Citation Nr: 21005363 Decision Date: 02/01/21 Archive Date: 02/01/21 DOCKET NO. 17-21 670 DATE: February 1, 2021 REMANDED Entitlement to an increased initial rating evaluation in excess of 0 percent for maxillary sinusitis is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Navy from December 1981 to September 1990. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a May 2015 rating decision issued by the Regional Office (RO) in Jackson, Mississippi. The Veteran recently testified before the undersigned at a September 2020 video-conference hearing. A transcript of the hearing is included in the electronic claims file. 1. Entitlement to an increased initial rating evaluation in excess of 0 percent for maxillary sinusitis is remanded. In its May 2015 rating decision, the Veteran was granted service connection for his maxillary sinusitis disability at a noncompensable rating, effective August 20, 2013, the date of his claim. As its basis for a noncompensable (0 percent) rating, the RO stated that during the Veteran’s September 2014 VA examination, sinusitis was detected by x-ray only and that the Veteran’s episodes of sinusitis did not manifest non-incapacitating episodes of sinusitis headaches, pain and purulent discharge and that the Veteran had not had any incapacitating episodes of sinusitis requiring prolonged (4 to 6 weeks) antibiotics treatment. The Veteran filed a Notice of Disagreement (NOD) in September 2015. In his subsequent correspondence, the Veteran asserts that based on the severity of his sinusitis and frequency of his episodes, his disability rating should be more that his current noncompensable rating. Specifically, that he frequently experiences sinus pressure and headaches associated with nonstop drainage, which causes him pain and discomfort, and as such he should be awarded a rating of 20 percent. See, November 2017 Correspondence. He also attached a corresponding log of his report of his episodes of sinusitis. During his Board hearing, the Veteran testified that as a commercial airline pilot his sinusitis disability has negatively impacted him because he has had to take time off work during flareups of his sinusitis resulting in him missing several trips (6 to 7 days, 3 day trips annually) since filing his original claim. The record reflects that the Veteran was afforded an examination in January 2018 for his sinus headaches in a related claim, which reflects that he suffers from painful headaches in association with his sinuses. However, this examination did not evaluate the severity of the Veteran’s sinusitis disability. Further his treatment records reflect various notations of “chronic sinusitis issues,” also showing corresponding treatments with nasal saline rinse and nasal spray. For instance, a December 2015 record reflects the Veteran’s report that he experiences two sinus infections a year, requiring antibiotics, but he denied any mucopurulent drainage. See, June 2019 Capri Records. A February 2019 treatment record also reflects treatment (oral tablets) for “acute sinusitis.” Consequently, given the Veteran’s consistent report of the worsening of his symptoms and the length of time that has elapsed since his last VA sinusitis examination (September 2014), the Board finds that a new examination is warranted to fully evaluate the current nature and severity of his sinusitis disability, for rating purposes. The matters are REMANDED for the following action: 1. Schedule the Veteran for a new VA sinus examination to provide an accurate assessment of the current severity of his service-connected maxillary sinusitis. The claims file, particularly the Veteran’s treatment records, should be reviewed by the examiner and his examination report should reflect that such a review was conducted. All necessary tests and studies should be performed, and the results reported accordingly. The examiner should specifically comment as to the number of incapacitating episodes of sinusitis that the Veteran has experienced within a 12-month period requiring prolonged (4-6 weeks) antibiotic treatment, and the frequency (in terms of number of episodes in the last year) and severity of the Veteran's non-incapacitating episodes of sinusitis characterized by headaches, pain, and purulent discharge or crusting. The examiner is requested to address the Veteran's report of treatment for his sinusitis with antibiotics. See, September 2020 Board Hearing Transcript. The examiner should also discuss any functional impact of the Veteran's maxillary sinusitis on his ability to work, specifically taking into consideration his current occupation as a commercial airline pilot. 2. After completing the development noted above, the RO should readjudicate the Veteran’s claim. Michael J. Skaltsounis Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J.B. King, 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.