Citation Nr: 1318740 Decision Date: 06/10/13 Archive Date: 06/21/13 DOCKET NO. 09-39 766 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUES 1. Entitlement to service connection for diabetes mellitus, claimed as due to herbicide exposure including Agent Orange. 2. Entitlement to service connection for ischemic heart disease, claimed as due to herbicide exposure including Agent Orange. 3. Entitlement to a higher initial disability rating (evaluation) for residuals of a left ankle fracture with traumatic arthritis, in excess of 10 percent prior to November 30, 2012, and in excess of 30 percent from November 30, 2012. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD Christine C. Kung, Counsel INTRODUCTION The Veteran, who is the appellant in this case, served on active duty from December 1973 to December 1977. This matter comes on appeal before the Board of Veterans' Appeals (Board) from November 2008 and April 2012 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri which, in pertinent part, granted service connection for residuals of a left ankle fracture and assigned a 10 percent initial disability rating from June 12, 2008, and denied service connection for type II diabetes mellitus and ischemic heart disease, both claimed as due to herbicide exposure including Agent Orange. In June 2009, the Veteran requested a Board personal hearing (Travel Board) to address his left ankle disability; however, the Veteran withdrew his hearing request in a November 2009 correspondence. In an October 2011 rating decision, the RO granted a 30 percent evaluation for residuals of a left ankle fracture for the period from November 30, 2012, thus creating a staged rating of 10 percent prior to November 30, 2012 and 30 percent from that date. The Board has accordingly recharacterized the issue on appeal as entitlement to a higher initial disability rating for residuals of a left ankle fracture with traumatic arthritis, in excess of 10 percent prior to November 30, 2012, and in excess of 30 percent from November 30, 2012. An August 2012 statement of the case addressed the appeal for a higher initial rating for bilateral hip coxalgia and an increased rating for bilateral hearing loss; however, an October 2012 substantive appeal which addressed these issues was not timely and the RO has not taken any action to indicate that the filing of a timely substantive appeal has been waived. Cf. Percy v. Shinseki, 23 Vet. App. 37, 45 (2009) (holding that the filing of a timely substantive appeal may be waived, and that, where the RO takes actions to indicate that such filing has been waived (for instance by certifying the appeal), the Board has jurisdiction to decide the appeal). Therefore, the issues of entitlement to a higher initial rating for bilateral hip coxalgia and an increased rating for bilateral hearing loss are not currently on appeal. FINDINGS OF FACT 1. The Veteran was not stationed at or near the Demilitarized Zone (DMZ) in Korea, was not presumptively exposed to herbicides during active service, and was not actually exposed to herbicides during service. 2. The Veteran does not have a current diagnosed disability of diabetes mellitus. 3. The Veteran has currently diagnosed ischemic heart disease, to include arteriosclerotic heart disease. 4. The Veteran did not sustain an injury or disease of the cardiovascular system in service. 5. Symptoms of ischemic heart disease were not chronic in service and were not continuous after service separation. 6. Arteriosclerotic heart disease did not manifest to a compensable degree within one year of separation from service. 7. Currently diagnosed ischemic heart disease is not related to an in-service injury, disease, or event. 8. Prior to November 30, 2012, residuals of a left ankle fracture with arthritis were manifested by pain, 10 degrees dorsiflexion, and 45 degrees plantar flexion with pain at the end of range of motion without additional loss of motion. 9. From November 30, 2012, residuals of a left ankle fracture with arthritis have been manifested by pain, 5 degrees dorsiflexion, 5 degrees plantar flexion, approximating ankylosis of the ankle in plantar flexion at less than 30 degrees, in dorsiflexion between 0 degrees and 10 degrees, with abduction, adduction, inversion, or eversion deformity. CONCLUSIONS OF LAW 1. The criteria for service connection for diabetes mellitus are not met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 5103(a), 5103A, 5107(b) (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2012). 2. The criteria for service connection for ischemic heart disease are not met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 5103(a), 5103A, 5107(b) (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2012). 3. Prior to November 30, 2012, the criteria for a disability rating in excess of 10 percent, for residuals of a left ankle fracture with traumatic arthritis, have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.159, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71, Plate II, 4.71a, Diagnostic Codes 5270 and 5271 (2012). 4. Resolving reasonable doubt in the Veteran's favor, from November 30, 2012, the criteria for a 40 percent disability rating for residuals of a left ankle fracture with traumatic arthritis have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.159, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71, Plate II, 4.71a, Diagnostic Code 5270 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.156(a), 3.326(a) (2012). The notice requirements of VCAA require VA to notify the claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, the VA will attempt to obtain. Id. The United States Court of Appeals for Veterans Claims (Court) issued a decision in the appeal of Dingess v. Nicholson, 19 Vet. App. 473 (2006), which held that the notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service-connection claim, including the degree of disability and the effective date of an award. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. Id. In July 2008 and October 2011 letters, the RO provided preadjudicatory notice to the Veteran regarding what information and evidence is needed to substantiate service connection, as well as what information and evidence must be submitted by the Veteran, and what evidence VA would obtain. The July 2008 and October 2011 notice letters included information regarding how disability ratings and effective dates are assigned. The Veteran's appeal for a higher initial rating for residuals of left ankle fracture arises from disagreement with the initial evaluation following the grant of service connection. VCAA notice regarding the service connection claim was furnished to the Veteran in October 2009. Courts have held that, once service connection is granted the claim is substantiated, additional notice is not required and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007); VAOPGCPREC 8-2003 (in which the VA General Counsel interpreted that separate notification is not required for "downstream" issues following a service connection grant, such as initial rating and effective date claims); 38 C.F.R. § 3.159(b)(3)(i) (no duty to provide VCAA notice upon receipt of a notice of disagreement). Therefore, no further notice is needed under VCAA regarding this issue. The Veteran was afforded VA examinations in October 2008 and November 2012 to address his left ankle disability. 38 C.F.R. § 3.159(c)(4) (2012). When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the VA examinations obtained in this case are adequate for rating purposes. VA examinations included complete physical examinations of the Veteran and addressed all the relevant rating criteria for rating the Veteran's left ankle disability. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the issues on appeal has been met. 38 C.F.R. § 3.159(c)(4). The Veteran has not been afforded a VA medical examination with respect to service connection for ischemic heart disease and a claimed diabetes mellitus; however, the Board finds that a VA examination is not necessary in order to decide these issues. VA must provide a VA medical examination when there is: (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, and (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with a veteran's service or with another service-connected disability, but (4) insufficient competent medical evidence on file for the VA Secretary to make a decision on the claim. See McClendon v. Nicholson, 20 Vet. App. 79, 81 (2006). An August memorandum from the RO Military Records Specialist shows that a review of records from the National Personnel Records Center (NPRC) and the U.S. Army and Joint Services Records Research Center (JSRRC) shows that there were no records showing that the Veteran was exposed to herbicides in service and that the Veteran's unit was not stationed at or located along the DMZ in Korea while he was in service. For these reasons, the Board finds that development completed in this case is adequate, that VA has complied with procedures for determining whether the Veteran was exposed to herbicides in a vicinity other than the Republic of Vietnam as delineated in VA's Adjudication Procedure Manual, M21-1MR, Part IV, Subpart ii, Chapter 2, Section C., para 10(o). In this case, because the weight of the evidence demonstrates that the Veteran the Veteran does not have confirmed exposure to Agent Orange or other tactical herbicide agent within the meaning of 38 C.F.R. § 3.307 in service, there was no injury to or disease of the endocrine system or cardiovascular system in service, there is no duty to provide a VA medical examination. As explained in this decision, the Board finds that the weight of the evidence demonstrates no in service exposure to an herbicide agent, no injury or disease of either the endocrine or cardiovascular systems, no symptoms of ischemic heart disease symptoms in service, and no continuity of symptoms since service separation. Thus, there is no reasonable possibility that a VA examination or opinion could aid in substantiating the current claim for service connection for ischemic heart disease or claimed diabetes mellitus because there is no relevant injury, disease, or event in service to which any current disabilities could be related by competent opinion. See 38 U.S.C.A. § 5103A(a)(2) (West 2002) (VA "is not required to provide assistance to a claimant . . . if no reasonable possibility exists that such assistance would aid in substantiating the claim"); 38 C.F.R. § 3.159(d) (VA to discontinue assistance where there is "no reasonable possibility that further assistance would substantiate the claim"); see also Bardwell v. Shinseki, 24 Vet. App. 36, 40 (2010) (holding that where the evidence has failed to establish an in-service injury, disease, or event, VA is not obligated to provide a medical examination). Because the evidence demonstrates no in-service exposure, disease, or injury, or even in-service symptoms, referral of this case to obtain an examination and/or an opinion as to the etiology of ischemic heart disease or claimed diabetes mellitus would in essence place the examining physician in the role of a fact finder, would suggest reliance on an inaccurate history of occurrence of an in-service injury or disease, and could only result in a speculative opinion or purported opinion of no probative value. The Court has held on a number of occasions that a medical opinion premised upon an unsubstantiated account of a claimant is of no probative value. See, e.g., Swann v. Brown, 5 Vet. App. 229, 233 (1993) (generally observing that a medical opinion premised upon an unsubstantiated account is of no probative value, and does not serve to verify the occurrences described); Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (the Board is not bound to accept a physician's opinion when it is based exclusively on the recitations of a claimant that have been previously rejected). The Board is also satisfied VA has made reasonable efforts to obtain relevant records and evidence. Specifically, the information and evidence that has been associated with the claims file includes service treatment records, service personnel records, correspondence from the NPRC and JSRRC, VA examinations, VA and private treatment records, the Veteran's statements, and research articles submitted by the Veteran. The Veteran and his representative have not identified any outstanding evidence that needs to be obtained. For these reasons, the Board finds that VA has fulfilled the duties to notify and assist the Veteran. Service Connection Laws and Regulations Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). As a general matter, service connection for a disability requires evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004); see also Hickson v. West, 12 Vet. App. 247, 253 (1999), citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996). In this case, claimed diabetes mellitus and diagnosed arteriosclerotic heart disease (a cardiovascular disease) are "chronic diseases" listed under 38 C.F.R. § 3.309(a); therefore, the presumptive service connection provisions of 38 C.F.R. § 3.303(b) based on chronic in service symptoms and continuous post-service symptoms apply. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Where the evidence shows a "chronic disease" in service or "continuity of symptoms" after service, the disease shall be presumed to have been incurred in service. With a chronic disease shown as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected, unless clearly attributable to intercurrent causes. For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. If a condition noted during service is not shown to be chronic, then generally, a showing of continuity of symptoms after service is required for service connection. 38 C.F.R. § 3.303(b). Where a veteran served ninety days or more of active service, and certain chronic diseases, such as diabetes mellitus or cardiovascular disease (including arteriosclerotic heart disease), become manifest to a degree of 10 percent or more within one year after the date of separation from such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309(a). While the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. Id. A veteran who had active service in the Republic of Vietnam during the period beginning on January 9, 1962 and ending on May 7, 1975 will be presumed to have been exposed to an herbicide agent during such service unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service. See 38 U.S.C.A. § 1116(f) (West 2002); 38 C.F.R. § 3.307(a)(6)(iii). The presumption of herbicide exposure is warranted for service in the waters offshore and service in other locations if the conditions of service involved duty or visitation in the Republic of Vietnam. 38 C.F.R. § 3.307(a)(6)(iii); see also Haas v. Nicholson, 20 Vet. App. 257 (2006), rev'd sub nom. Haas v. Peake, 525 F.3d 1168 (Fed. Cir. 2008), cert. denied, 77 U.S.L.W. 3267 (Jan. 21, 2009) (No. 08-525). In order to establish qualifying "service in Vietnam," a veteran must demonstrate actual duty or visitation in the Republic of Vietnam to have qualifying service. 38 C.F.R. § 3.307(a)(6)(iii); VAOPGCPREC 27-97. Pursuant to the authority granted by the Agent Orange Act of 1991, VA may determine that a presumption of service connection based on exposure to herbicides used in Vietnam is warranted for conditions that VA has found to have a statistically significant association with such exposure. As such, VA has determined that a statistically significant association exists between exposure to herbicides and subsequent development of the following conditions: chloracne or other acneform disease consistent with chloracne, non-Hodgkin's lymphoma, soft tissue sarcoma, Hodgkin's disease, porphyria cutanea tarda (PCT), multiple myeloma, acute and subacute peripheral neuropathy, prostate cancer, cancers of the lung, bronchus, larynx, trachea, Type II (adult-onset) diabetes mellitus, chronic lymphocytic leukemia, AL amyloidosis, Parkinson's disease, ischemic heart disease, and B-cell leukemias, such as hairy cell leukemia. See 38 C.F.R. § 3.309(e). The diseases listed at 38 C.F.R. § 3.309(e) shall have become manifest to a degree of 10 percent or more at any time after service, except that chloracne or other acneform disease consistent with chloracne, porphyria cutanea tarda, and acute and subacute peripheral neuropathy shall have become manifest to a degree of 10 percent or more within a year after the last date on which the veteran was exposed to an herbicide agent during active military, naval, or air service. 38 C.F.R. § 3.307(a)(6)(ii). VA's Secretary has determined that a presumption of service connection based on exposure to herbicides used in the Republic of Vietnam during the Vietnam era is not warranted for any condition for which the Secretary has not specifically determined a presumption of service connection is warranted. See 68 Fed. Reg. 27,630 (May 20, 2003). In this regard, the Board observes that VA has issued several notices in which it was determined that a presumption of service connection based upon exposure to herbicides used in Vietnam should not be extended to certain specific disorders, based upon extensive scientific research. See, e.g., Notices, 68 Fed. Reg. 27,630 -41 (2003); 64 Fed. Reg. 59,232 -243 (1999); 61 Fed. Reg. 57,586 -589 (1996). However, the United States Court of Appeals for the Federal Circuit has determined that an appellant is not precluded from establishing service connection with proof of actual direct causation. Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994); Ramey v. Brown, 9 Vet. App. 40, 44 (1996), aff'd sub nom, Ramey v. Gober, 120 F.3d 1239 (Fed. Cir. 1997), cert. denied, 118 S. Ct. 1171 (1998). In rendering a decision on appeal the Board must also analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). The Board is charged with the duty to assess the credibility and weight given to evidence. Wensch v. Principi, 15 Vet. App. 362, 367 (2001); Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). In weighing credibility, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. Caluza v. Brown, 7 Vet. App. 498 (1995). The Board may weigh the absence of contemporaneous medical evidence against the lay evidence in determining credibility, but the Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). Generally, the degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider takes into account such factors as its thoroughness and degree of detail, and whether there was review of the veteran's claims file. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Also significant is whether the examining medical provider had a sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting clinical data. See Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005) (rejecting medical opinions that did not indicate whether the physicians actually examined the veteran, did not provide the extent of any examination, and did not provide any supporting clinical data). The Court has held that a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). Service Connection for Ischemic Heart Disease and Type II Diabetes Mellitus The Veteran claims that presumptive service connection is warranted for ischemic heart disease and diabetes mellitus due to Agent Orange exposure. He contends that he was exposed to Agent Orange while stationed in the DMZ in Korea. After reviewing all the lay and medical evidence, including the Veteran's statements and testimony, the Board finds that the weight of the evidence demonstrates that the Veteran was not exposed to an herbicide agent in service, that he does not have a current diagnosed disability of diabetes mellitus, and that ischemic heart disease is not related to service. With regard to claimed herbicide exposure during service, the Veteran's DD Form 214 and personnel records show that he served in the Republic of Korea from January 1972 to March 1973. The Veteran does not allege that he had service in the Republic of Vietnam, but instead contends that he was exposed to Agent Orange while stationed in the DMZ in Korea. However, the evidence of record does not show that the Veteran served in the DMZ in Korea, nor does the evidence of record confirm exposure to a qualifying herbicide agent in Korea to warrant the presumption of service connection. See 38 C.F.R. § 3.307(a)(6)(iii) (2012); Haas v. Peake, 525 F.3d 1168 (Fed. Cir. 2008), cert. denied, 77 U.S.L.W. 3267 (Jan. 21, 2009) (No. 08-525). VA has developed specific procedures to determine whether a veteran was exposed to herbicides in vicinity other than the Republic of Vietnam or along the demilitarized zone (DMZ) in Korea. See VA's Adjudication Procedure Manual, M21-1MR, Part IV, Subpart ii, Chapter 2, Section C., para 10(o). An August 2012 Memorandum from the RO's Military Records Specialist shows that they were unable to corroborate the Veteran's claimed Agent Orange exposure. A May 2012 response from the NPRC to an inquiry for exposure to herbicides outside of Vietnam shows that there were no records showing that the Veteran was exposed to herbicides in service. A June 2012 response to a JSRRC inquiry shows that the Veteran's unit was not stationed within the DMZ at the time he claims to have been exposed to Agent Orange. Instead, the JSRRC response shows that the unit histories dated from 1971 to 1973 submitted by the 1st Battalion, 15th Field Artillery and its higher headquarters document that the Veteran's unit was stationed at Camp Stanley located approximately 10 miles from the DMZ. Unit histories dated from 1971 to 1973 do not document the use, storage, spraying, or transporting of herbicides, nor do they document any specific duties performed by the 1st Battalion, 15th Field Artillery along the DMZ. Furthermore, JSRRC response shows that while the 1st Battalion, 15th Field Artillery was on a list of units identified by the Department of Defense as having operated in an area in or near the Korean DMZ, the Veteran was not stationed at this unit within the required time period where the unit was located in or near the DMZ. Service personnel records show that the Veteran had foreign service in the Republic of Korea from January 1972 to March 1973, but do not confirm any duty assignments in the DMZ. Service treatment records also indicate that the Veteran was located at Camp Stanley from 1972 to 1973. Clinical treatment reports dated during this time show that the Veteran was seen frequently at the Camp Stanley Dispensary and he was referred to the United States Army Hospital in Seoul for treatment of his ankle. Service treatment records do not reflect any reports or complaints related to the alleged herbicide exposure or endocrine system or cardiovascular disorders. In a June 2012 statement, the Veteran contends that he was assigned to the 1st Battalion, 15th Field Artillery on the DMZ. He reported that he performed rotations along the DMZ with his unit from March to May 1992. The Veteran is competent to describe exposure an herbicide agent in service and he is competent to describe service in the DMZ; however, the Board finds that the Veteran has not identified a specific incident of exposure in this case, and, due to discrepancies in the Veteran's statements and due to the lack of corroborating evidence in official documents, the Board finds that the Veteran's lay statements with regard service in the DMZ are not credible. In that regard, during the course of a January 2011 VA psychiatric examination, the Veteran reported that he was stationed at Camp Stanley in Korea, and not in the DMZ as he has asserted in statements made in support of his claim. JSRRC correspondence shows that the Veteran's unit was stationed at Camp Stanley and not in the DMZ and unit histories do not document any specific duties performed by the 1st Battalion, 15th Field Artillery along the DMZ during the Veteran's period of service. While the Veteran contends in multiple lay statements, to include statements offered to VA health care providers, that he was exposed to Agent Orange in the DMZ in Korea, the Board finds that weight of the evidence, to include evidence provided by the RO's Military Records Specialist, the NPRC, and the JSRRC, which show that the Veteran was not exposed to an herbicide agent while stationed in Korea and that he was not stationed in the DMZ, outweigh the Veteran's recent statements with regard to exposure made for VA compensation purposes, which the Board finds are not credible. In a September 2012 statement, the Veteran contends that dioxin, present in Agent Orange, is endurable in the environment and that the half-life of dioxin in the surface layer of the soil is very long. The Veteran submitted research articles on Agent Orange and other qualifying herbicide agents in support of his contention that which identify the half-life of dioxin as ranging from 9 to 25 years. While the Veteran's September 2012 statement, supported by research articles, shows that dioxin remains present in the environment for many years, the weight of the evidence establishes that the Veteran was not stationed in an area in Korea where Agent Orange or other tactical herbicide agent within the meaning of 38 C.F.R. § 3.307 was used; thus, the research articles submitted do not establish the Veteran's exposure to an herbicide agent in Korea. The Veteran submitted a copy of a January 2010 VA ophthalmology note in support of his claim. The VA ophthalmologist stated that the Veteran was stationed on the Korean DMZ in 1972 or 1973 in an area that had been cleared in 1968 or 1969 via Agent Orange/dioxin which had a half-life of 7 to 11 years. The ophthalmologist stated that the Veteran would have been exposed to the herbicide during the assignment, which could possibly contribute to impaired glucose status. The Board finds that the January 2010 opinion with regard to the Veteran's exposure is not probative and appears to be based solely on an inaccurate history of herbicide exposure as provided by the Veteran, which the Board has found not to be credible. Medical opinions premised upon an unsubstantiated account of a claimant are of no probative value and does not serve to verify the occurrences described. See Swann v. Brown, 5 Vet. App. 229, 233 (1993); Reonal, 5 Vet. App. at 461. The VA ophthalmologist based her opinion with regard to Agent Orange or dioxin exposure on the Veteran's reported history of being stationed in the Korean DMZ in 1972 or 1973; however, the Board has found that the Veteran was not stationed in the DMZ during this time period based on findings from personnel records, service treatment records, and unit histories which do not document any specific duties performed by the Veteran's unit along the DMZ during his period of service. For these reasons, the Board finds that the January 2010 VA ophthalmology note is not probative in establishing either exposure to an herbicide agent in service or in establishing a link between any alleged exposure and a currently claimed disability. The Veteran's DD Form 214, service treatment records, personnel records, and a search of the Veteran's unit history through the NPRC and JSRRC all failed to confirm any herbicide exposure in Korea or duty in the DMZ. The Board finds that, in the context of reported inconsistencies by the Veteran with respect to where he served, the lack of corroborating evidence in the official records also weighs against a finding of in-service herbicide exposure. The Board finds that the evidence provided from the official sources, to include the service treatment records, service personnel records, and information provided by the NPRC and JSRRC, outweigh the inconsistent lay statements provided by the Veteran. Absent service in the DMZ, the Board finds that research articles provided by the Veteran and a January 2010 VA ophthalmologist's statement fail to support the Veteran's alleged herbicide exposure in Korea. Absent corroborating evidence of exposure to herbicides outside of Vietnam, the Board finds that there is no basis for presumptive service connection due to herbicide exposure. See 38 U.S.C.A. § 1116(f) (West 2002); 38 C.F.R. § 3.307(a)(6)(iii) (2012). The Veteran may also establish service connection for a diagnosed disability with proof of direct causation. See Combee v. Brown, 34 F.3d 1039, 1041-42 (Fed. Cir. 1994). After reviewing all the lay and medical evidence, including the Veteran's statements and testimony, the Board finds that the weight of the evidence demonstrates that the Veteran does not have a current diagnosis of diabetes mellitus and that ischemic heart disease is not related to service. VA treatment records dated from 2011 to present do not reflect a recent diagnosis of diabetes mellitus; a January 2010 VA ophthalmology note reflects only an assessment of impaired glucose tolerance or mild glucose fluxuations, but not a diagnosis of diabetes mellitus. The Veteran has not otherwise identified a current diagnosis or treatment for diabetes mellitus. The existence of a current disability is the cornerstone of a claim for VA disability compensation. See 38 U.S.C.A. § 1110, 1131; Degmetich v. Brown, 104 F. 3d 1328 (1997). Because the Veteran is not shown to have currently diagnosed diabetes mellitus the Board finds that service connection for diabetes mellitus is not warranted. VA treatment records show that the Veteran has currently diagnosed arteriosclerotic heart disease and ischemic heart disease. VA treatment records show that arteriosclerotic heart disease was diagnosed in November 2006. A November 2006 stress test was suggestive of ischemia. A December 2011 Ischemic Heart Disease Disability Benefits Questionnaire completed by the Veteran's VA physician confirms that the Veteran has a currently diagnosed ischemic heart disease, first diagnosed in November 2010. The Board finds, however, that the Veteran did not sustain an injury or disease of the cardiovascular system in service. Service treatment records do not reflect any symptoms related to ischemic heart disease in service. The Veteran did not have continuous symptoms related to ischemic heart disease after his separation from service. Instead, VA and private treatment records show that heart disease was first diagnosed in November 2006, which is 29 years after the Veteran's separation from service. Arteriosclerotic heart disease did not manifest to a compensable degree within one year of separation from service. The evidence of record does not include competent, credible, and probative evidence which relates currently diagnosed arteriosclerotic heart disease or ischemic heart disease to his period of service. Laypersons are competent to speak to symptomatology when the symptoms are readily observable. Layno v. Brown, 6 Vet. App. 465, 469 (1994). However, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the question of diagnosis and causation for most disabilities. See Jones v. Brown, 7 Vet. App. 134, 137 (1994). To the extent that the Veteran contends that heart disease is related to Agent Orange exposure in service, as a lay person, he is not competent to offer an opinion on a matter clearly requiring medical expertise, such as providing a medical nexus opinion. Such an opinion would require an understanding of both the complex chemical effects as well as its causative effect on the unseen and complex cardiovascular system. See Rucker v. Brown, 10 Vet. App. 67, 74 (1997) (stating that a lay person is not competent to diagnose or make a competent nexus opinion about a disorder as complex as cancer). Likewise, the Veteran is not credible in identifying exposure to Agent Orange in service, which he claims is the cause of ischemic heart disease. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). For the reasons discussed above, the Board finds that service connection for diabetes mellitus and ischemic heart disease, to include arteriosclerotic heart disease, is not warranted on either a direct or presumptive basis. Because a preponderance of the evidence is against findings of in-service herbicide exposure, chronic or continuous symptoms of ischemic heart disease since service, current disability (diabetes), and relationship of current disability to service (heart disease), the claims must be denied, and there is not reasonable doubt to resolve in the Veteran's favor. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. Disability Rating Laws and Regulations Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities. The percentage ratings are based on the average impairment of earning capacity and individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2012). If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3. The Veteran has challenged the initial disability ratings assigned to the service-connected left ankle disability by seeking appellate review. Fenderson v. West, 12 Vet. App. 119, 125-26 (1999) (noting distinction between claims stemming from an original rating versus increased rating); see also Proscelle v. Derwinski, 2 Vet. App. 629, 631-32 (1992) (discussing aspects of a claim for increased disability rating). Separate ratings may be assigned for separate periods of time based on the facts found, a practice known as "staged" rating. Fenderson, 12 Vet. App. at 126. Because the RO issued a new rating decision in December 2012, granting a 30 percent evaluation for residuals of a left ankle fracture with traumatic arthritis for the period from November 30, 2012, the Board will evaluate the "staged" levels of disability both prior to and from November 30, 2012. In evaluating disabilities of the musculoskeletal system, it is necessary to consider, along with the schedular criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. DeLuca, 8 Vet. App. 202. Functional loss may be due to due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. 38 C.F.R. § 4.40. Weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity, or atrophy of disuse are relevant factors in regard to joint disability. 38 C.F.R. § 4.45. With any form of arthritis, painful motion is an important factor of disability, the facial expression, wincing, etc., on pressure or manipulation, should be carefully noted and definitely related to affected joints. Muscle spasm will greatly assist the identification. Sciatic neuritis is not uncommonly caused by arthritis of the spine. The intent of the schedule is to recognize painful motion with joint or particular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. Crepitation either in the soft tissues such as the tendons or ligaments, or crepitation within the joint structures should be noted carefully as points of contact which are diseased. Flexion elicits such manifestations. The joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint. 38 C.F.R. § 4.59. Pyramiding, that is the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when evaluating a veteran's service-connected disability. 38 C.F.R. § 4.14 (2012). However, it is possible for a veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes; the critical element in permitting the assignment of several evaluations under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261- 62 (1994). The "amputation rule" set forth at 38 C.F.R. § 4.68 (2012) provides that the combined rating for disabilities of an extremity shall not exceed the rating for the amputation at that elective level, were amputation to be performed. The regulation elaborates that, for example, the combined evaluations for disabilities below the knee shall not exceed the 40 percent evaluation under Diagnostic Code 5165. Under Diagnostic Code 5003, degenerative arthritis is rated based on limitation of motion under the appropriate diagnostic codes for the specific joint involved. However, when the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, a 10 percent evaluation is assigned with x-ray evidence of involvement of two or more major joints; a 20 percent rating is assigned with x-ray evidence of involvement of two or more major joints with occasional incapacitating exacerbations. 38 C.F.R. § 4.71a. Normal ranges of motion of the ankle are dorsiflexion from 0 degrees to 20 degrees, and plantar flexion from 0 degrees to 45 degrees. 38 C.F.R. § 4.71, Plate II. Ankylosis of the ankle is rated Diagnostic Code 5270. A 20 percent evaluation is assigned with ankylosis of the ankle in plantar flexion at less than 30 degrees. A 30 percent evaluation is assigned with ankylosis in planter flexion between 30 degrees and 40 degrees, or in dorsiflexion between 0 degrees and 10 degrees. A 40 percent evaluation is assigned with ankylosis in plantar flexion at more than 40 degrees, or in dorsiflexion at more than 10 degrees, or with an abduction, adduction, inversion or eversion deformity. 38 C.F.R. § 4.71a. Limitation of motion of the ankle is rated under Diagnostic Code 5271. A 10 percent evaluation is assigned with moderate limited motion of the ankle, and a maximum 20 percent evaluation is assigned with marked limited motion of the ankle. 38 C.F.R. § 4.71a. The Board notes that words such as "severe" and "moderate" are not defined in the Rating Schedule. Rather than applying a mechanical formula, VA must evaluate all evidence, to the end that decisions will be equitable and just. 38 C.F.R. § 4.6 (2012). Although the use of similar terminology by medical professionals should be considered, is not dispositive of an issue. Instead, all evidence must be evaluated in arriving at a decision regarding a request for an increased disability rating. 38 U.S.C.A. § 7104 (West 2002); 38 C.F.R. §§ 4.2, 4.6 (2012). Initial Rating for Residuals of a Left Ankle Fracture with Traumatic Arthritis The Veteran is service connected for residuals of a left ankle fracture with traumatic arthritis, which has been rated as 10 percent disabling from June 12, 2008, and 30 percent disabling from November 30, 2012. After a review of all the evidence, lay and medical, the Board finds that, prior to November 30, 2012, an evaluation in excess of 10 percent is not warranted for a left ankle disability under Diagnostic Codes 5270 and 5271. For the period prior to November 30, 2012, the evidence shows that the Veteran's left ankle disability has been manifested by pain, with 10 degrees dorsiflexion, and 45 degrees plantar flexion with pain at the end of range of motion without additional loss of motion. An October 2008 VA examination shows that the Veteran reported pain in the left ankle with weakness and stiffness in the morning and flare-ups of pain occurring every morning. The Veteran treated pain with over-the-counter medications and wore high-top boots. On physical examination, he had full range of motion in the left ankle with 10 degrees dorsiflexion and 45 degrees plantar flexion. There was no additional limitation of motion with repetition. There was increased pain at end-point range of motion but it did not prevent movement. The Veteran's gait was antalgic. X-rays revealed mild degenerative arthritis, old trauma to the medial malleolus, and a small spur on the plantar aspect to the calcaneus. VA treatment records dated from 2008 to 2010 reflect complaints of left ankle pain and instability, crepitus present at end range of motion, and mild degenerative joint disease in the left ankle. An April 2010 VA examination of the feet shows that the limited motion in the ankle precipitates an abnormal gait. For the period from June 12, 2008 to November 30, 2012, the evidence of record shows that the Veteran had 10 degrees loss of motion on dorsiflixion and full plantar flexion in the left ankle with pain noted to be at the end or range of motion. The evidence does not show additional limitations due to pain. See 38 C.F.R. §§ 4.40, 4.45; DeLuca, 8 Vet. App. 206. For these reasons, the Board finds that, for the initial rating period from June 12, 2008 to November 30, 2012, the evidence of record does not reflect marked limited motion of the left ankle or ankylosis of the left ankle to warrant a higher evaluation under Diagnostic Code 5270 or 5271. See 38 C.F.R. §§ 4.3, 4.7, 4.71a. The Board also finds that, for the initial rating period from November 30, 2012, the Veteran's left ankle disability has been manifested by pain, 5 degrees dorsiflexion and 5 degrees plantar flexion, more nearly approximating ankylosis of the ankle in plantar flexion at less than 30 degrees, and in dorsiflexion between 0 degrees and 10 degrees with abduction, adduction, inversion, or eversion deformity. Resolving the benefit of the doubt in the Veteran's favor, the Board finds that from November 30, 2012 the impairment of the left ankle disability more nearly approximates the criteria for a higher 40 percent disability rating under Diagnostic Code 5270. A November 30, 2012 VA examination shows that the Veteran had 5 degrees dorsiflexion with pain at 0 degrees, and 5 degrees plantar flexion with pain at 0 degrees. There were no additional limitations with repetitive motion, and there were no additional limitations to range of motion after three repetitions of motion. The Veteran had symptoms of weakened movement, excess fatigability, pain on movement, swelling, disturbance of locomotion, and stiffness and pain causing ambulation with external gait deviation on the left. The left ankle joint was stable on anterior drawer and taler tilt testing. The examiner identified ankylosis of the left ankle in planter flexion at less than 30 degrees and in dorsiflexion between 0 and 10 degrees. The Veteran's 30 percent rating was assigned based on findings related to ankylosis of the left ankle in dorsiflexion between 0 and 10 degrees. The examiner also identified ankylosis of the left ankle with abduction, adduction, inversion, or eversion deformity. Activities of prolonged walking, standing, climbing, and walking on uneven surfaces aggravated the Veteran's left ankle condition. The VA examiner stated, however, that the left ankle disability did not prevent sedentary employment opportunities. The Veteran had been a farmer and farm laborer for several years, with his last employment at the end of the harvest in November 2012, the month of the examination. The Veteran reported great difficulty walking across uneven fields and on irregular surfaces. Because the November 30, 2012 VA examination shows that the Veteran had limitations of motion that approximated ankylosis of the left ankle with abduction, adduction, inversion, or eversion deformity, the Board finds that the Veteran's left ankle disability more nearly approximates the rating criteria as described for a 40 percent rating under Diagnostic Code 5270. Resolving reasonable doubt in the Veteran's favor, the Board finds that, for the initial rating period from November 30, 2012, a 40 percent rating is warranted under Diagnostic Code 5270. See 38 C.F.R. §§ 4.3, 4.7, 4.71a. A 40 percent evaluation is the maximum evaluation available under Diagnostic Code 5270; therefore, a higher evaluation is not available under this Diagnostic Code. Because the record shows that the Veteran is in receipt of a 10 percent disability rating for plantar fasciitis of the left foot, the award of a 40 percent rating for residuals of a left ankle fracture with traumatic arthritis will be subject to the amputation rule and to the law and regulations governing the payment of monetary benefits. See 38 C.F.R. § 4.68. Extraschedular Consideration The Board has considered whether referral for an extraschedular evaluation is warranted. In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321 (2012). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). When the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for completion of the third step-a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Id. Turning to the first step of the extraschedular analysis, the Board finds that the symptomatology and impairment caused by the Veteran's left ankle disability is specifically contemplated by the schedular rating criteria, and no referral for extraschedular consideration is required. The schedular rating criteria, including Diagnostic Codes 5270 and 5271 specifically provide for disability ratings based on limitation of motion or ankylosis of the affected joints, including due to pain and other orthopedic factors. See 38 C.F.R. §§ 4.21, 4.40, 4.45, 4.59 (2012); see also DeLuca. In this case, considering the lay and medical evidence, the Veteran's ankle disability has been manifested by 10 degrees dorsiflexion and 45 degrees plantar flexion with pain at the end of range of motion prior to November 30, 2012 and by ankylosis of the ankle in plantar flexion at less than 30 degrees, in dorsiflexion between 0 degrees and 10 degrees, with abduction, adduction, inversion, or eversion deformity. These symptoms and impairment are part of or similar to symptoms listed under the schedular rating criteria. See 38 C.F.R. § 4.20 (schedular rating criteria provides for rating by analogy based on similar functions, anatomical location, and symptomatology). Additionally, the Board has considered probative that while a November 30, 2012 VA examination notes functional limitations to walking, standing, and climbing, which are contemplated by the Veteran's assigned 40 percent rating from that date, the Veteran was also able to perform employment doing farm work with his most recent harvest being in November 2012. For these reasons, the Board finds that the schedular rating criteria is adequate to rate the Veteran's left ankle disability, and referral for consideration of an extraschedular evaluation is not warranted. The schedule is intended to compensate for average impairments in earning capacity resulting from service-connected disability in civil occupations. 38 U.S.C.A. § 1155 (2012). "Generally, the degrees of disability specified [in the rating schedule] are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability." 38 C.F.R. § 4.1 (2012). In this case, the problems reported by the Veteran are specifically contemplated by the criteria discussed above, including the effect on his occupation and daily life. In the absence of exceptional factors associated with a left ankle disability, the Board finds that the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). ORDER Service connection for diabetes mellitus is denied. Service connection for ischemic heart disease is denied. An initial disability rating for residuals of a left ankle fracture with traumatic arthritis, in excess of 10 percent prior to November 30, 2012 is denied; an initial disability rating of 40 percent from November 30, 2012 is granted. ____________________________________________ J. PARKER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs