RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2013-01123
BRANCH OF SERVICE:  Army	BOARD DATE:  20140514
SEPARATION DATE:  20020920

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (92G/Food Service Specialist) medically separated for a chronic pelvic pain condition.  The condition could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty or satisfy physical fitness standards.  She was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The pelvic condition was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other conditions were submitted by the MEB.  The Informal PEB adjudicated “chronic pelvic pain status post subtotal hysterectomy emergently after cesarean section” as unfitting, rated 10%, IAW VA Schedule for Rating Disabilities (VASRD) and citing U.S. Army Physical Disability Agency Policy, Guidance Memorandum #12, dated 8 April 2002, for analogous conditions.  The CI initially non-concurred, but withdrew her appeal and was medically separated.

CI CONTENTION:  “The condition is much more severe than was acknowledged by DOD.  I have been evaluated by the VA and am receiving service connected compensation.  There are secondary conditions which have developed as well.”

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 chronic pelvic condition is addressed below; 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:

Service IPEB – Dated 20020506	VA - (4 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pelvic Pain	7699-7629	10%	Chronic Pelvic Condition…	7618	30%	20030107	
Other MEB/PEB Conditions in Scope x 0	Other x 6		
Combined:  10%	Combined:  40%	
Derived from VA Rating Decision (VARD) dated 20030421 (most proximate to date of separation [DOS]).

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 (DES) 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, operating under a different set of laws.

Chronic Pelvic Condition. The CI began having pelvic pain in 1998 secondary to an ovarian cyst.  This continued despite resolution of the cyst and into a pregnancy.  On 29 April 2000, she underwent a cesarean section for failure to progress.  This was complicated by poor uterine contractions after delivery and subsequent life threatening hemorrhage refractory to treatment.  Consequently, she underwent an emergent sub-total hysterectomy (removal of the uterus) without removal of her ovaries.  Following the surgery, she had depressive symptoms secondary to the loss of future child bearing capability.  She continued to have pelvic pain after recovery from the surgery.  A note dated 2 October 2001 documented no significant decrease (of her chronic abdominal pain) with “post-pregnancy and emergent hysterectomy” and that there had been no significant change during her pregnancy.  It noted that endometriosis had been considered as a diagnosis, but this diagnosis was not made.  Further surgery was not indicated on examination and conservative treatment recommended.  This was not successful.  She was initially restricted from field duty and then entered into the DES process for chronic abdominal pain.  The Board did note that she was not placed on a profile for the pelvic pain until after the hysterectomy.  The narrative summary was dated 19 November 2001.  It noted a history of chronic pelvic pain since 1998 which continued through her pregnancy and afterwards.  She did report that the pain increased after the surgery.  Evaluation, including bowel studies, had not revealed the cause of the pain.  Additional surgery was discussed, but not pursued as there was no guarantee that it would lead to resolution of the pain.  The physical examination was unremarkable other than an absent uterus and pain free.  The CI reported that at the time of the examination, she continued to have constant, chronic pain which increased with bending, lifting over 10-15 pounds and intercourse.  She was unable to participate in field activities or wear field equipment and was limited to administrative duties.  At the VA Compensation and Pension examination performed on 7 January 2003, 4 months after separation, the CI reported chronic pelvic pain and painful intercourse.  Manipulation of the cervix was tender, but otherwise pain was not noted.  The examination was otherwise unremarkable other than the absent uterus.  Removal of the cervix was recommended as a consideration; this had previously be entertained while she was on active duty, but declined by the CI.

The Board directs attention to its rating recommendation based on the above evidence.  The PEB rated the chronic pelvic pain at 10% coding it 7699-7629, analogous to endometriosis (a painful condition in which uterine lining tissue exists in the abdomen outside the uterus).  The VA rated the CI at 30% for the sub-total hysterectomy using the code 7618 (removal of the body of the uterus).  The Board first considered if the hysterectomy was an unfitting condition.  A hysterectomy is medically unacceptable, IAW AR 40-501 3-18.c., if residual symptoms interfere with satisfactory duty performance.  The MEB determined that chronic pelvic pain status post subtotal hysterectomy emergently after cesarean section was medically unacceptable and cited 40-501 3-18.c.  However, it also noted the onset of the pain as 1998, 2 years prior to the hysterectomy.  The MEB examination did not demonstrate tenderness related to the surgery.  The Board did not find evidence to support the addition of complications of a hysterectomy as an unfitting condition as the pain clearly preceded the surgery and while the intensity of the pain was reported to have increased, the nature of the pain did not.  Also, the PEB did not utilize the hysterectomy code implying that it did not find the hysterectomy or any sequelae to be unfitting.  The PEB used an analogous code for endometriosis to rate the CI’s pelvic pain; a commonly accepted approach among the Service departments as well as the VA.  The Board noted endometriosis was not diagnosed while on active duty (or subsequently) and not seen at the time of the cesarean section and later hysterectomy.  It is reasonable to assume that a careful inspection of the abdomen was done in the setting of a life-threatening hemorrhage to ensure that all bleeding was controlled.  Also, no evidence was seen on pathological examination of the uterus.  The Board then considered the appropriate code and rating for the chronic pelvic pain.  The PEB utilized an analogous code for endometriosis and rated it at 10% for chronic pain requiring continuous treatment.  The Board observed that the CI reported chronic pain despite treatment which would rate at 30% using this coding option.  It considered if the evidence supported the higher rating.  Although the CI was actually not diagnosed with endometriosis, no etiology for the pain was ever confirmed other than an ovarian cyst 4 years prior to separation which had resolved.  The pain preceded her pregnancy, continued during the pregnancy and then reportedly increased after the hysterectomy.  There was no evidence showing the CI’s pelvic pain was controlled.  The Board did also considered the possibility of abdominal adhesions following the surgery using code 7301.  While this would be speculative as these were not diagnosed, this would support a 10% rating, absent bowel obstruction, would not adequately describe her disability picture encompassing her chronic pelvic pain and thus would provide no benefit to the CI.  The Board considered the clinical picture and the Board majority determined that the use of the analogous code 7699-7629 (endometriosis) was the best fit of the options available and recommended a rating of 30% for chronic pain not controlled with medications.  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 7699-7629 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 chronic pelvic pain condition, the Board by a vote of 2:1, recommends a disability rating of 30%, coded 7699-7629 IAW VASRD §4.116.  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 re-characterized to reflect permanent disability retirement, effective as of the date of her prior medical separation:

UNFITTING CONDITION	VASRD CODE	RATING	
Chronic Pelvic Pain Status Post Subtotal Hysterectomy Emergently after Cesarean Section	7699-7629	30%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130802, 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, AR20140021044 (PD201301123)

1.  Under the authority of Title 10, United States Code, section 1554(a), I approve the enclosed recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) pertaining to the individual named in the subject line above to recharacterize the individual’s separation as a permanent disability retirement with the combined disability rating of 30% effective the date of the individual’s original medical separation for disability with severance pay.  

2.  I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum:

	a.  Providing a correction to the individual’s separation document showing that the individual was separated by reason of permanent disability retirement effective the date of the original medical separation for disability with severance pay.

	b.  Providing orders showing that the individual was retired with permanent disability effective the date of the original medical separation for disability with severance pay.

	c.  Adjusting pay and allowances accordingly.  Pay and allowance adjustment will account for recoupment of severance pay, and payment of permanent retired pay at 30% effective the date of the original medical separation for disability with severance pay.

	d.  Affording the individual the opportunity to elect Survivor Benefit Plan (SBP) and medical TRICARE retiree options.

3.  I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

BY ORDER OF THE SECRETARY OF THE ARMY:

Encl						     
						
CF: 
(  ) DoD PDBR
(  ) DVA