Citation Nr: 1801152 Decision Date: 01/09/18 Archive Date: 01/19/18 DOCKET NO. 15-03 844A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to an initial rating in excess of 10 percent for sinusitis. 2. Entitlement to a compensable initial rating for allergic rhinitis. 3. Entitlement to service connection for a typical facial pain or headaches, claimed as sinus headaches (sinus headaches), to include as secondary to the service-connected disability of sinusitis. REPRESENTATION The Veteran represented by: Florida Department of Veterans Affairs WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD V-N. Pratt, Associate Counsel INTRODUCTION This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2017). 38 U.S.C.A. § 7107(a)(2) (West 2014). The Veteran served on active duty from July 1954 to December 1958. He is the recipient of various service awards, including the National Defense Service Medal, Good Conduct Medal, and Air Force Longevity Service Award. These matters come before the Board of Veterans' Appeals (Board) on appeal from April 2011 and October 2011 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. The April 2011 rating decision granted service connection for sinusitis at a 10 percent disability rating evaluation, effective March 15, 2007, as well as service connection for allergic rhinitis at a non-compensable disability rating, effective March 15, 2007. The October 2011 rating decision denied service connection for sinus headaches. In November 2017, the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge. A transcript of this hearing is of record. The issues of entitlement to an initial rating in excess of 10 percent for sinusitis and an initial compensable rating for allergic rhinitis are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDING OF FACT The Veteran's sinus headaches are related to his active service. CONCLUSION OF LAW The criteria for service connection for sinus headaches are met. 38 U.S.C. § 1110 (West 2014); 38 C.F.R. § 3.303 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSION Service connection may be granted for disability resulting from disease or injury incurred in or aggravated during service. 38 U.S.C. § 1110 (West 2014); 38 C.F.R. § 3.303 (2017). That determination requires a finding of current disability that is related to an injury or disease in service. Service connection may be granted for a disability diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability is due to disease or injury that was incurred or aggravated in service. 38 C.F.R. § 3.303(d) (2017). At his videoconference hearing, the Veteran testified that his doctor told him that his headaches are the result of his service-connected sinus issues. See November 2017 Videoconference Hearing Transcript. In support of his claim, the Veteran submitted an October 2010 private medical opinion from his physician, Dr. E.N.T. Specifically, in addition to diagnosing the Veteran with sinus headaches, Dr. E.N.T. opined that they were most likely caused by or a result of pollen exposure, when he was transferred from Florida to Texas, while in service, and also as a result of abroad exposure to other environmental allergens. See October 2010 Private Medical Opinion. As the basis and rationale for his opinion, Dr. E.N.T. explained that exposure to other pollens and environmental allergies are usually the cause of development of sinus headaches, for which he had been treating the Veteran for the prior three years. Id. The Board finds that this October 2010 private opinion is the most probative evidence of record, which is dispositive of the issue. Dr. E.N.T.'s opinion provides a clear, detailed rationale that is based on the treatment he provided to the Veteran during the prior three years before this opinion, as well as his review of the Veteran's in-service and post-service medical records. Therefore, the Board finds that service connection for sinus headaches are warranted. ORDER Entitlement to service connection for sinus headaches is granted. REMAND The Board regrets further delay, but finds that additional development is necessary before a decision may be rendered on the remaining issues on appeal. At his videoconference hearing, the Veteran asserted that his service-connected sinusitis and rhinitis conditions have worsened. See November 2017 Videoconference Hearing Transcript. In this regard, the Board notes that the last time the Veteran was afforded a VA examination on his nose and sinus was in October 2011. Therefore, given the Veteran's assertions, a remand is required for a contemporaneous VA examination to determine the current level of severity for the Veteran's service-connected disabilities of sinusitis and rhinitis. See Snuffer v. Gober, 10 Vet. App. 400 (1997); Caffrey v. Brown, 6 Vet. App. 377 (1994) (finding that the Board should have ordered a contemporaneous examination of the Veteran because a 23-month old examination was too remote in time to adequately support the decision in an appeal for an increased rating); VAOPGCPREC 11-95 (1995). Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested.) 1. Obtain any outstanding private and/or VA treatment records and associate them with the claims file. 2. Then, after obtaining all outstanding treatment records, if applicable, schedule the Veteran for a VA examination to assess the current level of severity for his service-connected disabilities of sinusitis and rhinitis. A copy of this remand must be provided to the VA examiner. Then, the VA examiner must review the claims file and must note that review in the report. If possible, the appropriate Disability Benefits Questionnaires (DBQs) should be completed. 3. After ensuring compliance with the above-mentioned development, readjudicate the claims. If any decision remains adverse to the Veteran, issue a supplemental statement of the case and allow the appropriate time for response from the Veteran or his representative. Then, return the case to the Board for further development. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (West 2014). ______________________________________________ BRADLEY W. HENNINGS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs