RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2013-01861
BRANCH OF SERVICE:  Army	BOARD DATE:  20150529
SEPARATION DATE:  20040208

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Healthcare Specialist) medically separated for Diabetes Mellitus.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS).  The CI’s profile permitted him to take the alternate aerobic (walk) portion of the Army physical fitness test.  He was issued a permanent P3/L3/H3 profile and was referred for a Medical Evaluation Board (MEB).  The MEB forwarded “insulin dependent diabetes mellitus” and “bilateral knee pain, left more than right” to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other condition was submitted by the MEB.  The Informal PEB (IPEB) did not consider the CI’s referred bilateral knee condition (as the original MEB did not forward this condition for PEB adjudication) and only adjudicated the referred diabetes mellitus condition as unfitting, rated 20%, with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI non-concurred with the IPEB and demanded a Formal PEB (FPEB).  The FPEB received a revised MEB submission, which now included the bilateral knee condition as mentioned above and adjudicated the diabetes mellitus as unfit rated 20%, with likely application of the VASRD; and adjudicated the bilateral knee condition as not unfitting.  The CI made no further appeals and was medically separated. 

CI CONTENTION:  “I feel that they made a mistake regarding my overall condition.  I also felt rushed through the whole process in Texas”.  [Sic]  

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:  

FPEB – Dated 20031003	VA* - (~3 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Diabetes Mellitus	7913	20%	Diabetes Mellitus	7913	20%	20040428	
			Hypertension Associated with Diabetes Mellitus	7101	0%		
			Erectile Dysfunction Associated with Diabetes Mellitus	7522	0%		
			Diabetic Retinopathy	6099-6011	NSC		
Bilateral Knee Pain	Not Unfitting	Chronic Left Knee Strain	5257	NSC		
		Chronic Right Knee Strain	5257	NSC		
Other x 0 (Not In Scope)	Other x 10	
RATING:  20%	RATING:  40%	
*Derived from VA Rating Decision (VARD) dated 20040916 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:   

Diabetes Mellitus.    The narrative summary (NARSUM) indicated that the history related to the onset of the CI’s condition of diabetes was unclear.  However, primary care clinic note dated 25 April 2003 documented the CI was first diagnosed in December 2002 and was treated with oral medications and calorie restriction (2200).  At that visit, the CI was started on insulin and referred to the diabetes clinic.  Although the CI was treated with insulin his glycosylated hemoglobin A1C in June 2003 was 13.6%; which is above the target range for diabetics (6-7%). The CI was treated in the emergency room (ER) on two occasions for dehydration; however, episodes of hypoglycemic reaction or diabetes ketoacidosis were not noted in any treatment record and the CI had no hospitalizations secondary to his diabetes.  Labs obtained in July 2003 recorded HBA1C of 14.6.  He was referred to nutrition and was prescribed dietary counseling, increased physical activity, and diet restrictions via behavior modification.  The CI had a BMI of 31.77 (obese).  He had blood glucose measures in the range of 400-500 that at times were erratic and in the 24-500 range.  The commander’s statement (3 March 2003), approximately 9 months prior to separation, documented the CI could not perform his duties secondary to reporting late to duty or missed duty because of multiple medical evaluations, and sick-call visits.  Additionally, he was not medically capable to perform basic military requirements such as physical fitness and operation of a tactical vehicle.  His profile included restriction due to insulin dependent diabetes, bilateral knee pain, low back pain and hearing loss.  His profile restricted duty assignments to assure him access to medications, refrigeration, and appropriate medical care.  It indicated that he had dietary restriction that would prevent him from consuming combat rations and there were limitations in running, marching, standing for long periods and lifting up to 40 pounds.  There were no clear restrictions of activity based solely on his condition of diabetes.  The MEB/NARSUM evaluation dated 16 July 2003, 7 months prior to separation, documented that the CI was treated and released from the ER on the previous day with a blood sugar of 583. His physical examination recorded height of 77 inches and weight of 260 pounds.  The examiner stated, “The patient is presently stable as he takes his insulin with the occasional elevation.”  The diagnosis of insulin-dependent diabetes mellitus was recorded and there was no recommendation made to restrict activities based on this condition.  An addendum to the MEB dated 12 September 2003 noted glucose level taken 16 August 2003 was 301.  At the VA Compensation and Pension (C&P) evaluation dated 28 April 2004, 2 months after separation, the CI reported no symptoms (neurological, vascular, cardiac, or urological) and no restriction of activities.  The examiner documented that the CI has specialty care visits every three months.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB and VA both rated the condition at 20% coded 7913 (Diabetes mellitus); 20% rating under this code requires the use of insulin or hypoglycemic agent and a restricted diet.  A higher rating of 40% requires insulin, diet restriction and regulation of activities.  Beyond the 40% rating in addition to the above requirements, there must be evidence of worsening of disease state, such as hospitalizations, frequent specialty care visits, and diabetic complications.  Although the profile indicated certain restrictions on physical activities, more likely than not due to his other profiled conditions, the nutritionist prescribed increased exercises and the physician stated, his condition of diabetes “does not affect any activities whatsoever.”  Additionally, the record demonstrated there were difficulties controlling his blood sugars; however, there were no recorded episodes of hypoglycemia or ketoacidosis requiring treatment, and no hospitalizations.  The Board members agreed the evidence reflected no impairment in ordinary conditions of daily life, including employment and no medically prescribed avoidance of strenuous activities due to her diabetes.  The Board unanimously agreed that the profile restrictions and permissions did not meet the VASRD 7913 criteria for regulation of activities (avoidance of strenuous occupational and recreational activities) and agreed that the 40% rating criteria were not reasonably supported by the evidence at hand.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication of the insulin-dependent diabetes mellitus condition.

Contended PEB Conditions.  

Bilateral Knee Pain.  The Board’s main charge is to assess the fairness of the PEB’s determination that the bilateral knee pain condition was not unfitting.  The Board’s threshold for countering fitness determinations requires a preponderance of evidence, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  The Board noted that the condition was profiled and the commander’s statement implicated the left knee pain.  However, the review of the evidence showed that the NARSUM addendum dated 12 September 2003 documented flexion to 140 degrees bilaterally (NL=140); absence of tenderness to palpation, absence of clicks or catches in the patella, and a normal gait.  The examiner documented bilateral knee pain, left more than right.  In October 2003, that same examiner documented pain severity “minimal” and frequency “intermittent.”  The C&P examination of bilateral knees, 2 months after separation, was normal and radiographs of each knee were normal.  The VA rating decision noted that his condition was not considered chronic because there was no permanent residual or chronic disability, therefore, service connection was denied. The bilateral knee pain condition was judged not to fail retention standards.   Although the commander’s performance statement implicated the left knee as a condition that interfered with satisfactory duty performance, the Board concluded that preponderance of evidence was not overcome to support a finding that either the CI’s left knee or right knee or a combination of the knees would have made him separately unfit.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the bilateral knee pain condition and so no additional disability rating is recommended.

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 diabetes mellitus condition and IAW VASRD §4.119, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended bilateral knee pain condition, the Board unanimously recommends no change from the PEB determination as not unfitting.  There were no other conditions within the Board’s scope of review for consideration.  

RECOMMENDATION:  The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination. 

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

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 XXXXXXXXXXXXXXX, AR20150012510 (PD201301861)

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:

Encl		
						         
CF: 
(  ) DoD PDBR
(  ) DVA