Citation Nr: 1801508 Decision Date: 01/10/18 Archive Date: 01/23/18 DOCKET NO. 14-10 775 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Oakland, California THE ISSUE Entitlement to service connection for sinusitis. REPRESENTATION Veteran represented by: The American Legion ATTORNEY FOR THE BOARD C. Cooklin, Associate Counsel INTRODUCTION The Veteran served in the Air Force from June 1961 to June 1965. This case comes before the Board of Veterans' Appeals (Board) on appeal from a March 2010 rating decision (RD) by the Department of Veterans Affairs (VA) Regional Office (RO) in Oakland, California. The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the appellant if further action is required. REMAND A remand is required to ensure the Veteran receives adequate due process and claim development assistance. In June 2008, the Veteran filed a claim for hearing loss and tinnitus. In January 2009, in his Statement in Support of Claim (SISC), he writes that during boot camp, he was doing leg lift exercises in 100-degree weather, and the left side of his face swelled. He reported he was kicked in his side by his drill sergeant in order to lift his legs higher. He went to the hospital, and was under an oxygen tent for 2-3 days as his sinuses had ruptured. The sinusitis claim was then added to the Veteran's claims. In March 2010, a RD denied service connection for all three claims. The RD noted the Veteran was treated in service for sinusitis in June 1961, but that service treatment records (STR) were silent for any ongoing problems. The RD notes the Veterans separation physical indicates the Veteran having acute episodes of sinusitis once a year occurring in the spring. The RD indicates part of the evidence considered was the Veterans September 2008 SISC. However, the VBMS entry for the SISC is largely blank, containing no relevant information. In May 2009, another SISC was filed from which the sinusitis claim was later added, and the RD indicates no reference to it. In this SISC, the Veteran generally outlines his claim for sinusitis. In April 2010, the Veteran filed his notice of disagreement, specifically appealing only the sinusitis claim. The Veteran stated additional facts, indicating that after boot camp, he was assigned to Kinchelow AFB in Michigan, where he took nose drops for his sinusitis every day, day and at night, but did not complain. In March 2014, the Veteran appealed. In his VA Form 9, the Veteran states that prior to service entry, he never had any sinus conditions. He indicated his sinusitis began in boot camp, and that he has self-medicated for this condition ever since. In determining whether the duty to assist requires that a VA medical examination be provided or medical opinion obtained for a veterans claim, four factors are considered: (1) whether there is competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) whether there is evidence establishing that an event, injury, or disease occurred in service, or evidence establishing certain diseases manifesting during an applicable presumption period; (3) whether there is an indication that the disability or symptoms may be associated with the veteran's service or with another service-connected disability; and (4) whether there otherwise is sufficient competent medical evidence of record to make a decision on the claim. 38 U.S.C. § 5103A (d); 38 C.F.R. § 3.159 (c)(4). The threshold for determining a possibility of a nexus to service is a low one. McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Board finds that under the "low threshold" of McLendon, the VA has not met its duty to assist, and therefore a VA exam is required. The Veteran claims to have a current diagnosis, and statements of the Veteran and the evidence in his STR reflect a related in service injury. The Veteran had a clear service entrance exam, and during boot camp, reported to the hospital for what he indicates were burst sinuses. While his STR reflects one sinusitis incident, STR also reflects treatment for related symptomology on two occasions for respiratory infection with swollen turbinates' and nasal passage tenderness. Sinusitis problems were noted on his service exit exam, and the Veteran reports continuity of symptomatology ever since. Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for appropriate VA examination for his claimed sinusitis to determine the nature and etiology of the condition. The claims folder should be reviewed in conjunction with the examination. If a condition is diagnosed, the examiner should opine as to whether it is at least as likely as not that such is related to service. In service complaints and related medical treatments should be discussed. A rationale for any opinion expressed is requested. 2. Readjudicate. The Veteran has the right to submit additional evidence and argument on the matter or 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.A. §§ 5109B, 7112 (2012). _________________________________________________ R. FEINBERG Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (2012), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2017).