RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXX	CASE:  PD-2013-01602
BRANCH OF SERVICE:  army 	BOARD DATE:  20141104
DATE OF PLACEMENT ON TDRL:  20030706
Date of Permanent SEPARATION:  20040720

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty Army SPC/E-4 (88M1O/Motor Transport Operator) medically retired and placed on the temporary disability retired list (TDRL) for asthma, food allergies and eczema. These conditions could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty (MOS) or satisfy physical fitness standards.  She was issued a permanent P3 profile and referred for a Medical Evaluation Board (MEB).  The conditions, characterized as “chronic eczema”, “food allergies” and “asthma”, were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded three other conditions (allergic rhinitis, headaches and pes planus) for PEB adjudication.  The Informal PEB adjudicated her asthma and food allergies together as unfitting, rated at 30% and eczema as unfitting, rated at 10%.  The remaining conditions were determined to be not unfitting.  The CI made no appeals and was placed on the TDRL with a combined rating of 40%.  The re-evaluation TDRL MEB exam addressed both the asthma and eczema conditions, but did not address the food allergies condition.  The TDRL IPEB adjudicated the asthma and eczema as unfitting; rated at 10% and 0%.  The CI submitted a written rebuttal to the IPEB’s president, who after reviewing the IPEB’s proceedings, re-affirmed the original IPEB findings and ratings.  The CI made no further appeals and was medically separated.

CI CONTENTION:  “At separation I was at 40%. It was dropped to 0% from the Army.”

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 ratings for the unfitting asthma, allergy and eczema conditions are 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.

RATING COMPARISON:  

Final Service PEB - 20040624	VA (13.5 Months Prior to Adjudication Date*)  
Effective 20030707	
On TDRL – 20030707	Code	Rating	Condition	Code	Rating	Exam	
Condition		TDRL	Sep.					
Asthma, with Normal Spirometry	
6602
	30%	10%	Asthma	6602	30%	20030606	
Food Allergies (including MREs)**				Allergic Rhinitis	6522	0%	20030606	
				Multiple Food Allergies	7199-7118	0%	20030606	
Eczema	7806	10%	0%	Atopic Dermatitis	7806	0%	20030606	
Others x 3 (Not in Scope)	                                 Others x 1 (Not in Scope)		
Combined:  40% → 10%	Combined: 30%	
*Reflects VA rating exam proximate to TDRL placement; no VA rating evidence proximate to permanent separation.             **Not addressed by the Final Service PEB.

ANALYSIS SUMMARY:  

Asthma Condition.  The DA Form 199 dated 20030403, section 8.b states: “asthma, aggravated by strenuous physical activity and a variety of environmental allergens and foods and unable to wear the chemical protective mask, requires daily inhaled corticosteroids and beta agonists”. 

In January 2003, the CI had a pulmonary function test (PFT) that revealed mild improvement of respiratory symptoms post bronchodilator treatment indicating possible asthma.  A repeat PFT in June 2003 continued were poor, FEV1 and FVC at 70% and 75%, respectively.  The diagnosis of asthma was established; [CI’s] had symptoms of shortness of breath (SOB); wheezing and coughing that worsened with running or exercise.  Initially treated with profiled restrictions and an “as needed” rescue medication, Proventil (inhalational “non-steroid” bronchodilator); both Advair (inhalational steroid/bronchodilator combination) and Singulair (oral indirect-acting bronchodilator) were added later to her medication regimen.  Additionally, she had various food and environmental allergies which often were associated with her respiratory symptoms.

The MEB narrative summary (NARSUM) performed on 13 March 2003 (4 months prior to TDRL placement); the CI reported the inability to wear her chemical protective mask for more than 45 minutes because of difficulty breathing.  She could not run more than 15 minutes but was able to walk at her own pace and distance without limitation.  Her pulmonary physical examination was normal.  There was no history of hospital admissions or courses of systemic steroids.

The commander’s statement reflected that the CI’s medical condition did not impact her ability to complete assigned tasks, but rather increased the risk of becoming a [workplace] casualty as a result of her asthma.  Her permanent profile listed asthma and two other conditions.  Various pharmacy authored profiles validated the prescribed medications as stated above.

At the VA Compensation and Pension (C&P) examination (a month prior to TDRL placement), the CI reported SOB with exertion, but “feeling better” by taking her prescribed medications.  Her pulmonary focused physical examination was normal.  The VA examiner also cited PFT findings that were obtained over the previous year.  There was no evidence of current PFT testing was performed.  The TDRL re-evaluation physical exam, dated 30 April 2004 (3 months prior to permanent separation), the examiner noted continuous use of inhaled corticosteroids.  Her pulmonary focused physical examination was normal.  Her diagnosis remained moderate / persistent asthma and her condition was described as “currently stable”.  The PFT evaluations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized below.

DOS 20030706
Pulmonary Exam	MEB ~4 Mo. Pre-TDRL (20030313) 	VA ~1 Mo. Pre-TDRL entry
(20030606) 	MEB ~6 Mo.  Pre-TDRL exit (20040123) 	TDRL NARSUM ~3 Mo.  Pre-TDRL exit (20040430) 	
FEV1 (% Predicted)	76%	cited remote (>1 year) PFT	95%	-	
FEV1/FVC	-		118%	-	
Meds	Inhaled corticosteroids	Inhaled corticosteroids	-	Inhaled corticosteroids	
§4.97 Rating	30%	30%	0%-30%	30%	

The Board directs attention to its rating recommendation based on the above evidence.  The PEB bundled the asthma condition with the food allergies and rated under VASRD code of 6602 at 30% for TDRL placement, citing corticosteroid use and 10% at permanent separation, citing intermittent bronchodilator use.  The VA separately rated asthma at 30% and food allergies analogously under 7118 (angioneurotic edema) at 0%.

The Board first considered whether the food allergy condition remained separately unfitting, having decoupled it from the combined PEB adjudication.  Although the primary condition in this case was asthma, the record clearly revealed that occasionally, the allergic response to certain foods included “asthma-like” respiratory symptoms, but not always.  Members deliberated and agreed that the food allergies could be contributors to the primary condition, but was not judged to be a separately unfitting condition and accordingly cannot be recommended for a separate rating.

The PEB’s TDRL rating was IAW VASRD §4.97 which defines both PFT derived criteria and clinical treatment criteria for rating under 6602.  The non-pulmonary function test’s criteria under 6602 were “intermittent inhalational or oral bronchodilator therapy” for 10%; “daily inhalational or oral bronchodilator therapy, or; non-daily inhalational anti-inflammatory medication” for 30% and, “intermittent (at least 3 per years) courses of systemic (oral or parenteral) corticosteroids” for 60%.  The record did not reflect her being placed on corticosteroids; therefore, Board members agreed that the initial 30% rating for TDRL placement was appropriate.  With regards to the permanent rating recommendation, all Board members agreed that the §4.97 threshold for the 60% rating was not applicable.  The TDRL NARSUM dated 30 April 2004 (3 months prior to removal from TDRL) clearly revealed her with continued use of (non-systemic) inhaled corticosteroids thus supporting a 30% impairment level under code 6602.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a permanent disability rating of 30% for the asthma condition.

Skin Condition.  The CI was formally diagnosed with atopic dermatitis (eczema-rash) flare-ups in early 2003.  Referred to dermatology notes in CI’s STR, her skin symptoms improved with topical medication.  At the NARSUM, she reported “chronic problems” with hand and facial dermatitis which were aggravated by her duty in the motor pool by being constantly exposed to solvents, grease and dirt.  Her physical examination revealed hyperpigmentation and swollen dermatitis-type rash on the hands and anterior elbows.

At the VA C&P examination (a month prior to TDRL placement), the CI had no new complaints and her skin exam was normal.  At the TDRL re-evaluation (3 months prior to permanent separation), the CI reported eczematous flare-ups approximately every other month with a duration of 2 weeks each episode.  She took antihistamines as needed for the flare-ups.  The physical examination revealed several non-infected areas of “resolving eczema” on her shoulders, upper back and extremities.  The skin condition was implicated in the commander’s statement and was profiled as “allergic rashes”; one of three diagnoses.

Both the PEB and VA rated the skin condition under VASRD code 7806 (dermatitis or eczema).  The PEB rated the skin condition at 10% upon initial placement on TDRL and 0% at permanent separation citing aggravation of a pre-existing skin condition with minimal surface area involvement, respectively.  VASRD §4.118 defines both involved body surface area (BSA) derived criteria and clinical treatment criteria for rating under 7806.  The BSA criteria involves levels of less than 5%, 5-20%, 20-40% and 40% for total body; corresponding to impairments of 0%, 10%, 30% and 60%, respectively.  Board members agreed that the evidence of a normal skin examination by the VA near the time of TDRL entry would not support a higher rating than the PEB’s current 10%.  

With regards to the permanent rating recommendation, Board members acknowledged that the TDRL re-evaluation physical examination did not accurately list the amount of BSA involved, but rather stated “body areas” such as upper back, shoulders and extremities.  Based upon practical and literature cited medical principles, Board members concluded that the cited involved body areas would reasonably be considered at least 5% total BSA.  The examiner stated “several” areas of lesions were present, but members further agreed that greater than 20% BSA was not implied by that same description.  Therefore, after due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a permanent disability rating of 10% for the skin 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 asthma condition and IAW VASRD §4.97, the Board unanimously recommends no change in the PEB adjudication for the period of temporary retirement and a 30% rating at permanent retirement.  In the matter of the skin condition and IAW VASRD §4.118, the Board unanimously recommends no change in the PEB adjudication for the period of temporary retirement and a 10% rating at permanent retirement.  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 her prior medical separation.  

UNFITTING CONDITION	VASRD CODE	RATING	
		TDRL	PERMANENT	
Asthma	6602	30%	30%	
Eczema	7806	10%	10%	
COMBINED	40%	40%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130923, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

			

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 XXXXXXXXXXXXXXXXX, AR20150002640 (PD201301602)

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 40% 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 40% 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