RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00324
BRANCH OF SERVICE:  AIR FORCE	BOARD DATE:  20150529
Separation Date:  20050201

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty O-2 (Weather Officer) medically separated for Crohn’s disease.  The condition could not be adequately rehabilitated to meet the physical requirements of his Air Force Specialty (AFS) or satisfy physical fitness standards.  He was issued a temporary P3 profile and referred for a Medical Evaluation Board (MEB).  The “Crohn’s disease” was forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123.  No other conditions were submitted by the MEB.  The Informal PEB (IPEB) adjudicated “Crohn’s disease with extensive scarring and ilio-colon fistula” as unfitting, rated 10%, citing application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The IPEB also adjudicated a hypertension condition as category II, a condition that can be unfitting but is not currently compensable or ratable.  The CI made no appeals and was medically separated.

CI CONTENTION:  The VA rating 40% for his Crohn’s disease and high blood pressure.  His complete submission is at Exhibit A.

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:

IPEB – Dated 20041124	VA* - (~2 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Crohn’s Disease with Extensive Scarring and Iliocolon Fistula	7323-7399	10%	Crohn’s Disease	7323	30%	20050323	
Hypertension	Category II	Hypertension	7101	10%	20050323	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 7 	
RATING:  10%	RATING:  40%	
*Derived from VA Rating Decision (VARD) dated 20061014 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Crohn’s Disease Condition.  The CI developed a 2-week history of fatigue, periumbilical abdominal pain after eating in 1 to 2 hours and melena (tarry feces) and black stools for 3 days in March 2004.  His hematocrit (the proportion of your total blood volume that is composed of red blood cells normal 40.7% to 50.3%) fell to 19%.  The abdominal exam was normal, the rectal exam showed stool was heme positive (blood in stool) and the examiner advised an admission along with a blood transfusion and inpatient workup.  The CI refused admission and was given two units of packed cells.  He returned the next day and was admitted for several gastrointestinal procedures.  An esophagogastroduodenoscopy (passage of a scope down the throat to view the stomach and upper intestines) procedure which demonstrated non erosive gastritis, single linear whitish ulcer in the pre pyloric area (stomach), mild edema of the pyloris and duodenitis (inflammation of the first part of the bowel).  The colonoscopy demonstrated cecal scarring, some areas of erythema and punctate hemorrhages and small internal hemorrhoids.  The abdominal-pelvic CT scan showed no inflammatory changes to this region.  The Gastroenterologist (GI) noted that the CI was feeling well, the fatigue had decreased and there was no reports of abdominal pain.  The small bowel follow-through test demonstrated focal narrowing at the terminal ileum (end of small bowel) and also in the ileum in the left flank, and there was ileal stenosis with focal dilatation immediately upstream from it which was indicative of a Crohn’ disease or lymphoma.  The Barium enema demonstrated a fistula (abnormal tubular connection) in the right upper quadrant, likely a coloileal fistula with additional fistulae between the cecum and adjacent loops of the small bowel, most likely the effects of inflammatory bowel disease, specifically Crohn’s disease.  The GI noted that the CI still reported periumbilical pain after meals that lasted approximately an hour with a formed bowel movement every 2 to 3 days.  The CI was started on Asacol and folic acid for the Crohn’s disease symptoms.  The abdominal-pelvic CT scan demonstrated lesions of small and large bowel, most consistent with Crohn’s disease.  The GI noted that the CI was feeling better with medication regime for Crohn’s disease.  A colonoscopy demonstrated Crohn’s disease-at least one entero-colic fistula.

The MEB narrative summary exam approximately 5 months prior to separation documented that the CI was compliant with his treatment regimen of 6-MP, Asacol, Folic Acid and iron supplement.  He was doing well, had not missed any work duty days, required recurrent hospitalization or unanticipated urgent outpatient visits and his weight remained stable over this period of time.  There were physical exam findings of a normal abdominal exam and a rectal exam with no areas of abscesses or fistulas opening.  There was no evidence of anemia on the blood count.  The examiner opined that the CI’s symptoms which included bleeding, segmental ileal stricturing with fistulas was most consistent with Crohn’s disease and this was also supported by positive serology testing specific for Crohn’s disease.  The examiner further opined that the Crohn’s disease was thought to be in remission.  The examiner documented that the Crohn’s Disease was a chronic inflammatory bowel disease of undetermined etiology characterized by periods of flares and remissions.  The commander’s statement documented that the CI’s disease had been very much under control and had not impacted his ability to perform his AFS duties.  The commander further recommended the CI for a more advanced position once he completed additional training.  A bone density demonstrated that the CI was at moderate risk for a fracture

The VA Compensation and Pension (C&P) exam approximately 2 months after separation documented that the CI reported current pain in the stomach that occurred after eating and that he had a flare-up that occurred once a month and would last 1 to 2 hours during which he was unable to work.  The CI was compliant with his medication.  The abdominal and rectal exams were normal.  The blood count was within normal limits.  The examiner noted that the CI’s daily activities were affected when he had abdominal flare pain which interfered with him performing his regular work.
The Board directed attention to its rating recommendation based on the above evidence.  The PEB coded the Crohn’s Disease with Extensive Scarring and Iliocolon Fistula condition as 7323 analogous to 7399 (colitis, ulcerative) and rated at 10% (moderate; with infrequent exacerbations).  The VA coded the Crohn’s Disease condition as 7323 and rated at 30% (moderately severe; with frequent exacerbations).  The predominate coding was 7299-7323; however, the Board also considered code 7330 (intestine, fistula of, persistent, or after attempt at operative closure) at 30% (slight infrequent, fecal discharge), although the CI’s fistula was between bowel loops and therefore there was no fecal discharge.  The Board agreed that the VA C&P exam was closer to separation; more accurately reflected the CI’s condition at the time of separation and therefore had a higher probative value.  The CI was not anemic at separation, he was considered stable, and his health was better than fair during remissions.  The Board considered that there was insufficient evidence of marked malnutrition, anemia (chronic), or general debility; and that the “extensive scarring and iliocolon fistula” did not adequately equate to “with serious complication as liver abscess” to support a 100% rating.  There were not “numerous attacks a year and malnutrition, the health only fair during remissions” to support a 60% rating and the Board therefore deliberated between a rating of 30% “Moderately severe; with frequent exacerbations” and a rating of 10% “Moderate; with infrequent exacerbations.”

For adjudging the severity of the disease, the Board discussed the differences between Crohn’s disease and ulcerative colitis, as well as the differences between symptom severity and the severity of clinical findings of the bowel disease.  The frequency and severity of symptoms (pain after meals; monthly flares with inability to work for 2 hours) was adjudged as closer to “moderate and infrequent.”  However, for rating based on the severity of the Crohn’s disease, the Board deliberated on the multiple gastrointestinal studies documented strictures and at least one entero-colic fistula.  The Board majority considered the severity of the documented pathology on GI testing demonstrated moderately severe bowel disease.  Board consensus was that the CI’s condition more nearly approximated the disability picture for a 30% rating under analogous disability code 7323.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt) and §4.7 (higher of two evaluations), the Board majority recommends a disability rating of 30% for the Crohn’s Disease condition coded 7399-7323.

Contended PEB Condition.  The Board’s main charge is to assess the fairness of the PEB’s determination that hypertension 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 CI was noted to have hypertension in 2002 and was poorly controlled on a single medication (Metoprolol/Lopressor) through 2005 with systolic blood pressures between 135-180 (normal 140) and diastolic blood pressures consistently over 100 (normal 80).  There was no evidence of end-organ disease (eyes, heart, kidney, etc.).  The hypertension condition was not profiled or implicated in the commander’s statement and was not judged to fail retention standards.  There was no performance based evidence from the record that hypertension 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 hypertension 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 “Crohn’s Disease with Extensive Scarring and Iliocolon Fistula” condition, the Board  majority recommends a disability rating of 30%, coded 7399-7323 IAW VASRD §4.114a.  In the matter of the contended hypertension condition and IAW VASRD §4.104, 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 recommends that the CI’s prior determination be modified as follows; and, that the discharge with severance pay be recharacterized to reflect permanent disability retirement, effective as of the date of his prior medical separation:

UNFITTING CONDITION	VASRD CODE	RATING	
Crohn’s Disease with Extensive Scarring and Iliocolon Fistula	7399-7323	30%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131217, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD  20762

Dear XXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2014-00324.

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was not appropriate under the guidelines of the Veterans Affairs Schedule for Rating Disabilities.  Accordingly, the Board recommended your separation be re-characterized to reflect disability retirement, rather than separation with severance pay.

I have carefully reviewed the evidence of record and the recommendation of the Board.    I concur with that finding, accept their recommendation and determined that your records should be corrected accordingly.  The office responsible for making the correction will inform you when your records have been changed.

As a result of the aforementioned correction, you are entitled by law to elect coverage under the Survivor Benefit Plan (SBP).  Upon receipt of this letter, you must contact the Air Force Personnel Center at (210) 565-2273 to make arrangements to obtain an SBP briefing prior to rendering an election.  If a valid election is not received within 30 days from the date of this letter, you will not be enrolled in the SBP program unless at the time of your separation, you were married or had an eligible dependent child, in such a case, failure to render an election will result in automatic enrollment.

Sincerely,

Attachment:
Record of Proceedings

cc:
SAF/MRBR
DFAS-IN