Citation Nr: 22018291 Decision Date: 03/28/22 Archive Date: 03/28/22 DOCKET NO. 17-57 276 DATE: March 28, 2022 ORDER Entitlement to service connection for sinusitis is denied. REMANDED Entitlement to service connection for a back disability is remanded. Entitlement to service connection for a bilateral knee disability is remanded. Entitlement to service connection an acquired psychiatric disorder, to include posttraumatic stress disorder and insomnia, is remanded. FINDING OF FACT The evidence of record persuasively weighs against finding that the Veteran has had chronic sinusitis at any time during or approximate to the pendency of the claim. CONCLUSION OF LAW The criteria for service connection for sinusitis have not been met. 38 U.S.C. §§ 1110, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty with the U.S. Army from October 1984 to October 1987, from December 1989 to August 1994 and from April 2005 to August 2006. He had additional service in the Army National Guard. He testified at a Board hearing in November 2021 before the undersigned Veterans Law Judge. A transcript is associated with the record. Service Connection 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). 1. Entitlement to service connection for sinusitis. The Veteran contends he has sinusitis that had its onset in service due to environmental exposures while he was in Afghanistan. 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. The Board concludes that the Veteran does not have a current diagnosis of sinusitis 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). Rather, he has been repeatedly diagnosed and treated for allergic rhinitis. Moreover, the December 2021 rating decision awarded service connection for allergic rhinitis. The September 2021 VA examiner evaluated the Veteran, diagnosed him with allergic rhinitis, and indicated that the condition had its onset in service. Further, treatment records dated from September 2016 to present do not contain a diagnosis of sinusitis. Again, records either discuss the Veteran's condition in symptoms (sinus congestion, etc.) or label it as rhinitis. The November 2021 and private examiner confirmed a diagnosis of chronic sinusitis. However, the Board notes that allergic rhinitis and chronic sinusitis can have similar symptoms and representations, which is why they are rated the same. Despite indicating that all treatment records were reviewed, the private examiner did not confirm which testing method was used to confirm the Veteran's diagnosis as sinusitis versus the allergic rhinitis, which is noted in his records. Instead, the diagnosis appears to be based on the Veteran's self-reported medical history, which is inconsistent with VA treatment records that show the same symptoms but with a diagnosis of allergic rhinitis and not sinusitis. Consequently, the Board gives more probative and persuasive weight to the September 2021 VA examiner's findings and treatment records showing no chronic sinusitis. Although the Veteran believes he has a current diagnosis of chronic sinusitis, he is not competent to provide a diagnosis in this case. The issue is medically complex. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). The most persuasive evidence does not show a valid diagnosis of chronic sinusitis related to service, and his symptoms are due to his already service-connected allergic rhinitis. Therefore, service connection for chronic sinusitis is denied. REASONS FOR REMAND 1. Entitlement to service connection for a lumbar spine disability is remanded. 2. Entitlement to service connection for a bilateral knee disability is remanded. During the Board hearing, the Veteran testified that he received treatment from a private physician after separating from service. Those records have not been associated with the claims file and could contain information crucial to the Veteran's claim. As such a remand is necessary to obtain those records. The Board appreciates the Veteran submitting nexus opinions regarding these claims. However, the November 2021 private opinions are insufficient as the clinician did not provide a detailed rationale for the stated opinions as to the etiology of the Veteran's knee and back disabilities. Importantly, Dr. Martinez indicated that he has been treating the Veteran for these disabilities since 1998, and the file does not include copies of such records. As such, a remand is necessary to obtain an addendum opinion following receipt of these private records. 3. Entitlement to service connection an acquired psychiatric disorder, to include posttraumatic stress disorder and insomnia is remanded. The Veteran last underwent a VA examination in April 2017 for PTSD. The examiner found that he did not meet the criteria for any diagnosis. Since that time, the Veteran has received treatment from a VA psychiatrist, including therapy and medication. As such, the Board remands the claim to schedule the Veteran for another VA examination to address whether he has a current mental health disorder that is due to his military service. The matters are REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-4142 for Dr. Eduardo Martinez. Make two requests for the authorized records from Dr. Eduardo Martinez unless it is clear after the first request that a second request would be futile. 2. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran's back disability is at least as likely as not related to his service. The need for an in-person examination is left to the discretion of the examiner. 3. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran's bilateral knee disability is at least as likely as not related to his service, to include multiple injuries caused by sprained ankles. The need for an in-person examination is left to the discretion of the examiner. 4. Schedule the Veteran for a psychiatric examination to determine the nature and etiology of any acquired psychiatric disorder, to include PTSD. If the Veteran is diagnosed with PTSD, the examiner must explain how the diagnostic criteria are met and opine whether it is at least as likely as not related to a verified in-service stressor. If any other acquired psychiatric disorders are diagnosed, the examiner must opine whether each diagnosed disorder is at least as likely as not related to an in-service injury, event, or disease, to include the death of another serviceman. The examiners are asked to include a detailed rationale for any opinions proffered. H.M. WALKER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Price, Esq. 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.