RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXX		BRANCH OF SERVICE: NAVY
CASE NUMBER:  PD0900423		SEPARATION DATE: 20050804
BOARD DATE: 20110215		
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SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (CTT2, Cryptology Technician) medically separated from the Navy in 2005 after four years of service.  The medical basis for the separation was narcolepsy.  Her symptoms began with chest wall pain that developed during basic training.  The pain persisted despite treatment, became more widespread, and eventually met the criteria for fibromyalgia.  She was issued a permanent Limited Duty (LIMDU) and underwent a Medical Evaluation Board (MEB) in early 2004 which referred the conditions of fibromyalgia, status post breast reduction, depression, and asthma to the Physical Evaluation Board (PEB) where the CI was found fit for duty.  Later that year she was diagnosed with narcolepsy and began treatment.   She did not respond adequately to perform within her military occupational specialty or participate in a physical fitness test and underwent a second MEB.  Narcolepsy, Posttraumatic Stress Disorder (PTSD), and Attention Deficit Hyperactivity Disorder (ADHD) were forwarded to the PEB on NAVMED 6100/1.  No other conditions with fitness implications were identified in the Disability Evaluation System (DES) file.  The Informal PEB (IPEB) adjudicated narcolepsy as the only unfitting condition, rated 20% IAW with the Veterans Administration Schedule for Rating Disabilities (VASRD).  The CI made several appeals.   Narcolepsy and six other conditions from both prior IPEBs, as identified in the rating chart below, were considered by the Formal PEB (FPEB).  The adjudications were upheld by the FPEB, and later by a Petition for Relief, and the Board for Correction of Naval Records (BCNR), and she was medically separated with a 20% disability rating.  

CI CONTENTION:  The CI states: “Received only 20% for Fibromyalgia and 0% for Narcolepsy, which was the original reason for second medical board, I was given 60% overall disability rating 40% was for Fibromyalgia and 10% for Narcolepsy.” The Board notes an apparent transposition of terms in the CI’s contention in that she received a 20% rating for Narcolepsy and a not unfitting determination for Fibromyalgia.  She additionally lists all of her VA conditions and ratings as per the rating chart below.  A contention for their inclusion in the separation rating is therefore implied.  
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RATING COMPARISON:

Service FPEB – Dated 20050321	VA (5 Mo. Prior to Separation) – All Effective 20050805	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Narcolepsy	8108	20%	Narcolepsy	8108	10%	20050316	
PTSD	CAT III	PTSD	9411	10%	no show	
Fibromyalgia		Fibromyalgia	5025	40%	20050316	
Status Post Breast Reduction		Bilateral Breast Reduction	7626	0%	20050304	
Asthma		Asthma	6600-6602	10%	20050316	
ADHD	CAT IV	Adult Attention Deficit	9499-9400	NSC		
Obesity		No VA Entry	
↓No Additional MEB Entries↓	Other X 4 / NSC X 3		
TOTAL Combined:  20%	TOTAL Combined: 60%	
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ANALYSIS SUMMARY:
	
Narcolepsy Condition.  The diagnosis of narcolepsy with cataplexy (sudden and transient episode of loss of muscle tone) was established by sleep study after the CI was found fit by the first PEB for other conditions.  Prior to the initial PEB the CI had complained of insomnia which was suspected to be associated with her fibromyalgia pain.  The narcolepsy was treated with medications with some improvement.  However, due to the cataplexy episodes “once or twice a week” it was recommended that she not drive, carry or fire a loaded weapon, or be assigned to shipboard or other hazardous duty.  Additionally, she was put on a half day work schedule to allow for afternoon naps.  The PEB applied the VASRD directive to rate narcolepsy as epilepsy: petit mal, under the general rating formula for minor seizures.  The PEB appears to have recognized the cataplexy episodes as equivalent to minor seizure episodes in arriving at a 20% rating.  The VA rating of 10% under the same VASRD code does not appear to recognize cataplexy episodes as equivalent to minor seizure episodes.  The Board acknowledges VASRD 8108 Note (2) which states, “a minor seizure consists of a brief interruption in consciousness or conscious control…) as adequate to encompass cataplexy as a minor seizure equivalent.  There is no evidence to support the higher 40% rating which requires five to eight minor seizures per week.  All evidence considered, there is not reasonable doubt in the CI’s favor supporting a change from the PEB’s rating decision for the narcolepsy condition.

Other PEB Conditions.

Fibromyalgia Condition.  The CI’s symptoms of myalgias and arthralgias began during basic training.  Despite a number of interventions including breast reduction surgery, her symptoms persisted and worsened, resulting in a LIMDU in June 2003 and referral to the MEB.  She was formally diagnosed with fibromyalgia by rheumatology.  The examining physician noted that the CI “misses 60% of her work due to medical appointments.  She in specific cannot climb ladders aboard a ship, sleep in small racks, or perform late night or all-night shifts, or work on odd work schedules.  She has not performed any physical readiness test since boot camp.”  Fibromyalgia was forwarded to the CI’s initial PEB on NAVMED 6100/1.  The Commander’s assessment stated that the CI “…is a fine Petty Officer and can be counted on to perform her assigned duties when she is on duty.  However, the myriad of health and family issues currently in her life have had a profound and detrimental affect on her overall well-being and an adverse impact on her abilities to perform her daily work in a reliable effective manner.”  The PEB found the fibromyalgia condition not unfitting and returned the CI to duty.  This decision was upheld on reconsideration.  Although the MEB’s judgment that a condition does not meet retention standards is but a factor in the PEB’s fitness determination, it raises the bar for an adjudication of not unfitting.  The Board considered the Commander’s assessment of the CI’s duty performance and the decreased emphasis on the fibromyalgia symptoms after the initial PEB.  All evidence considered, there is not reasonable doubt in the CI’s favor supporting addition of fibromyalgia as an unfitting condition for separation rating.

PTSD Condition.  The CI was diagnosed with PTSD when she developed anxiety and depression symptoms following her grandmother’s death.  These symptoms were related to past abuse.  Her mental status exam was consistently normal.  She was treated with medications and counseling, to which she responded positively.  The examiner opined that the PTSD condition “likely existed prior to enlistment and is considered to have neither incurred in nor to have been aggravated by a period of active duty.”  He assigned a Global Assessment of Functioning (GAF) of 65 connoting mild symptoms and generally good function.  There is no apparent linkage to fitness for the CI’s PTSD symptoms.  The Board notes that the VA did service-connect the CI’s PTSD and rated it 10% connoting mild or transient symptoms or symptoms controlled by continuous medication.  All evidence considered, there is not reasonable doubt in the CI’s favor supporting the addition of PTSD as an additional unfitting condition for rating.

Breast Reduction Condition.  The CI underwent reduction mammoplasty as a suggested mitigation strategy for ongoing back and chest pain.  She developed a left breast infection and keloid formations as complications.  She required two subsequent surgeries to address nipple revision and breast size asymmetry.  No linkage to fitness is in evidence for the breast reduction condition.  The VA service connected the breast reduction and surgical scar on each breast with a noncompensable rating.  All evidence considered, there is not reasonable doubt in the CI’s favor supporting recharacterization of the PEB fitness adjudication for the breast reduction condition.

Asthma Condition.  The CI’s diagnosis of asthma preceded her entry onto active duty.  While in service her asthma symptoms were mild and intermittent.  Treatment consisted of a bronchodilator inhaler on an as needed basis.  No linkage to fitness is in evidence for the asthma condition.  The VA service connected the asthma condition with a 10% rating consistent with her normal physical examination and intermittent use of medications.  All evidence considered there is not reasonable doubt in the CI’s favor supporting recharacterization of the PEB fitness adjudication for the asthma condition.

ADHD Condition.  The CI had a diagnosis of ADHD that preceded her entry onto active duty.  ADHD is a condition that does not constitute a physical disability; hence Service PEBs do not have the authority to adjudicate ADHD as an unfitting condition.  The Board does not have the authority under DoDI 6040.44 to render fitness or rating recommendations for any conditions not eligible for consideration by the DES.   

Obesity Condition.  At the time of the MEB the CI was overweight with a Body Mass Index (BMI) of 29.  The Centers for Disease Control (CDC) defines obesity as a BMI of 30 or greater.  Regardless, obesity is a condition that does not constitute a physical disability; hence Service PEBs do not have the authority to adjudicate obesity as an unfitting condition.  The Board does not have the authority under DoDI 6040.44 to render fitness or rating recommendations for any conditions not eligible for consideration by the DES.

Remaining Conditions.  The only other condition in the DES file was an abnormal visual field noted on the MEB physical.  This condition was service connected as optic neuritis with atrophy and assigned a 10% rating by the VA at separation.   The condition was not clinically active during the MEB period or at any time during the CI’s military service.  The condition was not profiled or implicated in the Commander’s statement.  The Board has no reasonable basis for recommending this condition as unfitting for additional separation rating.  No other conditions were identified by the VA within 12 months of separation or contended by the CI in her application to the Board.
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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 Board 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 narcolepsy condition and IAW VASRD §4.124a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the Fibromyalgia, PTSD, Breast Reduction, Asthma, and Optic Neuritis conditions or any other medical conditions eligible for Board consideration; the Board unanimously agrees that it cannot recommend any findings of unfit for additional rating at separation.
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RECOMMENDATION: The Board therefore recommends that there be no recharacterization of the CI’s disability and separation determination.

UNFITTING CONDITION	VASRD CODE	RATING	
Narcolepsy	8108	20%	
COMBINED	20%	
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The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20090629, w/atchs.
Exhibit B.  Service Treatment Record.
Exhibit C.  Department of Veterans' Affairs Treatment Record.

                             	

MEMORANDUM FOR DIRECTOR, SECRETARY OF THE NAVY COUNCIL OF REVIEW   
                                         BOARDS 

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATION
    ICO XXXXXX, FORMER USN, XXX XX XXXX

Ref:   (a) DoDI 6040.44
             (b) PDBR ltr dtd 25Feb 11

      I have reviewed the subject case pursuant to reference (a) and, for the reasons set forth in reference (b), approve the recommendation of the Physical Disability Board of Review that Ms. XXXXX’ records not be corrected to reflect a change in either her characterization of separation or in the disability rating previously assigned by the Department of the Navy’s Physical Evaluation Board.