Citation Nr: 1808490 Decision Date: 02/09/18 Archive Date: 02/20/18 DOCKET NO. 11-11 734 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES 1. Entitlement to a rating in excess of 10 percent for Achilles tendon rupture of the left ankle (hereinafter "left ankle disability"). 2. Entitlement to service connection for prostatic hypertrophy (hereinafter "prostate disorder"), to include as secondary to service-connected pancytopenia with cyclic neutropenia or service-connected auto-immune/Behcet's syndrome. 3. Entitlement to an effective date earlier than July 1, 2009 for the assignment of a 30 percent rating for service-connected irritable bowel syndrome (IBS). 4. Entitlement to service connection for diabetes mellitus, type II, to include as secondary to service-connected pancytopenia with cyclic neutropenia, service-connected auto-immune/Behcet's syndrome, or treatment for service-connected chronic uveitis. REPRESENTATION Veteran represented by: The American Legion ATTORNEY FOR THE BOARD T. Carter, Counsel INTRODUCTION The Veteran served on active duty in the United States Army from June 1980 to April 1992. This case comes before the Board of Veterans' Appeals (Board) on appeal from February 2010 and June 2013 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee. In the April 2011 substantive appeal, VA Form 9, for the issue of a higher rating for service-connected left ankle disability, the Veteran did not indicate whether he wanted a Board or DRO hearing. In a May 2011 statement, he clarified that he does not request a hearing. Nevertheless, pursuant to the April 2014 Board remand, the Veteran was notified by a May 2014 letter that he was scheduled for a video conference hearing in July 2014. The Veteran's request to withdraw his hearing was received in May 2014. In April 2015 and March 2017, the Board, in part, remanded the issue of a higher rating for service-connected left ankle disability for additional evidentiary development, and it has been returned to the Board for further appellate review. In April 2015, the issues of entitlement to service connection for prostate disorder and diabetes mellitus, type II, were remanded for issuance of a Statement of the Case (SOC). In response to an April 2016 SOC, the Veteran perfected the appeal for these issues by submission of a VA Form 9 in May 2016 and they were certified to the Board in a June 2016 VA Form 8. In March 2017, these issues were remanded by the Board for additional evidentiary development, and they have been returned to the board for further appellate review. The Board has recharacterized the Veteran's claim for prostatic hypertrophy more broadly to a prostate disorder in order to clarify the nature of the benefit sought and ensure complete consideration of the claim. Clemons v. Shinseki, 23 Vet. App. 1, 5-6, 8 (2009). The issues of entitlement to an effective date earlier than July 1, 2009 for the assignment of a 30 percent rating for service-connected IBS and service connection for diabetes mellitus, type II, are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. Prior to June 14, 2012, the Veteran's service-connected left ankle disability has not been manifested by at least marked limited motion. 2. Since June 14, 2012, the Veteran's service-connected left ankle disability is more accurately described as marked limitation of motion without ankylosis. 3. A current prostate disorder, diagnosed as benign prostatic hyperplasia (BPH), was not demonstrated in or related to an occurrence during active service, and was not caused or aggravated by service-connected connected pancytopenia with cyclic neutropenia or service-connected auto-immune/Behcet's syndrome. CONCLUSIONS OF LAW 1. The criteria for entitlement to a rating in excess of 10 percent for left ankle disability have not been met prior to June 14, 2012. 38 U.S.C. §§ 1155, 5110(a) (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.21, 4.40, 4.45, 4.71a, Diagnostic Code 5271 (2017). 2. With resolution of reasonable doubt in the Veteran's favor, the criteria for entitlement to a rating of 20 percent, for left ankle disability have been met since June 14, 2012. 38 U.S.C. §§ 1155, 5110(a); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.21, 4.71a, Diagnostic Code 5271. 3. The criteria for entitlement to service connection for prostate disorder, to include as secondary to service-connected pancytopenia with cyclic neutropenia or service-connected auto-immune/Behcet's syndrome, have not been met. 38 U.S.C. §§ 1110, 1131, 1153, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Neither the Veteran nor his representative have raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Higher Rating for Service-Connected Left Ankle Disability Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When reasonable doubt arises as to the degree of disability, such doubt will be resolved in the veteran's favor. 38 C.F.R. § 4.3. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, such as for the service-connected left ankle disability in this case, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability to make a more accurate evaluation, the regulations do not give past medical reports precedence over current findings. 38 C.F.R. § 4.2; Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. Therefore, the Board has considered the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran's disabilities in reaching its decision. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). In a November 1998 VA rating decision, service connection for left ankle disability was granted because the disability was deemed to be directly related to treatment for repair of the left Achilles tendon in May 1990 during his military service. The Veteran was assigned a 10 percent disability rating effective for the entire rating period from October 22, 1996. See 38 C.F.R. § 4.71a, Diagnostic Code 5271. On July 10, 2009, the Veteran's request for a higher rating for the issue on appeal was obtained and associated with the record. The Board considers whether a rating in excess of 10 percent for left ankle disability is warranted at any time since or within one year prior to the date of claim on July 10, 2009. Diagnostic Code 5271 provides the following rating criteria for limitation of motion of the ankle: a 10 percent rating for moderate limited motion and 20 percent, the maximum available, for marked limited motion. 38 C.F.R. § 4.71a. For VA compensation purposes, 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. The rating schedule does not define the terms "moderate" or "marked," as used in Diagnostic Code 5271 to describe the degree of deformity of the ankle. Instead, adjudicators must evaluate all of the evidence and render a decision that is "equitable and just." 38 C.F.R. § 4.6. Review of the evidentiary record since July 10, 2009, to include within one year prior, documents the following musculoskeletal symptomatology of the left ankle disability. At the December 2009 VA examination for joints, the Veteran reported current left ankle symptoms of pain, being able to stand for more than one hour but less than three hours, and being able to walk one to three miles. Upon clinical evaluation, the Veteran demonstrated limited left dorsiflexion to 15 degrees and limited plantar flexion to 35 degrees, full right dorsiflexion and plantar flexion, and normal gait. There were no findings of abnormal weight bearing, instability, tendon abnormality, objective pain with active motion on either side, objective evidence of pain following repetitive motion, additional limitations after three repetitions of range of motion, arthritis, ankylosis, malunion of os calcis, astragalus, or astragalectomy. The examiner also noted the Veteran has moderate effects of the left ankle disability on the following usual daily activities: chores, shopping, exercise, sports, and recreation. At the June 14, 2012 VA Disability Benefits Questionnaire (DBQ) examination for ankle conditions, the Veteran reported that flare-ups impact the function of his left ankle by daily pain and stiffness, constant use of a brace on the left ankle, and being unable to stand or walk longer than 20 minutes. Upon clinical evaluation, the Veteran demonstrated full left dorsiflexion and limited left plantar flexion to 20 degrees with objective evidence of painful motion, and full right dorsiflexion and plantar flexion with no objective evidence of painful motion. The examiner noted the Veteran could not complete repetitive-use testing because of pain and demonstrated functional loss of the left ankle by less movement than normal, weakened movement, excess fatigability, and pain on movement. He also demonstrated localized tenderness or pain on palpation. There were no findings of ankylosis, arthritis, malunion of os calcis, astragalus, or astragalectomy. At the March 2016 VA DBQ examination for ankle conditions, the Veteran reported that flare-ups impact the function of his left ankle by increased pain with standing and walking, being unable to walk or stand on left ankle for prolonged periods, and constant use of a brace. Upon clinical evaluation, the Veteran demonstrated limited left dorsiflexion to 5 degrees, limited left plantar flexion to 15 degrees, painful motion, pain with weight bearing, generalized ankle tenderness, and instability or dislocation suspected. There were no findings of crepitus, additional loss of function or range of motion after three repetitions, or ankylosis. At the March 2017 VA DBQ examination for ankle conditions, the Veteran reported less flexibility, regular use of a brace, and denied flare-ups of the ankle. Upon clinical evaluation, the Veteran demonstrated full right dorsiflexion and plantar flexion without painful motion, pain with weight bearing, or tenderness. With regard to the left ankle, he demonstrated full dorsiflexion to 20 degrees and limited plantar flexion to 40 degrees with painful motion but no pain with weight bearing or tenderness. There were no findings of additional loss of function or range of motion after three repetitions of either ankle, ankylosis, or instability or dislocation suspected. The VA examiner also concluded the examination is neither medically consistent or inconsistent with the Veteran's statements describing functional loss with repetitive use over time. In a March 2017 VA DBQ medical opinion report, the VA examiner noted that the range of motion testing results, noted above, are the same for active/passive and nonweight-bearing and weight bearing. The examiner further concluded the following: Pain with active and passive range of motion with weight bearing and nonweight-bearing of left ankle with plantar flexion [is] between 20 and 40 degrees. Ankle movement as noted in exam is 3/5 in weight bearing and non-weight bearing, thus [V]eteran does have weakened movement of left ankle. Concerning incoordination, excess fatigability of left ankle, and additional functional impairment in terms of degrees of additional range of motion, I would have to resort to mere speculation to answer this. Opinions regarding functional limitations during flare-ups or repeated use over a period of time are not feasible as this relies on subjective data. Therefore, the examiner would be resorting to mere speculation in rendering such opinions. Review of records from the Social Security Administration (SSA), pursuant to the Veteran's claim for benefits, evaluation of the left ankle in October 2010 revealed edema. In a statement, the Veteran reported wearing a brace and limited walking and standing over 10 to 15 minutes due to pain. Review of VA treatment records document the Veteran's report of limited walking due to left ankle pain in September 2009, creation and use of custom orthotics in October 2009 and November 2009, and use of walking boot to limit ankle range of motion in November 2010 and March 2011. Treatment records also document his use of brace and cane for the left ankle in May 2014 and July 2014. The Veteran reported pain in left ankle in April 2010, October 2010, July 2015, and October 2015. An October 2010 treating physician noted physical findings revealed "almost a full range of motion of [left] ankle." Prior to June 14, 2012 After a review of the evidence discussed above, the Board finds that the Veteran's service-connected left ankle disability was not manifested by at least marked limited motion. The symptomatology included pain, edema, standing limitations, walking limitations, limited left dorsiflexion to, at worst, 15 degrees without painful motion, limited left plantar flexion to, at worst, 35 degrees without painful motion, and moderate effects of the left ankle disability on some usual daily activities; nevertheless, such symptomatology was contemplated in the assigned 10 percent rating. As a result, a rating in excess of 10 percent is denied for service-connected left ankle disability prior to June 14, 2012. See 38 C.F.R. § 4.71a, Diagnostic Code 5271. While the schedule of ratings does not provide any information as to what manifestations constitute "moderate" or "marked" limitation of ankle motion, guidance can be found in VBA's M21-1 Adjudication Procedures Manual. Specifically, the M21-1 states that moderate limitation of ankle motion is present when there is less than 15 degrees dorsiflexion or less than 30 degrees plantar flexion, while marked limitation of motion is demonstrated when there is less than 5 degrees dorsiflexion or less than 10 degrees plantar flexion. See VBA Manual M21-1, III.iv.4.A.3.k. As noted above, the Veteran's ranges of motion fell outside this range and did not cause pain on clinical examination. The Board considers whether a higher rating is warranted in this case prior to June 14, 2012 under additional rating criteria for the ankle: Diagnostic Code 5270 (ankylosis), Diagnostic Code 5272 (ankylosis of subastrangalar or tarsal joint), Diagnostic Code 5273 (malunion of os calcis or astragalus), and Diagnostic Code 5274 (astragalectomy). 38 C.F.R. § 4.71a. After a review of the evidence discussed above, to include the Veteran's lay statements, these conditions are not shown on examination and application of these Diagnostic Codes is not warranted. Moreover, arthritis has not been clinically established, so the provisions of Diagnostic Code 5003 are not for application. Next, the Veteran's disability picture is not more closely approximated by an increased rating prior to June 14, 2012 based on the presence of additional functional loss based on the criteria set forth in 38 C.F.R. §§ 4.40 4.45, and the holdings in DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). After a review of the evidence discussed above, the Board finds that the functional equivalent of marked limited motion was not shown at any time during the appeal period prior to June 14, 2012. Such findings were not shown, even when considering the Veteran's credibly reported symptomatology for the left ankle disability. The Veteran's reported symptomatology did not, when viewed in conjunction with the medical evidence, tend to establish additional limitations of motion to the degree that would warrant a rating in excess of 10 percent for the service-connected left ankle disability at any time during the appeal period prior to June 14, 2012 under 38 C.F.R. §§ 4.40, 4.45, and the holdings in DeLuca. Since June 14, 2012 After a review of the evidence discussed above, the Board finds that the Veteran's service-connected left ankle disability has been manifested by at least marked limited motion since June 14, 2012. The symptomatology includes pain, stiffness, use of a brace, standing limitations, walking limitations, limited left dorsiflexion to, at worst, 5 degrees, limited left plantar flexion to, at worst, 15 degrees, painful motion, less movement than normal, weakened movement, excess fatigability, localized tenderness or pain on palpation, pain with weight bearing, instability or dislocation suspected, and less flexibility. The Board considers whether a higher rating is warranted in this case under Diagnostic Code 5270 (ankylosis). 38 C.F.R. § 4.71a. After a review of the evidence discussed above, to include the Veteran's lay statements, ankylosis of the left ankle is not shown on examination and application of this Diagnostic Code is not warranted. He retains mobility in his ankle and therefore does not manifest ankylosis. See Dinsay v. Brown, 9 Vet. App. 79, 81 (1996); Lewis v. Derwinski, 3 Vet. App. 259 (1992). As a result, a rating of 20 percent, and no higher, is warranted for service-connected left ankle disability since June 14, 2012. See 38 C.F.R. § 4.71a, Diagnostic Code 5271. Given that the Veteran is already in receipt of the schedular maximum for limitation of motion of the left ankle, inquiry into the DeLuca factors is moot for the appeal period since June 14, 2012. DeLuca, 8 Vet. App. at 206; Johnston v. Brown, 10 Vet. App. 80, 87 (1997). Additional Considerations for Both Appeal Periods The Board has considered whether a separate rating is warranted under the diagnostic codes for a scar. See 38 C.F.R. § 4.118, Diagnostic Codes 7801-7805 (2017). As reflected in the June 2012 and March 2016 VA examination reports and September 2009 VA treatment record, the Veteran has a scar related to the service-connected disability on appeal. The March 2016 VA examiner noted the scar is located on the left posterior foot/ankle, 11 centimeters long and 0.3 centimeters wide. The June 2012 and March 2016 VA examiners marked "no" for the scar being painful and/or unstable, the total area of the scar as greater than 39 square centimeters (6 square inches), or located on the head, face, or neck. Thus, the evidence of record shows the Veteran's scar is not 144 square inches or greater to warrant application of Diagnostic Code 7802, scars, other than head, face, or neck that are superficial and do not cause limitation of motion. The evidence does not show the scar is unstable or painful to warrant application of Diagnostic Code 7803, superficial, unstable scars or Diagnostic Code 7804, superficial, painful on examination scars. Additionally, the evidence of record does not indicate the Veteran's scar limits his motion to warrant application of Diagnostic Code 7801, scars, other than head, face, or neck, that are deep or that cause limited motion; or Diagnostic Code 7805, scars, other, which are rated on limitation of function of the affected part. Therefore, 38 C.F.R. § 4.118, Diagnostic Codes 7801-7805 does not assist the Veteran in obtaining higher ratings for his service-connected disability on appeal. The Board has considered the Veteran's reported history of symptomatology related to the service-connected left ankle disability. He is competent to report such symptoms and observations because this requires only personal knowledge as it comes through ones senses. Layno v. Brown, 6 Vet. App. 465, 470 (1994). In this case, the Veteran is not competent to identify specific levels of his service-connected musculoskeletal disability according to the appropriate Diagnostic Code and relevant rating criteria. Kahana v. Shinseki, 24 Vet. App. 428 (2011). In this case, such competent evidence concerning the nature and extent of the Veteran's disability has been provided in the medical evidence of record. As such, the Board finds these records to be more probative than the Veteran's subjective reported worsened symptomatology. See Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991). The Board has also considered the possibility of staged ratings and finds that the schedular ratings for the service-connected disability on appeal have been in effect for appropriate periods on appeal. Accordingly, additional staged ratings are inapplicable. See Hart, 21 Vet. App. at 505. During the course of the appeal, the issue of entitlement to a total disability rating based on individual unemployability (TDIU) was granted in an April 2013 VA rating decision, effective from August 30, 2010 to June 14, 2012. In the April 2013 VA rating decision, the issue of entitlement to Special Monthly Compensation (SMC) based on housebound criteria was also granted, effective from June 14, 2012. In an April 2015 VA rating decision, TDIU was granted, effective from July 1, 2015, and SMC based on housebound criteria was discontinued, effective from July 1, 2015. The Board further notes that the combined schedular rating is 100 percent effective from May 1, 2012 to June 30, 2015 and since March 5, 2016. As a result, the Board considers whether TDIU has been raised in connection with the claim on appeal during the appeal period prior to August 30, 2010. After a review of the claims file, the Board finds the evidence does not show that the service-connected left ankle disability rendered him unemployable during the appeal period prior to August 30, 2010. Rice v. Shinseki, 22 Vet. App. 447 (2009); see also Jackson v. Shinseki, 587 F.3d 1106 (Fed. Cir. 2009). While the Veteran reported in the October 2010 VA Form 21-8940 (Application for Increased Compensation based on Unemployability) that he last worked in July 2010, there was no indication that this period of unemployment was due to the service-connected left ankle disability. Moreover, the December 2009 VA examiner noted the Veteran was currently unemployed for 1 to 2 years due to being laid off. Therefore a TDIU is not for consideration in this case. Service Connection for a Prostate Disorder In June 2013, the Veteran requested service connection for prostatic hypertrophy as secondary to service-connected pancytopenia with cyclic neutropenia. In a statement attached to the May 2016 substantive appeal, VA Form 9, the Veteran reported experiencing deep pelvic pain and testicular pain and swelling while on active duty and asserted service connection is secondary to service-connected auto-immune/Behcet's syndrome. Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty in the active military, naval, or air service. 38 U.S.C. §§ 1110, 1131. Service connection may be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). Service connection may also be granted on a secondary basis when there is sufficient evidence to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. See 38 C.F.R. § 3.310. In order to establish entitlement to service connection on a secondary basis, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical evidence establishing a nexus between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). At the outset, review of the evidentiary record shows the Veteran has a current diagnosis of a prostate condition, diagnosed as BPH noted during the appeal period in VA treatment records and the March 2017 VA DBQ examination report for male reproductive system conditions. As a result, the Board finds the element of a current disability has been met in this case. Review of service treatment records document the Veteran's report of pain in the groin area, with no enlargement or tenderness of prostate, in January 1981. The Veteran also reported left testicular pain radiating to deep pelvic area aggravated by activity, with no enlargement of either testicle, in May 1981. As a result, the Board finds the element of an in-service occurrence has been met and the claim on appeal will be discussed on a direct basis below. Nevertheless, the Board finds that the element of a nexus between the current prostate disability and in-service occurrence has not been met in this case. In a March 2017 VA DBQ medical opinion report, the examiner opined the following: Veteran's BPH is less likely than not proximately due to, incurred in, or aggravated by military service . . . [to include] in-service groin, or flank pain. Concerning the groin area pain documented in service, I am not aware of a mechanism for which this would be responsible for BPH. . . . BPH is more likely than not due to independent factors. Based on the evidence of record, there is no probative and competent evidence that demonstrates this current disorder was demonstrated in or related to an occurrence of the genitourinary system during active service, to include the Veteran's documented complaints and treatment for the groin and left testicular area during active service. See 38 C.F.R. § 3.303. In sum, the Board finds that the evidentiary record does not contain positive probative evidence to establish that the third criterion to establish service connection on a direct basis has been met. Next, the Board considers whether service connection is warranted for a prostate disorder on a secondary basis. In a June 2016 VA DBQ medical opinion report, the examiner opined the following: The condition claimed is less likely than not proximately due to or the result of the Veteran's service connected condition. There is no medical evidence that the [V]eteran's prostatic hypertrophy is due to his [service-connected] Behcet's/autoimmune disorder. BPH is not an inflammatory condition and it is very common in the general population of males as they age. Pursuant to the March 2017 Board remand directives, the Veteran underwent a VA DBQ examination for male reproductive system conditions, in March 2017. Following the clinical evaluation, the VA examiner opined that "BPH is a separate diagnosis not secondary to any service connected conditions." In a March 2017 VA DBQ medical opinion report, the examiner further opined that, "Veteran's BPH is less likely than not proximately due to, incurred in, or aggravated by . . . any service connected conditions (including [B]ehcet's syndrome and pancytopenia, or respective medications) . . . BPH is more likely than not due to independent factors." The examiner explained that 50 percent of men ages 51-60 have BPH and increased to 90 percent for men age 80 years or older. Based on the evidence of record, there is no probative and competent evidence that demonstrates the Veteran's prostate disorder is caused by or aggravated by his service-connected pancytopenia with cyclic neutropenia or auto-immune/Behcet's syndrome. See 38 C.F.R. § 3.310. In sum, the Board finds that the evidentiary record does not contain positive probative evidence to establish that the criteria to establish service connection on a secondary basis has been met. The Board has considered the Veteran's reported history of symptomatology related to his prostate disorder throughout the appeal period. He is competent to report such symptoms and observations because this requires only personal knowledge as it comes through ones senses. Layno, 6 Vet. App. at 470. Because there is no universal rule as to competence on this issue, the Board must determine on a case-by-case basis whether a particular condition is the type of condition that is within the competence of a lay person to provide an opinion as to etiology. See Jandreau v. Nicholson, 492 F.3d 1372, 1376 -77 (Fed. Cir. 2007); see also Kahana, 24 Vet. App. at 428. In this case, the Veteran's statements do not rise to a level of competency to offer a probative opinion as to the etiology of this diagnosed disability on appeal. Determining the etiology of the Veteran's current disorder on appeal requires inquiry into internal physical processes are not readily observable and are not within the competence of the Veteran in this case, who has not been shown by the evidence of record to have medical training or skills. As a result, the probative value of his lay assertions is low. Additionally, his assertions have been investigated by a competent medical professional and found to be not supportable. The Board further acknowledges the Veteran's submission of internet articles regarding prostatitis in May 2016 and BPH in June 2016. While a medical article or treatise "can provide important support when combined with an opinion of a medical professional," if the medical article or treatise evidence discusses generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least "plausible causality" based upon objective facts rather than on an unsubstantiated lay medical opinion. Mattern v. West, 12 Vet. App. 222, 228 (1999). In this case, these articles submitted by the Veteran do not show a nexus in this case between the Veteran's prostate disorder and service and/or service-connected disability; therefore, they are not probative evidence. The March 2017 VA examiner acknowledged the articles and stated that they were "... not related to this discussion and show[] no evidence concerning BPH's etiology in himself." In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against this claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER A rating in excess of 10 percent for left ankle disability prior to June 14, 2012 is denied. A rating of 20 percent for a left disability beginning June 14, 2012 is granted, subject to the regulations governing the award of monetary benefits. Service connection for prostate disorder, to include as secondary to service-connected pancytopenia with cyclic neutropenia or service-connected auto-immune/Behcet's syndrome, is denied. REMAND In the March 2017 decision, the Board assigned a 30 percent disability rating for the service-connected IBS prior to June 14, 2012. In a March 2017 VA rating decision, the AOJ assigned the 30 percent disability rating, effective from July 1, 2009. In April 2017, the Veteran was notified, and within one year of such notice, he submitted a timely notice of disagreement (VA Form 21-0958) with this issue in the March 2017 VA rating decision, particularly with the assignment of the 30 percent disability rating. Review of the record does not show the AOJ has issued a SOC for this particular issue. As such, this issue is remanded for issuance of a SOC as of this date. Manlincon v. West, 12 Vet. App. 238, 240-241 (1999). Next, pursuant to the March 2017 remand, the Veteran was afforded a VA DBQ examination for diabetes mellitus in March 2017. Following the examination and review of the claims file, the VA examiner rendered a diagnosis of diabetes mellitus, type II, and provided medical opinions on secondary bases for causation and aggravation. Nevertheless, the opinion did not reflect consideration of the Veteran's VA treatment records including diagnoses of "new onset diabetes" and "steroid response diabetes," as specifically noted in the remand directives. In light of such findings, unfortunately, an additional remand is needed to obtain an addendum to this VA medical opinion for the issue of entitlement to service connection for diabetes mellitus, type II, to include as secondary to service-connected pancytopenia with cyclic neutropenia, service-connected auto-immune/Behcet's syndrome, or treatment for service-connected chronic uveitis. When VA undertakes to provide a VA medical opinion, it must ensure that the examination and/or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Accordingly, the case is REMANDED for the following actions: 1. Issue a Statement of the Case addressing the issue of entitlement to an effective date earlier than July 1, 2009 for the assignment of a 30 percent rating for service-connected IBS. A timely perfected appeal must be filed to vest the Board with appellate jurisdiction over the claim. Otherwise the appeal may be closed by the AOJ. 2. Return the Veteran's claims file to the examiner who conducted the March 2017 VA DBQ examination for diabetes mellitus so a supplemental opinion may be provided. If that examiner is no longer available, provide the Veteran's claims file to a similarly qualified clinician. The entire claims file and a copy of this remand must be made available to the examiner for review, and the examiner must specifically acknowledge receipt and review of these materials in any reports generated. A new examination is only required if deemed necessary by the examiner. Although an independent review of the claims file is required, the Board calls the examiner's attention to the following: VA treatment records include diagnoses of "new onset diabetes" dated in March 2013 and "steroid response diabetes" dated in September 2013. The examiner must provide an opinion as to whether any of the previously rendered medical opinions are changed in light of such highlighted diagnoses for diabetes in the VA treatment records. The examiner must provide all findings, along with a complete rationale for his or her opinion in the examination report. If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such conclusion. 3. Then, the AOJ should review the medical opinion to ensure that the requested information was provided. If the opinion is deficient in any manner, the AOJ must implement corrective procedures. 4. Then, readjudicate the issue of entitlement to service connection for diabetes mellitus, type II, to include as secondary to service-connected pancytopenia with cyclic neutropenia, service-connected auto-immune/Behcet's syndrome, or treatment for service-connected chronic uveitis. If the decision is adverse to the Veteran, issue a Supplemental Statement of the Case and allow the applicable time for response. Then, return the case to the Board. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). ______________________________________________ D. Martz Ames Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs