RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	 	CASE: PD1300864
BRANCH OF SERVICE:  MARINE CORPS		BOARD DATE:  20140410
SEPARATION DATE:  20041231

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SSGT/E-6 (3381/Food Service Specialist) medically separated for recurrent deep venous thrombosis (DVT).  The CI reportedly had his first episode of DVT (a clot in a large leg vein), left lower extremity (LLE), in 1985.  His second episode occurred in February 2003.  Laboratory evaluation revealed the CI was severely deficient in Protein C and Protein S, explaining his hyper-coagulable state (excessive ability to clot blood) and necessitating indefinite anticoagulation therapy with Coumadin (an anti-coagulant).  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty or satisfy physical fitness standards.  He was placed on limited duty and referred for a Medical Evaluation Board (MEB).  The MEB forwarded embolism and thrombosis (both are clots) of other specified-veins and congenital deficiency of other clotting factors conditions to the Physical Evaluation Board (PEB) IAW SECNAVINST 1850.4E.  No other conditions were submitted by the MEB or adjudicated by the PEB.  The Informal PEB adjudicated the recurrent DVT condition as unfitting, rated 10%.  The remaining condition was determined to be Category II (a condition which is related to and contributes to the unfit condition).  The CI made no appeals and was medically separated.

CI CONTENTION:  “Migraine Headaches, Deep vein thrombosis of left and right lower extremity Hypertension all should have been rated higher due to the conditions at hand.”

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 DVT condition is addressed below; no additional conditions are within the Board’s defined DoDI 6040.44 purview.  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 Naval Records.

RATING COMPARISON:

Service IPEB – Dated 20040414	VA - (Exam ~ 2 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Recurrent DVT	7199-7121	10%	DVT of LLE***	7199-7121	10%	20050208	
			DVT of RLE	7199-7121	10%	20050208	
Protein S & C Deficiency* 	Category 2**	Subsumed under DVT	
No Additional MEB/PEB Entries	Other x 19	20050208	
Combined:  10%	Combined:  30%	
Derived from VA Rating Decision (VARD) dated 20050518 (most proximate to date of separation [DOS]).  * Requiring Life-Long Anticoagulation Therapy with Coumadin.  **A condition which is related to and contributes to the unfit condition.  ***

ANALYSIS SUMMARY: 

Recurrent Deep Venous Thrombosis (DVT) Condition. The CI was first noted to have problems with coagulation at the age of 16 when he had a DVT of the LLE following a right knee injury.  There are no records in evidence of any evaluation done at that time.  He apparently did well and next presented with a DVT of the LLE in February 2003 after a 14-hour plane flight.  He was begun on Coumadin for anti-coagulation therapy.  His evaluation revealed deficiencies in both Protein S and C (these are involved in the inactivation of some of the clotting factors.  Thus, a deficiency of either leads to an increased tendency to form clots).  The MEB narrative summary was dated 10 December 2003.  It noted that the CI was severely deficient in both Protein C and S.  He had DVT of the LLE twice; first in 1985, prior to service and then 2003.  He denied shortness of breath or a history of pulmonary emboli (lungs clots, a potentially life threatening condition).  It was noted that he required lifelong anti-coagulation for this condition and, consequently, could not meet full duty requirements due to the risk of bleeding if injured.  He also required access to medical care for ongoing medication management.  His physical examination was unremarkable.  He was found to not meet retention standards for the clotting disorder which was determined to be congenital.  On 24 February 2004, the CI was evaluated in internal medicine.  It was noted that he had another DVT, this time in the right lower extremity (RLE), after playing basketball.  On examination of the RLE, there was mild tenderness to palpation, but no swelling or erythema.  The examiner noted that the levels of Protein S and C had been measured while on Coumadin (this can artificially lower the levels) and that other testing was more consistent with anti-phospholipid syndrome, an autoimmune disease (when the body’s immune system targets “self.”)  Regardless, the manifestations and treatment are the same.  At the VA Compensation and Pension examination performed 2 months after separation, the CI reported the two DVTs of the LLE and one of the RLE in November 2003.  He endorsed aching of both lower extremities after prolonged standing or walking.  He did not require the use of compressive hosiery, but both calves were tender to deep palpation.  He had an ecchymotic area (like a bruise, but not due to trauma) with a palpable vein near the back of the right foot and slight discomfort to palpation.  The examiner noted that this was an area of prior trauma 9 to 10 years earlier.  No edema was present.

The Board directs attention to its rating recommendation based on the above evidence.  The PEB and VA both used the analogous code for DVT (post-phlebitic syndrome), 7199-7121, but rated it at 10% and 20% (10% + 10% for each leg) respectively.  The PEB did not assign the rating to one lower extremity or another.  The VA rated each leg.  The Board considered that the CI had a DVT in each leg while on active duty and that he reported deep aching in BLE after prolonged walking or standing.  Each calf was tender to deep compression.  The Board determined that the DVT in either leg, in the presence of the requirement for lifelong anti-coagulation, was separately unfitting and separate ratings are warranted.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the recurrent DVT condition for each lower extremity.

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 bilateral DVT condition, the Board unanimously recommends a disability rating of 10% each, coded 7199-7121 IAW VASRD §4.71a.  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, effective as of the date of his prior medical separation:

UNFITTING CONDITION	VASRD CODE	RATING	
Deep Venous Thrombosis Right Lower Extremity	7199-7121	10%	
Deep Venous Thrombosis Left Lower Extremity	7199-7121	10%	
COMBINED (w/ BLF)	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130614, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

				

MEMORANDUM FOR DEPUTY COMMANDANT, MANPOWER & RESERVE AFFAIRS
	         COMMANDER, NAVY PERSONNEL COMMAND
	                          
Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS          

Ref:   (a) DoDI 6040.44
       (b) XXXXXXXXXXXXXXXXXX 
       (c) PDBR ltr dtd 18 Sep 12 ICO XXXXXXXXXXXXXXXXXX
          
1.  Pursuant to reference (a) I approve the recommendations of the Physical Disability Board of Review set forth in references (b) through (c).

2.  The official records of the following individuals are to be corrected to reflect the stated disposition:

    a.  XXXXXXXXXXXXXXXXXX

    b.  XXXXXXXXXXXXXXXXXX, XXX XX XXXX, former USMC:  Disability separation with entitlement to disability severance pay with a rating of 20 percent (increased from 10 percent) effective date of discharge.
    
3.  Please ensure all necessary actions are taken to implement these decisions, including the recoupment of disability severance pay, if warranted, and notification to the subject members once those actions are completed.