RECORD OF PROCEEDINGS AIR FORCE BOARD FOR CORRECTION OF MILITARY RECORDS IN THE MATTER OF: DOCKET NUMBER: BC-2014-01900 COUNSEL: NONE HEARING DESIRED: NO APPLICANT REQUESTS THAT: His voluntary retirement be changed to a medical retirement due medical illnesses and injuries that occurred while on active duty. A medical board was not conducted prior to his voluntary retirement. APPLICANT CONTENDS THAT: Prior to his retirement he was diagnosed and treated for “Chronic Post Traumatic Stress Disorder” after returning from a deployment to Iraq. In addition, he has other illnesses and injuries to include; depression, insomnia, dislocation of left knee, lumbago and degenerative and bulging disks in his lower back, and arthritis in both ankles. The applicant’s complete submission, with attachments, is at Exhibit A. STATEMENT OF FACTS: The applicant initially entered the Regular Air Force on 22 Aug 89. On 31 Oct 11, the applicant was retired from the Air Force, and was credited with 22 years, 2 months, and 9 days of active service. The remaining relevant facts pertaining to this application are contained in the memoranda prepared by the Air Force offices of primary responsibility (OPR), which are attached at Exhibits C and E. AIR FORCE EVALUATION: AFBMCR Medical Consultant recommends denial indicating there is no evidence of an error or an injustice. The applicant received evaluations and treatment for a number of acute injuries [some chronic] and illnesses during his military career. Noteworthy is the applicant’s history of left knee pain, dating to CY 91, which presented as periodic dislocation of the patella; particularly when performing squats. The applicant experienced acute exacerbations of knee pain in Mar 2003 and again in Jan, Feb, and Mar of 2011; the latter occurrence after performing a pivoting motion. An MRI scan conducted back in Feb 2011 demonstrated “minor degenerative changes in posterior horn of medial meniscus, without definite tear.” A small left knee joint effusion was also noted. The applicant also experienced recurrent ankle sprains [92, 95, and Jun 2007; the latter for a suspected ankle fracture]. In each case, the applicant was issued short-term duty restrictions and was treated conservatively with physical therapy, rest, ice, elevation, crutches, a non-steroidal anti-inflammatories, and in the latter instance, Percocet for pain. By 16 Aug 07, the applicants Jun 2007 ankle injury was better and he was fully functional. Additionally, the applicant received recurring treatment for chronic low back pain. A Sep 2008 episode of care indicates that the applicant had experienced pain for the previous one year; but that he had also experienced recurrent back pain for “around eighteen years.” An MRI scan was ordered in Oct 10, in preparation for an upcoming [“in two weeks”] PCS. The applicant reported onset of back pain Sep 10 after moving furniture around. The MRI demonstrated L4-L5 degenerative disc changes with bilateral moderate foraminal stenosis, more severe on the left, with mild L4-5 canal stenosis. There was also L5- S1 degenerative disc changes noted with moderate left foraminal stenosis. He was placed on work restrictions from 25 Oct 10 to 24 Nov 10. He was instructed to follow-up with Physical Therapy at his gaining facility at Seymour-Johnson AFB upon PCS. In regards to the applicant’s mental wellness, the record indicated he experienced an episode of Adjustment Disorder in Jan 2004. He was also deployed twice; the last one to Iraq. A Post-Deployment Questionnaire, dated 23 Dec 10, shows applicant characterized his overall health in the past month as “very good.” When asked to compare/rate his current health with that before his most recent deployment, the applicant checked the response, “About the same as before I deployed.” The applicant disclosed exposure to a blast or explosion and answered “yes” to the question asking if he was constantly on guard, watchful or easily startled. The applicant responded “no” to the question asking if he had an experience so frightening, horrible, or upsetting that, in the past month he experienced nightmares, avoidance of thinking about it or avoidances of situations that remind him of it. The provider assessment showed blackening of the circle indicating a “minor concern” regarding existence of PTSD symptoms. The provider blackened the recommendation for mental health specialty care within seven days. The applicant was seen in follow-up thereafter. On 26 Jan 11, the evaluating provider assigned a “working diagnosis PTSD,” referred the applicant to mental health, but released him without limitations. Among complaints, the applicant reported “sensitivity to loud noises since back from deployment in Iraq which was six months ago. A 24 Feb 11, episode of care shows the applicant reported “sleeping issues” for the past three months, difficulty concentrating the last month, and a recent gastrointestinal disturbance that had resolved. Among stressors, he disclosed that his wife had filed for divorce, that his nephew recently passed away, and the depression had “hit him in Jan after his kids left.” The provider acknowledged the applicant’s insomnia; joint pain localized to knee, and assigned a diagnosis of Adjustment Disorder. The entry shows that the applicant was “released without limitations. 6 Apr 11, the applicant restated his experiences to include a divorce from his second wife of thirteen years [finalized Jul 10], the sudden death of nephew in 2010, and his “PCS from Arkansas to North Carolina in Nov 2010.” The applicant denied experiencing any one traumatic event or combat, but “felt constant stress related to his job due to not being unable to trust the Iraqi nationalist that he had to work very closely. He was given a diagnosis of Major Depression, recurrent, moderate. In smaller print for the same episode of care appears the diagnosis “MDD, single episode, moderate; Anxiety Disorder, NOS [not otherwise specified]. The applicant was prescribed Zoloft 50 mg [starting at 25 mg], with titration of dosage to 100 mg daily. He was, again, released without limitations. At follow-up on 7 Sep 11, the applicant disclosed fearing for his life and feeling helpless after being shot at from the ground while in a military helicopter. The provider also noted the applicant’s report of “recurrent intrusive distressing recollections of the event with frequent thoughts and images as well as nightmares.” Other symptoms included difficulty concentrating, an exaggerated startle response, hypervigilance, and avoiding thoughts, feelings, and conversations about the event. The provider noted the applicant was “interested in PTSD treatment at this time.” He concluded: “Not WWQ [worldwide qualified] from a mental health perspective.” At the point the applicant was granted the approved retirement date, he would have been presumed fit even if a Medical Evaluation Board (MEB) narrative summary was completed within the 12-month window of the approved retirement date. Specifically, under DoDI 1332.38, Physical Disability Evaluation, Enclosure 3, Paragraph E3.P3.5 and subparagraph E3.P3.5.2, in effect at the time of the applicant’s service addresses the presumptive period as, "Service members shall be considered to be pending retirement when the dictation of the member's MEB occurs after any of the circumstances designated in paragraph E3.P3.5.2.1 through E3.P3.45.2.4, which respectively read: (1) "When a member's request for voluntary retirement has been approved, revocation of voluntary retirement orders for purposes of referral into the Disability Evaluation System (DES) does not negate application of the presumption. (2) An officer has been approved for Selective Early Retirement (3) An officer is within twelve months of mandatory retirement due to age or length of service, and (4) An enlisted member is within twelve months of his or her retention control point (RCP) or expiration of active obligated service (EAOS), but will be eligible for retirement at his or her RCPIEAOS. The presumption of fitness can be overcome, however, if one of the following applies: (1) Within the presumptive period an acute, grave illness or injury occurs that would prevent the member from performing further duty if he or she were not retiring, (2) Within the presumptive period a serious deterioration of a previously diagnosed condition, to include a chronic condition, occurs and the deterioration would preclude further duty if the member were not retiring, or (3) The condition for which the member is referred is a chronic condition and a preponderance of evidence establishes that the member was not performing duties befitting his or experience in the office, grade, rank, or rating before entering the presumptive period. When there has been no serious deterioration within the presumptive period, the ability to perform duty in the future shall not be a consideration." In regards to the applicant’s expressed desire for a medical retirement, the DES, established to maintain a fit and vital fighting force, can by law, under Title 10, United States Code (U.S.C.), only offers compensation for those service incurred diseases or injuries which specifically rendered a member unfit for continued active service and were the cause for career termination; and then only for the degree of impairment present at the time of separation and not based on post-service progression of illness or injury. Department of Defense Instruction 1332.32, Physical Disability Evaluation, Enclosure 3, Part 3, Standards For Determining Unfitness Due To Physical Disability Or Medical Disqualification, paragraph E3.P3.2.1, reads:” A Service member shall be considered unfit when the evidence establishes that the member, due to physical disability, is unable to reasonably perform the duties of his or her office, grade, rank, or rating (hereafter called duties) to include duties during a remaining period of Reserve obligation.” The applicant is likely to be eligible for disability compensation for several medical conditions found service- connected through the Department of Veterans Affairs (DVA). However, EXCEPT for the September 2011 entry, no service evidence is supplied that indicated that the applicant was restricted in performance of his duties of a sufficient level, e.g., “S4T” profile restrictions for a mental impairment or “L4T” for a lower extremity or spine ailment, and cumulative duration, e.g., 12 or more months [or sooner if not expected to return to normal functioning] that warranted MEB and Physical Evaluation Board processing. The Department of Defense (DoD) and the DVA operate under separate laws. The DVA is authorized to offer compensation for any medical condition determined service incurred, without regard to [and independent of] its demonstrated or proven impact upon a service member’s fitness for continued service or narrative reason for release from military service. With this in mind, Title 38, U.S.C., which governs the DVA compensation system, was written to allow awarding compensation ratings for all conditions with a nexus with military service; even those with no demonstrable functional impairment at the time of assessment. This is the reason why an individual can be released from active military service for one reason and yet sometime thereafter receive compensation ratings from the DVA for conditions found service-connected, but which was not proven militarily unfitting during the period of service or the cause for career termination. The DVA is also empowered to conduct periodic re-evaluations for the purpose of adjusting the disability rating awards (increase or decrease) as the level of impairment from a given service connected medical condition may vary (improve or worsen, affecting future employability) over the lifetime of the veteran. A complete copy of the AFBMCR Medical Consultant evaluation is at Exhibit C. AFBMCR Clinical Psychology Consultant recommends denial indicating there is no evidence of an error or an injustice. On 26 Jan 11, applicant was evaluated in primary care and completed a PTSD screening form. He was diagnosed with PTSD as a “working diagnosis only” and referred to mental health for further evaluation. On 14 Feb 11, the applicant completed intake with a mental health social worker. He was noted to be experiencing stress from returning from deployment in Jul 2010, a recent divorce, changes in leadership, mild financial issues, poor sleep, problems with children, and anxiety symptoms. His diagnosis was deferred. At follow up he was diagnosed with anxiety disorder not otherwise specified, insomnia, and adjustment disorder with depressed mood. On 2 Mar 11, the applicant’s diagnosis was changed to recurrent major depression and anxiety disorder not otherwise specified. He was listed as worldwide qualified (WWQ) and deployable. These diagnoses and WWQ status were maintained over the next two sessions. On 6 Apr 11, he was evaluated by a psychiatrist. His diagnosis was noted to be a single episode of moderate major depression with anxiety disorder not otherwise specified. He was listed as not WWQ or deployable. At follow up with the social worker 26 Apr 11, his recurrent major depression diagnosis was retained. On 29 Apr 11, telephone contact between the applicant and his social worker stated, “This provider spoke to patient and advised that this provider can write a letter with the facts and will be unable to make recommendation for medical justification for retirement. [Patient] verbalized understanding and agreed to this letter.” He did not show for his next scheduled appointment because he was “stuck in a meeting.” He was noted to be on leave and attending the Transition Assistance Program over the next few weeks. At follow up with his psychiatrist on 23 May 11, he reported he was pursuing permission to retire a year before completing the commitment he had incurred as the result of a permanent change of station. Psychiatrist noted concern that the applicant was using mental health as a means of obtaining this permission and noted inconsistency in self-report of symptom severity between same-day appointments with the psychiatrist and social worker. The social worker documented same concerns about the incongruity of the applicant’s symptom report between providers and after initially considering a diagnosis of PTSD she determined further evaluation was warranted. The applicant had reported vicarious trauma from hearing an Iraqi soldier’s story of family-related traumatic events and memories of hearing this story were triggered by seeing “Middle Eastern” people on a plane and at his daughter’s graduation. He was transferred to a new social worker and started therapy with her 24 Jun 11. He was not WWQ. On 29 Jun 11, the applicant was seen in primary care for his retirement physical. The primary care provider diagnosed PTSD and noted mental health had “changed” his diagnosis, although it is unclear why the primary care provider assumed there was a change. The primary care provider’s note does not contain a rationale for diagnosing PTSD. On 12 Jul 11, he was listed as WWQ and deployable by his psychiatrist. His depression and anxiety diagnoses were maintained. His next follow up was 16 Aug 11. At that time he reported being drugged and abducted the previous weekend and was in distress as a result. He was listed as not WWQ. He was hospitalized for three days due to expressing suicidal ideation during an interview with the Office of Special Investigations when inconsistencies in his retelling of abduction events were identified. The applicant was cited as believing his alleged abduction had occurred but was unable to remember what happened. By 23 Aug 11, he was reported to be very worried about his impending retirement and the transition to civilian life. On 31 Aug 11, the applicant reported to his therapist that he had failed to report a previous traumatic event in which he allegedly took fire from the enemy while riding in a helicopter. He reported the men he was riding with shot back and women and children were being shot at. He cited fear about what it would do to his career as the reason for not reporting it earlier. The therapist noted the applicant had recently been notified about the Wounded Warrior Program and that he would qualify for services if he was diagnosed with PTSD. The social worker added a diagnosis of PTSD 7 Sep 11 based on the applicant’s report of symptoms while also noting the account was unverified. The applicant went on terminal leave for retirement and did not follow up for treatment. IAW DoDI 1332.38 (in effect at the time of the applicant’s discharge) in order for the applicant to have been entered into the disability evaluation system (DES) he must have met criteria for such a referral as listed in Enclosure 3 Part 2 of the regulation. Specifically in this case, he must have suffered from a medical condition that was eligible at that time for referral and received optimal medical treatment benefits, or he must have been expected to be unable to return to full military duty within one year of diagnosis of his medical condition. The applicant was profiled following initiation of psychotropic medication by his psychiatrist in Apr 2011 and the profile was lifted by the psychiatrist after he demonstrated 90 days of stability In accordance with (IAW) AFI 44-172. Throughout his mental health record in 2011 it was noted that he did not require a medical evaluation board and the applicant has not supplied evidence to suggest his medical providers believed he was too impaired to perform military duty. Diagnostic variability may occur in situations in which there are multiple medical providers administering care to a patient. In this case, the social worker and the psychiatrist differed regarding whether the applicant’s major depressive disorder was recurrent (i.e., had experienced more than one episode in his lifetime) versus a single episode. This diagnostic variability does create significant doubt that he was fit for military service when he retired as none of his medical providers deemed him appropriate for DES processing. Thus, a diagnosis alone would not trigger DES processing in this case and a medical evaluation board is not simply “offered” to a Service member in lieu of years of service retirement. The Military Department operates under Title 10, United States Code (U.S.C.), and must base its actions upon evidence available at the “snap shot” in time of final military disposition. The medical records reviewed for this case, which documented the applicant’s functioning during military service and at the time of discharge, do not support the presence of a mental health condition meeting criteria for initiating DES processing as listed in DoD Instruction 1332.38. Even if the DVA rates the applicant for his various medical conditions this is no cause for a presumption that he was unfit at the time of his years of service retirement. The DVA operates under a different set of laws (Title 38, U.S.C.), with a different purpose, and is authorized to offer service connection and compensation for any medical condition for which it has established a nexus with military service regardless of the narrative reason for separation or the length of time transpired since discharge. Therefore, post-service VA ratings would not equate to a Military Department conclusion that a Service member is no longer fit for continued military service. A complete copy of the AFBMCR Clinical Psychology Consultant evaluation is at Exhibit E. APPLICANT'S REVIEW OF AIR FORCE EVALUATION: Copies of the Air Force evaluations were forwarded to the applicant on 27 Jan 15 and 30 Jun 15, for review and comment within 30 days (Exhibits D and F). As of this date, no response has been received by this office. THE BOARD CONCLUDES THAT: 1. The applicant has exhausted all remedies provided by existing law or regulations. 2. The application was timely filed. 3. Insufficient relevant evidence has been presented to demonstrate the existence of an error or injustice. We took notice of the applicant’s complete submission in judging the merits of the case; however, we agree with the opinion and recommendation of the AFBMCR Medical and Clinical Psychology Consultants and adopt their rationale as the basis for our conclusion the applicant has not been the victim of an error of injustice. Therefore, in the absence of evidence to the contrary, we find no basis to recommend granting the requested relief. THE BOARD DETERMINES THAT: The applicant be notified the evidence presented did not demonstrate the existence of material error or injustice; the application was denied without a personal appearance; and the application will only be reconsidered upon the submission of newly discovered relevant evidence not considered with this application. The following members of the Board considered AFBCMR Docket Number BC-2014-01900 in Executive Session on 11 Aug 15, under the provisions of AFI 36-2603: The following documentary evidence pertaining to AFBCMR Docket Number BC-2014-01900 was considered: Exhibit A. DD Form 149, dated 1 May 14, w/atchs. Exhibit B. Applicant's Master Personnel Records. Exhibit C. Memorandum, AFBMCR MED CONSLT, dated 22 Dec 14. Exhibit D. Letter, SAF/MRBR, dated 27 Jan 15. Exhibit E. Memorandum, AFBCMR, CLINICAL PSYCHOLOGY CONSLT, dated 15 Jun 15. Exhibit F. Letter, SAF/MRBR, dated 30 Jun 15.