Citation Nr: 21013400 Decision Date: 03/09/21 Archive Date: 03/09/21 DOCKET NO. 18-14 955 DATE: March 9, 2021 ORDER Service connection for an acquired psychiatric disorder, including posttraumatic stress disorder (PTSD), is denied. A rating in excess of 30 percent for sinusitis is denied. REMANDED Entitlement to service connection for gastroesophageal reflux disease (GERD) is remanded. Entitlement to service connection for an injury of the left hand is remanded. Entitlement to service connection for hypertension is remanded. FINDINGS OF FACT 1. The preponderance of the evidence of record is against finding that the Veteran has had an acquired psychiatric disorder, including PTSD, at any time during or approximate to the pendency of the claim. 2. The Veteran’s sinusitis is currently manifested by seven or more non-incapacitating episodes of sinusitis characterized by headaches, pain and purulent discharge or crusting over the past 12 months; without evidence of osteomyelitis, near constant sinusitis, or purulent discharge after repeated surgeries. CONCLUSIONS OF LAW 1. The criteria for service connection for an acquired psychiatric disorder, including PTSD, have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for a rating in excess of 30 percent for sinusitis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.97; Diagnostic Code (Code) 6513. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1964 to July 1964, from September 1964 to September 1966 and from October 1976 to March 1993. He had additional periods of active duty for training (ACDUTRA) and inactive duty training (INACDUTRA). In January 2121, a videoconference board hearing was held before the undersigned. A transcript of the hearing is associated with the Veteran’s claims file. Entitlement to service connection for an acquired psychiatric disorder, including PTSD The Veteran contends that service connection should be established for an acquired psychiatric disorder, which he asserts is related to service. During the Board hearing in January 2121, the Veteran testified that he experienced depression related to family matters during service. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. After review of the record, the Board concludes that the Veteran does not have a current diagnosis of an acquired psychiatric disorder and has not had one at any time during the pendency of the claim or recent to the filing of the claim. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Review of the Veteran’s service treatment records (STRs) shows that while on active duty, in November 1983, the Veteran was afforded a psychiatric evaluation due to a lack of motivation since a suicide attempt by his son a year earlier. Evaluation resulted in a mental status examination that was within normal limits with no sign of a psychotic disorder, major affective disorder, or brain dysfunction. The impression was no mental illness; situational stress associated with continued family problems. It was recommended that the Veteran have brief individual follow-up and consider family counseling. In August 1984, during an annual flight examination, it was noted that the Veteran had suffered from situational depression one year earlier related to his son’s suicide attempt. It was reported that the Veteran felt better now. On examination for retirement from service in November 1992, the Veteran reported having or having had depression. His psychiatric clinical evaluation was normal. An examination was conducted by VA in February 2018. At that time, the examiner found that the Veteran’s psychiatric symptoms did not meet the diagnostic criteria for PTSD and he did not have a mental disorder that conformed with any DSM-5 criteria. The examiner then rendered an opinion that the claimed condition was less likely than not incurred in or caused by a claimed in-service injury, event, or illness. The rationale was that the Veteran did not have a current mental disorder diagnosis. The VA examiner evaluated the Veteran and determined that, while he experienced subjective symptoms of depression, he did not have a diagnosis of any acquired psychiatric disorder. Further, a review of postservice private and VA treatment records does not show that they contain a diagnosis of any mental disorder. Significantly, at the January 2021 Board hearing, the Veteran testified that he had not sought any mental healthcare treatment subsequent to service. He also testified that although he had a future appointment to discuss issues with his treatment provider, in his opinion, he did not have any mental health issues. For these reasons, the Board finds that a preponderance of the evidence is against the Veteran’s claim for service connection for an acquired psychiatric disorder, including PTSD, and the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Entitlement to a rating in excess of 30 percent for sinusitis The Veteran contends his service-connected sinusitis is more disabling than currently evaluated. During the hearing before the undersigned, he stated that he used saline solution twice per day and took asprin for almost daily headaches. (The Board notes that service connection has been established for headaches that have been separately rated and are not currently a part of this appeal.) He also stated that he had crusting several times per week. The Board notes that service connection for sinusitis was granted by rating decision dated in February 2018. The initial 30 percent rating was assigned under Diagnostic Code 6513. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) found in 38 C.F.R. Part 4. 38 U.S.C. § 1155. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. The United States Court of Appeals for Veterans Claims (Court) has held that “staged” ratings are appropriate for an increased rating claim where the factual findings show distinct time periods when the service-connected disability exhibits symptoms that would warrant different ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). The Board notes that it has reviewed all of the evidence in the Veteran’s claims file, with an emphasis on the evidence relevant to these appeals. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence where appropriate and the Board’s analysis below will focus specifically on what the evidence shows, or fails to show, as to the claim. An examination was conducted by VA in January 2018. The diagnosis was chronic sinusitis. The Veteran stated that he had frequent recurrent sinusitis with seasonal variations and had been on medication, including a Z pack and Flonase nasal spray that he used before bed. He stated that he had congestion lightly of the frontal sinus on one side or the other that usually affected whichever side he was lying on. He stated that in 2013 he had had laser surgery on his nasal adenoids to shrink them, which had helped some of the sinus congestion. He reported having seven or more non-incapacitating episodes of sinusitis characterized by headaches, pain and purulent discharge or crusting over the past 12 months. He had not had any incapacitating episodes. Imaging studies demonstrated evidence of bilateral maxillary sinusitis and right frontal sinusitis. For chronic maxillary sinusitis, with one or two incapacitating episodes of sinusitis per year requiring prolonged (lasting four to six weeks) antibiotic treatment or; three to six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting, a 10 percent rating is warranted; with three or more incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or, more than six non-incapacitating episodes per year of sinusitis characterized by headaches, pain and purulent discharge or crusting, a 30 percent rating is warranted. Following radical surgery, with chronic osteomyelitis, or; near constant sinusitis characterized by headaches, pain and tenderness of the affected sinus, and purulent discharge or crusting after repeated surgeries, a 50 percent rating is warranted. 38 C.F.R. § 4.97; Code 6513. The Veteran’s sinusitis is currently manifested by seven or more non-incapacitating episodes of sinusitis characterized by headaches, pain and purulent discharge or crusting over the past 12 months. While he did report having a single surgical procedure that has helped to some extent, there is no evidence of osteomyelitis, near constant sinusitis, or purulent discharge after repeated surgeries. As such, he has not met the criteria for a rating in excess of the current 30 percent rating at any time during the pendency of this appeal. As the examination of record show no evidence of osteomyelitis, near constant sinusitis, or purulent discharge after repeated surgeries, the Board finds that a preponderance of the evidence is against the Veteran’s appeal for a higher initial rating for sinusitis, and the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. REASONS FOR REMAND Entitlement to service connection for GERD is remanded. The Board cannot make a fully-informed decision on the issue of service connection for GERD because no VA examiner has opined whether the Veteran has current manifestions of GERD that had are related to episodes of gastric distress that he had while on active duty. As such, an examination is found to ge warranted. McLendon v. Nicholson, 20 Vet. App. 79 (2006). Entitlement to service connection for an injury of the left hand is remanded. Regarding the issue of service connection for a left hand disorder, the Board notes that the Veteran was examined to ascertain whether he had residuals of a cold injury. During his hearing before the undersigned, the Veteran clarified that this was mistaken and that he actually wished service connection for arthritis of the left hand. This has been demonstrated in the record. Under these circumstances, the Board finds that an addendum opinion is necessary to adequately adjudicate the claim. Entitlement to service connection for hypertension is remanded. The Veteran claims service connection for hypertension. Review of the record shows that he did have several elevated blood pressure readings while on active duty, While the recent VA examination found that the Veteran did not meet the criteria for a diagnosis of hypertension, the Board notes that a private treatment records from January to June 2017 show a diagnosis of hypertension for which the Veteran was given the medication Metoprolol. The presence of a disability at the time of filing of a claim or during its pendency warrants a finding that the current disability requirement has been met, even if the disability resolves prior to the Board’s adjudication of the claim. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). The Veteran filed his claim of service connection in May 2017. As such, an addendum opinion is found to be warranted. The matters are REMANDED for the following actions: 1. Schedule the Veteran for a VA examination for his GERD. The examiner must review the claims file. If a diagnosis cannot be provided but the Veteran’s condition manifests in symptoms that cause functional impairment, then the examiner should consider them a “disability” for the purpose of providing the requested opinion. The examiner is asked to opine as to whether it is at least as likely as not that the Veteran’s GERD is related to service, to include as due to the episodes of gastric distress that he had while on active duty. Provide a rationale to support the opinion. 2. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s current left hand disorder (arthritis of the left hand) is at least as likely as not related to the in-service injury that he had while on active duty. 3. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s current hypertension is at least as likely as not related to the in-service manifestations of hypertension that he had while on active duty. A. ISHIZAWAR Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Joseph P. Gervasio 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.