Can the VA deny a sinusitis claim because a CT scan looked normal, even if the rating is based on episodes?

Sinusitis is rated under 38 CFR 4.97, Diagnostic Codes 6510 through 6514, using the General Rating Formula for Sinusitis. That formula rates based on the frequency and severity of incapacitating episodes and the presence of symptoms like headaches, pain, tenderness, purulent discharge, or crusting - not on whether a single CT scan shows swelling at the moment it was taken. A 0 percent rating applies when sinusitis is detected only by imaging with no symptoms. Higher ratings (10, 30, and 50 percent) require documented episodes of incapacitating sinusitis requiring prolonged antibiotic treatment, or three to six (or more) non-incapacitating episodes per year characterized by headaches, pain, and discharge.

A denial based on one normal CT scan is a common but often incorrect application of this rating schedule, especially when there is a longitudinal record from a PCP, ENT, and multiple allergists documenting recurring symptoms, diagnoses, and treatment over several years. Sinus imaging can look clear on a given day while the underlying chronic condition still meets the frequency and treatment criteria required for a compensable rating. The rating criteria do not require that imaging show active inflammation at the time of every exam; they require evidence of episode frequency and treatment history over time.

If a claim is denied primarily because one scan did not show swelling, while years of treatment records document multiple diagnosed episodes, antibiotic courses, and specialist visits, this is worth challenging. Veterans in this situation typically request review through a Higher-Level Review (VA Form 20-0996), a Supplemental Claim (VA Form 20-0995) with new evidence such as a nexus letter or updated symptom diary, or an appeal to the Board of Veterans' Appeals (VA Form 10182) if the evidentiary record was already complete but the rating criteria appear to have been misapplied. It is also useful to have a treating provider explicitly state, in writing, how many incapacitating and non-incapacitating episodes occurred and their duration, since this is the exact metric the rating schedule requires.

The concrete next step is to request a Higher-Level Review or file a Supplemental Claim with a detailed symptom/episode log and a supporting statement from the treating ENT or allergist that directly addresses the frequency and treatment history the rating code requires, rather than relying on the single CT scan result.