RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00608
BRANCH OF SERVICE:  COAST GUARD 	SEPARATION DATE: 20060214

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Health Services) medically separated for epilepsy.  The epilepsy could not be adequately rehabilitated to meet the physical requirements of his Rating.  The “idiopathic hypersomnia,” was the only condition forwarded to the Physical Evaluation Board (PEB) IAW COMDTINST M1850.2C.  The Informal PEB adjudicated “idiopathic hypersomnia rated as narcolepsy rated as epilepsy, petit mal: a confirmed diagnosis of epilepsy with a history of seizures” as unfitting, rated 10%, with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI made no appeals and was medically separated.  

CI CONTENTION:  The CI contended for a higher rating for his unfitting condition.  The applicant’s 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 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 20051205	VA* -  based on Service Treatment Records (STR)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Idiopathic Hypersomnia Rated as Narcolepsy
Rated as Epilepsy, Petit Mal: A Confirmed
Diagnosis of Epilepsy with a History of Seizures	8199/8108-8911	10%	Hypersomnia	8199-8108	10%	STRs	
Other MEB/PEB Conditions x 0 (Not in Scope)	Other x 2	
RATING: 10%	RATING:  10%	
*Derived from VA Rating Decision (VARD) dated 20101004 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:  

Idiopathic Hypersomnia.  The earliest note in the service treatment record (STR) dated 21 April 2005 indicated the CI had not been able to get up in the mornings and slept excessively on the weekends.  He had increased fatigue in the mornings for the first 30 minutes after awakening for the 3 weeks prior to the medical visit.  He had a heavy workload after work at school and a stressful job.  He was late for work twice in the week prior to the visit.  His mother had Addison’s (adrenal insufficiency) disease and chronic fatigue.  The diagnosis of primary hypersomnia was made; sleep hygiene was reviewed; and laboratory studies were ordered.  The CI was seen by a sleep specialist for excessive daytime sleepiness on 28 April 2005 at which time he denied three of the four symptoms of the narcoleptic (sudden falling asleep) tetrad, which include hypnogogic (from wakefulness to sleep) hallucinations (visual, tactile, auditory, or other sensory events), sleep paralysis or cataplexy (physical collapse though remaining conscious).  Snoring was not an issue and the were no symptoms of the restless legs syndrome.  The sleep specialist believed the CI had a neurological sleep disorder, either narcolepsy, which was monosymptomatic, or idiopathic hypersomnia.  A nocturnal polysomnogram dated 18 May 2005 interpretation was no snoring, sleep efficiency 98%, sleep latency of 6 minutes and REM (rapid eye movement) latency of 116.5 minutes, low SpO2 (oxygen), and no significant number of periodic leg movements, while the Multiple Sleep Latency Test (MSLT) performed on 19 May 2015 revealed pathological hypersomnolence with sleep onset REM in one of five 20-minutes nap opportunities.  At a second MSLT there was no sleep onset REM in four 20-minutes nap opportunities, but his mean sleep latency was 6 minutes.  He had none of the auxiliary symptoms of the narcoleptic tetrad, but fit the diagnostic criteria for idiopathic CNS hypersomnia.  The CI was started on Provigil (to promote wakefulness), but had unacceptable posterior headaches, and was given Ritalin (methylphenidate, a central nervous stimulant) instead.  On 9 June 2006, a Flight Surgeon noted the CI was okay if moving, but if he sat down, he fell asleep and it took 3-45 minutes until he was “in with it.” However, although he tired at the wheel, he had not fallen asleep in the recent past, but he did fall asleep at the wheel 3 year earlier.  The CI was grounded from duties involving flight, and it was noted that Ritalin was not authorized for active duty members.  However, by 30 June 2005, the sleep specialist indicated the Ritalin helped the CI greatly by improving his focus, concentration, alertness, and his ability to perform work and to study.  The dose of the Ritalin was increased by use of sustained release and short acting tablets, which the CI was to determine the best dose for himself, because the original dose lasted for only 2 hours.  On 12 September 2005, the CI’s request for a waiver to be treated with Ritalin was not authorized.    

The undated MEB narrative summary (NARSUM) noted the laboratory studies for CBC (complete blood count), CMP (comprehensive metabolic panel), cortisol, TSH (thyroid stimulating hormone), free T3 and free T4 (thyroid tests), Epstein Barr virus, and total testosterone were within limits.  Although the CI’s waiver was denied, he desired to continue the Ritalin since it was so effective at treating his symptoms.  Without the use of a disqualifying the CI had excessive somnolence making his activities of daily living difficult.  However, it was recommended that the CI continue taking the Ritalin as prescribed since he desired to continue the treatment since it had been so effective at treating his symptoms.  Nevertheless, because of the use of Ritalin, he was recommended for discharge.  The commander’s statement dated 21 November 2005 indicated the CI had been unable to remain proficient or continue to complete all assigned duties without the assistance of a disqualifying medication.  At the MEB examination dated 20 January 2006, the CI reported on DD Form 2807-1 hypersomnia with Ritalin use.  The MEB physical examiner did not note any physical findings on DD Form 2808 other than tattoos.  No profile or limited duty (LIMDU) documentation was available for review.  
The CI did not report for the VA Compensation and Pension (C&P) examinations scheduled for 1 September 2010 and 7 September 2010.  However, the VA Rating Decision (VARD) dated 4 October 2010 used the STR for history (see above) and rating purposes.  The entrance examination of 20 March 2002 was negative for complaints or treatment for hypersomnia prior to service.  VA outpatient treatment records indicated that the CI continued to be prescribed Ritalin for the treatment of hypersomnia after release from service.  A VA treatment record in July 2010 indicated that Ritalin was to be taken in the morning and at noon each day.

The Board directed its attention to its rating recommendation based on the above evidence.  The Coast Guard PEB assigned a 10% rating using code 8199/8108-8911 (Narcolepsy-Epilepsy, petit mal) for idiopathic hypersomnia rated as narcolepsy.  The VA assigned a 10% rating using code 8199-8108 for hypersomnia.  The Board sought a route for a higher rating using the General Rating Formula for Major and Minor Epileptic Seizures to rate the hypersomnia coded analogously to narcolepsy.  At the time of separation the CI was greatly improved with the Ritalin and a note indicated he had not fallen asleep in the recent past.  The absence of a timely VA C&P examination, which could have given follow-up details within 12 months of separation of the use and efficacy of the Ritalin was not performed nor was a C&P examination performed in 2010.  However, the VARD indicated in 2010 Ritalin was prescribed.  Therefore, while taking the medication prior to separation the CI did well, and the Board members did find have any credible medical evidence to document or suggest there were significant episodes of hypersomnia analogous to minor seizures to interfere with the CI’s duties to warrant any 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 idiopathic hypersomnia 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.  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 idiopathic hypersomnia 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.  

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 20131217, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

Commandant
United States Coast Guard	Mail Stop 7907
2703 Martin Luther King Jr. Ave SE
Washington, DC 20593-7907
Staff Symbol: CG-1
Phone: (202) 475-5000

								   XXXX

Dear XXXXXXXXXX,
I am the Designated Decision Authority for the Coast Guard on applications submitted to the Department of Defense Physical Disability Board of Review (PDBR).  Under the authority of Title 10, United States Code, section 1554a, I accept the PDBR’s recommendation in your case (Case Number PD-2014-00608) and decline to modify your findings. 

Enclosed for your information are a copy of the PDBR’s recommendation and a copy of the record of proceedings. 

A copy of this decision has also been provided to Coast Guard Enlisted Personnel Management Branch, the PDBR, and the Department of Veterans Affairs. 

If you have any further questions, please contact the Coast Guard Personnel Service Center at (703) 872-6628. 
	Sincerely,

2 Enclosures		
	
Copy:	CG Personnel Service Center (EPM-1)
DoD Physical Disability Board of Review
Department of Veterans Affairs