Citation Nr: 21011702 Decision Date: 03/02/21 Archive Date: 03/02/21 DOCKET NO. 17-10 586 DATE: March 2, 2021 REMANDED Entitlement to an initial compensable disability rating for sinusitis is remanded. REASONS FOR REMAND The Veteran served in the United States Air Force on active duty from January 1988 to January 1994 and July 1998 to October 2012. The issue comes before the Board of Veterans’ Appeals (Board) on appeal from a December 2013 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a hearing before the undersigned Veterans Law Judge in January 2021. A transcript of the hearing has been included with the record. Entitlement to an initial compensable disability rating for sinusitis is remanded. The Veteran contends that he suffers from symptoms of sinusitis warranting a compensable disability rating. In August 2013, the Veteran underwent a VA examination to address his sinus condition. The Veteran reported a history of sinusitis with symptoms of post-nasal drainage and congestion. The Veteran noted he usually experienced sinus infections in the Spring and Fall of every year for the previous 10 years. The VA examiner confirmed the Veteran’s diagnosis of chronic maxillary sinusitis characterized by episodes of headaches, pain and tenderness of the affected sinus, and purulent discharge or crusting. The VA examiner provided that the Veteran did not experience incapacitating or non-incapacitating episodes of sinusitis over the previous 12 months. In November 2016, the Veteran again underwent a VA sinus examination. The Veteran reported symptoms of near constant post-nasal drainage and congestion. The Veteran also reported intermittent frontal maxillary pressure. The VA examiner confirmed the Veteran’s diagnosis of chronic frontal maxillary sinusitis characterized by episodes of pain and tenderness of the affected sinus, and purulent discharge or crusting. The VA examiner provided that the Veteran did not experience incapacitating or non-incapacitating episodes of sinusitis over the previous 12 months. The Veteran provided lay testimony during his January 2021 Board hearing that he suffered from sinus headaches nearly every day. The Veteran stated that he regularly experienced congestion and discharge in the back of his throat. He noted that his nose will run when he goes outside due to the temperature change. The Veteran reported using a daily steroid nasal spray and oral allergy treatment. He noticed congestion typically without the use of his nasal spray. The Veteran noted that, in the past, he experienced sinus infections regularly twice a year. Currently, the Veteran reported his symptoms have changed to more regular headaches. The Veteran is competent to provide opinions on certain subjective medical issues and of observable symptomatology. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). He is not, however, competent to identify a specific level of disability for his condition, according to the appropriate diagnostic codes, or, to attribute specific symptoms to a disability. See Robinson v. Shinseki, 557 F.3d 1355 (2009). Such competent evidence concerning the nature and extent of the Veteran's disability shall be provided by medical personnel. However, as the Veteran provided lay testimony to the worsening of severity and regularity of his headaches, a new examination is required to address the symptoms associated with the Veteran’s diagnosed chronic sinusitis. Without a medical opinion that clearly addresses the relevant facts and medical science, the Board is left to rely on its own lay opinion, which it is forbidden from doing. Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Remand is necessary to provide the Veteran with an updated sinus condition examination. The matters are REMANDED for the following action: Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected sinusitis and confirm the appointment with the Veteran. The examination may be conducted via telehealth or similar service during the social distancing restrictions of the COVID-19 pandemic. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. The examiner must provide a comprehensive report including a clearly stated rationale for any opinions offered and conclusions reached. In this regard, the Board emphasizes that the Veteran is competent to report his symptoms and history, and such statements by the Veteran regarding symptomatology and medical history must be specifically acknowledged and considered in formulating any opinions concerning the onset and severity of his disability. If such reports are rejected by the examiner, a reason for doing so must be provided. JENNIFER HWA Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A.V. Bona, 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.