RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00122
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060629

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E4, Financial Specialist, medically separated for “lymphedema praecox…left foot and ankle…” with a disability rating of 20%.  

CI CONTENTION:  CI’s condition was debilitating, affecting her “mentally, emotionally, socially and physically.”  The CI’s complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  It is limited to those conditions determined by the Physical Evaluation Board (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 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:  

SERVICE PEB - 20060512	VARD -20061016	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Lymphedema Praecox (Left)	7199-7121	20%	Chronic Lymphedema Left Leg	7199-7120	20%	20060803	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Lymphedema Praecox.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s swollen left leg and ankle condition began in May 2001 following pregnancy.  Over the following years, her left leg progressively worsened with swelling and pain.  Evaluation by Internal Medicine found her free of any underlying disease.  

Despite treatment, the leg and ankle condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for an MEB.  The MEB forwarded “left leg swelling” for PEB adjudication.  The initial PEB was discontinued for additional information and the second MEB referred “Lymphedema Praecox” to the PEB.  

At the time of the Vascular Surgery clinic appointment (Addendum to MEB) on 20 March 2006 (3 months prior to separation), the CI reported that she was unable to wear boots or perform physical fitness training due to the swelling and pain.  The examiner stated that “the left leg is edematous from the toes to the knee in a typical lymphedema pattern.  There are no skin changes.  The venous and pulse exams are normal.”  The CI had undergone multiple imaging examinations which have been negative.  

The MEB examination conducted on 1 May 2006 (2 months prior to separation) the CI reported her condition was worse and not going to change.  There was no significant family history of primary lymphedema.  Interval history indicated that the CI had years of a “two component swelling of the left foot and ankle, brawny edema and pitting edema.  Only the pitting edema can be controlled with elevation and compression stockings.  [The CI] has been refitted with compression stockings ….”  The MEB physical performed on 25 April 2006 documented 2+ brawny edema plus trace to 1+ pitting edema of the left foot and ankle.  The examiner noted the condition would not improve without “scrupulous care” and the CI’s condition interfered with her military duties.  

At the VA Compensation and Pension (C&P) examination on 3 August 2006 (2 months after separation) the CI reported burning pain and swelling in her left leg and foot.  Physical examination showed the CI had a normal gait when walking, and no impairment in the functioning of joints.  The CI was noted to have swelling of the left foot without pitting.  An endocrine exam noted that hair and skin was normal.  The examiner stated the swelling was not relieved by elevation.  

The Board noted the evidence supplied by the CI from 2013, including pictures with discolored edema; however, they were adjudged as post-separation worsening and not indicative of the CI’s disability proximate to separation (as stated above, any post-separation progression or complications of service-connected conditions should be addressed to the VA).  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the lymphedema praecox (left foot and ankle) condition 20% analogously coded 7199-7121 (post-phlebitic syndrome) citing “rated as persistent edema.”  The VA rated the chronic lymphedema, left leg condition 20% analogously coded 7199-7120 (varicose veins) citing persistent edema and the 20% rating criteria.  

The VASRD does not have a specific code for lymphedema praecox and the rating criteria under codes 7120 and 7121 are essentially the same.  There was no evidence of massive board-like edema or ulcerations for any rating higher than 40%, and the Board deliberated between the 40% and 20% rating criteria extracted below:  

Persistent edema and stasis pigmentation or eczema, with or without 
	intermittent ulceration	40
Persistent edema, incompletely relieved by elevation of extremity, 
	with or without beginning stasis pigmentation or eczema	20

The Board deliberated the probative values of the Service and VA exams.  All exams documented persistent edema that was not completely relieved by elevation of the extremity, and no exams documented eczema or ulcerations.  Discussions centered on whether there was sufficient evidence of stasis pigmentation to warrant the 40% rating.  The NARSUM finding of “2+ brawny” edema was equated to stasis pigmentation and would support a 40% rating.  Although the vascular surgeon MEB addendum had noted “no skin changes,” that would typically indicate no eczema and no ulcers, would not specifically exclude pigmentation changes, and was also prior to the NARSUM evaluation.  The subsequent post-separation VA exam noted “normal” hair and skin under the endocrine exam, but did not address pigmentation or lack of pigmentation in the extremity, hemic/lymphatic, muscle/joint, or foot exams.  The Board adjudged that the NARSUM exam had the highest probative value for rating at separation, and that the brawny edema noted in that exam was sufficiently equivalent to stasis pigmentation and persistent edema to warrant a higher 40% rating under the 7121 or 7120 criteria.  The Board therefore adjudged that there was sufficient evidence of persistent edema and stasis pigmentation to justify the 40% rating under the code 7121 criteria.  

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 40% for the left lower extremity lymphedema praecox condition, coded 7199-7121.  

BOARD FINDINGS:  In the matter of the left lower extremity lymphedema praecox condition, the Board unanimously recommends a disability rating of 40%, analogously coded 7199-7121 IAW VASRD §4.71a.  There were no other conditions within the Board’s scope of review for consideration.  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 the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Lymphedema Praecox … Left Foot and Ankle …	7199-7121	40%	
COMBINED	40%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131230, 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 XXXXXXXXXXXXXXXXXX, AR20160008267 (PD201400122)

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 re-characterize the individual’s separation as a permanent disability retirement with the combined disability rating of 40% 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 40% 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:
						      					
Enclosure
					
CF: 
(  ) DoD PDBR
(  ) DVA