Citation Nr: 20026058
Decision Date: 04/15/20	Archive Date: 04/15/20

DOCKET NO. 15-00 941
DATE: April 15, 2020

REMANDED

Entitlement to an increased rating, in excess of 10 percent, for service-connected sinusitis is remanded.

REASONS FOR REMAND

The Veteran served on active duty from March to July 1984 and April 1986 to September 1989 in the United States Army.

Entitlement to increased rating, in excess of 10 percent, for service-connected sinusitis is remanded.

The claim must be remanded again because there has not been substantial compliance with the directives in a May 2018 Board remand. Stegall v. West, 11 Vet. App. 268 (1998).

On a September 2019 VA examination, the Veteran was noted to have developed a maxillary mucous retention cyst which was identified in a CT scan.  The VA examiner indicated that the cyst is a progression of the service-connected sinusitis.  It is unclear what additional symptoms if any, manifest as a result of the cyst, or if a separate rating should be granted. On remand, an opinion should be obtained to clarify whether there are any symptoms associated with the maxillary mucous retention cyst and confirm whether the cyst is a progression of the sinusitis or separate condition.  If the condition is separate the AOJ must readjudiacte and determine whether a separate rating is warranted. 

If the Veteran’s cyst is not a separate condition from the service-connected sinusitis and manifests with symptoms not reasonably contemplated by the relevant diagnostic codes, the Veteran’s claim for an increased rating for sinusitis must be referred to VA’s Director of Compensation Service for extraschedular consideration.  Thun v. Peake, 22 Vet. App. 111, 115-16 (2008).

The matters are REMANDED for the following action:

1.  Obtain an addendum opinion from an appropriate clinician to determine the current severity of his service-connected sinusitis, to include the nature of the maxillary mucous retention cyst. Copies of all pertinent records must be made available to the examiner for review. If the examiner determines that an opinion cannot be provided without an examination, one should be scheduled. 

(a) The examiner should provide a full description of the sinusitis and report all signs and symptoms specifically related to the sinusitis, and all detail necessary for evaluating the Veteran’s disability under the rating criteria.

(b) The examiner must specifically identify whether there any symptoms associated with the Veteran’s maxillary mucous retention cyst that are distinct from the sinusitis and opine whether this condition is separate from the Veteran’s sinusitis.

2.  After the above development, review the record to determine whether separate rating is warranted for maxillary mucous retention cyst as secondary to sinusitis.

3.  If a separate rating is not warranted, refer the Veteran’s claim for an increased rating for sinusitis to VA’s Director of Compensation Service for extraschedular consideration.  

 

M.E. Larkin

Veterans Law Judge

Board of Veterans’ Appeals

Attorney for the Board	P.S. McLeod

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.