Citation Nr: 21030938 Decision Date: 05/20/21 Archive Date: 05/20/21 DOCKET NO. 15-16 973 DATE: May 20, 2021 REMANDED Entitlement to service connection for chronic sinusitis is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Marine Corps from October 2005 to October 2009 with service in Afghanistan. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2012 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In October 2017, the Veteran testified at a Board hearing conducted via videoconference before the undersigned Veterans Law Judge. In July 2018, the Board granted service connection for lumbar degenerative disc disease and allergic rhinitis and remanded the claims of entitlement to service connection for a right shoulder disability and chronic sinusitis. The RO subsequently granted the Veteran's right shoulder claim in a December 2020 rating decision. Accordingly, the only claim on appeal before the Board is the service connection claim for chronic sinusitis. Of note, there are pending claims for an entitlement to service connection for a psychiatric condition and an increased rating claim for a bilateral eye condition. As these claims are in different appeal streams, and as the Veteran has requested hearings for both, they will be addressed in separate Board decisions. The Veteran presented for a VA examination in December 2020. Notably, during that examination he was only diagnosed with rhinitis and not sinusitis, and the examiner rendered a nexus opinion on already service-connected rhinitis, apparently through RO error. See December 2020 VA examination report, Section 2A (requesting a nexus opinion on rhinitis). The RO attempted to rectify this error through another medical opinion. In the subsequent January 2021 addendum opinion, the VA examiner noted that the Veteran was seen in July 2010 for a sinus problem, and a CT scan "came back with no report of sinusitis, therefore the claim regarding the sinus problem, diagnosed as rhinitis, is not related to the Veteran's time in service." The Board finds this opinion inadequate as it is based on an incomplete premise. Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that a medical opinion based upon an inaccurate or incomplete factual premise is not probative). Specifically, while the examiner notes that the 2010 CT report came back with no evidence of sinusitis, there are subsequent diagnoses of both acute and chronic sinusitis of record during the appeal period. See, e.g., June 2014, February 2016 and June 2016 private medical records. Accordingly, remand is warranted for an adequate addendum opinion. Additionally, the record indicates that there are still outstanding private treatment records, which should be obtained on remand. The matters are REMANDED for the following action: 1. Obtain any outstanding VA treatment records. 2. With any necessary assistance from the Veteran, obtain any relevant private treatment records, to include his reported sinusitis treatment from Denton Allergy and Asthma Specialist. See August 2019 VA Form 21-0820. 3. Then obtain an addendum opinion from a VA examiner other than the July 2010 and December 2020 examiners to determine the etiology off the Veteran's sinusitis. No examination is necessary unless the examiner determines otherwise. For diagnosed sinusitis (see June 2014, February 2016 and June 2016 private medical records), please opine as to whether it is at least as likely as not (50 percent or greater probability) that such disability had its onset in service or is otherwise related to service, to include as a result of conceded environmental exposures in Afghanistan and exposure to cleaning solutions in Fort Worth. In addressing this question, please do not rely solely on negative service treatment records, and please concede in-service self-treated sinus symptoms and exposure to dusty environments and cleaning fluids per the Veteran's Board hearing testimony, although not documented and determine whether a nexus between sinusitis and service is "medically plausible," given the same. If you find that the Veteran has never had sinusitis, please reconcile your findings with the notations of diagnosis of record. A robust rationale should accompany all opinions expressed. If unable to opine without speculation, please provide an explanation for that conclusion. S. BUSH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. J. Rogers, 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.