RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD1300699
BRANCH OF SERVICE:  Army	BOARD DATE:  20140701
DATE OF PLACEMENT ON TDRL:  20030401
FINAL SEPARATION DATE:  20040616

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SGT/E-5 (27T/Avenger System Repairer) medically separated for vocal cord dysfunction (VCD) syndrome.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty.  He was issued a permanent P3S3 profile and referred for a Medical Evaluation Board (MEB).  The VCD syndrome was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also forwarded Axis 1 adjustment disorder with mixed disturbances in mood and anxiety as disqualifying.  The PEB determined the VCD syndrome condition was unfitting and not sufficiently stable for final adjudication, and placed the CI on the Temporary Disability Retired List (TDRL) on 1 April 2003 with a rating of 30%, with application of the VA Schedule for Rating Disabilities (VASRD).  The PEB determined the adjustment disorder was not unfitting and not ratable.  After reevaluation on 26 February 2004 the PEB adjudicated the VCD as unfitting, rated 10%.  The CI non-concurred and forwarded a written rebuttal to the PEB.  After consideration, the PEB found that no change was warranted.  The findings were affirmed by the U.S. Army Physical Disability Agency and the CI was permanently separated.

CI CONTENTION:  “VA rated veteran at 90% disabled and 100% unemployable due to service related disability.” 

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 applicant.  The ratings for conditions meeting the above criteria are addressed below.  In addition, the Secretary of Defense directed a comprehensive review of Service members with certain mental health conditions referred to a disability evaluation process between 11 September 2001 and 30 April 2012 that were changed or eliminated during that process.  The applicant was notified that he may meet the inclusion criteria of the Mental Health Review Terms of Reference.  The mental health condition was reviewed regarding diagnosis change, fitness determination and rating in accordance with VASRD §4.129 and §4.130.  Any conditions or contention not requested in this application, or otherwise outside the Board’s defined scope of review, may be eligible for future consideration by the Board for Correction of Military Records.

RATING COMPARISON: 

Final Service PEB - 20040421	VA (7 Mo. Prior to Final Adjudication*) - Effective 20040421	
On TDRL - 20040401	Code	Rating	Condition	Code	Rating	Exam	
Condition		TDRL	Sep.					
Vocal Cord Dysfunction Syndrome 	6599 6520	30%	10%	Vocal Cord Dysfunction Syndrome	8299 8210	0%	20030924	
				Healed Granuloma, Right Lung with Bilateral Hilar Calcifications and Rhinitis	6699 6602	30%	20030924	
Adjustment D/O with Mixed Disturbances in Mood and Anxiety	Not Unfitting	Adjustment D/O with Mixed Anxiety D/O and Depressed Mood D/O	9499 9413	10%	20030924	
No Other Conditions in Scope	Other X 1	
Rated:  30% → 10%	Combined: 40%	
*Reflects VA rating exam proximate to TDRL removal and adjudication date was based on final PEB.  Included are both VCD and Healed Granuloma because both were used for rating the CI’s contended condition.

ANALYSIS SUMMARY:

Vocal Cord Dysfunction (VCD).  The narrative summary (NARSUM) notes the CI developed shortness of breath (SOB), light headedness and cardiac palpitations with anxiety during strenuous activity in 1997 with increase in symptoms in 2000.  Cardiac disease and primary asthma were ruled out as etiologies by appropriate diagnostic studies.  Routine chest X-ray performed in February 2001 revealed a questionable mass in the right mid and lower lung fields as a possible source of the symptoms.  CT scan of the chest performed on 20 March 2001, revealed small benign masses in the mid and upper right lung fields felt to be old lymph nodes or granulomas (evidence of old infections).  A full medical workup for any active disease process, to include tuberculosis, fungus, sarcoidosis, pneumonitis and malignancy was negative.  Subsequent CT scans in October 2001 and August 2002 were unchanged.  Direct laryngoscopy of the throat performed on 27 February 2001, revealed dysfunction of the vocal cords during deep expiration and a diagnosis of VCD was rendered.  The CI was treated with speech and home rehabilitation therapy.  At a family practice evaluation on 19 February 2002, the CI was noted to be “not motivated to get better,” and reluctant to do his own home rehabilitation.  The CI was scheduled for a repeat direct laryngoscopy for the MEB process at the University of South Carolina in September 2002, but was non-attendant for the appointment.  At the MEB NARSUM evaluation on 11 November 2002, a month prior to placement on the TDRL, the CI reported his attacks to be increasing in frequency and intensity and to occur primarily after physical exertion.  The MEB physical exam noted the CI to be in no distress.  Examination of the neck, heart and lungs was normal.  Pulmonary function tests (PFT) for the MEB on 9 December 2002, revealed an FEV-1 of 65%, FVC of 71% and FEV-1/FVC of 76 % all post-bronchodilator.  At the VA Compensation and Pension (C&P) general exam performed on 24 September 2003, 9 months prior to final separation, the CI reported his attacks to occur approximately every other week but “not regularly.”  On physical exam, voice, airway and neck exams were normal.

The Board directs attention to its rating recommendation based on the above evidence.  The PEB coded the condition 6520, larynx, stenosis, IAW §4.97; determined the condition to be unstable, and placed the CI on TDRL at 30%, citing an FEV-1 on PFT of 65%.  Under this code a rating of 30% requires an FEV-1 of 56% to 71%.  A higher rating of 60% requires FEV-1 of 40% to 55%.  The VA rated the VCD syndrome 0%, coded 8210, paralysis of the vagus nerve (the nerve enervating the vocal cords) IAW §4.124 citing no demonstrated evidence of vocal cord paralysis on examination.  The Board noted the VA to rate the symptoms of SOB, thought related to the VCD at 30%, coded 6602, asthma, IAW §4.97 citing FEV-1 of 63%.

The Board first undertook to determine if a rating higher than 30% was indicated at the time of TDRL placement.  The Board unanimously agreed that the record in evidence supported no rating higher than 30% for the VCD condition based on PFT and found no other appropriate codes for rating consideration.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the VCD condition at TDRL entry.  The examination for TDRL removal was undertaken on 26 February 2004.  On this exam, the CI reported no hospitalizations for the condition, attacks of SOB twice weekly with three to four emergency department visits over the last year.  He noted working up until 2 weeks prior, but had been terminated for frequent medical absences.  He reported his symptoms to remain unchanged the past year, but had been receiving no definitive treatment.  The CI was able to perform activities of daily living but had difficulty with any type of strenuous exercise.  He articulated his intent to reengage with VA vocational rehabilitation.  On examination, heart, lungs and throat were normal.  PFT at this time revealed an FEV-1 of 77% and an FEV-1/FVC of 102%.  The Board noted one emergency department visit for treatment of the VCD condition in the 12-month period prior to this examination, that occurring approximately 3 months prior.

The Board directs attention to its rating recommendation based on the above evidence.  The PEB permanently rated the VCD condition 10% coded 6520 citing FEV-1 of 77% on PFT.  The Board unanimously agreed that the record in evidence supported a rating of 10% under this code.  The Board was unable to find any other applicable codes for rating consideration.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the VCD condition at TDRL removal.  Therefore, the Board recommends no change in the PEB’s adjudication for the unfitting VCD condition at TDRL entry or removal.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the adjustment disorder condition was not unfitting.  The Board’s threshold for countering fitness determinations is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  According to the psychiatry addendum for the MEB on 25 September 2002, the CI had been treated earlier in his military career with good results for mood and anxiety symptoms, allowing a deployment in 2002.  During deployment the VCD condition worsened with resultant reappearance of his MH symptoms.  At the time of this evaluation, the CI was experiencing sad mood and constant worry which related to his health problems, worry about separation from the military, his ability to take care of his family, and future occupation.  He denied anxiety before the VCD attacks.  On mental status exam, the CI was oriented, calm and cooperative without evidence of psychosis, panic attacks, suicidal or homicidal ideation, hallucinations or delusions.  The examiner rendered an Axis 1 diagnosis of adjustment disorder with mixed disturbances in mood and anxiety and assigned a Global Assessment of Function of 70 (some mild symptoms OR some difficulty in social, occupational, or school functioning, but generally functioning pretty well, has some meaningful interpersonal relationships).  This diagnosis was confirmed by the VA C&P Mental Disorders exam on 24 September 2003.

The Board unanimously agreed that the VCD was the source of the MH symptoms and that diagnosis of adjustment disorder was supported by the preponderance of evidence in record.  The Board found no DSM-IV evidence to support a diagnosis of posttraumatic stress disorder.  There was no performance based evidence from the record that any primary MH condition significantly interfered with satisfactory duty performance.  The Board agreed that no MH condition was unfitting and that §4.130 and §4.129 were not applicable.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the any MH condition and therefore no additional disability rating is recommended.  The Board agreed that this applicant did not appear to meet the inclusion criteria in the Terms of Reference of the MH Review Projects as no MH diagnosis was changed during the DES process.

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 VCD condition and IAW VASRD §4.97, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended adjustment disorder condition, the Board unanimously recommends no change from the PEB determination as not unfitting.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  The Board, therefore, recommends that there be no recharacterization of the CI’s disability and separation determination.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130529, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

		

SAMR-RB									

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXX, AR20140018682 (PD201300699)

I have reviewed the enclosed Department of Defense Physical Disability Board of Review (DoD PDBR) recommendation and record of proceedings pertaining to the subject individual.  Under the authority of Title 10, United States Code, section 1554a,   I accept the Board’s recommendation and hereby deny the individual’s application.  
This decision is final.  The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail.

 BY ORDER OF THE SECRETARY OF THE ARMY:

Encl						     
						         
CF: 
(  ) DoD PDBR
(  ) DVA