RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2013-01743
BRANCH OF SERVICE:  AIR FORCE 	SEPARATION DATE:  20050322

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Security Forces Craftsman) medically separated for obstructive sleep apnea (OSA).  The condition could not be adequately rehabilitated to meet the physical requirements of his Air Force Specialty (AFS).  He was issued a temporary P4 profile and referred for a Medical Evaluation Board (MEB).  The “obstructive sleep apnea” was forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123.  No other condition was submitted by the MEB; however, the MEB narrative summary (NARSUM) identified and forwarded one other condition (loss of sensation right thumb).  The Informal PEB (IPEB) adjudicated obstructive sleep apnea as unfitting, rated 0%, citing application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The remaining condition was determined to be Category II (conditions that can be unfitting but are not currently compensable or ratable).  The IPEB also adjudicated a third condition (obesity) as Category III (conditions that are not separately unfitting and not compensable or ratable) which was not included on the MEB Board Proceedings or the NARSUM.  The CI made no appeals and was medically separated.  

CI CONTENTION:  He was given a higher rating for his conditions by the VA.  His complete submission is at Exhibit A.”

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 when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting.  Any conditions outside the Board’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the Board for Correction of Military/Naval Records.  Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the VASRD standards to the unfitting medical condition at the time of separation.  The Board has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions.  That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.  The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation. 

RATING COMPARISON:  

IPEB - Dated 20050117	VA* - (~12 Days. Pre-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Obstructive Sleep Apnea Status Post Surgery, on CPAP, Mild Social Industrial Adaptability Impairment	6847	0%	Obstructive Sleep Apnea Status-Post Uvulopalatopharyngoylasty and Genioglossal Advancement	6847	50%	20050310	
Other MEB/PEB Conditions x 2 (Not In Scope)	Other x 6 (equals SC, NSC & deferred)	
RATING:  0%	RATING:  50%	
*Derived from VA Rating Decision (VARD) dated 20050707 (most proximate to date of separation (DOS)).  
ANALYSIS SUMMARY:

Obstructive Sleep Apnea (OSA).  The service treatment record (STR) documents a history of excessive daytime somnolence (sleepiness).  The CI underwent a split-night polysomnogram (divided baseline sleep study followed by continuous positive airway pressure [CPAP] titration [calibration]).  The Epworth sleepiness scale ([ESS] self-administered questionnaire to assess level of daytime sleepiness or average sleep propensity) score of 16/24 demonstrated a moderate degree of daytime sleepiness.  Oxygen saturation levels remained between 95% and 99% and the respiratory effort related arousal (RERA) index was 37/hour.  The CPAP titration eliminated snoring, and abnormal respiratory events, and there were minimal arousals while on CPAP.  The medical interpretation listed upper airway resistance syndrome ([UARS] disorder characterized by airflow limitation due to increased upper airway resistance inducing arousals from sleep).  Suggested therapeutic options included CPAP, surgery, or an oral appliance.  The CI was unable to tolerate CPAP and was referred to otolaryngology.  The CI underwent an uvulopalatopharyngoplasty ([UPPP] surgical resection of uvula, tonsils, distal soft palate, and excessive lateral pharyngeal tissue to treat OSA).  At the sleep clinic follow-up the CI reported significant improvement, resolution of his excessive daytime somnolence, and the ESS score of 9/24 demonstrated a lack of daytime sleepiness.  The CI underwent a follow-up polysomnogram.  Oxygen saturation remained between 91 % and 98%, the RERA index was 18/hour, and the respiratory events pattern demonstrated UARS.  The degree of UARS was characterized as moderate and it was modestly improved compared to the previous study.  The medical interpretation confirmed a failure of the UPPP to cure his UARS.  Suggested therapeutic options included continued efforts to adapt to CPAP, further surgery, or a trial of an oral appliance.  The CI underwent a genioglossal advancement (surgical procedure in which tongue base is pulled forward to expand and stabilize the airway).  A dental sleep medicine consultation recorded an ESS score of 21/24 and they prescribed an oral appliance for sleep apnea treatment.  An adjustable mandibular advancement oral appliance was delivered and use was initiated.  The CI underwent surgical hardware removal because of a persistent wound with mandibular implant granulation tissue (wound surface vascular connective tissue forming granular projections) and pain.  

The narrative summary (NARSUM), 4 months before separation, recounted the history and interventions.  The CI complained of chronic sleepiness, fatigue, and difficulty keeping his oral appliance in his mouth at night.  He had been limited in advancing the adjustable appliance secondary to pain from tension at a certain threshold.  The examiner documented that since the CI had been relying solely on this oral appliance, “… his daytime somnolence has increased to dangerous levels.”  The CI stated “… he is unable to make his 22 mile drive home after work without pulling over to sleep in the middle of the trip, and is now afraid to drive with his wife and child in the car because of concerns of falling asleep while driving and causing an accident.”  The physical exam revealed the CI was mildly overweight, but was otherwise unremarkable.  The diagnosis listed OSA requiring CPAP.  The physician recommended the CI resume his CPAP as it had been effective early in his clinical course.  The compensation and pension (C&P) exam, two weeks before separation recounted the history and interventions.  The examiner reported the CI had severe sleep apnea which he attempted to correct with three surgical procedures.  The CI complained of chronic fatigue and presently used a CPAP mask which “works best.”  The diagnosis listed sleep apnea.  

The Board directed attention to its rating recommendation based on the above evidence.  The informal PEB, 2 months before separation, rated the OSA condition at 0% (VA code 6847; sleep apnea syndromes) citing status post-surgery, on CPAP, and mild social and industrial adaptability impairment.  The VA rating decision (VARD), citing the C&P exam 2 weeks before separation, rated the OSA condition at 50% (6847).  The VARD cited OSA diagnosed by sleep study, status post UPPP, genioglossal advancement, and hardware removal, hypersomnolence, fatigue, and CPAP use.  The OSA and associated fatigue was implicated in the commander’s statement, profile, MEB and PEB.  The preponderance of evidence showed that the CI was diagnosed with OSA and required CPAP for chronic treatment.  The required use of a breathing assistance device such as CPAP is consistent with the 50% rating under code 6847.  In the matter of the OSA condition, the Board unanimously recommends a disability rating of 50%, coded 6847 IAW VASRD §4.71a.

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 OSA condition, the Board unanimously recommends a disability rating of 50%, coded 6847 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; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of his prior medical separation:  

CONDITION	VASRD CODE	RATING	
Obstructive Sleep Apnea Status Post Surgery, on CPAP, Mild Social Industrial Adaptability Impairment	6847	50%	
RATING	50%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131023, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

Dear XXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2013-01743.

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.

Attachment:
Record of Proceedings 
cc:
SAF/MRBR