RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD1301389
BRANCH OF SERVICE:  Army	BOARD DATE:  20140605
SEPARATION DATE:  20040606

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SSG/E-6 (13M/Multiple Launch Rocket System Crewmember) medically separated for vasovagal syncope.  He experienced an onset of recurrent syncopal episodes in 2003, which could not be adequately remedied to meet the physical requirements of his Military Occupational Specialty or satisfy physical fitness standards.  He was issued a permanent P3 profile and referred for a Medical Evaluation Board (MEB).  The MEB forwarded “vasovagal syncope” to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other conditions were submitted by the MEB.  The Informal PEB (IPEB) adjudicated “vasovagal syncope” as unfitting, rated 10%, citing criteria of the VA Schedule for Rating Disabilities (VASRD).  The IPEB reconsidered its findings in response to appeal, but determined that no change was indicated.  The CI withdrew a request for a Formal PEB and was medically separated.

CI CONTENTION:  “Condition was not fully diagnosed due to recruiter duty, PCS, and a determination by Medical Officer to seek discharge 7 days after.”

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 syncopal 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 (BCMR).  The Board acknowledges the CI’s assertion that his disability disposition was unfairly rushed.  It is noted for the record that the Board has no jurisdiction to investigate or render opinions in reference to such allegations and, redress in excess of the Board’s scope of recommendations (as noted above) must be addressed by the BCMR and/or the United States judiciary system.

RATING COMPARISON:

Service IPEB – Dated 20040225	VA (2 Mo. Pre-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Vasovagal Syncope	8299-8210	10%	Tachycardia/Vasovagal Syncope	7099-7011	10%	20040401	
Other X 0 (Not in Scope)	Other x 5	20040401	
Rating:  10%	Combined:  30%	
Derived from VA Rating Decision (VARD) dated 20040612 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Vasovagal Syncope.  The CI’s initial symptoms for this condition were manifest in March 2003 associated with exertion during physical fitness testing.  These consisted of dizziness and near syncope (faintness without loss of consciousness) lasting 2-3 hours, for which care was not immediately sought.  The earliest entry in the service treatment record (STR) is from May 2003, and is a primary care request for cardiology consultation referencing the above event.  An outpatient specialty and ancillary evaluation ensued.  Ambulatory heart monitoring (Holter) identified two episodes of tachycardia (narrow complex), although these were not associated with symptoms.  A tilt table test was positive, suggesting a diagnosis of vasovagal syncope; which is an abnormal response of heart rate and blood pressure to position change (or other stimuli) mediated by the vagus nerve (from brain stem to heart).  An echocardiogram was normal (includes chamber size and ejection fraction [65% in this case] as specified in VASRD rating criteria) and, a stress test was normal with achievement of 14 METs (metabolic equivalents of tasks; VASRD criterion; minimum 10% rating requires ≤ 10 METs).  The CI was placed on a low dose beta-blocker (keeps heart rate down) in July 2003 and remained on the same medication and dose through to separation.  In August 2003 he experienced a prolonged episode of near syncope and underwent a brief hospital admission.  The STR also documents a reported full syncopal episode (loss of consciousness for unknown period, unwitnessed) at home following exertion in November 2003 (7 months pre-separation).  Other than these two events, there is no STR documentation of any prolonged events and the latter is the only documentation of full syncope.

The narrative summary (NARSUM) documents the above history, although there is some conflict with the history of the syncopal event at home; leaving some doubt as to whether they were the same or separate events.  The NARSUM reflects transient symptoms (palpitations, dizziness) “2 to 3 times daily” and documented limitations of self-modulated running, with prohibition of driving military vehicles.  The VA Compensation and Pension evaluation (2 months pre-separation and 2 months after the NARSUM) described symptoms of dizziness and “easy fatigue when doing physical labor” which “occur intermittently, as often as five or more times a day, with each occurrence lasting 1-5 seconds.”

The Board directs attention to its rating recommendation based on the above evidence.  The PEB coded the syncopal condition analogously to 8210 for vasovagal nerve impairment.  This provides a 10% rating for “moderate” impairment (the PEB conclusion, but disputed by CI in service) and 30% for “severe” impairment.  The VA arrived at a 10% rating under analogous criteria of code 7011 (ventricular arrhythmias, sustained).  It is noted, however, that the choice of that code is easily challenged on clinical grounds, since the episodes of tachycardia in evidence were neither ventricular nor sustained.  It is also noted that the rationale articulated in the VARD reflects inaccurate clinical interpretation of the evidence by the rater.  The most clinically applicable code, if one wishes to rate for arrhythmia in this case, is analogous to 7010 (supraventricular arrhythmias) which equates to narrow complex tachycardia.  Under criteria of that code, the Holter evidence would support a 10% rating (for 1-4 episodes).  Other than the analogous 8210 and 7010 options just discussed, the only other code offered by the VASRD which might be analogously applied is 8999-8911 (petit mal epilepsy).  This code defaults to the VASRD §4.124a general formula for major and minor seizures and fairly reflects the disability associated with conditions manifested primarily by syncope (analogous to major seizure), pre-syncope (analogous to minor seizure) or other non-specific alterations of sensorium.  Although the frequent daily episodes of momentary duration could not logically be equated to even minor seizures (all members concurred), it was deliberated whether the more prolonged and symptomatic episodes in evidence could be considered analogously equivalent to minor or major seizures.

Members agreed that the analogous 7099-7010 coding and rating option was a poor reflection of the disability since the captured arrhythmias were not correlated with symptoms.  With regards to the analogous 8999-8911 option, there was concern that the nature of those events was too speculative, since most were unwitnessed and poorly described, with considerable uncertainty as to whether there were one or two events associated with loss of consciousness (critical to 8911 rating criteria) and, it was further argued that the link with the disability rated for seizures under 8911 was too tenuous.  The Board consensus was that a higher rating recommendation under this analogous coding approach was not adequately supported.  There is convincing clinical evidence (tilt table result, nature of events) that the syncopal episodes were correlated with vagus nerve dysfunction and a consensus of members, considering and deliberating the principles of VASRD §4.7 (higher of two evaluations), agreed that the 8299-8210 coding approach was the most applicable to this case.  Members next considered whether a 30% rating for severe impairment under 8299-8210 was supported by the evidence.  Given the fleeting nature of the frequent episodes and infrequent occurrence of significant episodes and noting that the disability from the condition could be accommodated by modest lifestyle modifications, members agreed (including the member preferring an alternate coding approach) that the impairment was more reasonably characterized as moderate rather than severe.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), Board consensus was that there was insufficient cause to recommend a change in the PEB adjudication of the syncope 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 syncope condition and IAW VASRD §4.124a, the Board by a vote of 2:1 recommends no change in the PEB adjudication.  The single voter for dissent did not elect to submit a minority opinion.  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 20130414, 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, AR20140016355 (PD201301389)

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:

CF: 
(  ) DoD PDBR
(  ) DVA