RECORD OF PROCEEDINGS
AIR FORCE BOARD FOR CORRECTION OF MILITARY RECORDS

IN THE MATTER OF:	DOCKET NUMBER:  02-01063
		INDEX CODE:  100.03
		COUNSEL:  NONE
		HEARING DESIRED:  NO

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APPLICANT REQUESTS THAT:

The assignment limitation code “C” restricting her from worldwide duty or mobility be removed.

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APPLICANT CONTENDS THAT:

The Medical Evaluation Board (MEB) treated her unfairly.  Before arriving at Incirlik AB, Turkey, she was selected for follow-on assignment to Aviano AB, Italy.  She had been previously cleared for her assignment to Turkey as well as being declared worldwide qualified 4 months prior during her annual Physical Health Assessment (PHA) performed by the Incirlik clinic.  The physical exam section refused to sign off on her letter due to a pre-existing condition of Ocular Myasthenia Gravis.  She was originally diagnosed with this condition in the fall of 1997 at Landstuhl Army Hospital, while stationed at Ramstein AB, Germany.  She has seen several neurologists over the years and all agree that her condition does not restrict her from performing her duties as a personnel technician or from being worldwide qualified.  A Medical Evaluation Board (MEB) was initiated in October 2000 which would determine her worldwide eligibility and if she was qualified to remain overseas and retain her assignment to Aviano AB.  Because the process was taking long, she contacted the base IG at Incirlik.  The Inspector General (IG) felt she had a justifiable complaint, not only on the length of time that the MEB was taking, but also because the MEB should not have been initiated since the Air Force had already set a precedent by authorizing her worldwide qualification to complete two previous tours in overseas areas since her diagnosis in 1997.  The MEB returned a decision that she was to be returned to duty, but she was not worldwide qualified.  She was devastated with the decision.  The decision was based on the fact that she needed to be in an area to receive necessary medical treatment.  She currently does not receive any medical treatment for ocular myasthenia gravis.  She was issued a prescription called Mestinon, which is taken as needed and is available at all the base pharmacies and at her previous overseas bases.  Her only other requirement in the form of care is an annual visit to a neurologist, which she would have been able to complete more accessibly from her follow-on assignment in Italy.  

Upon her arrival at Peterson AFB, CO she was encouraged by her chain of command to try for a new MEB.  The neurologist at the Air Force Academy hospital proposed submitting a narrative summary in lieu of initiating a new MEB and supported her request to have the restriction code for worldwide duty revoked.  On November 14, 2001, she was notified that despite another specialist recommending that she is fit for worldwide duty, the decision to restrict her from worldwide duty stood.  She was told by Headquarters Air Force Personnel Center that the reason for her restriction was based on the guidance in Air Force Instructions and not what the neurologists recommended.  

She is qualified on the M-16, has participated in mobility exercises (to include the wear of chemical warfare gear) and received firewall 5 ratings on all of the Enlisted Performance Reports written on her during her overseas tours after her medical diagnosis.  She has received no exclusions from completing the annual fitness test as a result of her condition.  She is very active in base sports, successfully completed her last annual fitness test and works out on a regular basis.  She feels there is nothing about her physical health that should preclude her qualification for worldwide duty.  

Despite the AFI stating that cases are evaluated on a case-by-case basis, it seems to be generalized.  Ocular Myasthenia Gravis is not life threatening nor does it prevent her from performing her duties.  She feels that the recommendation of Neurologists with first-hand knowledge of her condition, were ignored and the case-by-case consideration was not taken into account.  This decision seemed to be based on the AFI that was not specific for a case-by-case basis or less serious types of this disorder.  The logic that she is restricted to a CONUS assignment, or to an overseas assignment listed in the AFI, to receive proper medical care, is not justified.  

She has devoted over 14 years of her life to the Air Force and feels that her ability to serve in the military is being limited with the removal of her worldwide qualification.  She feels that she is medically qualified for overseas deployments and tours and is willing to volunteer for both.  The Air Force MEB refused to take her specific case into consideration.  She believes the MEB threw her into a general category and didn’t really consider the inputs and recommendations of her doctors as well as her supervisors and commanders.  She would like the opportunity to finish her Air Force career without restriction or limitation of service.  

In support of her request, applicant provides a personal statement, associated medical documents tabbed from letters A-K, and copies of EPRs for the periods ending 30 November 1997, 8 July 1998 and 2 January 2001.  The applicant’s complete submission, with attachments, is at Exhibit A. 

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STATEMENT OF FACTS:

Applicant contracted her initial enlistment in the Regular Air Force on 7 December 1987.  She is currently serving on a 26-month extension of her enlistment she entered on 2 April 1996 giving her a new ETS date of 1 July 2004.  She has been progressively promoted to the grade of technical sergeant, having assumed that grade effective and with a date of rank of 1 February 2002.  Applicant is currently assigned as an NCOIC, Class and Retraining at Peterson AFB, CO. 

The remaining relevant facts pertaining to this application extracted from the applicant’s military medical records, are contained in the letters prepared by the appropriate offices of the Air Force at Exhibits C-F.

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AIR FORCE EVALUATION:

The BCMR Medical Consultant recommends the application be denied.  The BCMR Medical Consultant states that the applicant has ocular myasthenia gravis which was diagnosed in 1997, that has been mild and has remained stable without any evidence of progression in the nearly 5 years since diagnosis.  Myasthenia Gravis is an autoimmune disease in which antibodies against neurotransmitter receptors interferes with normal neuromuscular function typically manifesting as muscle weakness that becomes progressively worse with effort and improves somewhat with rest.  It often starts with eye involvement causing blurring and double vision.  Many patients experience progression to generalized weakness that can be fatal over the subsequent 1 to 5 years.  Approximately 10 to 15 percent of myasthenia gravis patients will not progress to have generalized weakness.  These patients are considered to have “ocular myasthenia.”  Ocular Myasthenia Gravis is a subtype of myasthenia gravis that causes relatively mild disability, but may progress to severe generalized muscle weakness.  

The BCMR Medical Consultant states that myasthenia gravis is an unusual condition and most primary care physicians are not familiar with the diagnosis and management of this disease.  Referral to neurology for ongoing management is the usual practice.  In overseas settings, medical resources are limited and resourced to care for a healthy active duty population.  Military Treatment Facility commanders are reluctant to accept active duty members with chronic medical illnesses however stable they appear to be, as their experience has been too often to the contrary, and their limited resources become quickly strained by patients with unusual diseases or requirements.  The applicant’s mild and stable course over 5 years seems to predict an excellent prognosis, and would suggest that she is unlikely to develop problems inappropriate to an overseas assignment.  This, however, is not an absolute guarantee, and there is no clear data to give a more specific quantification of risk.  Medically clearing the applicant for overseas assignments is a calculated risk.  Taking this risk, however small, is unnecessary to meet the needs of the Air Force.  The assignment of a Code C limitation in this case is conservative and prudent and retains the applicant on active duty without exposing her to any additional risk related to her condition.  The BCMR Medical Consultant states that the action and disposition of this case is proper and equitable reflecting compliance with Air Force directives that implement the law.  

The BCMR Medical Consultant evaluation is at Exhibit C.

The Chief Medical Standards Branch reviewed the application and concurs with the conclusions and the recommendation of the BCMR Medical Consultant.  A consultation between the Chief Medical Standards Branch and the Air Force consultant in Neurology determined that patients with Ocular Myasthenia Gravis should not be assigned overseas.  The Chief Medical Standards Branch evaluation is at Exhibit D.

AFPC/DPPD reviewed the application and concurs with the BCMR Medical Consultant’s recommendation.  DPPD states that the applicant underwent processing through the Air Force Disability Evaluation System (DES) and the results were forwarded to the Informal Physical Evaluation Board (IPEB) for adjudication of her case.  The IPEB determined her medical condition for Ocular Myasthenia Gravis did not prevent her from reasonably performing her duties and found her physically fit.  Subsequently, the IPEB recommended that she be returned to duty for further care and treatment.  The DPPD evaluation is at Exhibit E.

AFPC/DPMAF2 reviewed the application and concurs with the conclusions and recommendation of the BCMR Medical Consultant.  The DPMAF2 evaluation is at Exhibit F.  

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APPLICANT'S REVIEW OF AIR FORCE EVALUATION:

Applicant advises that there is nothing specific listed for her condition of ocular myasthenia gravis.  She hopes that her condition, despite being categorized as myasthenia, would be considered for its less severe symptoms.  Applicant refutes the BCMR Medical Consultant’s reference to her having Myasthenia Gravis.  She states she has Ocular Myasthenia Gravis, which is a less severe, milder condition and does not affect her ocular muscles and does not have an effect on her respiratory system.  She has taken into consideration that there is the possibility that her condition could deteriorate, but all the neurologists she has spoken to have told her that deterioration would likely occur within 3-5 years of diagnosis.  She is on her 5th year.  Applicant states that the precedent of her previous tours after being diagnosed should show that she is capable of serving the Air Force anywhere.  Applicant states that with the exception of her prescription for Mestonin, and annual visits to the neurologist, no medical facility is required for her condition.  

Applicant states that removing her “C” code may be unnecessary to meet the needs of the Air Force; however, no consideration is being given to the emotional and mental needs of the active duty member in a situation where physical evidence cannot be provided to warrant such a restriction.  She understands the Air Force reluctance to remove the code based on the fear that something may happen in the future; however, she is confident that her health meets worldwide qualifications.  

Applicant attaches a current examination and narrative opinions from Optometry, Opthamology and Neurology.  The applicant’s complete rebuttal with Tabs 1-8 are at Exhibit H. 

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ADDITIONAL AIR FORCE ADVISORY:

The BCMR Medical Consultant reviewed the current examination and narrative opinions the applicant provided in her rebuttal.  The BCMR Medical Consultant states the recent neurology consultation dated September 7, 2001, reports that she has continued to do very well only taking her medication (pyridostigmine also called Mestinon) as needed once or twice per month.  The BCMR Medical Consultant also noted the neurologist and the neuro-ophthalmologist recommendation that she is worldwide qualified for duty.  The BCMR Consultant states that the risk of progression to the generalized form is lower in patients such as the applicant, however the actual risk in an individual cannot be specifically quantified.  The applicant states that the medical standards for the generalized form of myasthenia gravis were unfairly applied to her.  They were not.  The applicant’s condition is unusual, and she has been retained on active duty with the conservative placement of a Code “C” restriction.  The BCMR Medical Consultant’s discussion with the Neurology consultant to the Air Force Surgeon General confirms the opinion that the risk for progression in this case is present, but unknown.  However, reconsideration of her request can be done based on a re-evaluation by the Neuromuscular and Neuro-ophthalmology department at Wilford Hall Medical Center, and the recommendation of the Neurology Consultant to the Air Force Surgeon General to the Air Force Medical Standards Branch.  

The BCMR Medical Consultant evaluation is at Exhibit I.

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APPLICANT'S REVIEW OF ADDITIONAL AIR FORCE EVALUATION:

Applicant states she fails to see how consulting with more specialists in the Neurological field will benefit her case when all the specialists have had the same conclusion.  Since she has previously accomplished all the recommendations the BCMR Medical Consultant stated in his additional advisory, she does not see any reason to spend government funds to go to Wilford Hall to again obtain documentation that is already in her records.  Applicant states she fails to see what the difference would be whether she was stationed overseas or CONUS if her condition worsened, which she doesn’t believe it will after five years and a great period of remission.  

The applicant is in the process of applying for retraining and would like to go into the Contracting career field.  However, the contracting field has numerous deployments to overseas locations.  Because of her limitation code, this may come into play during the review of her package and her retraining may be denied.  She asks that her individual case be based on the results of examinations of her current condition, and past history of her disorder, not on what might be or what is considered a more severe condition of general Myasthenia Gravis.  

The applicant’s rebuttal Tabbed 1-3 is at Exhibit K.

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THE BOARD CONCLUDES THAT:

1.  The applicant has exhausted all remedies provided by existing law or regulations.

2.  The application was timely filed.

3.  Sufficient relevant evidence has been provided to demonstrate the existence of injustice that warrants the removal of the Assignment Limitation Code (ALC) “C.”  After a review of the facts and circumstances of this case, we have reached a conclusion different from the Air Force offices of primary responsibility in this matter.  We are sufficiently persuaded that the applicant has provided the necessary and appropriate documentation to sustain her burden that she has been the victim of an injustice and that she should be found qualified for “world-wide” duty.  It appears to us that the physicians who actually evaluated and treated the applicant’s condition are in unanimous agreement that she has a very mild symptom of ocular myasthenia gravis, which does not impair her ability to perform her tasks, is readily treatable and she is world-wide qualified despite her diagnosis.  We note that at the time of her initial diagnosis, she was stationed overseas, a tour she completed with no significant problems, returned to CONUS and served on another overseas assignment, all for which she was cleared for world-wide duty.   In a recent neurology consultation dated 26 June 2002, the Chief, Neurology Service, reports that her ocular myasthenia gravis, is distinct from generalized MG and the two conditions should not be grouped together.  This physician further stated that since it has been over 5 years since her diagnosis of ocular myasthenia gravis, the risk of progression is extremely low, that the applicant appears to be world-wide qualified and her request for the removal of the ALC “C” should be reviewed.  In view of the strong opinions of the physicians who actually treated the applicant and the fact that she was able to successfully function in an overseas assignment after the diagnosis was made, we do not believe the applicant should be barred from securing career opportunities that would be beneficial to the Air Force and the individual.  Therefore, as an exception to policy, we recommend that her records be corrected to the extent indicated below.   

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THE BOARD RECOMMENDS THAT:

The pertinent military records of the Department of the Air Force relating to APPLICANT be corrected to show that on 26 June 2002, competent authority determined that the Assignment Limitation Code “C” should be removed and that she is medically qualified for world-wide duty.  

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The following members of the Board considered this application AFBCMR Docket Number 02-01063 in Executive Session on 5 February 2003, under the provisions of AFI 36-2603:

All members voted to correct the records as recommended.  The following documentary evidence was considered:

    Exhibit A.  DD Form 149, dated 19 March 2003, w/atchs.
    Exhibit B.  Applicant's Master Personnel Records.
    Exhibit C.  Letter, BCMR Medical Consultant, dated 8 May 02.
    Exhibit D.  Letter, Chief Medical Standards Branch, 
                dated 6 Jun 02.
    Exhibit E.  Letter, AFPC/DPPD, dated 29 May 02.
    Exhibit F.  Letter, AFPC/DPMAF2, dated 7 Jun 02.
    Exhibit G.  Letter, SAF/MRBR, dated 14 Jun 02.
    Exhibit H.  Letter, Applicant, undated w/atchs.
    Exhibit I.  Letter, BCMR Medical Consultant, dated 9 Aug 02.
    Exhibit J.  Letter, AFBCMR, dated 12 Aug 02.
    Exhibit K.  Letter, Applicant, undated, w/atchs.

AFBCMR 02-01063

MEMORANDUM FOR THE CHIEF OF STAFF

	Having received and considered the recommendation of the Air Force Board for Correction of Military Records and under the authority of Section 1552, Title 10, United States Code (70A Stat 116), it is directed that:

	The pertinent military records of the Department of the Air Force relating to xxxxxxxxx, be corrected to show that on 26 June 2002, competent authority determined the Assignment Limitation Code “C” should be removed and that she is medically qualified for world-wide duty.