RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:	 XXXXX	  BRANCH OF SERVICE: ARMY
CASE NUMBER:  PD0900243		BOARD DATE: 20090903
SEPARATION DATE: 20040926
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SUMMARY OF CASE: This covered individual (CI) was an Army Guard enlisted member who was medically separated in 2004 after 7 years of combined service.  The medical basis for the separation was chronotropic incompetence necessitating placement of a pacemaker.  During mobilization for Operation Noble Eagle, he developed dyspnea on exertion and easy fatigue.  Cardiology work-up confirmed a diagnosis of chronotropic incompetence with poor performance on stress test (4 METS).  He underwent pacemaker placement in late 2002, with a repeat stress test in early 2003.  This was much improved; achieving 15 METS at 90% predicted maximum heart rate.  Restrictions imposed by cardiology at that time were confined to heavy lifting, avoiding electromagnetic interference and accessibility for device checks.  Because of his assignment limitations, he was referred to the PEB.  The CI developed depression following the pacemaker procedure, and his civilian employer notified him that his employment was terminated because of the pacemaker issue.  He was evaluated by psychiatry during the MEB process and diagnosed with chronic adjustment disorder and mixed depression.  This was noted as medically unacceptable on the DA 3947 from the MEB.  The PEB found him unfit only for the cardiac condition and he was separated at 10% disability.
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CI CONTENTION: The CI re-stated his PEB conditions in the PDBR application, without specifying a distinct contention.	
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RATING COMPARISON:

Service PEB	VA (5 Mo. after Separation)	
Condition	Code	Rating	Date	Condition	Code	Rating	Exam	Effective	
CHRONOTROPIC INCOMPETENCE NECESSITATING … PACEMAKER.	7018	10%	20040826	CHRONOTROPIC INCOMPETENCE, S/P PACEMAKER  PLACEMENT	7018-7011	60%	20050311	20040927	
AXIS I: ADJUSTMENT DISORDER, CHRONIC, WITH MIXED ANXIETY AND DEPRESSED
MOOD	Fit	-	-	MAJOR DEPRESSIVE DISORDER ASSOCIATED WITH CHRONOTROPIC
INCOMPETENCE, S/P PACEMAKER PLACEMENT	9440	10%	20050311	20040927	
TOTAL Combined:  10%	TOTAL Combined (Includes Non-PEB Conditions):    60%                                                                          	

ANALYSIS SUMMARY:

Chronotropic Incompetence.  The PEB coded the condition under the 7018 pacemaker code.  This code specifies rating under the appropriate arrhythmia according to MET tolerance, with a minimum rating of 10%.  The 15 MET stress test result obtained by the Army was not compensable under the referred codes, and the minimum rating under 7018 was justified.  The 7011 reference code chosen by the VA was imprecise for the pathology, but equivalent for rating purposes to any other choice.  The rating decision stated, ‘On current examination, a METS level of 4 to 6 was noted following stress testing’.  This meets 60% rating criteria for the code.  The evidence for that statement, however, is not substantiated by the record.  The VA rating examiner referenced a stress test on February 2, 2005 which was ‘inconclusive due to insufficient heart rate’.  The examiner provided an estimated MET level of 4 to 6 based on severity of symptoms as described by the CI.  This is presumably the foundation for the rating decision, unsubstantiated by stress testing (as allowed under §4.104).  This determination, based on subjective data, carries a significantly lower probative value compared to the objective evidence available to the PEB.  The Army stress test report documented the absence of chest pain during the exam, noting fatigue as the end point.  The stress test demonstrated that the CI was maintaining an adequate exercise heart rate with the pacemaker.  Normal ventricular function had already been documented by ultrasound and cardiac catheterization.  A cardiac basis for the symptoms on which the VA examiner’s estimated METS were premised is therefore suspect.  This further lowers the probative value of the VA rating.  Although, there was an extended period between the Army stress test and the separation rating, the nature of the CI’s pathology (corrected by a functioning pacemaker) would not be clinically suspect of significant deterioration over that period.  At least more likely than not, the PEB rating better reflects the CI’s level of disability than the VA rating.  There does not exist a degree of reasonable doubt, IAW VASRD §4.3, which would resolve the disparity between the PEB and VA ratings in favor of the CI.

Psychiatric.  Adjustment disorder, in and of itself, is not unfitting IAW AR 40-501, 3-36.  The associated depression is potentially unfitting and ratable.  It was deemed medically unacceptable by psychiatry and judged to carry ‘considerable’ social and industrial impairment.  He was suffering from insomnia, mild depression, and moderate anxiety as described in the NARSUM.  There, however, is no evidence in the record that his job performance was being significantly impacted by the psychiatric symptoms.  In the Commander’s statement and in the termination letter from his civilian employer, only the pacemaker requirement was cited as detrimental to his qualifications.  His profile carried a firearm restriction, but that would not have been singularly disqualifying in his MOS (metal worker).  The linkage of the psychiatric condition with his unfitting diagnosis is clear, but not as an intrinsic contribution to unfitness.  There is no firm basis for a Board recommendation to add the psychiatric condition as additionally unfitting, contrary to the PEB’s expertise in its finding.
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BOARD FINDINGS:  IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the PDBR to the extent they were inconsistent with the VASRD in effect at the time of the adjudication.  The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised.  In the matter of the cardiac condition, chronotropic incompetence, the Board unanimously concurs with the PEB coding and rating, IAW VASRD §4.104.  In the matter of the psychiatric condition, the Board unanimously agreed that it could not be recommended as additionally unfitting for separation rating.
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RECOMMENDATION:  The Board therefore recommends that there be no recharacterization of the CI’s disability and separation determination. 
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The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20040926, w/atchs.
Exhibit B.  Service Treatment Record.
Exhibit C.  Department of Veterans' Affairs Treatment Record.