Citation Nr: 22014971
Decision Date: 03/15/22	Archive Date: 03/15/22

DOCKET NO. 17-02 768
DATE: March 15, 2022

REMANDED

Entitlement to a compensable rating prior to January 3, 2022, and a rating in excess of 50 percent on and after January 3, 2022, for maxillary fracture residuals with sinusitis, to include entitlement to a separate compensable rating, is remanded.

REASONS FOR REMAND

The Veteran had active service from October 1975 to January 1998.  

Entitlement to a compensable rating prior to January 3, 2022, and a rating in excess of 50 percent on and after January 3, 2022, for maxillary fracture residuals with sinusitis, to include entitlement to a separate compensable rating, is remanded.

The report of a January 2022 Department of Veterans Affairs (VA) sinus examination indicates that the Veteran sustained an in service a non-displaced right maxillary fracture.  The examiner noted that the Veteran exhibited "minimal facial asymmetry with the R cheek a bit more prominent than the left."  

The Veteran has not been provided a VA examination, including color photographs, which addresses the service connected maxillary fracture residuals and associated facial disfigurement/asymmetry.  

VA's duty to assist includes, in appropriate cases, the duty to conduct a thorough and contemporaneous medical examination which is accurate and fully descriptive.  McLendon v. Nicholson, 20 Vet. App. 79 (2006); Green v. Derwinski, 1 Vet. App. 121, 124 (1991).  When VA undertakes to obtain an evaluation, it must ensure that the evaluation is adequate.  Barr v. Nicholson, 21 Vet. App. 303, 312 (2007).  Further VA evaluation is needed.  

Clinical documentation dated after May 2014 is not of record.  VA should obtain all relevant VA and private treatment records which could potentially be helpful in resolving the Veteran's claim.  Murphy v. Derwinski, 1 Vet. App. 78 (1990); Bell v. Derwinski, 2 Vet. App. 611 (1992).  

The matter is REMANDED for the following:

1. Ask the Veteran to complete a VA Form 21-4142 for each private healthcare provider who treated him for the service connected maxillary fracture residuals with sinusitis.  Make two requests for the authorized records from all identified healthcare providers unless it is clear after the first request that a second request would be futile.  

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2. Obtain the Veteran's VA treatment records not already of record, including those pertaining to treatment after May 2014.  

3. Schedule the Veteran for a VA respiratory examination conducted by a medical doctor to assist in determining the current nature and severity of the service connected maxillary fracture residuals including any associated facial assymetry/disfigurement.  A rationale for all opinions should be provided.  The examiner should note whether any maxillary malunion, nonunion, or displacement is identified.  If appropriate, color photographs should be taken of any identified facial assymetry/disfigurement.

 

 

J. T. HUTCHESON

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	T. C. KING

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.