diagnostic Code (DC) 6513 (2016). 2. The criteria for a rating in excess of 30 percent for sinusitis, to include on an extra-schedular basis, from February 17, 2009 are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107(b) (West 2014); 38 C.F.R. §§ .102, 3.159, 3.321, 4.1 -4.7, 4.96, 4.97, DC 6513 (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2014) includes enhanced duties to notify and assist claimants for VA benefits. VA regulations implementing the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2016). After a complete or substantially complete application for benefits is received, notice requirements under the VCAA essentially require VA to notify a claimant of any evidence that is necessary to substantiate the claim(s), as well as the evidence that VA will attempt to obtain and which evidence he or she is responsible for providing. See, e.g., Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002) (addressing the duties imposed by 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b)). VCAA-compliant notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the AOJ Id; Pelegrini, 18 Vet. App. at 112. See also Disabled American Veterans v. Secretary of Veterans Affairs, 327 F.3d 1339 (Fed. Cir. 2003). However, the VCAA notice requirements may, nonetheless, be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Id. In rating cases, a claimant must be provided with information pertaining to assignment of disability ratings (to include the rating criteria for all higher ratings for a disability), as well as information regarding the effective date that may be assigned. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Furthermore, with respect to claims for increase, the VCAA requires only generic notice as to the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270, 1277 (2009). VCAA-compliant notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (AOJ). Id.; Pelegrini, 18 Vet. App. at 112. See also Disabled American Veterans v. Secretary of Veterans Affairs, 327 F.3d 1339 (Fed. Cir. 2003). However, the VCAA notice requirements may, nonetheless, be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Id. In an April 2009 pre-rating letter sent to the Veteran in connection with his claim, the AOJ provided notice to the Veteran explaining what information and evidence must be submitted by the appellant, and what information and evidence would be obtained by VA. This letter also provided the Veteran with general information pertaining to VA's assignment of disability ratings and effective dates, as well as the type of evidence that impacts those determinations, consistent with Dingess/Hartman. The record also reflects that, consistent with applicable duty-to-assist provisions, VA has made reasonable efforts to develop the Veteran's claim, to include obtaining or assisting in obtaining all relevant records and other evidence pertinent to the matter herein decided. Pertinent medical evidence associated with the claims file consists of service records; private and VA treatment records; and reports of VA examinations and opinions. Also of record and considered in connection with the claims are the lay statements from the Veteran. The Board finds that no further AOJ action on this claim, prior to appellate consideration, is required. As noted, the Veteran had an opportunity to orally advance his contentions during a Board hearing. During the June 2013 Board hearing, the undersigned identified the claim on appeal as that herein decided. Information was elicited regarding the nature of the disability, current severity, and treatment. Although the undersigned did not explicitly suggest the submission of any specific additional evidence, on these facts, such omission was harmless. After the hearing, the Board sought further development of the claim, as the result of which additional evidence was added to the claims file. Thus, the hearing was legally sufficient. See 38 C.F.R. § 3.103 (c)(2) (2016); Bryant v. Shinseki, 23 Vet. App. 488 (2010). As indicated above, in January 2014 and July 2016, the Board remanded the claim on appeal for additional development, and the record reflects initial compliance with the prior remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). See also D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) and Dyment v. West, 13 Vet. App. 141, 146-47 (1999) aff'd, Dyment v. Principi, 287 F.3d 1377 (2002) (holding that substantial, rather than strict, compliance is sufficient). In January 2014, the Board instructed the AOJ to obtain VA evaluation and/or treatment records of the Veteran from April 2010 to December 2011. The Veteran did not provide any further authorization forms, and no private medical records were identified or submitted. Additionally, in May 2014 the Veteran underwent a VA sinus examination. Pursuant to the January 2014 remand, VA evaluation and/or treatment records of the Veteran from April 2010 to December 2011, and since December 2013, were obtained. Medical treatment records were also obtained from Tripler Army Medical Center since March 2014. There is no indication that there is existing pertinent evidence outstanding to obtain or submit. In July 2016, the Board instructed the AOJ to obtain an addendum opinion, which was completed in December 2016. In summary, the duties imposed by the VCAA have been considered and satisfied. There is no additional notice that should be provided, nor is there any indication that there is additional existing evidence to obtain or development required to create any additional evidence to be considered in connection with the claim. As such, the Veteran is not prejudiced by the Board proceeding to a decision on the claim on appeal, at this juncture. See Mayfield v. Nicholson, 20 Vet. App. 537, 543 (2006) (rejecting the argument that the Board lacks authority to consider harmless error). See also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). II. Analysis Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3. While the Veteran's entire history is reviewed when assigning a disability rating, 38 C.F.R. § 4.1, where service connection has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). However, in determining the present level of a disability for any increased rating claim, the Board must consider the applicability 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 may be warranted. The Veteran's chronic maxillary sinusitis has been rated 10 percent disabling from December 21, 2006 to February 17, 2009, and as 30 percent disabling thereafter, and the ratings assigned are under 38 C.F.R. § 4.97, DC 6513. However, the actual criteria for rating sinusitis is set forth in a General Rating Formula under 38 C.F.R. § 4.97. Under that formula, a 10 percent rating is warranted for one or two incapacitating episodes of sinusitis per year requiring prolonged (lasting four to six weeks) antibiotic treatment; or three to six non-incapacitating episodes of sinusitis per year characterized by headaches, pain, and purulent discharge or crusting. A 30 percent rating requires three or more incapacitating episodes of sinusitis per year requiring prolonged (lasting four to six weeks) antibiotic treatment, or more than six non-incapacitating episodes of sinusitis per year characterized by headaches, pain, and purulent discharge or crusting. A 50 percent rating is assigned following radical surgery with chronic osteomyelitis, or for near-constant sinusitis characterized by headaches, pain, and tenderness of the affected sinus, and purulent discharge or crusting after repeated surgeries. A Note to the General Rating Formula provides that an incapacitating episode of sinusitis means one that requires bed rest and treatment by a physician. Id. Turning to the relevant evidence of record, the Veteran underwent a computerized tomography (CT) scan in February 2007 that revealed mild mucosal thickening seen in the left maxillary sinus posteriorly but no air-fluid levels or mass lesions. Large defects were seen in the medial walls of both maxillary sinuses, which the examiner identified as most likely due to prior surgery. The sphenoid, ethmoid, and frontal sinuses showed no abnormality. The Veteran underwent a VA examination in March 2007 for his sinusitis. At the time of the examination, he reported that he had fiberoptic endoscopic sinus surgery (FESS) done at the Naval hospital in San Diego in 2004 for his sinusitis. He reported a history of post nasal drainage and congested which he was given antibiotics for on three occasions. He noted that he did not stay home with the infections, but continued to work, and missed no work over the past year. The Veteran reported that he has taken an inhaled nasal steroid and a non-sedating antihistamine in the past. An ear, nose, and throat examination revealed both external auditory canals and tympanic membranes to be normal in appearance. An examination of the nose revealed minimal swelling involving the middle and inferior turbinates, although there was no significant nasal obstruction present. There were no nasal polyps and crusting present. There was also no mucopus present in the nose or nasopharynx. The examination of the mouth and oropharynx were unremarkable. The examiner reported that a CT scan done in February 2007 showed only minimal mucosal thickening in the left maxillary sinus, but no air-fluid levels or mass lesions were present. The examiner further reported that there was no evidence of acute pathology present. The examiner stated that the Veteran had a history of chronic maxillary sinusitis with no active disease at that time as well as allergic rhinitis. He further stated that at that time, the Veteran had only minimal findings as both the physical and CT findings were both unremarkable. During the February 2008 VA examination, the Veteran complained of nasal congestion and drainage. He stated that his problem was chronic and occurred on a daily basis. He stated that he was constantly blowing his nose and had drainage present most of the time. He reported that his last antibiotic treatment occurred in March 2007 and he continued to use an inhaled nasal steroid and non-sedating antihistamine as prescribed. An ear, nose, and throat examination revealed both external auditory canals and tympanic membranes to be normal in appearance. An examination of his nose revealed minimal swelling involving the middle and inferior turbinates, although the nasal mucosa appeared to be inflamed. The examiner did not see mucopus present, although there did appear to be some mucoid material present in the nasal cavity. The examiner also did not see purulent material and there were no nasal polyps present. Significant nasal obstruction was not present. The Veteran was diagnosed with a history of chronic maxillary sinusitis and allergic rhinitis. The examiner noted that the physical examination appeared essentially unchanged from that of the March 2007 examination. The examiner reported that the Veteran's nasal airway appeared not to be constructed, although there appeared to be chronic inflammation present involving the nasal mucosa. In July 2010, the Veteran underwent a CT scan which revealed continued presence of bilateral medial maxillary wall resection; continued presence of minimal mucosal thickening with bilateral maxillary sinuses (minimally increased from his prior examination); and appearance of mucosal thickening within ethmoid and right sphenoid sinuses, without bony erosions. In December 2011, a CT scan was revealed mild pansinusitis. There was no evidence of sinus polyps or cysts and the Veteran did not wish to pursue any additional treatment medically or surgically. In January 2012, the Veteran underwent a fiberoptic nasal endoscopy which revealed patent ostiomeatal unit and no polyposis. An August 2012 CT scan revealed mild pansinusitis with no evidence of sinus polyps or cysts. There was slight leftward deviation of the mid portion of the bony nasal septum. No sinus wall destruction or thickening was noted. In June 2013, the Veteran testified during a Board hearing that since he filed his notice of disagreement, his condition has progressed. He reported that the 2004 surgery he underwent was unsuccessful. He reported that his medication included antibiotics, steroids, and nasal sprays. He stated that he had pain in his sinus area; difficulty breathing out of one side of his nose as compared to the other side; headaches (separate from his migraines); and continuous discharge (which reportedly led to a sinus infection). He stated that his sinus condition affected his voice box and decongestants did not help. He reported that his condition had become so chronic, that he was forced to leave work. He stated that work leave was a liberal situation where they would just allow him to leave instead of having to go through the process of being put to bed rest. A co-worker testified on the Veteran's behalf and reported that the Veteran constantly tried to clear his head or nose; she observed him using nasal sprays; he complained about headaches; and he left work early. She also reported that if he took a full day off, his condition was really bad. In June 2013, Dr. M.R.D. submitted a letter on the Veteran's behalf, noting that he received care from the VA Medical Center (VAMC) in Honolulu, Hawaii since December 2011. She reported that he continued to have worsening of his sinusitis symptoms which she classified as debilitating to his current function. She reported that he has had no improvement and he reported that his condition was affecting his ability to function to his fullest capacity for work. Additionally, in June 2013, Dr. B. F., a staff physician at the VAMC in Hawaii submitted a letter on the Veteran's behalf where he noted that the Veteran's chronic sinusitis was seriously affecting his ability to effectively perform his job. The physician noted that this was due to frequent and recurrent bouts of severe sinus symptoms. The physician reported that each time he has a non-incapacitating episodes, he is forced to leave work and go home. In June 2013, several of the Veteran's co-worker's submitted statements which indicated that the Veteran's medical condition caused a debilitating effect on his employment and his daily life. They further reported that sometimes the Veteran came into work with crusting, nasal congestion, mucous thickening in his nose, and complaints of not being able to breathe. One co-worker reported that on several occasions, the Veteran was unable to continue work for the rest of the day due to severe headaches and pain. Another co-worker Veteran's condition seemed to have steadily worsened over time, and that the Veteran was told that his frequent absence could result in his loss of his position. The February 2014 Disability Benefits Questionnaire (DBQ) documents that the Veteran underwent bilateral endoscopic sinus surgery, inferior turbinate reduction cautery and reduction, and bilateral maxillary antrostomy. The examiner noted that the sinuses currently affected by the Veteran's chronic sinusitis were maxillary, frontal, and ethmoid. The examiner noted that the Veteran had near constant sinusitis (once a month, 12 times a year), headaches, pain and tenderness of the affected sinus, purulent discharge or crusting, and fatigue. There were seven or more non incapacitating episodes of sinusitis characterized by headaches, pain, and purulent discharge or crusting in the past 12 months noted. There were three or more incapacitating episodes of sinusitis requiring prolonged use of antibiotic treatment in the past 12 months noted. The examiner noted that the Veteran had a radical, endoscopic surgery in July 2004 and chronic osteomyelitis did not follow the surgery. The examiner also noted the Veteran had chronic laryngitis with hoarseness. The Veteran's functional impact was noted as difficulty with breathing and significant nasal congestion with severe migraine. He also had headaches which influenced his ability to concentrate and could be debilitating because it affected his appetite as well. The examiner noted that he has missed work frequently, at least once a week, because of recurrent infection, headache, nausea, and nasal discharge. In a March 2014 clinical note, an endoscopic/fiberoptic examination revealed widely patent maxillary ostia bilateral with patent ethmoid ostia on the left. The examiner noted that his sinus pressure/pain was not supported by CT findings. In May 2014, a CT scan revealed bilateral clouding of maxillary sinuses with significant mucosal thickening with no fluid levels. There were additional findings of clouding/opacity of frontal sinus, ethmoid and sphenoid sinuses. An impression of chronic pansinusitis was noted. In May 2014, the Veteran underwent a VA examination where he continued to report symptoms of nasal congestion, nasal discharge, sinus headaches, and itchy eyes. He reported that his symptoms have worsened and he has had to call in sick from work at least once a month. He described these episodes as "non-incapacitating." He reported that he has sinus symptoms daily. On examination, the Veteran reported headaches, tenderness of affected sinus, and purulent discharge or crusting. He further reported that he did not have incapacitating episodes of sinusitis requiring prolonged (four to six weeks) treatment of antibiotics in the past 12 months. The examiner noted that the Veteran's sinusitis did have functional impact on his ability to work, and stated that the Veteran had to call in sick once a month in the past 12 months. The examiner reported that the most recent CT scan revealed clear worsening of his sinus condition as compared to the 2007 VA examination (where the Veteran only had maxillary sinusitis and sparing of the other paranasal sinuses). The Veteran underwent a CT of his sinuses in August 2016 which revealed left frontal and anterior ethmoid sinus that had mild mucosal thickening. His nasal septum was mildly elevated to the left with a left lateral spur. Visualized portions of mastoid air cells and the middle ear cavity were clear. A November 2016 clinical note from his primary care provided notes that the Veteran continued to have sinusitis symptoms and a physical examination revealed mild sinus pressure that the examiner assessed not to be significant at that time. A December 2016 VA medical opinion was provided in order for the examiner to comment upon the extent of occupational impairment resulting from the Veteran's chronic sinus disability. After a review of the medical evidence and statements made by the Veteran, and a review of medical literature, the physician reported that there were three subtypes of chronic rhinosinusitis and the Veteran had chronic rhinosinusitis without nasal polyposis. The characteristic presentation of chronic rhinosinusitis without nasal polyposis is that of persistent symptoms with periodic exacerbations characterized by increased facial pain/pressure and/or increased anterior or posterior drainage. The examiner noted that there was no hospitalization, emergency room visits, and periods of incapacitation secondary to his rhinosinusitis. A review of the Veteran's medications revealed that he had no treatment with antibiotics for his condition in the past 12 months. Based on this information, the physician found that his sinus disability will have moderate to severe effect on physical employment and mild to moderate effect on sedentary employment. Considering the pertinent evidence of record in light of the applicable rating criteria, the Board finds that with respect to a rating in excess of 10 percent for the period prior to February 17, 2009, or a rating in excess of 30 percent from that date, is not warranted. At the outset, the Board notes that the Veteran was diagnosed with allergic rhinitis, which he is service-connected for under 38 C.F.R. § 4.97, DC 6512. Additionally, the Veteran was diagnosed with pansinusitis which is evaluated under General Rating Formula under 38 C.F.R. § 4.97, as well as his chronic maxillary sinusitis. For the period prior to February 17, 2009, the evidence reflects that the Veteran experienced symptoms suggestive of the level of impairment contemplated in the 10 percent rating for chronic maxillary sinusitis. The Veteran's sinusitis has been detected by an X-ray and further imaging testing. During his March 2007 VA examination, the Veteran reported that he used antihistamines and a nasal steroid in the past, but only used Astelin nasal spray at the time of the evaluation. The Veteran did not report, and the examiner did not note, any further use of antibiotic treatment for incapacitating episodes. Non-incapacitating episodes were not reported at that time. The examiner noted that the Veteran had only minimal findings of sinusitis at that time. During his February 2008 VA examination, the Veteran complained of chronic nasal congestion and drainage, and confirmed that his last antibiotic treatment was in March 2007. The examiner noted that the Veteran's sinusitis was essentially unchanged from his prior examination in March 2007. Again, no incapacitating or non-incapacitating episodes were reported by the Veteran or noted by the examiner. Based on the evidence above, the Board finds that a rating in excess of 10 percent for service-connected sinusitis is not warranted for the period prior to February 17, 2009. His VA examination reports reflect no incapacitating episodes lasting four to six weeks with the treatment of antibiotics. They also do not reflect more than six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. Although the Veteran did describe chronic symptoms of nasal congestion and drainage, he did not report them as non-incapacitating and crusting was not reported. Thus, the evidence of record for the period prior to February 17, 2009 presents no basis for an assignment of a rating greater than 10 percent. As noted, a rating in excess of 10 percent requires three or more incapacitating episodes per year of sinusitis requiring prolonged antibiotic treatment; or more than six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. The Board finds that prior to February 17, 2009, the Veteran did not manifest symptoms of the type, extent, frequency, and/or severity contemplated by the next higher, 30 percent rating. As for the period since February 17, 2009, the evidence shows that a rating in excess of 30 percent is not warranted. The Veteran had one surgery that was characterized as radical in 2004; fiberoptic endoscopic sinus surgery. Following the surgery, the February 2014 examiner noted that the Veteran did not have chronic osteomyelitis. Furthermore, although the Veteran did report chronic headaches, pain and tenderness, purulent discharge and crusting, he did not undergo repeated surgeries. Moreover, a March 2014 clinical note reflected that the Veteran's sinus pressure/pain was not supported by CT findings. A November 2016 clinical note revealed mild sinus pressure that the examiner assessed to be insignificant at that time. As of December 2016, the Veteran had not used antibiotics for the past 12 months for his sinus disability, and the examiner noted that there was no hospitalization, emergency room visits, and periods of incapacitation secondary to his rhinosinusitis. Based on the evidence pertinent to the period from February 17, 2009 forward, the Board finds that the record presents no basis for assignment of a rating for the Veteran's sinus disability greater than the 30 percent assigned. As noted, a rating in excess of 30 percent would require 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. As the evidence shows no chronic osteomyelitis and no repeated surgeries, the symptoms of the type, and extent, frequency, and/or severity appropriately align with no more than the assigned 30 percent under the General Rating Formula criteria. In evaluating the claim for increased rating for the Veteran's service-connected sinusitis, the Board has considered the Veteran's assertions regarding his symptoms, which he is certainly competent to provide. See, e.g., Layno v. Brown, 6 Vet. App. 465, 470 (1994) and Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). Generally, however, the criteria needed to support higher ratings require medical findings that are within the province of trained medical professionals. See Jones v. Brown, 7 Vet. App. 134, 137-138 (1994). In this regard, the lay assertions are not considered more persuasive than the objective medical findings which, as indicated above, do not support assignment of any higher ratings for sinusitis at any pertinent point. The above determinations are based on consideration of applicable provisions of VA's rating schedule. Additionally, the Board finds that, at no pertinent point has the Veteran's sinus disability has been shown to reflect so exceptional or so unusual a picture as to render the schedular criteria for rating the disability inadequate, and to warrant the assignment of any higher rating on an extra-schedular basis. See 38 C.F.R. § 3.321(b). The threshold factor for extra-schedular consideration is a finding on the part of the Agency of Original Jurisdiction (AOJ) or the Board that the evidence presents such an exceptional disability picture that the available schedular ratings for the service-connected disability at issue are inadequate. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993); see also 38 C.F.R. § 3.321 (b)(1). Therefore, initially, there must be a comparison between the level of severity and the symptomatology of the claimant's disability with the established criteria provided in the rating schedule for this disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the disability picture is contemplated by the rating schedule, the assigned rating is therefore adequate, and no referral for extra-schedular consideration is required. See VAOGCPREC 6-96 (Aug. 16, 1996); Thun v. Peake, 22 Vet. App. 111 (2008). If the rating schedule does not contemplate the claimant's level of disability and symptomatology, and is found inadequate, the AOJ 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" (including marked interference with employment and frequent periods of hospitalization). 38 C.F.R. § 3.321 (b)(1). If so, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for completion of the third step: a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extra-schedular rating. Thun, 22 Vet. App. 111. In this case, the Board finds that it appears that the schedular criteria are adequate to rate the Veteran's sinus disability at all pertinent points. As discussed above, the Veteran's symptoms have been consistently reported as headaches, pain and tenderness of affected sinus, and purulent discharge and crusting. No other symptoms have been reported in connection with his sinus disability. Moreover, the applicable rating criteria provide for evaluation based on consideration of incapacitating and non-capacitating episodes, although, in this case, there is no evidence that a physician ever required bed rest and treatment for the is sinus disability, and his non-incapacitating episodes were not treated by antibiotics or additional surgeries. Thus, the Veteran's symptoms are all contemplated by the appropriate rating criteria under the General Rating Formula, and there is no explicit evidence or argument that the schedular criteria are inadequate to rate the disability. However, given the additional evidence submitted, and the development undertaken with respect to the second step of Thun, the Board finds that, even if was determined that the schedular criteria are not adequate to rate the disability, an exceptional or unusual disability picture with such factors as marked interference with employment simply is not persuasively shown. In support of his extra-schedular contentions, the Veteran submitted numerous statements from co-workers and one statement from a treating physician. In the June 2013 letter from his treating physician, Dr. B.F. noted that the Veteran's chronic sinusitis was seriously affecting his ability to effectively perform his job. The physician reported that each time he has a non-incapacitating episodes, he is forced to leave work and go home. Co-workers reported that the Veteran came into work with crusting, nasal congestion, mucous thickening in his nose, and complaints of not being able to breathe. They also reported that he would have to leave work due to his sinus disability, and one co-worker stated that he was at risk of losing his job. The Board finds, however, that none of proffered evidence is entitled to significant probative weight on the question of whether an extra-schedular rating is warranted. Significantly, wat Dr. B.F. reported in his letter appears to a mere reiteration of what the Veteran reported to him regarding his ability to effectively perform at his job, as opposed to a actual medical opinion. See LeShore v. Brown, 8 Vet.App. 406, 409 (1995) (holding that evidence which is simply information recorded by a medical examiner, unenhanced by any additional medical comment by that examiner, does not constitute "competent medical evidence, and that a bare transcription of a lay history is not transformed into "competent medical evidence" merely because the transcriber happens to be a medical professional.). Likewise, the Veteran's co-workers all reported their observations of the Veteran's symptomatology and what the Veteran complained of to them. As regards the Veteran's alleged risk of losing his job, notably, this was reported by a co-worker, and not the Veteran's employer or a human resources representative The Board also finds that such appears contrary to the Veteran's own June 2013 hearing testimony that he had a "liberal" situation at work; indicating that he was free to leave if need be without any issue with his employer. As noted, following receipt of the above-described evidence, the December 2016 VA medical opinion was obtained to address the extent of occupational impairment the Veteran had as a result of his sinus disability. Based on the evidence, the physician found that his sinus disability will have moderate to severe effect on physical employment and mild to moderate effect on sedentary employment. Notably, in this case, the Veteran's employment does not require physical exertion, and is mostly sedentary. The December 2016 VA medical professional reviewed the entire claims file, noting all treatment the Veteran has received for his sinusitis and all statements he has made regarding his employment. As the December 2016 VA medical professional rendered an opinion based on consideration of all evidence of record, the Board finds that his comments constitute the most persuasive evidence of record on the question of whether marked interference with employment is shown. See, e.g., Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007); Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). The Board also finds that the disability has not necessitated frequent hospitalization, and an exceptional or unusual disability picture has not otherwise been shown. The Board further notes that, pursuant to Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014), a veteran may be awarded an extra-schedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where evaluation of the individual conditions fails to capture all the symptoms associated with service-connected disabilities experienced. Here, however, the issue has not been argued by the Veteran or reasonably raised by the evidence of record. The Veteran has not asserted, and the evidence of record does not suggest, any such combined effect or collective impact of multiple service-connected disabilities that create such an exceptional circumstance so as to render the schedular rating criteria for evaluating the disability inadequate. See Yancy v. McDonald, 27 Vet. App. 484, 495 (Fed. Cir. 2016). Accordingly, this is not an exceptional circumstance for extra-schedular consideration within the meaning of Johnson. As the requirements for invoking the procedures set forth in 38 C.F.R. § 3.321(b)(1) for assignment of a higher, extra-schedular rating are not met, referral of this matter for extra-schedular consideration is not warranted. See Bagwell v. Brown, 9 Vet. App. 337, 338-9 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). As a final point, the Board notes that if a claimant or the record reasonably raises the question of whether the claimant is unemployable due to the disability for which a higher rating is sought, then part and parcel to that claim for a higher rating is the matter of whether a total disability rating based on individual unemployability (TDIU) as a result of that disability is warranted. See Rice v. Shinseki, 22 Vet. App. 447 (2009). In this case, the Board notes that the Veteran is employed full-time. There is no evidence or argument that the Veteran's service-connected chronic maxillary sinusitis, alone, has actually or effectively rendered him unable to obtain or retain substantially gainful employment at any point pertinent to the current claim. Under these circumstances, the Board finds that the matter of the Veteran's entitlement to a TDIU due to his sinus disability has not been raised in conjunction with the current claim for higher rating, and need not be addressed herein. For all the foregoing reasons, the Board finds there is no basis for further staged rating of the disability under consideration, and that a rating in excess of 10 percent prior to February 17, 2009, and a rating in excess of 30 percent from that date, for service-connected chronic maxillary sinusitis, must be denied. In reaching these conclusions, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against assignment of a higher rating at any pertinent point, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). ORDER The claim for a disability rating in excess of 10 percent prior to February 17, 2009 and in excess of 30 percent thereafter for chronic sinusitis, to include on an extra-schedular basis pursuant to 38 C.F.R. § 3.321(b)(1), is denied. ____________________________________________ JACQUELINE E. MONROE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs