RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXX	CASE:  PD-2014-00605
BRANCH OF SERVICE:  AIR FORCE	BOARD DATE:  20140827
SEPARATION DATE:  20070122

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SSgt/E-5 (1C072/Aviation Resource Management Craftsman) medically separated for neurocardiogenic syncope.  The condition could not be adequately rehabilitated to meet the physical requirements of her Air Force Specialty or satisfy physical fitness standards.  She was issued a permanent P4 profile and referred for a Medical Evaluation Board (MEB).  The neurocardiogenic syncope condition was forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123.  No other conditions were submitted by the MEB.  The Informal PEB adjudicated “neurocardiogenic syncope” as unfitting, rated 10% citing Department of Defense Instruction (DoDI) 1332.39 and the VA Schedule for Rating Disabilities (VASRD) guidelines.  The CI made no appeals and was medically separated.

CI CONTENTION:  “Granted 20%, then 10% added/approved.  Unsure that (30%) has been updated with dependents.  Please review.”  

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 neurocardiogenic syncope condition 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 Military Records.

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 VASRD standards, based on ratable severity at the time of separation.

RATING COMPARISON:

Service IPEB – Dated 20061211	VA - (2 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Neurocardiogenic Syncope	8299-8210	10%	Neurocardiogenic Syncope	6299-6204	10%	20070322	
Other x 0 (Not in Scope)	Other x1 (Not in Scope)		
Combined:  10%	Combined:  20%	
Derived from VA Rating Decision (VARD) dated 20080422 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Neurocardiogenic Syncope Condition.  The CI developed episodes of syncope (loss of consciousness) in approximately 2000.  The events could be briefly preceded by lightheadedness or dizziness, or could appear abruptly without warning; and could occur while exercising or sitting at rest.  Thorough cardiac evaluation included normal cardiac rhythm monitoring, normal echocardiogram and normal exercise stress test.  Left ventricular size and function was normal and ejection fraction was 60%; and exercise capacity was 17.2 metabolic equivalents (METs) with no abnormal rhythms observed during exercise.  Tilt-table testing in July 2005 reproduced the symptoms of dizziness and near-syncope and resulted in the diagnosis of neurocardiogenic syncope.  Medication management did not sufficiently ameliorate her symptoms, or was associated with fatigue as a side effect.

At a cardiology follow-up evaluation in February 2006 (11 months prior to separation), the CI reported that 15-20 syncopal episodes had occurred since onset in 2000 and that she had experienced many more episodes that she successfully aborted by sitting down.  Most syncopal episodes occurred while standing.  On 13 September 2006 (5 months prior to separation), the cardiologist reported that since beginning an anti-hypotensive agent (prevents low blood pressure) in February 2006, she continued to experience episodes of lightheadedness when standing up, but had no further fainting spells.  The cardiologist considered her symptoms inadequately controlled, and recommended a medication change (beta blocker).

The narrative summary on 12 October 2006 (3 months prior to separation) noted that the CI had two syncopal episodes during the previous few weeks.  Her exercise tolerance had not changed.  Physical examination was normal.  At the VA examination on 22 March 2007 (2 months after separation), the CI reported that episodes of tachycardia (fast heart rate) and bradycardia (slow heart rate) occurred intermittently, but as often as three times per day.  She was taking a medication (beta-blocker) for the condition and was not having symptoms at the time of the evaluation.  She was currently employed as a trainer.  Examination showed normal blood pressure and pulse rate, and normal cardiac findings.  An electrocardiogram was reportedly normal.  The examiner considered the condition “controlled on medication.”

At an outpatient clinic visit on 26 April 2007, the CI was “feeling fine” and denied shortness of breath or dizziness.  However, at a follow-up evaluation on 15 May 2007 (4 months after separation) she reported 4 days of dizziness and lightheadedness for which she was seen 2 days previously in the emergency room (evaluation was reportedly negative).  Examination showed a normal blood pressure and heart rate; normal cardiovascular findings and normal coordination, balance and gait.  The examiner concluded that symptoms were likely due to allergic effects on the Eustachian tube in the ear.  At a clinic visit for a record review on 3 December 2007 (10 months after separation) the CI stated that her last episode of syncope was over a year previously.  She was not taking any medication for the condition, and did not require follow-up with cardiology.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB coded neurocardiogenic syncope analogously to 8210 (paralysis of tenth cranial nerve) and rated at 10% for moderate, incomplete paralysis.  The VA initially did not service-connect the condition, but based on a Compensation and Pension exam performed over a year after separation, rated the condition at 10% effective to the date of separation, under an analogous 6204 code (peripheral vestibular disorders).  The CI’s disability is not specifically listed in the VASRD and Board members agreed that these coding approaches were reasonable.  The Board considered if a rating higher than 10% was justified.  It was agreed that “severe, incomplete” was not an accurate descriptor of the condition under the 8210 code and therefore the next higher 30% rating was not supported on this basis.  Under the 6204 coding pathway, “dizziness and occasional staggering” is required for the next higher 30% rating; but Board members agreed this stipulation was not present.  Other coding options were considered.  Under the 7005 code (arteriosclerotic heart disease) a 30% rating requires a MET level between 5-7, or evidence of cardiac hypertrophy or dilatation.  Since neither of these stipulations was present, a higher rating is not justified using this code.  The 7011 (ventricular arrhythmias) and 7015 (atrioventricular block) codes use the same 7005 coding criteria and likewise provide no route to a higher rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the neurocardiogenic syncope 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.  As discussed above, PEB reliance on DoD guidelines for rating neurocardiogenic syncope was operant in this case and the condition was adjudicated independently of that instruction by this Board.  In the matter of the neurocardiogenic syncope condition and IAW VASRD §4.124a, the Board unanimously recommends no change in the PEB adjudication.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140107, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

		
SAF/MRB

Dear XXXXXXXXXXXXXX:

	Reference your application submitted under the provisions of DoDI 6040.44 (Title 10 U.S.C. §  1554a), PDBR Case Number PD-2014-00605.

	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 appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

	I have carefully reviewed the evidence of record and the recommendation of the Board.    I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.