RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	    CASE:  PD-2014-00523
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20040708

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, 0-3, Air Defense Artillery Officer, medically separated for “narcolepsy,” with a disability rating of 20%.  

CI CONTENTION:  She was given a higher rating for her conditions by the VA and contends for a separate rating for obstructive sleep apnea (OSA).  The applicants 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 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 - 20040430	VARD - 20040912	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Narcolepsy	6847-8108	20%	OSA with Narcolepsy	6847	50%	20040624	
Obstructive Sleep Apnea	Unfitting. Subsumed under Narcolepsy					
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Narcolepsy and OSA.  Although two separate diagnoses, the histories of each overlap as do the clinical manifestations.  In addition, the PEB and VA rated the CI for a single combined condition.  Accordingly, the history is presented for both in a continuous manner.  The record shows that the CI was diagnosed with OSA and treated successfully with continuous positive airway pressure (CPAP) for several years with recommendation for early promotion when she presented to pulmonary medicine on 22 September 2003.  Her complaint was excessive daytime sleepiness (EDS) despite treatment.  She reported that she fell asleep while driving “not infrequently” and reported one accident due to this.  The examiner noted a “questionable history of sleep attacks and hypnagogic hallucinations, no significant vivid dreams.”  (All are symptoms of narcolepsy.)  The examiner thought that her symptoms were out of proportion to her sleep study done the prior month and recommended a neurology evaluation.  She was advised to stop driving pending resolution of the EDS.  She was seen in neurology on 15 October 2003 and reported the onset of EDS in childhood.  Her history was thought to be consistent with narcolepsy and testing ordered.  A genetic screen was positive.  A sleep study was positive for hypersomnolence, but not diagnostic for narcolepsy.  She was placed on medications with improvement in her sleep at night, but persistent EDS.  She was then given a stimulant with a reduction in her EDS symptoms.  Due to the requirement for a stimulant, a MEB was initiated.  The narrative summary (NARSUM) was dated 13 January 2004.  She reported a 5-year history of EDS with progressive worsening.  She had not lost work, but had slept through physical training (PT) at least once a week and could take 45 minutes to awaken.  She reported a family history of EDS without a definite diagnosis.  She was determined to fail retention standards due to the need for stimulants for the narcolepsy and for CPAP for the OSA.  There was no documentation of frequency and duration of any episodes of involuntary sleep.  On 29 February 2004, in neurology, the CI reported that her EDS was improved on medications and that she felt better rested; she still woke up late and slept through PT in the morning though (how often is not noted).  An addendum to the NARSUM was dictated by pulmonary medicine on 8 March 2004.  It noted that she was initially diagnosed with and treated for OSA in 2001.  She was referred to an MEB and found fit for duty.  The pulmonologist opined that the OSA was less of a contributing factor to her EDS than the narcolepsy; however, he also noted it was not possible to determine the relative contribution of each condition.  The OSA condition was thought to fail retention standards.  The treating neurologist wrote a medical statement, dated 26 April 2004, in support of the CI’s rebuttal to the IPEB adjudication.  It noted that the CI suffered from EDS, visual hallucinations, cataplexy (a sudden loss of muscle tone upon awakening), and possible sleep paralysis.  However, the frequency of these conditions was not recorded.  At the VA Compensation and Pension (C&P) examination performed on 24 June 2004, 2 weeks prior to separation, the CI reported that her initial symptoms for narcolepsy included hallucinations, sleep problems, and EDS.  Her current status was not recorded.  Her OSA was improved on CPAP.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the narcolepsy condition at 20%, citing DoDI 1332.39 E2.A1.4.1.5., coded 6847 (OSA) and 8108 (narcolepsy).  The OSA condition was not separately rated to avoid pyramiding (VASRD §4.14, but this was not specifically cited) although the use of CPAP was also unfitting.  The VA rated the CI at 50% for OSA with narcolepsy, citing the use of CPAP.  The CI specifically addressed the use of “industrial impairment” by the PEB.  This was the language in the DoDI, but not in the VASRD in effect at the time of separation.  The Board is obligated to use the latter.  The VASRD in effect in 2004 rates narcolepsy as analogous to petit mal epilepsy.  The rating criteria for the 8108 code depend on the frequency of seizures.  The frequency of these was not recorded after the CI was treated for both conditions.  Accordingly, a rating using the code 8108 is indeterminate.  The use of CPAP for OSA does support a 50% rating.  The Board did note that the primary impairment documented at separation was EDS coupled with poor sleep; this can be attributed to the narcolepsy condition, OSA, or both.  Therefore, the Board concurred that the PEB and VA were correct in combining the conditions for rating purposes and that assigning separate ratings would violate VASRD §4.14.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 50% for the OSA condition (treated with CPAP) with narcolepsy condition, coded 6847-8108.  

BOARD FINDINGS:   In the matter of the OSA with narcolepsy condition, the Board unanimously Recommends a disability rating of 50%, coded 6847 and 8108 IAW VASRD §4.100 and 4.124a.  There were no other conditions within the Board’s scope of review for consideration.  The Board, therefore, 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	
Obstructive Sleep Apnea with Narcolepsy	6847-8108	50%	
RATING	50%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140117, with attachments
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, AR20160005540 (PD201400523)

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 50% 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 50% 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