RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2014-00038
BRANCH OF SERVICE:  MARINE CORPS 	BOARD DATE:  20140723
SEPARATION DATE:  20051231

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty Sgt/E-5 (4641/Combat Photographer) medically separated for (overall effect) bradycardia and sick sinus syndrome, transient light headedness, chest pain, mild distal esophageal stricture currently asymptomatic, dyspnea on exertion and gastroesophageal reflux currently controlled.  The conditions could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS) or satisfy physical fitness standards.  He was placed on limited duty and referred for a Medical Evaluation Board (MEB).  The “sinoatrial node dysfunction” and “lumbago” conditions were forwarded to the Physical Evaluation Board (PEB) IAW SECNAVINST 1850.4E.  The Informal PEB adjudicated bradycardia and sick sinus syndrome, transient light headedness, chest pain, mild distal esophageal stricture currently asymptomatic, dyspnea on exertion, and gastroesophageal reflux (GERD) currently controlled as unfitting, rated at 0%.  The remaining conditions, migraines, chronic lower back pain and obesity conditions were determined to be Category III and not unfitting. The CI made no appeals and was medically separated.

CI CONTENTION:  “All conditions which were rated at 0% were worse @ that time.  All have become worse.  No Physical Exam was conducted.  Please review all medical conditions at the time of discharge.”  

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 Board rating determination for both the Category I and Category III conditions are addressed below.  No additional conditions are within the DoDI 6040.44 defined purview of the Board.  Any condition 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.

The Board acknowledges the CI’s information regarding the significant impairment with which his service-connected conditions continue to burden him.  The Board also acknowledges the CI’s contention that suggests a higher service rating should have been granted on the unfitting medical condition documented at the time of separation.  IAW DoDI 6040.44, the Board’s authority is limited to making recommendations on correcting disability determinations.  The Board’s role is thus confined to the review of medical records and all evidence at hand to assess the fairness of PEB rating determinations, compared to Veterans Affairs Schedule for Rating Disabilities (VASRD) standards, based on ratable severity at the time of separation and to review those fitness determinations within its scope (as elaborated above) consistent with performance-based criteria in evidence at separation.

RATING COMPARISON:

Service IPEB – Dated 20050914	VA* - (8 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bradycardia and Sick Sinus Syndrome	Category I
Overall Effect	0%	Bradycardia (Sick Sinus Syndrome)	7018-7011	0%	20060801	
Transient Light Headedness							
			Light Headedness	7011	NSC	20060801	
Chest Pain			Chest Pain	7011	NSC	20060801	
Mild Distal Esophageal Stricture currently Asymptomatic			Distal Esophageal Stricture and GERD	7346	10%	20060801	
GERD currently controlled							
Dyspnea on Exertion			Dyspnea	7011	NSC	20060801	
Migraines	Category III	Migraine Headaches	8100	0%	20060801	
Chronic Lower Back Pain	Category III	Chronic Lumbar Strain	5237	10%	20060801	
Obesity	Category IIII	No VA Entry	20060801	
Other x 0 (Not in Scope)	Other x 6	20060801	
Combined:  0%	Combined:  30%	
*Derived from VA Rating Decision (VARD) dated 20060912 (most proximate to date of separation)

ANALYSIS SUMMARY:  The PEB combined the bradycardia and sick sinus syndrome, light headedness, chest pain, distal esophageal stricture, dyspnea on exertion and gastroesophageal reflux conditions under a single disability rating for “overall effect” as permitted by DoDI 1332.38 (E3.P3.4.4).  This approach by the PEB reflects its judgment that the constellation of conditions was unfitting, but that each condition was not individually unfitting.  Since this is an intrinsic service prerogative outside the scope of the VASRD, the Board does not recommend separate codes and ratings in this circumstance unless members agree that one or more conditions were separately unfitting independently of overall effect.  In support of a recommendation for two or more separate ratings derived from a PEB overall effect adjudication, members must be satisfied, based on a preponderance of the evidence, that each condition recommended for separate rating would have independently resulted in MEB referral and a PEB finding that the member was unfit due to physical disability.  The Board’s initial charge in this case was therefore directed at determining if the PEB’s single overall effect rating was justified in lieu of separate unfit determinations and ratings.

Bradycardia and Sick Sinus Syndrome, Lightheadedness, Chest Pain and Dyspnea on Exertion Conditions.  In October 2003 the CI was hospitalized for evaluation of chest pain and bradycardia (slow heart rate).  A diagnosis of possible early sick sinus syndrome (heart rhythm disturbance in which the heart’s natural pacemaker does not work properly) was made at that time.  An echocardiogram (cardiac ultrasound) showed an ejection fraction of 60% (normal).  A cardiologist in April 2004 reported that dizziness was present for several years and occurred primarily upon arising quickly from a laying or sitting position and resolved spontaneously.  It was noted that symptoms of chest discomfort, dyspnea (shortness of breath) on exertion and dizziness could not be clearly linked to bradycardia.

At a follow-up cardiology visit in August 2004, it was reported that a cardiac catheterization showed normal left ventricular size and function.  Although a bradycardia was present at rest, heart rate response to exercise was normal.  Exercise stress testing was normal and a peak heart rate of 172 was achieved.  The cardiologist stated that the CI should not be allowed to operate heavy equipment or to obtain a pilot’s license.  The placement of a pacemaker to regulate heart rate was discussed, but would only be considered if symptoms impaired daily activities.  Current recommended treatment was a medication (pindolol) which hopefully would prevent symptomatic bradycardia; but which the CI had previously self-discontinued.
At the narrative summary (NARSUM) evaluation on 21 March 2005 (9 months prior to separation), the CI complained of chest pain that occurred 2-3 times per month, for duration of 30 to 45 seconds as well as frequent dizzy episodes.  He denied loss of consciousness.  Physical examination determined the CI to be alert.  Blood pressure and pulse rate were normal; however skipped heart beats were present.  The NARSUM examiner noted that the CI was allowed to operate a motor vehicle and opined that chest pain and exertional shortness of breath were due to the bradycardia and sick sinus syndrome.

The non-medical assessment (NMA) on 22 August 2005 (4 months prior to separation), stated that “because he needs specialty medication he cannot be considered worldwide deployable.”  It was noted that the CI regularly missed work for specialty follow-up care.

At the VA Compensation and Pension (C&P) exam dated 1 August 2006 (7 months after separation), the CI reported that orthopedic issues prevented him from playing basketball; however, he injured himself in August 2005 “when he was exercising or playing basketball.”  He complained of episodes of dizziness, lightheadedness, fatigue, chest pain and shortness of breath, but denied any episodes of loss of consciousness.  Chest pain lasted 15-30 seconds.  Running just a few feet could cause shortness of breath, but at times this symptom occurred at rest.  He was not taking the medication (pindolol) previously prescribed by his cardiologist because he did not feel like it “made any difference.”  Symptoms did not cause him to miss any work in his capacity as a loan officer for a mortgage company.  Physical exam showed a regular but low pulse rate.  On 12 September 2006, the VA rater reported that the exercise treadmill test performed in 2004 (not in evidence) reflected an exercise capacity of 15 metabolic equivalents (METs).

Directing attention to its recommendations, the Board first considered if the bradycardia and sick sinus syndrome condition met the Board’s threshold for separate rating (as elaborated above).  This condition was the basis for clinical concern and for any restricted activities recommended by the cardiologist (i.e. not engaging in operating heavy equipment or obtaining a pilot’s license).  The NMA indicated that it was the medication being taken for this condition and required specialty follow-up that represented an impediment to performance of duties.  Members agreed therefore, that the bradycardia and sick sinus syndrome condition was reasonably justified as separately unfitting.  Accordingly, it should be afforded separate disability rating IAW VASRD §4.104.  Although the transient light headedness, chest pain and dyspnea on exertion were not definitively linked to the bradycardia and sick sinus syndrome condition, an association was reasonably assumed, as noted by the NARSUM examiner and therefore, these conditions should appropriately be subsumed under the bradycardia and sick sinus syndrome condition.  Regardless of a clinical connection however, members agreed that the transient light headedness, chest pain and dyspnea on exertion conditions were not reasonably justified as separately unfitting, therefore they cannot be recommended for separate disability rating.

The VA assigned a 0% rating for the bradycardia and sick sinus syndrome condition under a combination 7018-7011 code (implantable cardiac pacemaker; ventricular arrhythmias – sustained); and found that chest pain, dyspnea and light headedness were not service-connected.  The CI’s disability is not specifically listed in the VASRD, but Board members agreed 7011 was a reasonable option.  Under this code, a 10% rating is justified for “workload of greater than 7 METs but not greater than 10 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; continuous medication required.”  Board members noted that the CI’s exercise capacity easily exceeded 10 METs.  However, the Board majority concluded that the “continuous medication required” stipulation was met and therefore a 10% rating was warranted on this basis.  The only other reasonable coding option, 7015 (atrioventricular block) did not provide a pathway to a higher rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the bradycardia and sick sinus syndrome condition, coded 7099-7011 IAW §4.104.

Mild Distal Esophageal Stricture and Gastroesophageal Reflux Conditions.  Due to nausea and vomiting, an upper endoscopy was performed in May 2002 which showed GERD and a distal esophageal stricture due to the reflux.  Medication resulted in some relief of vomiting, but frequent heartburn persisted.  The NARSUM examiner (9 months prior to separation) indicated that the GERD was “currently controlled” and that the esophageal stricture was “currently asymptomatic.”  At the MEB separation exam on 19 August 2005 (5 months prior to separation) the CI indicated that acid reflux was a current health issue.  The C&P examiner (7 months after separation) reported that medication “seemed to relieve his symptoms most of the time.  He does occasionally have burning in his esophagus and vomiting.”

As previously elaborated, the Board first considered if the mild distal esophageal stricture and gastroesophageal reflux condition met the Board’s threshold for separate rating.  The NARSUM examiner noted that the condition was controlled and asymptomatic, while the NMA made no mention of this condition.  There was no performance based evidence from the record that GERD or esophageal stricture significantly interfered with satisfactory duty performance.  The Board concluded therefore that this condition could not be recommended for additional disability rating.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that migraines, chronic lower back pain and obesity were not unfitting.  The Board’s threshold for countering fitness determinations is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.

Migraine Headaches.  The CI underwent two neurological evaluations in 2003 and 2004 for headaches.  The last clinical note in evidence regarding headaches was in March 2004.  The NARSUM examiner stated that migraines occurred two times per week and were treated with over the counter medication or “by going to sleep.”  The CI identified migraines as a current health issue at the separation exam, but did not list any current medications.  The C&P examiner reported that the CI experienced several headaches per month, for which he took Motrin and had not missed any work days due to migraines since separation 7 months previously.

Low Back Pain.  After playing basketball in 2000, the CI experienced the onset of low back pain.  Radiographic evaluation of persistent pain in 2003 revealed mild degenerative disc disease with small disc protrusion at L4-5 and L5-S1.  He was placed on LIMDU in 2003 and treated with pain medication and physical therapy.  He received one steroid injection in 2004.  The condition was exacerbated after a motor vehicle accident in January 2005.  The last clinical note in evidence regarding low back pain was in March 2005.  The NARSUM examiner indicated the pain was experienced “fairly continuously” since onset in 2000.  The chronic low back pain was characterized as “moderate and impacting ability to do PT.”  The NARSUM opined that the back pain should be considered disqualifying.  The CI identified back pains as a current health issue at the separation exam, but did not list any current medications.  He reportedly performed aerobic activity 5 times per week.  The exam noted no scoliosis and full flexion of the back.  The C&P examiner reported that the CI injured himself in August 2005 “when he was exercising or playing basketball.”  He had not missed any work days due to low back pain since separation 7 months previously.

The migraine headache and low back pain conditions were listed on the profiling section of the separation exam (DD Form 2808) and weight loss was advised for management of obesity.  None of the conditions were implicated in the NMA.  All were reviewed by the action officer and considered by the Board.  There was no performance based evidence from the record that any of these conditions significantly interfered with satisfactory duty performance.  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 any of the contended conditions and so no additional disability ratings are 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.  In the matter of the bradycardia and sick sinus syndrome condition, the Board by a vote of 2:1 recommends a disability rating of 10%, coded 7099-7011 IAW VASRD §4.104. The single voter for dissent did not elect to submit a minority opinion.  In the matter of the contended light headedness, chest pain, distal esophageal stricture, dyspnea on exertion and gastroesophageal reflux conditions, the Board unanimously agrees that it cannot recommend them for additional disability rating.  In the matter of the contended migraines, chronic lower back pain and obesity conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting.  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, effective as of the date of his prior medical separation:

UNFITTING CONDITION	VASRD CODE	RATING	
Bradycardia and Sick Sinus Syndrome	7099-7011	10%	
COMBINED	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131030, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

		
XXXXXXXXXXXXXXX
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 26 Feb 15 ICO XXXXXXXXXXXXXXXXX 
	 (c) PDBR ltr dtd 21 Jan 15 ICO XXXXXXXXXXXXXXXXX 
	 (d) PDBR ltr dtd 13 Jan 15 ICO XXXXXXXXXXXXXXXXX
	 (e) PDBR ltr dtd 5 Feb 13 ICO XXXXXXXXXXXXXXXXX
	 (f) PDBR ltr dtd 28 Feb 15 ICO XXXXXXXXXXXXXXXXX
          
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. XXXXXXXXXXXXXXX, former USN: Disability separation with final disability rating of 10 percent (increased from 0 percent) effective date of discharge.

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

     c. XXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 70 percent disability rating effective date of discharge.

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

     e. XXXXXXXXXXXXXXX, former USMC: Disability separation with final disability rating of 10 percent (increased from 0 percent) 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.

	XXXXXXXXXXXXXXX
	Assistant General Counsel
	  (Manpower & Reserve Affairs)