Citation Nr: 20021035 Decision Date: 03/24/20 Archive Date: 03/24/20 DOCKET NO. 19-32 591 DATE: March 24, 2020 REMANDED Entitlement to a compensable rating for headaches associated with sinusitis from August 1, 2018, to include whether the reduction of the rating from 30 percent to noncompensable was proper, is remanded. REASONS FOR REMAND The Veteran served on active duty from March 2003 to November 2003, from January 2006 to May 2007, from January 2009 to August 2009, and from May 2011 to July 2011. The Veteran also had periods of Reserve duty. Entitlement to a compensable rating for headaches associated with sinusitis from August 1, 2018, to include whether the reduction of the rating from 30 percent to noncompensable was proper, is remanded. The Veteran is seeking entitlement to a compensable rating for headaches associated with sinusitis. The Veteran is service connected for headaches associated with sinusitis to include headaches, a 30 percent rating was assigned from March 30, 2014 and a noncompensable rating was assigned from August 1, 2018. By way of history, in August 2013, the Agency of Original Jurisdiction (AOJ) issued a rating decision granting service connection for sinusitis with a noncompensable evaluation. In September 2015, the AOJ granted service connection for headaches associated with sinusitis and assigned an evaluation of 30 percent. In August 2016, the AOJ granted an increase in the evaluation of sinusitis from noncompensable to 30 percent. In August 2017, the AOJ issued a rating decision finding that a clear and unmistakable error (CUE) was found in the evaluation of headaches established and the AOJ proposed to sever service connection. In May 2018, the AOJ decreased the evaluation of headaches associated with sinusitis to include headaches from 30 percent disabling to noncompensable effective August 1, 2018. Regarding the Veteran’s private and VA medical treatment history, the Board notes that the Veteran has complained of sinus area headaches. However, the June 2017 VA examiner noted that the Veteran has a diagnosis of tension headaches and noted that the Veteran reported pulsating or throbbing head pain on both sides of the head. The examiner also noted that the Veteran does not have prostrating attacks of headache pain characterized as prostrating attacks of migraine pain. The examiner opined that the Veteran’s headaches are less likely than not incurred in or caused by the claimed in-service injury, event or illness. The examiner provided the rationale that the Veteran’s current description of headaches on that examination is described as tension headaches and the Veteran does not relate to his sinuses, and there is no documentation of chronic headache condition while in active duty. The AOJ issued the reduction of the evaluation for headaches due to the July 2017 VA examination. While the June 2017 VA examination noted that the Veteran’s headaches were tension headaches and not sinus headaches, the Board notes that the previous examinations and the Veteran’s private and VA medical treatment notes indicate that both the Veteran and his providers have attributed the Veteran’s headaches to the Veteran’s service-connected sinusitis. Remand is required to afford the Veteran a VA examination to assess the current nature and severity of his headaches and to further clarify the Veteran’s headache disability and its relation to his military service. The Board finds that the Veteran’s service-connected sinusitis and headaches have overlapping symptoms and clarification is necessary prior to assigning an evaluation for the Veteran’s headaches. That is, it is unclear whether the headaches represent the primary pathology of the sinusitis, or whether there are other ratable symptoms of the sinusitis and the headaches impose separate additional symptoms. The matters are REMANDED for the following action: 1. The AOJ should obtain copies of all pertinent, outstanding records from the VA Medical Center and its associated clinics where the Veteran receives treatment. If any pertinent private treatment has been rendered, the Veteran’s assistance in obtaining these records should be requested as needed. All attempts to obtain records should be documented in the claims folder. In addition, if the Veteran has kept any type of calendar or record of the onset, frequency and severity of headaches, it is requested that any such document be submitted for review. 2. Schedule the Veteran for a VA examination with an examiner of appropriate expertise to ascertain the current nature and severity of the Veteran’s headaches and his sinusitis. The claims file should be made available to and be reviewed by the examiner in conjunction with the examination. The VA examiner should provide a full description of the Veteran’s disability and report all signs and symptoms necessary for evaluating the Veteran’s headache disability under the rating criteria. The examiner must attempt to elicit information regarding the severity, frequency, and duration of symptoms. To the extent possible, the examiner must discuss the Veteran's headache symptoms and his sinusitis symptoms and state to which disorder they are attributable. Specifically, this should include a discussion of whether the Veteran’s headaches are proximately due to, the result of, or aggravated by the Veteran’s service-connected sinusitis or whether it is a symptom thereof. The VA examiner must fully describe the functional effects caused by the Veteran’s headaches disability in the final report. The examiner should provide a detailed rationale for all opinions offered, including a discussion of the evidence of record and medical principles which led to the conclusions reached. If an opinion cannot be provided without resort to speculation, the examiner should explain why it is not possible to provide an opinion. It should be noted that the Veteran is competent to attest to factual matters of which he had first-hand knowledge, including observable symptomatology. 3. After the development requested has been completed, the AOJ should review the expanded record to ensure complete compliance with the directives of this REMAND. If any report is deficient in any manner, implement corrective procedures at once. MICHAEL D. LYON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Frazier, Associate Attorney The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.