Citation Nr: 21015654
Decision Date: 03/18/21	Archive Date: 03/18/21

DOCKET NO. 14-17 234
DATE: March 18, 2021

REMANDED

Service connection for sinusitis is remanded.

REASONS FOR REMAND

The Veteran served on active duty from May 1973 to May 1977. 

This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a January 2012 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO).

1. Service connection for sinusitis is remanded.

The November 2019 VA medical opinion is inadequate, and therefore a remand is necessary.  The examiner concluded that the Veteran did not have chronic sinusitis.  The opinion is inadequate because the examiner did not consider the complete treatment records. The record shows that the Veteran complained of sinusitis and breathing difficulty in several, separate visits to VA medical facilities from the period October 2010 through January 2020.  The November 2019 VA examiner noted the nostrils were clear, there was no evidence of drainage, ears were clear.  The examiner denied evidence of chronic sinusitis.  In finding that the Veteran did not have chronic sinusitis, the examiner did not appear to consider the Veteran’s VA treament records documenting sinusitis.  Thus, that opinion is inadequate to accurately determine 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.  Consequently, there has not been substantial compliance with the Board’s previous remand directives regarding the issue of entitlement to service connection for sinusitis.  Stegall v. West, 11 Vet. App. 268, 271 (1998).

The matters are REMANDED for the following action:

1. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran has had any sinusitis disability during the pendency of the appeal (i.e. from September 2011 to the present).  A physical examination of the Veteran or telehealth examination is only required if deemed necessary by the clinician.  

The clinician’s attention is called to the following medical record notes:  

a.  October 2010 - Veteran reports sinuses congested at times;

b. November 2010 - acute sinusitis; severe sinus pain and congestion lasts longer than 2 hours;

c. April 2012 - 4 days of head and chest congestion, rhinitis; diagnosed with sinusitis;

d. December 2016 - assessment of sinusitis;

e. June 2019 - Veteran reports "ongoing issue" with sinuses (onset/duration as "years"). Especially bad at night.  Clear postnasal drainage, coughing, and headaches;

f. November 2019 - Veteran reports sinusitis;

g. January 2020 - upper respiratory infection.

If the clinician determines that the Veteran has a sinusitis disability, the clinician must provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s sinusitis disability began during active service, or is related to an incident of service.  

The clinician must provide all findings, along with a complete rationale for his or her opinion(s) in the examination report.  If any of the above requested opinions cannot be made without resort to speculation, the clinician must state this and provide a rationale for such conclusion.

2. If upon completion of the above action any benefit sought on appeal remains denied, the case should be returned to the Board after compliance with appellate procedure.

 

 

D. Martz Ames

Veterans Law Judge

Board of Veterans’ Appeals

Attorney for the Board	Kathleen M. Fiorillo, 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.