RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX		CASE:  PD-2014-00607
BRANCH OF SERVICE:  Army		SEPARATION DATE:  20060918

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Infantryman, medically separated by the Informal Physical Evaluation Board for “ulcerative colitis,” with a disability rating of 10%.

CI CONTENTION:  The applicant makes no specific contentions.  His 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– 20060501	VARD - 20090318	
Condition	Code	Rating	Condition	Code	Rating	
Ulcerative Colitis	7323	10%	Residuals of a Total Colectomy…	7323-7329	40%	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:

Ulcerative Colitis.  According to service treatment records (STR) and the narrative summary (NARSUM), the CI was diagnosed with ulcerative colitis (UC) in 2002.  Despite treatment with multiple medications, including immunosuppressive medication and oral steroids, the CI continued to have flares of UC.  A Medical Evaluation Board (MEB) was initiated in early 2003, but the CI underwent a total colectomy for intractable UC disease on 3 May 2003.  Following the surgery the CI went before an MOS Medical Review Board and he was offered a reclassification into an administrative MOS, but he opted for an MEB instead.  The CI developed stricture of the surgical anastomosis due to scarring which led to repeat bowel obstructions and required dilation three times; the most recent dilation prior to the NARSUM was in March 2005.  The MEB process was extended because the CI’s UC condition status post-surgery was not considered stable.  After the last dilation procedure, the CI continued to have chronic diarrhea with intermittent blood with strenuous exertion.  In September 2005, his symptoms worsened, characterized by frequent bloody bowel movement (BM) with even mild exertion, and he was diagnosed with pouchitis by biopsy on 12 January 2006.  (An ileal pouch is artificial rectum created in patients who have undergone a colectomy and pouchitis is inflammation of the ileal pouch).  An internal medicine note dated 19 December 2005 listed multiple chronic medications for UC maintenance treatment, as well as antibiotics and rectal steroid medication for the increased symptoms.  The CI responded to appropriate treatment for pouchitis and a possible UC flare, but the chronic diarrhea persisted.  The NARSUM noted the CI was on oral iron supplements for iron deficiency anemia secondary to blood loss and would likely have future flares of UC in the rectal remnant as well.

At the MEB NARSUM exam on 28 January 2006, 8 months before separation, the CI reported chronic diarrhea with seven to eight episodes per day, but no current abdominal pain or bloody BM.  The MEB physical exam noted a normal abdominal exam without tenderness or masses.  The MEB examiner indicated the CI’s present status was chronic diarrhea with intermittent UC flares.  He was unable to stand or walk long distances due to chronic diarrhea.  The commander’s statement noted the CI was able to perform all the duties required of him in an office setting, but indicated that the CI would likely have “considerable difficulties performing some basic soldier skills.”

The VA Compensation and Pension (C&P) exam performed on 21 October 2008, 26 months after separation, noted the history of anastomosis stricture with repeat dilations and a brief hospitalization in 2007 for a partial bowel obstruction that spontaneously resolved.  The CI reported twenty or more BM per day, often with blood and abdominal pain, and near nightly small quantity stool incontinence.  He reported current use of medications for chronic treatment of the UC and iron supplements.  The VA exam was normal, without abdominal tenderness or masses noted.  The CI reported he had not lost any time from work in the past 12 months due to the UC condition.

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB rated the UC condition 10%, coded 7323 (UC), for UC “moderate, with infrequent exacerbations” and the VA rated it 40%, coded 7323-7329 (large intestine resection with UC), for the UC condition status post-surgery “with severe symptoms.”  The Board considered that at the time of separation, the CI’s UC was managed by total colectomy and that his residual disability was predominately related to the sequelae of the surgical procedure, although it was anticipated he would have UC flares as well.  There are scant notes in record in the 12 months before the date of separation and the PEB Form 199 indicated the CI had no documented clinical visits since September 2005.  However, the NARSUM indicated that the CI actually had an exacerbation of symptoms with diagnosis of pouchitis in January 2006.  Furthermore, although the initial C&P exam was outside the 12 month period for special consideration of post-separation VA evidence IAW DoDI 6040.44, the C&P evidence is still considered to the degree that it provides information that reflects the CI’s condition proximate to the date of separation.  At the remote C&P exam, the CI reported that post-separation the chronic diarrhea continued,” often” with blood and abdominal pain, and he was hospitalized briefly for a repeat bowel partial obstruction approximately 12 months after separation.  The Board first considered coding as 7323 and agreed that the total evidence in record supports that the disability due to the UC condition was most closely approximated by the 30% rating criteria for “moderately severe UC, with frequent exacerbations” at separation, but not the next higher rating of 60% for “numerous attacks per year” malnutrition and only fair health during remissions.  The Board next considered coding as 7329 and deliberated between the 20% rating criteria of “moderate symptoms” status post-surgical resection and the 40% criteria of “severe symptoms, objectively supported by examination findings.”  According to these coding criteria the Board thought the 20% criteria was a closer approximation of the CI’s condition because he reported more than once in record that he felt well after the surgery with a baseline of frequent daily BMs.  However, the VASRD indicates under 7329 that if following an abdominal surgical procedure, adhesions (scarring) with actual partial bowel obstruction and pain, constituted the predominate disability, then coding with 7301 (peritoneal adhesions) is indicated and the CI’s episodes of bowel obstruction were related to post-operative scarring.  The Board therefore agreed that a “fair and equitable” rating of the CI’s disability could be also achieved with this code and the 30% rating was supported based upon partial obstruction with frequent episodes of pain, but not the next higher rating of 50% which specifies frequent and prolonged episodes of severe abdominal pain.  Thus the Board determined that the evidence in record supports a 30% rating for the UC condition at separation and no higher code either as 7323 or 7301 and chose to code as 7301-7323 for ulcerative colitis with scarring post-surgery.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 30% for the UC condition 

BOARD FINDINGS:  In the matter of the ulcerative colitis condition, the Board unanimously recommends a disability rating of 30%, coded 7301-7323 IAW VASRD §4.114.  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 his prior medical separation:

CONDITION	VASRD CODE	RATING	
Ulcerative Colitis	7301-7323	30%	
RATING	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140123, 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, AR20160003379 (PD201400607)

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 30% 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 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 30% 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