RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXX	CASE:  PD-2013-00220
BRANCH OF SERVICE:  AIR FORCE	BOARD DATE:  20140213
DATE OF PLACEMENT ON TDRL:  20040616
Date of Permanent SEPARATION:  20070211

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty A1C/E-3 (3M051/Services Journeyman) medically separated for pemphigus vulgaris.  The CI developed erythematous patches originally on her neck and abdomen in August 2002.  A biopsy performed in October 2002 was consistent with the systemic disease process, pemphigus vulgaris.  Her lesions became progressively worse and could not be adequately rehabilitated to meet the physical requirements of her Air Force Specialty or satisfy physical fitness standards.  She was issued a P4 profile and referred for a Medical Evaluation Board (MEB).  The pemphigus vulgaris condition (characterized as “painful erythematous vesicular patches scattered all over body) and “Pemphigus,” were forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123.  No other conditions were submitted by the MEB.  The Informal PEB adjudicated the pemphigus vulgaris condition as unfitting, rated 10%.  The CI appealed to the Formal PEB (FPEB) who increased the rating to 30%, citing criteria of the VA Schedule for Rating Disabilities (VASRD); and, placed the CI on the Temporary Disability Retired List (TDRL).  After 30 months on the TDRL, the pemphigus vulgaris condition was considered to be stable, but still unfitting.  She was removed from the TDRL and permanently separated without appeal.

CI CONTENTION:  The CI attached a one page statement to her application which was reviewed by the Board and considered in its recommendations.

SCOPE OF REVIEW: The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e.(2).  It is limited to those conditions determined by the PEB to be unfitting for continued military service and those conditions identified but not determined to be unfitting by the PEB when specifically requested by the CI.  The rating for the unfitting pemphigus vulgaris condition is addressed below; and, no additional conditions are within the DoDI 6040.44 defined purview of the Board.  Any conditions or contention not requested in this application, or otherwise outside the Board’s defined scope of review, remain eligible for future consideration by the Board for Correction of Military Records.

RATING COMPARISON:

Final Service PEB - 20061229	VA (32 Mo. Prior to TDRL removal) - Effective 20040616	
On TDRL - 20040616	Code	Rating	Condition	Code	Rating	Exam	
Condition		TDRL	Sep.					
Pemphigus Vulgaris	7815	30%	0%	Pemphigus Vulgaris	7815	60%*	20041028	
No Additional MEB/PEB Entries.	Other x 1	20041028	
Rating: 30% → 0%	Combined: 60%	
*Reflects VA rating exam proximate to TDRL placement. VA reduced rating to 30% effective 20070701, 4.5 months after removal from TDRL.

ANALYSIS SUMMARY:  The Board acknowledges the CI’s information regarding the significant impairment with which her service-connected condition continues to burden her; but, must emphasize that the Disability Evaluation System has neither the role nor the authority to compensate members for anticipated future severity or potential complications of conditions resulting in medical separation.  That role and authority is granted by Congress to the Department of Veterans Affairs (DVA), operating under a different set of laws.  The Board considers DVA evidence proximate to separation in arriving at its recommendations; and, DoDI 6040.44 defines a 12-month interval for special consideration to post-separation evidence.  Post-separation evidence is probative to the Board’s recommendations only to the extent that it reasonably reflects the disability at the time of separation.

Pemphigus Vulgaris.  The CI developed a pruritic skin rash of chest and neck, initially treated with topical steroid creams.  This rash extended to the chest, abdomen and flanks with the development of blisters and scaling scabs with drainage.  Skin biopsy in October 2002 revealed an immunologic mediated condition consistent with pemphigus vulgaris.  Treatment with a short course of oral steroids (Prednisone) was initiated with little improvement.  In March 2002, the CI became pregnant with progressive deterioration of the condition.  From this time until January 2004, the CI was treated with continuous oral Prednisone and addition of a stronger oral medication, Imuran, in increasing doses with little response of the condition.  At the narrative summary (NARSUM) on 4 December 2003, for the original IPEB, the CI was noted to have multiple draining lesions of the abdomen, breasts, neck and peri-rectal area.  Medications at that time included oral Prednisone.  In March 2004, the condition worsened and a new immunosuppressive medication, Cellcept, was added to the continued regimen of Prednisone and Imuran.  At the NARSUM for the FPEB on 10 March 2004, lesions were noted “all over the face, peri-orbital area, tongue and abdomen.”  Medications were reported as Imuran, Prednisone and Cellcept.  An addendum to the FPEB dated 19 March 2004 noted the condition to be “very severe” and that the CI was under treatment with three immunosuppressive medications.  Shortly thereafter the CI was admitted to the hospital for intravenous (IV) gamma globulin (IGG) treatment and underwent multiple 3-day courses of this medication.  Throughout this interval the three previously noted oral medications were continued.  This treatment regimen was continued through April, May, June, July and August 2004 and then decreased to one IV treatment per week.  In October 2004 the condition worsened and treatment was re-initiated with three daily IV treatments a week and continued through August 2005.  Oral medications were continued.  In March 2006, the condition deteriorated and new treatment was begun with IV Rituximab given weekly with continuation of prior oral medications.  In August 2006, after 8 weeks of treatment, the CI was asymptomatic, but oral medications (Prednisone and Cellcept) were continued.  At clinic visit on 28 October 2006, the CI was still taking both medications.  At clinic visit on 14 November 2006, the CI was in complete remission and taking no medications.  At the VA Compensation and Pension exam on 18 December 2006, 2 months prior to TDRL removal, the CI felt well and was taking no medication.  All lesions appeared healed with sequelae only of decreased bone density on testing.  The NARSUM exam for rating at TDRL removal was not in the record in evidence.  Closest proximate evaluations were those on 14 November and 18 December noted above.

The Board directs attention to its rating recommendation based on the above evidence.  The FPEB and VA both coded the condition 7815 (bullous disorders), IAW §4.118 (rating for the skin) at different ratings.  The FPEB rated the condition 30% and placed the CI on the TDRL and the VA rated the condition at 60%.  A 30% rating under this code requires a 20% to 40% cutaneous involvement or treatment with immunosuppressive medication (ISM) for a total of 6 weeks or more, but not constantly, during the past 12-month period.  The 60% rating, the highest under this code, requires a greater than 40% cutaneous involvement or constant, or near constant treatment with ISM during the past 12-month period.  The Board unanimously agreed with the placement of the CI on a period of TDRL as the condition was unstable.  The Board was unable to rate the condition based on quantative cutaneous extent from the record in evidence.  The Board agreed that the CI was treated near continuously in the 12-month period prior to TDRL placement with multiple oral ISM, to include Prednisone, Imuran, Cellcept and continued cycles of IV medication to include IGG and Rituximab.  The Board unanimously concluded that the record supported a 60% rating at TDRL entry.  At TDRL exit, the condition had responded and the CI was asymptomatic and receiving no medication.  The PEB rendered a permanent rating of 0% coded 7815 citing that the condition was cured and the CI was receiving no medication at that time.  The Board noted that the requirements for a 0% rating required less that 5% of cutaneous involvement and no more than topical therapy during the prior 12-month period.  The Board agreed that the CI was asymptomatic at TDRL exit, but opined that the record in evidence supported at least a 30% rating in that the CI had received ISM for greater than 6 weeks in the prior 12-month period.  The Board then considered the 60% rating, and unanimously agreed that the criterion for “near constant treatment” was met as the CI had received ISM for 10 months in the 12-month prior to TDRL removal.  The Board found no residuals from this condition for consideration of additional rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt) and VASRD §4.7 (higher of two evaluations), the Board unanimously recommends a disability rating of 60% for the Pemphigus vulgaris condition at TDRL entry and a permanent rating of 60% at TDRL removal.

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 pemphigus vulgaris condition, the Board unanimously recommends a disability rating of 60% at TDRL entry and a rating of 60% at permanent separation both coded 7815, IAW VASRD §4.118.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  The Board recommends that the CI’s prior determination be modified as follows; and, that the discharge with severance pay be recharacterized to reflect permanent disability retirement, effective as of the date of her prior medical separation:

UNFITTING CONDITION	VASRD CODE	RATING	
		TDRL	PERMANENT	
Pemphigus Vulgaris	7815	60%	60%	
RATING	60%	60%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130412, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

				

PDBR PD-2013-00220

MEMORANDUM FOR THE CHIEF OF STAFF

	Having received and considered the recommendation of the Physical Disability Board of Review and under the authority of Title 10, United States Code, Section 1554a (122 Stat. 466) and Title 10, United States Code, Section 1552 (70A Stat. 116) it is directed that:

	The pertinent military records of the Department of the Air Force relating to XXXXXXXXXXXXXX, be corrected to show that:

	a.  Upon final Temporary Disability Retired List (TDRL) disposition, the diagnosis in her finding of unfitness for Pemphigus Vulgaris, VASRD Code 7815,was rated at 60% rather than 0%.  

	b.  On 11 February 2007, she was not discharged with entitlement to disability severance pay; rather, on that date her name was placed on the Permanent Disability Retired List.