RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXX	CASE:  PD-2013-01980
BRANCH OF SERVICE:  Army	BOARD DATE:  20150414
SEPARATION DATE:  20040502

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-3 (Nuclear Medicine Specialist) medically separated for pseudotumor cerebri (increased pressure in the skull).  The pseudotumor cerebri condition could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty, but she was authorized to perform an alternate physical fitness test.  She was issued a permanent P3 profile and referred for a Medical Evaluation Board (MEB).  The “pseudotumor cerebri,” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other condition was submitted by the MEB.  The Informal PEB (IPEB) adjudicated “pseudotumor cerebri” as unfitting, rated 0% with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI appealed and provided a written statement to the PEB President who affirmed the IPEB decision and forwarded the CI’s case for US Army Physical Disability Agency (USAPDA) review.  The USAPDA upheld the PEB finding and the CI was medically separated.

CI CONTENTION:  The CI elaborated no specific contention in her application.

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 Veterans Affairs Schedule for Rating Disabilities (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 20040126	VA* - (~2 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Pseudotumor Cerebri	8199-8100	0%	Pseudotumor Cerebri	8099-8045	10%	20040706	
Other x 0 (Not In Scope)	Other x 10	
RATING:  0%	RATING:  40%	
*Derived from VA Rating Decision (VARD) dated 20041203 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Pseudotumor Cerebri.  The CI was seen in the Neurology Clinic on 7 January 2000 with the complaint of neck pain and paresthesias of both upper extremities attributed to a fall in July 1999.  A  note in the service treatment record (STR) dated 7 November 2001 indicated the CI sought emergency care of an acute onset of a severe headache associated with nausea, vomiting, and photophobia.  Symptoms resolved with IM (intramuscular), Compazine (prochlorperazine), to treat nausea; and the CI was prescribed Midrin (isometheptene mucate, dichloroalphenazone, and Acetaminophen), to treat migraine headaches.  A CT scan with contrast was normal.  In February 2002 she had a headache that lasted for a month associated with sinusitis that was treated with antibiotics.  In May 2002, the CI had a headache for 48 hours after taking “Go-Lytely” for fecal impaction that resolved with IM (intramuscular) Toradol (ketorolac), a nonsteroidal anti-inflammatory analgesic).  In July 2002 the CI had a Norplant (levonorgestrel) contraceptive removed.  The CI developed spasms of the back after a spinal tap confirmed the diagnosis of pseudotumor cerebri, which was treated with IM Toradol and Valium (diazepam), to treatment muscle spasms.  In October 2002, the CI was evaluated for blurred vision, headaches, and papilledema (optic disc swelling resulting from increased intracranial pressure) of the eyes noted a week earlier.  A repeat CT scan in October 2002 was normal.  The CI presented to the Emergency Room (ER) on 9 November 2002 with a headache, which followed a spinal tap with an elevated opening pressure and received IM Toradol.  A nutrition consultation suggested dietary strategies for CI to lose weight, which at the time was 208 pounds.  The CI was prescribed Diamox (acetazolamide), a diuretic for the headaches.  Papilledema was reported to have decreased with the treatment, but the headaches persisted.  A headache required an ER visit; treatment was with IM Toradol in December 2002.  Headache symptoms were limited when she was taking the Diamox, but when she voluntarily stopped the medication, she noticed the change and the Diamox was resumed at a higher dose.  A neurologic evaluation in January 2003 noted she also had occasional numbness, tingling, and paresthesias when sitting and lying down.  Because pseudotumor cerebri is associated with obesity, the CI was prescribed phentermine, an appetite suppressant, to promote weight loss along with diet and exercise in March 2003.  Another headache required an ER visit with IM Toradol in May 2003.  The dose of phentermine was decreased since the CI felt the headaches were worse and the Diamox was also discontinued in July 2003.  She received IM Toradol twice in July 2003 in the clinic and ER.  On 19 August 2003, the CI underwent a spinal tap and her pressure was 380 mm Hg (Normal 7-15 mm Hg with an upper limit at 20-25 mm Hg).  Papilledema continued to improve and visual field testing was within normal limits in November 2003, although the CI had ER and clinic visits in December 2003 and January 2004 requiring IM Toradol.

The MEB narrative summary dated 24 December 2003 indicated the CI first presented for evaluation after an optometry evaluation revealed papilledema.  She had complaints of blurred vision and headaches of intermittent nature for several years as well as syncope, which was never witnessed, and a history of carpal tunnel symptoms.  Laboratory tests of the blood and cerebrospinal fluid were essentially normal.  Spinal tap opening pressures were elevated initially as well as on subsequent spinal taps and ranged from 360 mm Hg to 380 mm Hg.  In November 2003 the Diamox dose was increased and she stated she was without any significant neurologic symptoms at the time of the examination and was quite functional.  She was able to generally perform her work in an asymptomatic fashion when taking medication even while she was experiencing significant headaches or visual changes.  At the MEB physical examination dated 6 October 2003 the examiner noted mild blurring of the optic cup margins and flattening of the optic cups; and her blood pressure was 134/72.  A permanent P3 profile was issued on 10 October 2003 for pseudotumor cerebri and papilledema with limitations of functional military activities, physical training, and deployability.  Additionally, she was required to be in proximity to a medical center.  The commander’s statement dated 23 October 2003 indicated she performed her duties satisfactorily when her condition allowed her to work, but it did impact the amount of time she could perform her duties.

At the VA Compensation and Pension examination dated 6 July 2004, performed 2 months after separation, the CI reported headaches, transient visual obscuration (blurred vision), progressive loss of peripheral vision, blurring and distortion, and visual loss.  The CI presented with uncontrolled vomiting, which occurred three times since 1998, fainting, which occurred ten times, and difficulty seeing on occasion.  She had five lumbar punctures to control the intracranial hypertension and took Diamox for the pseudotumor cerebri.  At the time of the examination the CI weighed 190 pounds.  The examiner noted moderate papilledema and an otherwise unremarkable physical examination except for early arthritis of the knees.  Additionally, she had probable Type II diabetes based on a fasting glucose of 135.2 mg/dL (Normal 65-105 mg/dL).

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 0% rating using analogous code 8199-8100 (Migraine headache) for pseudotumor cerebri without prostrating headaches, which was upheld by the USAPDA.  The VA likewise assigned a 10% rating using analogous code 8099-8045 (Residuals of traumatic brain injury) for pseudotumor cerebri based on the CI’s subjective complaints of headaches, visual disturbances, and memory loss.  The Board sought a route for a higher rating.  While the PEB indicated the CI did not have prostrating headaches, she did have headaches that were of significant severity to cause her to have at least seven ER and clinic visits in the year preceding separation for IM Toradol to relieve her pain.  It would not be inappropriate to consider the headaches that led to those visits to be close to prostrating, if not truly prostrating, but for the use of Toradol.  Therefore, using analogous code 8100 would be justified and warrant at least a 10% rating.  Documentation proximate to separation to support a 30% rating was reviewed to address the frequency of those headaches necessitating medical intervention in her last few months in the service.  The discussion by the Board members also included ER and clinic visits as well as an issue raised in the CI’s appeal, which indicated as a medic, she received treatment without official, formal entries being entered into the record.  Because the CI did not have marked fatigability or headaches requiring rest periods most days, a 40% rating using code 8099-8045 is not applicable.  Use of VASRD code 6080 (Visual field defects) was considered, but the CI’s visual fields were normal at the last recorded eye examination proximate to separation.  However, the CI had increased intracranial pressure.  VASRD §4.20 states “When an unlisted condition is encountered it will be permissible to rate under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous.”  Code 7908 (Acromegaly), which states “Evidence of increased intracranial pressure (such as visual field defect), arthropathy, glucose intolerance, and either hypertension or cardiomegaly” with a rating of 100% was considered.  However, the CI had neither significant hypertension (high blood pressure) requiring treatment, nor cardiomegaly at the time of separation, although she had increased intracranial pressure, arthropathy, and incipient glucose intolerance.  Nonetheless, the use of the analogous code 7905 (Hypoparathyroidism), which states “Marked neuromuscular excitability, or; paresthesias (of arms, legs, or circumoral (around the mouth) area) plus either cataract or evidence of increased intracranial pressure [such as papilledema]” does line up with the CI’s symptoms of paresthesias and increased intracranial pressure and rates 60%; however, the CI’s laboratory blood tests were reported to be normal, but the STR was silent on whether a parathyroid hormone level to evaluate her parathyroid status was obtained.  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 pseudotumor cerebri 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 pseudotumor cerebri condition, the Board unanimously recommends a disability rating of 30%, coded 8199-8100 IAW VASRD §4.119.  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:

CONDITION	VASRD CODE	RATING	
Pseudotumor Cerebri	8199-8100	30%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130924, 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 XXXXXXXXXXXXXXXXXXXX, AR20150012482 (PD201301980)

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