RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXX	CASE:  PD-2014-00007
BRANCH OF SERVICE:  NAVY	BOARD DATE:  20140923
SEPARATION DATE:  20070123

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty PO1/E-6 (IT1/Information Systems Technician) medically separated for back pain due to kidney disease.  The condition could not be adequately rehabilitated to meet the physical requirements of her Rating or satisfy physical fitness standards.  She was placed on limited duty (LIMDU) status and referred for a Medical Evaluation Board (MEB).  The MEB forwarded four conditions, “autosomal dominant polycystic disease,” nephalgia back pain attributed to polycystic kidney disease,” “hypertension” and “gerd” to the Informal Physical Evaluation Board (IPEB) for consideration.  No other conditions were submitted by the MEB.  The IPEB adjudicated “nephralgia back pain attributed to polycystic kidney disease” as unfitting, rated at 0%, under code 7533 respectively using Veterans Affairs Schedule for Rating Disabilities (VASRD).  The IPEB adjudicated the “hypertension,” “autosomal dominant polycystic disease” conditions as Category II and the “GERD” condition as Category III.  The CI made no appeals and was medically separated.

CI CONTENTION:  “I continue to suffer from severe pain in my back at this point I am prescribed 120 Percocet’s a month for pain management.”

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 back pain due to kidney disease (as described by the PEB in its finding of Category I and II conditions) 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 Naval Records.

RATING COMPARISON:

Service IPEB – Dated 20061018	VA - (1 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Nephralgia Back Pain Attributed to Polycystic Kidney Disease	7533	0%	Intervertebral Disc Syndrome with Herniated Disc L Spine	5243	10%	20061216	
			Intervertebral Disc Syndrome of the Sciatic Nerve, Left Lower Extremity	8520	10%	20061216	
			Intervertebral Disc Syndrome of the Sciatic Nerve, Right Lower Extremity	8520	10%	20061216	
Hypertension	Cat II	Polycystic Kidney Disease With Hypertension	7533-7504	10%	20061216	
Autosomal Dominant Polycystic Disease	Cat II					
Other x1 (not in scope)	Other x12	20061216	
Combined:  0%	Combined:  50%	
Derived from VA Rating Decision (VARD) dated 20070307(most proximate to date of separation)

ANALYSIS SUMMARY:  IAW DoDI 6040.44, the Board’s authority is limited to making recommendations on correcting disability determinations.  The Board reviews medical records and other available evidence to assess the fairness of PEB rating determinations, using the VASRD standards, based on ratable severity at the time of separation.

Back Pain due to Kidney Disease.  The CI had a well-documented history of polycystic kidney disease since November 1998.  In January 1990, the CI’s nephrologist started her on treatment for sustained hypertension (HTN).  While she was able to complete a 6-month cruise at the beginning of her Navy career; over the ensuing 7 years, the CI began experiencing numerous complaints of left sided flank and back pain.  These complaints of left side flank and back pain led to numerous emergency room visits (treatment for pain and HTN control) and two extended periods of LIMDU. .The service treatment records (STRs) documents that the CI was taking five medications to manage her HTN and post diagnostic studies confirmed an increase in size of her left kidney; a surgical procedure was performed to remove cysts in an attempt to reduce her pain.  When she experienced only mild improvement in her back pain symptoms, a magnetic resonance imaging (MRI) study of her lumbar spine was performed and revealed a herniated disc at L4-5 with impression on the left and right nerve roots at that level.  She did report occasion mild low back pain, but stated that that was not the pain which caused her to seek emergency room treatment.  Additionally, there was only one entry in the STRs (3 months prior to separation), which documented any complaint related to radicular symptoms from her herniated lumbar disc.

The narrative summary (NARSUM) (prepared 4 months prior to separation), noted the pain was intermittent in the mid region of back, mostly on the left, occasionally occurring on the right as well.  The pain was described as waxing and waning without exacerbating or relieving features and not related to trauma, exercise, or activity when it occurred.  The examiner noted that the CI was taking five medications for blood pressure control.   Essentially, the CI physical examination was normal including blood pressure.  All laboratory values related to kidney function were normal.

At the VA Compensation and Pension (C&P) exam performed a month prior to separation, the CI reported a history similar to that summarized above.  During the physical exam, the examiner revealed normal blood pressure with a normal gait.  Her lumbar spine range-of-motion measurements were normal with non-radiating pain at the end of motion without muscle spasm.  Also documented was slight weakness of the left and right hip muscles with “sensory deficit” of the medial and lateral aspect of both legs.  Her reflexes were normal.  All radiologic and laboratory tests performed at that exam were normal.

The Board directs attention to its rating recommendation based on the above evidence.  The PEB adjudicated the nephralgia back pain attributed to polycystic kidney disease by applying VASRD code 7533 (cystic diseases of the kidneys) and rated at 0%.  They also listed hypertension as a related Category II condition.  The VA applied the combination code of 7533-7504 (chronic pyelonephritis) and rated the polycystic kidney disease with HTN at 10% citing, the “…long-term drug therapy, one or two hospitalizations per year, or intermittent intensive management” aspects of the chronic pyelonephritis rating criteria.  There was no evidence that the CI suffered from chronic pyelonephritis, as required for use of code 7504.

Additionally, the VA granted a combined 30% rating for the CI’s symptoms related to intervertebral disc syndrome.  Although the CI did have a herniated disc documented by MRI, there was little STR evidence that her unfitting back pain was caused by any lumbar spine condition.  Board members agree that the CI’s unfitting back pain was attributable to her polycystic kidney disease as opposed to her herniated disc.  The Board reviewed all evidence related to the CI’s herniated disc and members agree that her low back pain condition was not unfitting.  According to VASRD code 7533, rating polycystic kidney disease (using the renal dysfunction criteria as directed) requires an assessment of both renal function and HTN.  The code 7533 refers to VASRD code 7101 (hypertensive vascular disease), for rating the HTN component of the renal dysfunction criteria.  All evidence related to the CI’s kidneys documented completely normal renal function prior to separation.  However, the evidence supports that the CI had longstanding, sustained HTN that required five medications to control.  While there is no documentation of the initial blood pressure readings prior to initiation of medication therapy, the CI was put on LIMDU status due to uncontrolled HTN.  The 10% rating criteria for code 7101 states “...minimum evaluation for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control”.  Board members agree that the CI met this 10% rating criteria under code 7101.  Using the criteria in code 7101 yields a 30% rating under code 7533 that states, “…or hypertension at least 10 percent disabling under diagnostic code 7101.”  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 nephralgia back pain attributed to polycystic kidney disease 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 nephralgia back pain attributed to polycystic kidney disease condition, the Board unanimously recommends a disability rating of 30%, coded 7533 IAW VASRD §4.115b.  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.

UNFITTING CONDITION	VASRD CODE	RATING	
Nephralgia Back Pain Attributed to Polycystic Kidney Disease	7533	30%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131221, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

		
XXXXXXXXXXXXXX
President
Physical Disability Board of Review

MEMORANDUM FOR COMMANDER, NAVY PERSONNEL COMMAND
		   DEPUTY COMMANDANT, MANPOWER & RESERVE AFFAIRS
	                          
Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS          

Ref:   (a) DoDI 6040.44
       (b) PDBR ltr dtd 29 Mar 15 ICO XXXXXXXXXXXXXX   
	 (c) PDBR ltr dtd 25 Mar 15 ICO XXXXXXXXXXXXXX
	 (d) PDBR ltr dtd 23 Mar 15 ICO XXXXXXXXXXXXXX
	 (e) PDBR ltr dtd 29 Mar 15 ICO XXXXXXXXXXXXXX
	 (f) PDBR ltr dtd 29 Mar 15 ICO XXXXXXXXXXXXXX

1.  Pursuant to reference (a) I approve the recommendations of the Physical Disability Board of Review set forth in references (b) through (f).

2.  The official records of the following individuals are to be corrected to reflect the stated disposition:

     a. XXXXXXXXXXXXXX, former USMC: Placement on the Permanent Disability Retired List with a disability rating of 30% effective date of discharge.

     b. XXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a disability rating of 30% effective date of discharge.

     c. XXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a disability rating of 30% effective date of discharge.

     d. XXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a disability rating of 30% effective date of discharge.

     e. XXXXXXXXXXXXXX, former USMC: Placement on the Permanent Disability Retired List with a disability rating of 30% effective date of discharge.
 
3.  Please ensure all necessary actions are taken to implement these decisions, including the recoupment of disability severance pay, if warranted, and notification to the subject members once those actions are completed.

	XXXXXXXXXXXXXX
	Assistant General Counsel
                                       (Manpower & Reserve Affairs)