Citation Nr: A21017176 Decision Date: 10/25/21 Archive Date: 10/25/21 DOCKET NO. 211006-189347 DATE: October 25, 2021 REMANDED Entitlement to an initial compensable rating for the service-connected status post nose fracture, on the basis of substitution and for accrued benefits purposes, is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from June 1966 to December 1969. The Veteran died in March 2018 and the Appellant is the Veteran's surviving spouse. The Appellant has been recognized as the valid substitute for the pending appeal. See April 2020 Department of Veterans Affairs (VA) notification letter. On August 23, 2017, the President signed into law the Veterans Appeals Improvement and Modernization Act, Pub. L. No. 115-55 (codified as amended in scattered sections of 38 U.S.C.), 131 Stat. 1105 (2017), also known as the Appeals Modernization Act (AMA). In an August 2017 rating decision, the Agency of Original Jurisdiction (AOJ) granted service connection for status post nose fracture and assigned a noncompensable (zero percent) rating effective May 18, 2016, the date of the Veteran's service connection claim. The Veteran timely appealed this decision and VA issued a Statement of the Case (SOC) in April 2020. Following the issuance of the April 2020 SOC, the Appellant opted into the AMA system by submitting a VA Form 20-0996 (Decision Review Request: Higher Level Review) in May 2020. Thereafter, in an October 2020 Higher Level Review rating decision, the AOJ again denied the claim. The Appellant timely appealed this decision to the Board of Veterans' Appeals (Board) and elected direct review of the evidence considered by the AOJ. See October 2021 VA Form 10182 (Decision Review Request: Board Appeal (Notice of Disagreement)). The Board will therefore review the claim based on the evidence of record at the time of the April 2020 SOC. 38 U.S.C. § 7113 (a); 38 C.F.R. § 20.301. Entitlement to an initial compensable rating for the service-connected status post nose fracture, on the basis of substitution and for accrued benefits purposes Under the modernized appeals process, the Board must remand appeals to the AOJ to correct pre-decisional duty to assist errors. Although the Board regrets the need for further delay, review of the record reveals two duty to assist errors that were evident prior to the decision on appeal and that necessitates remand. First, the Board cannot make a fully informed decision on the claim because it is unclear whether the Veteran's service-connected status post nose fracture manifested in symptoms of headaches, sinus attacks, and/or chronic sinusitis/allergic rhinitis. In this regard, the June 2016 sinusitis/rhinitis and other conditions of the nose, throat, larynx, and pharynx VA examination reflects, under the Veteran's medical history, that he experienced sinus attacks with headaches and nasal discharge on and off. However, the VA examiner did not otherwise address these reports nor note whether these symptoms were related to the Veteran's nose fracture. The examiner also diagnosed the Veteran with allergic rhinitis without indicating whether such was related to the Veteran's in-service nose fracture. Accordingly, as it was unclear what signs or symptoms were attributable to the Veteran's status post nose fracture, the AOJ should have obtained an addendum opinion. Therefore, a remand is warranted to assess the symptomatology of the service-connected status post nose fracture. Second, prior to the issuance of the April 2020 SOC, a December 2018 Social Security Administration (SSA) Profile and Benefit Data Report reflects that the Veteran may have been receiving disability benefits. Review of the record reveals no SSA documents in the claims file, nor is there any indication that VA attempted to obtain relevant documents from SSA. As any records from SSA may be relevant to the Appellant's claim, a remand is necessary to obtain them. The matters are REMANDED for the following action: 1. Obtain and associate with the claims file any records in the possession of the SSA concerning the Veteran. Make a notation in the claims file of all attempts to obtain these records and all responses received. 2. Then, obtain an addendum opinion from an appropriate medical professional to assess the severity of the Veteran's service-connected status post nose fracture disability. The claims file, to include a copy of this Remand, should be made available to and be thoroughly reviewed by the VA examiner. Based upon review of the record and the relevant VA examination(s), the examiner is asked to respond to the following: (a) Identify all manifestations of the Veteran's status post nose fracture during the appeal period. (b) The examiner should offer an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran's complaints of sinus attacks and headaches as well as the notations of diagnosed sinusitis/rhinitis were caused by or aggravated by the same pathology as his service-connected status post nose fracture or whether they are more likely attributable to another cause. A complete rational for all medical opinions must be provided. A discussion of the relevant facts and medical principles involved, including citations if appropriate, would be of considerable assistance to the Board. MARJORIE A. AUER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Amanda Purcell, Associate Counsel 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.