C&P Exam for Sinusitis, maxillary, chronic (DC 6513)

Diagnostic code: 6513Condition: Sinusitis, maxillary, chronicRegulation: 38 CFR § 4.97DBQ: DBQ ENT Sinusitis, Rhinitis and Other Conditions of the Nose, Throat, Larynx and Pharynx

Which form the examiner uses

For sinusitis, maxillary, chronic (DC 6513), the C&P examiner completes the following Disability Benefits Questionnaire (DBQ):

DBQs are Department of Veterans Affairs Form 21-0960 series documents. Public DBQs are hosted on benefits.va.gov. A handful are examiner-only and are not posted publicly.

What the examiner records

The fields below are reproduced from the DBQ form the examiner completes for this diagnostic code. This is the structural map of the form, showing what the examiner is asked to measure, observe, and record. It is a factual reproduction of the public DBQ, not advice on how to answer.

This DBQ evaluates sinusitis, rhinitis, and other conditions of the nose, throat, larynx, and pharynx, including deviated septum and laryngeal/pharyngeal disorders.

How DC 6513 maps to this DBQ: for this diagnostic code specifically, the examiner typically completes sections I-IV and IX-XII of this form. Section IV is the condition-specific section for this code. Sections V-VIII cover unrelated conditions on this DBQ and are skipped.

DIAGNOSIS (Section I)
  • 1A. List the claimed condition(s) that pertain to this questionnaire
  • 1B. Select diagnoses associated with the claimed condition(s) (check all that apply): The Veteran does not have a current diagnosis associated with any claimed condition(s) listed above
  • Chronic sinusitis - ICD code / Date of diagnosis
  • Allergic rhinitis - ICD code / Date of diagnosis
  • Non-allergic rhinitis - ICD code / Date of diagnosis
  • Bacterial rhinitis - ICD code / Date of diagnosis
  • Granulomatous rhinitis - ICD code / Date of diagnosis
  • Chronic laryngitis - ICD code / Date of diagnosis
  • Laryngectomy - ICD code / Date of diagnosis
  • Laryngeal stenosis - ICD code / Date of diagnosis
  • Aphonia - ICD code / Date of diagnosis
  • Pharyngeal injury - ICD code / Date of diagnosis / Describe
  • Deviated nasal septum - ICD code / Date of diagnosis / Traumatic or Non-traumatic
  • Anatomical loss of part of nose - ICD code / Date of diagnosis
  • Benign or malignant neoplasm of sinus, nose, throat, larynx or pharynx - ICD code / Date of diagnosis
  • Other diagnosis #1 / #2 / #3 - ICD code / Date of diagnosis
  • 1C. If there are additional diagnoses that pertain to the sinuses, nose, throat, larynx or pharynx condition(s), list using above format
MEDICAL HISTORY (Section II)
  • 2A. Describe the history (including onset and course) of the Veteran's sinus, nose, throat, larynx, or pharynx condition
NOSE, THROAT, LARYNX OR PHARYNX CONDITIONS (Section III)
  • 6A. Does the Veteran have chronic laryngitis?
  • If yes, does the Veteran have any of the following symptoms due to chronic laryngitis?: Hoarseness (describe frequency) / Inflammation of vocal cords / Inflammation of mucous membrane / Thickening of vocal cords / Nodules of vocal cords / Submucous infiltration of vocal cords / Vocal cord polyps / Other
  • 6B. Has the Veteran had a laryngectomy?: Total laryngectomy / Partial laryngectomy
  • If partial laryngectomy, does the Veteran have any residuals of the partial laryngectomy?
  • 6C. Does the Veteran have laryngeal stenosis, including residuals of laryngeal trauma (unilateral or bilateral)?
  • 6D. Does the Veteran have complete organic aphonia?: Constant inability to speak above a whisper / Constant inability to communicate by speech / Other
  • 6E. Does the Veteran have incomplete organic aphonia?: Hoarseness (describe frequency) / Inflammation of vocal cords / Inflammation of mucous membrane / Thickening of vocal cords / Nodules of vocal cords / Submucous infiltration of vocal cords / Vocal cord polyps / Other
  • 6F. Has the Veteran had a permanent tracheostomy?
  • If yes, describe reason for tracheostomy and potential for decannulation
  • 6G. Has the Veteran had an injury to the pharynx?: Obstruction of the pharynx / Obstruction of the nasopharynx / Stricture of the pharynx / Stricture of the nasopharynx / Absence of the soft palate secondary to trauma / Absence of the soft palate secondary to chemical burn / Absence of the soft palate secondary to granulomatous disease / Paralysis of the soft palate / Swallowing difficulty / Nasal regurgitation / Speech impairment / Other
  • 6H. Does the Veteran have vocal cord paralysis or any other pharyngeal or laryngeal conditions?
SINUSITIS (Section IV)
  • 4A. Indicate the sinuses/type of sinusitis currently affected by the Veteran's chronic sinusitis. Check all that apply: None / Maxillary / Frontal / Ethmoid / Sphenoid / Pansinusitis
  • 4B. Has the Veteran had a sinus-related surgical procedure?
  • Repeated sinus-related surgeries (of any type)
  • Radical (open sinus) surgery
  • If the Veteran has had radical sinus surgery, did chronic osteomyelitis follow the surgery?
  • Describe the type of procedure, sinuses operated on and side(s), to include the date(s) of surgery
  • 4C. Describe any findings, signs or symptoms attributable to chronic sinusitis: Chronic sinusitis detected only by imaging studies / Headaches / Pain of affected sinus / Tenderness of affected sinus / Purulent discharge / Crusting / Other
  • For all checked conditions, describe
  • 4D. Does the Veteran have near constant sinusitis?
  • 4E. Has the Veteran had non-incapacitating episodes of sinusitis characterized by headaches, pain and purulent discharge or crusting in the past 12 months?
  • If yes, provide the total number of non-incapacitating episodes over the past 12 months: 1 / 2 / 3 / 4 / 5 / 6 / 7 or more
  • 4F. Has the Veteran had incapacitating episodes of sinusitis requiring prolonged (4 to 6 weeks) of antibiotics treatment in the past 12 months?
  • If yes, provide the total number of incapacitating episodes of sinusitis requiring prolonged (4 to 6 weeks) of antibiotic treatment over the past 12 months: 1 / 2 / 3 or more
RHINITIS (Section V)
  • 5A. Is there greater than 50% obstruction of the nasal passage on both sides due to rhinitis?
  • 5B. Is there complete obstruction on the left side due to rhinitis?
  • 5C. Is there complete obstruction on the right side due to rhinitis?
  • 5D. Is there permanent hypertrophy of the nasal turbinates?
  • 5E. Are there nasal polyps?
  • 5F. Does the Veteran have any of the following granulomatous conditions?: Granulomatous rhinitis / Rhinoscleroma / Wegener's granulomatosis / Lethal midline granuloma / Other granulomatous infection
LARYNX AND PHARYNX CONDITIONS (Section VI)
  • 6A. Does the Veteran have chronic laryngitis?
  • If yes, does the Veteran have any of the following symptoms due to chronic laryngitis?: Hoarseness (describe frequency) / Inflammation of vocal cords / Inflammation of mucous membrane / Thickening of vocal cords / Nodules of vocal cords / Submucous infiltration of vocal cords / Vocal cord polyps / Other
  • 6B. Has the Veteran had a laryngectomy?: Total laryngectomy / Partial laryngectomy
  • If partial laryngectomy, does the Veteran have any residuals of the partial laryngectomy?
  • 6C. Does the Veteran have laryngeal stenosis, including residuals of laryngeal trauma (unilateral or bilateral)?
  • 6D. Does the Veteran have complete organic aphonia?: Constant inability to speak above a whisper / Constant inability to communicate by speech / Other
  • 6E. Does the Veteran have incomplete organic aphonia?: Hoarseness (describe frequency) / Inflammation of vocal cords / Inflammation of mucous membrane / Thickening of vocal cords / Nodules of vocal cords / Submucous infiltration of vocal cords / Vocal cord polyps / Other
  • 6F. Has the Veteran had a permanent tracheostomy?
  • If yes, describe reason for tracheostomy and potential for decannulation
  • 6G. Has the Veteran had an injury to the pharynx?: Obstruction of the pharynx / Obstruction of the nasopharynx / Stricture of the pharynx / Stricture of the nasopharynx / Absence of the soft palate secondary to trauma / Absence of the soft palate secondary to chemical burn / Absence of the soft palate secondary to granulomatous disease / Paralysis of the soft palate / Swallowing difficulty / Nasal regurgitation / Speech impairment / Other
  • 6H. Does the Veteran have vocal cord paralysis or any other pharyngeal or laryngeal conditions?
DEVIATED NASAL SEPTUM (Section VII)
  • 7A. Is there at least 50% obstruction of the nasal passage on both sides due to traumatic septal deviation?
  • 7B. Is there complete obstruction on left side due to traumatic septal deviation?
  • 7C. Is there complete obstruction on right side due to traumatic septal deviation?
TUMORS AND NEOPLASMS (Section VIII)
  • 8A. Does the Veteran currently have, or has had, a benign or malignant neoplasm or metastases related to any condition in the diagnosis section?
  • 8B. Is the neoplasm: Benign / Malignant
  • If malignant: Active / In remission
  • Primary / Secondary (metastatic) (If secondary, indicate the primary site, if known)
  • 8C. Has the Veteran completed treatment or is the Veteran currently undergoing treatment for a benign or malignant neoplasm or metastases?
  • Treatment completed
  • Surgery - If checked, describe / Date(s) of surgery
  • Radiation therapy - Date of most recent treatment / Date of completion of treatment or anticipated date of completion
  • Antineoplastic chemotherapy - Date of most recent treatment / Date of completion of treatment or anticipated date of completion
  • Other therapeutic procedure - If checked, describe procedure / Date of most recent procedure
  • Other therapeutic treatment - If checked, describe treatment / Date of completion of treatment or anticipated date of completion
  • 8D. Does the Veteran currently have any residuals or complications due to the neoplasm (including metastases) or its treatment, other than those already documented in the report above?
  • 8E. If there are additional benign or malignant neoplasms or metastases related to any of the diagnoses in the diagnosis section, describe using the above format
OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS, SYMPTOMS, AND SCARS (Section IX)
  • 9A. Does the Veteran have any other pertinent physical findings, complications, conditions, signs or symptoms related to the conditions listed in the diagnosis section above?
  • 9B. Does the Veteran have loss of part of the nose or other scars of the nose exposing both nasal passages?
  • 9C. Does the Veteran have loss of part of the nose or other scars causing loss of part of one ala?
  • 9D. Does the Veteran have loss of part of the nose or other scars causing any other disfigurement?
  • 9E. Does the Veteran have any scars (surgical or otherwise) related to any conditions or to the treatment of any conditions listed in the diagnosis section above?
  • 9F. Comments, if any
DIAGNOSTIC TESTING (Section X)
  • 10A. Have clinically relevant imaging studies of the sinuses or other areas been performed or reviewed in conjunction with this examination?
  • Magnetic resonance imaging (MRI) - Date / Results
  • Computed tomography (CT) - Date / Results
  • X-rays - Date / Results
  • Other imaging - Date / Results
  • 10B. Has endoscopy been performed?
  • Nasal endoscopy - Date / Results
  • Laryngeal endoscopy - Date / Results
  • Bronchoscopy - Date / Results
  • Other endoscopy - Date / Results
  • 10C. Has the Veteran had a biopsy of the larynx or pharynx?
  • Site of biopsy / Date
  • Results: Benign / Pre-malignant / Malignant / Describe results
  • 10D. Has the Veteran had pulmonary function testing to assess for upper airway obstruction due to laryngeal stenosis?
  • FEV-1 of 71 to 80% predicted
  • FEV-1 of 56 to 70% predicted
  • FEV-1 of 40 to 55% predicted
  • FEV-1 less than 40% predicted
  • Is the Flow-Volume Loop compatible with upper airway obstruction?
  • 10E. Are there any other significant diagnostic test findings and/or results?
FUNCTIONAL IMPACT (Section XI)
  • 11A. Regardless of the Veteran's current employment status, do the conditions listed in the diagnosis section impact his/her ability to perform any type of occupational task (such as standing, walking, lifting, sitting, etc.)?
  • If yes, describe the functional impact of each condition, providing one or more examples
REMARKS (Section XII)

    Rating Levels for DC 6513

    The following tiers are reproduced from 38 CFR Part 4, the VA Schedule for Rating Disabilities. Toggle between the official VA criteria and a Plain English explanation.

    Plain-English summaries are AI-generated to explain the official criteria. The official 38 CFR language is the binding legal standard. When in doubt, ask a VSO.

    Evidence cited in published BVA decisions for DC 6513

    The counts below are aggregated from published Board of Veterans Appeals decisions for this diagnostic code. Each row reports how often a given evidence type was discussed in the decision text, broken down by outcome. This is a factual aggregate of the public record, not a prediction or recommendation about any specific claim.

    • VA examination: appeared in 70 granted decisions (36 denied, 28 remanded; 134 total)
    • Private medical opinion: appeared in 36 granted decisions (4 denied, 6 remanded; 46 total)
    • Buddy / lay statements: appeared in 26 granted decisions (2 denied, 8 remanded; 36 total)
    • Medical literature: appeared in 15 granted decisions (1 denied, 5 remanded; 21 total)
    • Nexus letter: appeared in 7 granted decisions (3 denied, 3 remanded; 13 total)
    • Service treatment records: appeared in 4 granted decisions (6 denied, 3 remanded; 13 total)

    What the Board discussed in granted decisions for DC 6513

    The themes below were extracted by clustering 500 grant-factor sentences from published Board of Veterans Appeals decisions for this diagnostic code. Frequencies indicate how often each theme appeared in the sample. This is a factual aggregate of the public record, not advice or strategy for any specific claim.

    1. 32% Benefit of the doubt doctrine stated or applied generally
      The Board cited the statutory benefit of the doubt standard requiring VA to resolve approximate balance of positive and negative evidence in the claimant's favor, without reference to a specific sinusitis rating level.
      162 of 500 sample sentences
    2. 17% Sinusitis episodes count cited as basis for rating
      The Board found, after applying the benefit of the doubt, that the Veteran's sinusitis was manifested by a specific number of incapacitating or non-incapacitating episodes per year sufficient to warrant a particular schedular rating under DC 6513.
      87 of 500 sample sentences
    3. 16% Benefit of the doubt found inapplicable, claim denied
      The Board found that the preponderance or persuasive weight of the evidence was against the claim, rendering the benefit of the doubt doctrine inapplicable and resulting in denial.
      81 of 500 sample sentences
    4. 14% Medical nexus opinion noting at-least-as-likely-as-not relationship
      A VA or private examiner opined that a disability was at least as likely as not incurred in, caused by, or aggravated by service or a service-connected condition.
      72 of 500 sample sentences
    5. 10% Evidence found in equipoise, claim granted
      The Board found the lay and medical evidence to be in relative equipoise or approximate balance on a material question, resulting in a grant of service connection or an increased rating.
      48 of 500 sample sentences
    6. 3% Sinusitis symptoms documented as near-constant or severe
      The Board noted that the Veteran's sinusitis was characterized by near-constant or severe symptoms including headaches, pain, tenderness, and purulent discharge sufficient to support a higher disability rating.
      15 of 500 sample sentences
    7. 3% Secondary or secondary-aggravation nexus opinion cited
      A medical examiner opined that a disability was at least as likely as not proximately due to or aggravated by a service-connected condition, supporting secondary service connection.
      14 of 500 sample sentences
    8. 2% Sinusitis linked to toxic or in-service environmental exposure
      The Board or an examiner noted that the Veteran's chronic sinusitis was at least as likely as not caused by or related to in-service toxic exposures such as burn pit smoke or Gulf War environmental hazards.
      8 of 500 sample sentences
    9. 1% Veteran's credible lay testimony cited in rating determination
      The Board noted that the Veteran's competent and credible lay statements regarding sinusitis episode frequency or symptom severity were relied upon in reaching a rating determination.
      7 of 500 sample sentences
    10. 1% Allergic rhinitis or related condition documented as connected to sinusitis
      Medical evidence in the record documented a relationship between the Veteran's service-connected allergic rhinitis or nasal condition and the development or aggravation of chronic sinusitis.
      6 of 500 sample sentences
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    Disclaimer: This page reproduces public Department of Veterans Affairs forms (DBQs) and verbatim text from 38 CFR Part 4 (the VA Schedule for Rating Disabilities). It is informational only and is not legal or medical advice. For guidance on a specific claim, contact a VA-accredited representative.