Citation Nr: 21010707 Decision Date: 02/25/21 Archive Date: 02/25/21 DOCKET NO. 17-16 335 DATE: February 25, 2021 REMANDED Entitlement to service connection for a chronic sinus disorder is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Air Force from June 1966 to April 1970. This matter is before the Board of Veterans’ Appeals (Board) on appeal from a November 2014 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). In July 2020, the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge of the Board. A transcript of the hearing is of record. Entitlement to service connection for a chronic sinus disorder is remanded. A review of the claims file reveals that a remand is necessary before a decision on the merits of the claims for service connection for a chronic sinus disorder can be reached. The Veteran was afforded a VA examination for sinusitis in April 2017. The examiner reported that the Veteran had never been diagnosed with a sinus, nose, throat, larynx, or pharynx condition. The examiner opined that the Veteran’s sinus disorder was less likely as not (50 percent or greater probability) incurred in or caused by an in-service injury, event or illness. As rationale, the examiner explained that the Veteran’s March 1970 complaint of post nasal drip was no longer present on his exit examination, and his claimed sinusitis was not evident in x-rays and the examination conducted by the examiner. Although the examiner reported that the Veteran had never been diagnosed with a sinus, nose, throat, larynx, or pharynx condition, this statement conflicts with the evidence of record. A July 2008 private medical record reported that the Veteran was positive for nasal congestion and frequent rhinorrhea. The attending physician diagnosed him with seasonal allergic rhinitis and prescribed medication. A May 2011 private medical record reported that the Veteran complained of allergies and post nasal drip for one week. The Veteran was diagnosed with sinusitis and prescribed medication. In March 2017, the Veteran submitted a letter from his treating physician in support of his claim, which included the following: This letter is in reference to my patient, [the Veteran], who is currently under my care. [The Veteran] has been my patient since November 2016. 1 took over his care from my colleague Dr. [M.] whom he saw for many years. After reviewing his chart, there is a History of chronic Allergic Rhinitis with Post Nasal drip and nasal congestion. He also has a History of Sinusitis due to the symptoms listed previously. My current treatment plan is in line with what Dr. [M.] had in place for him. [The Veteran] is to take Nasonex daily when symptoms reoccur and to see me after 1 week use if symptoms [have] not cleared or gets worse, he will need to continue to follow up as directed as his symptoms can develop into Sinusitis which may require a treatment of Antibiotics. In my opinion, [the Veteran] suffers from Chronic Sinus issue that are consistent with an airborne allergens. I would recommend avoiding such allergens in order to keep symptoms at a minimum Because the examiner concluded the Veteran had never been diagnosed with a sinus, nose, throat, larynx, or pharynx condition, the Board finds the examiner’s opinion is inadequate, as a medical opinion based upon an inaccurate factual premise is not probative. Reonal v. Brown, 5 Vet. App. 458, 461 (1993). Notably, once VA undertakes the effort to provide an examination when developing a claim, it must provide an adequate one. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Thus, the Board finds that a remand is warranted for an addendum opinion to consider the complete history of the Veteran’s sinus disorder to determine whether service connection is warranted. By this remand, the Board makes no determination, express or implied, concerning the credibility of any lay statements on file. The matter is REMANDED for the following action: 1. Obtain all outstanding VA treatment records. 2. With any necessary assistance from the Veteran, obtain all outstanding relevant private treatment records. 3. Return the claims file, including a copy of this remand, to the VA examiner who conducted the April 2017 examination, or to another appropriate medical professional if that individual is unavailable, to provide an addendum opinion regarding the etiology of the Veteran’s chronic sinus disorder. The Veteran’s claims file, to include a copy of the remand, must be made available to the examiner along with any other information the medical professional deems pertinent. Unless the examiner finds that a new examination is required, the Veteran need not be examined again. 4. After a review of the claims file, the examiner should provide the following opinion: Is it at least as likely as not (a 50 percent or greater probability) that the Veteran’s chronic sinus disorder is etiologically related to the Veteran’s active service? 5. The provided examination opinion must reflect consideration of the medical and lay evidence of record and set forth a complete rationale for all findings and conclusions. 6. After the development described above, and any additionally indicated development, has been completed, readjudicate the issues on appeal. If any determination remains unfavorable to the Veteran, send the Veteran and his representative a Supplemental Statement of the Case and provide an opportunity to respond. If necessary, return the case to the Board for further appellate review. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). (Continued on the next page)   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. §§ 5109B, 7112. KELLI A. KORDICH Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Moore, 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.