RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2013-01119
BRANCH OF SERVICE:  AIR FORCE	BOARD DATE:  20140513
SEPARATION DATE:  20020820

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty Maj/0-4 (15W/Weather Officer) medically separated for celiac sprue condition.  His condition could not be adequately rehabilitated to meet the physical requirements of his Air Force Specialty or satisfy physical fitness standards.  He was issued a permanent P4 profile and referred for a Medical Evaluation Board (MEB).  The celiac sprue condition was forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123.  No other conditions were submitted by the MEB.  The Informal PEB (IPEB) adjudicated the celiac sprue condition as unfitting, rated 10%, with application of the VA Schedule for Rating Disabilities (VASRD).  The CI appealed to the Formal PEB and Secretary of the Air Force Personnel Counsel, which affirmed the IPEB finding and rating.  The CI made no further appeals and was medically separated.

CI CONTENTION:  “Please consider increasing my disability rating to at least 30% which is more consistent with the VA's initial rating of 30% for my chronic GI illness dated 20020821 (please note, the 30% I received was the maximum allowed rating in code 7325/7319 of the VA's Schedule of Ratings for Irritable Colon Syndrome at the time of my separation.)  The VA's code in 2002 for my condition stated, "Severe; diarrhea, or alternating diarrhea (continue) and constipation, with more or less constant abdominal distress."  I suggest the PEB returned an inaccurately low rating of 10% despite knowing a parasite from a Saudi deployment damaged my digestive system.  My AF Form 818 listed "Celiac Sprue, poorly controlled on gluten free diet with multiple systemic complaints and poor functional status."  I'd ask you to also consider my Anxiety Disorder related to general medical condition (VA 30% effective date 20060923) and Recurrent Prostatitis (VA 20% effective date 20020821 now VA 40% effective date 20060923) as part of the multiple systemic complaints.  Doctor notes from active duty & just 7-21 months after my separation depict my unfit physical & mental condition.  Some include:  On 16 Apr 03, Dr S-- in his VA Progress Notes p. 35 stated my GI malabsorption led to a "dramatic life disruption." On 17 Sep 03, on VA Note p. 30 GI Dr S-- makes note that my GI symptoms are, "severe and incapacitating."  On 28 Sep 05, VA Psychologist Dr K-- in her VA Progress notes, p 12, informed me my symptoms appear to be a type of Anxiety Disorder.  From 9 Nov 05, on VA Note p. 6, Dr K-- concluded that my "anxiety continues to be related to history of Giardia and IBS."  On 26 Sep 12, Dr C---T-- states in her VA Notes, "It is my opinion Mr D-- anxiety symptoms are directly related to his Giarda and IBS, which began during his military service."  On 30 Oct 02, Dr P-- in his VA Note for both my GI illness and prostatitis are "symptomatic in spite of treatment."  Please see attached in support of my request.  Thank you for taking the time to review my physical & mental health history and I'm hopeful for a positive result.  The CI also attached a 12 page statement to his 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 celiac sprue condition is addressed below.  The anxiety disorder and recurrent prostatitis, as per the contention, were not identified by the PEB; and, thus are not within the DoDI 6040.44 defined purview of the Board.  These, and any other condition or contention not requested in this application, remain eligible for future consideration by the Board for Correction of Military Records.

RATING COMPARISON:

SECAF Personnel Counsel – Dated 20020701	VA* - (2.3 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Celiac Sprue	7325	10%	Celiac Sprue	7399-7319	30%	20021028	
Other x 0 (Not in Scope)	Other x 4	20021028	
Rating:  10%	Combined:  40%	
*Derived from VA Rating Decision (VARD) dated 20020928 (most proximate to date of separation (DOS))

ANALYSIS SUMMARY:  The Board acknowledges the CI’s information regarding the significant impairment with which his service-connected conditions continue to burden him.  The Board acknowledges the CI’s contention that suggests a higher rating should have been granted on the unfitting medical condition documented at the time of separation.  IAW DoDI 6040.44, the Board’s authority is limited to making recommendations on correcting disability determinations.  The Board’s role is thus confined to the review of medical records and all evidence at hand to assess the fairness of PEB rating determinations, compared to VASRD standards, based on ratable severity at the time of separation; and, to review those fitness determinations within its scope (as elaborated above) consistent with performance-based criteria in evidence at separation.

Celiac Sprue Condition.  Celiac disease (also known as gluten-sensitive enteropathy or non-tropical sprue) is an immune-mediated inflammation of the small intestine caused by sensitivity to dietary gluten and related proteins in genetically sensitive individuals.  The CI developed abdominal cramping, frequent flatulence, nausea, watery diarrhea and a 20 pound weight loss while deployed to Saudi Arabia in 1993.  He did not receive treatment until 1996 when he was found to have a Giardia infection of the intestine as well as endoscopic findings of the small intestine suggestive of Celiac disease.  However, serologic testing (blood tests for antibodies) for Celiac disease was consistently negative.  Although antibiotic treatment for Giardiasis and avoidance of dietary gluten resulted in some symptomatic improvement, the CI continued to experience frequent gastrointestinal symptoms.

At the narrative summary examination on 15 January 2002 (7 months prior to separation), the CI reported an inability to gain weight and continuing problems with nausea, vomiting, diarrhea and abdominal cramping.  Symptoms were especially prominent after eating any foods containing gluten.  He also complained of chronic fatigue, poor concentration, insomnia and weakness.  Physical exam noted the CI to be very slender with low muscle mass.  The abdomen was non-tender.  The examiner’s diagnosis was “celiac sprue, poorly controlled on gluten free diet with multiple systemic complaints and poor functional status.”

In a letter to the medical board on 14 May 2002 a colleague wrote that “many times he would spend hours in the bathroom with diarrhea or nausea.”  His symptoms were noted to prevent him from attending many social events or interfere with attendance at spectator events due to his need to frequent the restroom.  Other co-workers noted his need to take several breaks to try to relieve abdominal cramps, his difficulty in attending longer duration meetings and estimated his productivity loss per day of at least one hour.  A former commander reported the CI’s need to excuse himself to “literally ‘run’ to the restroom,” and to leave during many staff meetings.  A fellow church member noted that he often could not sit during an entire service.  In his memo to the MEB on 15 March 2002 (5 months prior to separation), the CI complained of daily stomach aches and intestinal distress.  He reported that “gagging and nausea” occurred 5-6 days per week and intestinal discomfort interfered with sleep.  The commander’s statement on 26 March 2002 reported that, due to his condition, the CI could not support temporary duty missions normally assigned to his position.  Because of his symptoms, a substitute briefer was occasionally provided for command briefing shifts and a substitute representative provided for longer meetings.  The commander stated:  “The member averages about a 1-hour loss in productivity per shift due to work interruptions caused by his condition.  Believe this loss would be greater if not for his exemplary work ethic.”  Due to diagnostic uncertainty, the CI underwent repeat studies in June 2002, to include serologic tests for Celiac disease, an upper endoscopy which included the first part of the small intestine and a colonoscopy.  All tests were negative.

At the VA Compensation and Pension exam on 28 October 2002 (2 months after separation) the CI reported recurrent symptoms of lower abdominal cramping pain and watery diarrhea with 3-4 bowel movements per day.  A VA clinic note on 16 April 2003 reported that the CI was maintaining his weight under a highly restrictive diet.  His continued bouts of symptoms led to him “holding only a part-time delivery job.”  He currently complained of 3-4 formed stools per day with some mucus, bloating, gas and some relief of discomfort with bowel movements.  At a VA gastroenterology visit on 11 June 2003 (10 months after separation) the CI continued to complain of abdominal cramping, nausea, 4-5 bowel movements per day and bloating.  The examiner noted lab tests were negative for Celiac disease serologies (the genetic marker commonly seen in Celiac disease) and for intestinal parasites.  A radiological study of the small intestine was normal.  Post-infectious irritable bowel syndrome was considered the most likely diagnosis.

The Board directs attention to its rating recommendation based on the above evidence.  The VA assigned a 30% rating under the 7319 code (irritable colon syndrome).  The PEB assigned a 10% rating under a code 7325 (enteritis, chronic) that defaults to the 7319 rating criteria.  This pathway calls for a 10% rating for “moderate; frequent episodes of bowel disturbance with abdominal distress;” and for a 30% rating (the highest possible under this code) for “severe; diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress.”  VASRD §4.7 states:  “Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating.”  Board members agreed that the symptom frequency and regular work disruptions described in the evidence above more nearly approximated the 30% criteria.  Although it became clearer soon after separation that the diagnosis was irritable bowel syndrome, thereby firmly supporting the use of 7319 coding criteria, the Board nevertheless considered other rating options.  The 7323 code (ulcerative colitis) is a poor clinical fit since ulcerative colitis is characterized by chronic inflammation and ulcer formation of the large bowel, neither of which was present in this case.  The 6320 code (parasitic diseases otherwise not specified) requires rating chronic residuals of infection (in this case, Giardia) based on damage to the affected organ.  The CI’s follow-up endoscopic evaluation confirmed normalization of the intestinal lining; and in the absence of chronic inflammation, the appropriate coding option defaults to 7319.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 30% for the celiac sprue condition.

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 celiac sprue condition, the Board unanimously recommends a disability rating of 30%, coded 7325 IAW VASRD §4.114.  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 his prior medical separation:

UNFITTING CONDITION	VASRD CODE	RATING	
Celiac Sprue	7325	30%	
RATING	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130815, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

				

Dear XXXXXXXXXXXXXXXXXXXX:

	Reference your application submitted under the provisions of DoDI 6040.44 (Title 10 U.S.C. § 1554a), PDBR Case Number PD-2013-01119.

	After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was not appropriate under the guidelines of the Veterans Affairs Schedule for Rating Disabilities.  Accordingly, the Board recommended your separation be re-characterized to reflect disability retirement, rather than separation with severance pay.

	I have carefully reviewed the evidence of record and the recommendation of the Board.    I concur with that finding, accept their recommendation and determined that your records should be corrected accordingly.  The office responsible for making the correction will inform you when your records have been changed.

	As a result of the aforementioned correction, you are entitled by law to elect coverage under the Survivor Benefit Plan (SBP).  Upon receipt of this letter, you must contact the Air Force Personnel Center at (210) 565-2273 to make arrangements to obtain an SBP briefing prior to rendering an election.  If a valid election is not received within 30 days from the date of this letter, you will not be enrolled in the SBP program unless at the time of your separation, you were married or had an eligible dependent child, in such a case, failure to render an election will result in automatic enrollment.  

							Sincerely,

	

Attachment:
Record of Proceedings

cc:
SAF/MRBR
DFAS-IN