RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX		CASE:  PD-2014-00670
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20060912

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 for “posttraumatic headaches” with a 10% disability rating.  

CI CONTENTION:  The CI contends that there is a serious discrepancy between the military and VA rating.  The CI’s 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 Physical Evaluation Board (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 based upon a 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 – 20060628	VARD - 20070502	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Posttraumatic Headaches	8045-9304	10%	Right Epidural Hematoma, Migraine Headaches, Cognitive Disorder, Left Superior Visual Field Defect, Adjustment Disorder	8045-9304	100%	20070117	
Right Epidural Hematoma	Not Unfitting					
Left Superior Visual Field Defect	Not Unfitting					
Cognitive Disorder/Adjustment Disorder	Not Unfitting					
Anxiety Disorder	Not Unfitting 	No VA Placement	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  100%	

ANALYSIS SUMMARY:  

Posttraumatic Headaches.  According to the service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), in May 2005 the CI was a victim of an assault that resulted in an epidural hematoma requiring surgical evacuation.  He was unconscious for several minutes and for approximately 30-45 minutes he was unable to recall what had occurred immediately before and after the attack.  Since his head injury, he suffered chronic minor headaches and migraine headaches that were accompanied by light and sound sensitivity, and nausea with occasional vomiting.  His minor headaches occurred 3 to 4 times a week and they were usually relieved with rest.  However, he had migraine headaches at least once every 2 weeks and at most 3 per week.  He took injection medication for his migraines and also sought relief in a dark, quiet room.  Since the attack, the CI noted decreased cognitive skills.  He underwent neuropsychological evaluation on four separate occasions.  The NARSUM was accomplished in April 2006, approximately 5 months before separation, and was performed by the neurologist.  The CI noted he had problems with migraine headaches, as well as with his vision and memory.  He needed multiple cues to remember items such as appointments or carrying out simple tasks.  Neurological and mental status examinations (MSE) noted he was fully alert and appropriately oriented.  His memory was documented as relatively intact, his attention was assessed as normal, and other cognitive measures were normal.  Neurological examination demonstrated no deficits in cranial nerve function, motor, sensory, coordination, reflexes or gait.  The examiner cited cognitive results from a series of three neuropsychological examinations, the last one referenced was in October 2005.  The neurologist documented diagnoses of right epidural hematoma, status post-surgical evacuation, migraine headaches moderate to severe, and left superior visual field defect.  The examiner noted that a psychiatry consult had diagnosed him with adjustment disorder with mixed emotions and cognitive disorder not otherwise specified (NOS) with marked impairment for military duties.  The last neuropsychological evaluation was conducted in May 2006, approximately 7 months after the previous evaluation cited in the NARSUM, and 1 month after the NARSUM.  That examination documented high average intellectual functioning comprised of superior verbal intellectual abilities and average nonverbal intellectual abilities.  There were several areas of improvement; however, residual relative weaknesses remained in the areas of attention, verbal memory, and incidental visual memory.  The CI reported he felt his long-term memory was intact, but his short-term memory varied.  He had occasional problem with word-finding, and problems with reading retention, for example, not recalling all the material.  The diagnosis of cognitive disorder NOS was recorded with a Global Assessment of Functioning (GAF) score of 69 (mild).  The psychologist recommended regular use of an organizer/planner or portable electronic device to write down or record new important information that he would like to learn and remember.  The examiner also noted that in an academic environment, he might benefit from testing accommodations such as the allowance of extra time and a quiet testing environment.  The examiner documented that the CI also worked part-time in a health store in addition to his military service.

The commander’s statement dated 24 April 2006, one week after the NARSUM, noted the CI required medical care during the workday and had to go home to “recuperate from his migraines.” It was noted that he had not been able to come into work for morning formation due to his headache and he had been released early approximately once per week due to head pain.

The VA Compensation and Pension (C&P) examination was conducted approximately 4 months after separation.  That examination documented the CI had weekly headaches over the past 12 months in which less than half were prostrating.  His headaches lasted for hours and he would have to lay down and take medication.  

The Board directed attention to its rating recommendation based on the above evidence. The PEB assigned a 10% rating under the analogous coding 8045-9304 (residuals of traumatic brain injury and dementia due to head trauma), and noted that the condition was rated IAW VASRD, paragraph 2 (purely subjective symptoms) under the 8045 code.  As noted above, the VA combined all conditions and assigned a 100% disability rating under 38 CFR 4.28-prestabalization rating, and noted that his condition had not yet stabilized.  The VARSD in effect at the time of separation captured brain injuries under the generic category of brain disease due to trauma (8045).  There are two different scenarios for rating under this code; analogously with purely neurological deficits, or purely subjective symptoms.   Purely subjective complaints in this case included headaches, dizziness, vertigo, and post-concussive symptoms. In the absence of associated neurological disabilities (seizures, nerve paralysis, etc.), rating of this condition under 8045-9304 is limited to 10%, and cannot be combined with any other rating for a disability due to brain trauma.  The Board found absence of evidence that would support any neurological disability, and therefore, only 10% was supported under that coding scheme.  The Board next considered a different coding option, 8045-8100 (headaches secondary to brain trauma) given the record demonstrated that this coding option best reflected his condition and the Board is obliged to consider other coding options IAW VASRD §4.7 (higher of two evaluations).  The record clearly documented that the CI suffered migraine headaches after the head injury as diagnosed and documented by the neurologist, the profile and the C&P examiner.  The commander’s statement noted his headaches had caused significant disability with loss of work on many occasions.  He had headaches that caused his early release from work approximately once per week.  The commander’s statement documented he had been given quarters on several occasions.  The C&P examiner documented weekly headaches with half of them being prostrating.  Rating guidance under diagnostic code 8100 is based on the frequency of “prostrating attacks” over the “last several months.”  The VASRD does not further define prostrating attacks however commonly accepted definitions include “utter physical exhaustion or helplessness” (Webster's New World Dictionary of American English), “complete physical or mental exhaustion” or “extreme exhaustion or powerlessness” (Dorland's Illustrated Medical Dictionary).  A 50% rating requires evidence of very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability, and a 30% rating is for characteristic prostrating attacks occurring on an average once a month over last several months.  The Board carefully considered the frequency and nature of the CI’s headaches including objective and corroborating subjective evidence, and found the 50% disability level was sufficiently supported.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), and VASRD§ 4.7 (higher of two evaluations), the Board recommends a disability rating of 50%, coded 8045-8100 for the posttraumatic headache condition.  

Contended PEB Conditions: Left Superior Visual Field Defect, Cognitive Disorder NOS with Adjustment Disorder, Anxiety Disorder NOS.  The Board’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting. 

Left Superior Visual Field Defect.  The Board first considered the evidence related to the visual field defect.  The record documented the ophthalmologist findings of left superior visual field incongruous hemianopsia field defect, opined to be stable in February 2006, 7 months before separation.  Imaging in February 2006 revealed a left superior quadrant anopia (quadrantanopia- ¼ of visual field defect) that was not fully congruous in both eyes.  The Board noted that although the ophthalmologist wrote “left superior visual field incongruous hemianopia field defect (-1/4 defect)”, such wording is synonymous with quadrantanopia, since hemianopia represents defect in half of the visual field.  The ophthalmology addendum to the MEB opined that his condition did not meet retention standards.  The commander noted that because of his visual field defect, the CI was not permitted to drive a government vehicle nor could he participate in certain guard duties.  The eye condition was profiled.  The PEB wrote, “Right superior visual field quadrantanopia does not fail retention standards.  It must be hemianopsia to fail retention standards.”  The Board could find no evidence that at the time of separation the CI had suffered a hemianopia defect.  Therefore, the PEB’s statement was consistent with AR 40-501, 3-16 that notes only bilateral, permanent hemianopsia (blindness or loss of vision in half of the visual field) would fall below retention standards.  

Cognitive Disorder NOS with Adjustment Disorder. The Board next considered the cognitive disorder NOS with adjustment disorder.  As noted above, the CI was diagnosed with cognitive disorder NOS secondary to head injury.  He underwent four neuropsychological evaluations and the last evaluation documented high average intellectual abilities.  There were several areas of improvement; however, residual relative weaknesses remained in the areas of attention, verbal memory, and incidental visual memory.  The CI reported he felt his long-term memory was intact but his short-term memory seemed to vary.  He had occasional problems with word-finding, and problems with reading retention.  The VA C&P examination, 4 months post-separation, documented that the CI was having success in his college courses; he did not indicate an issue with reading or keeping up.  The neuropsychological examiner recorded with a GAF of 69 (mild).  Neurological examination and MSE at the NARSUM noted he was fully alert and appropriately oriented.  His memory was documented as relatively intact, his attention was assessed as normal, and other cognitive measures were normal.  The MSE at the psychiatric NARSUM recorded intact cognitive functioning and no impairment in thinking or judgment.  Although the psychiatrist documented the condition of cognitive disorder as not meeting retention standards, the examiner documented mild impairment for social and industrial capacity. The condition was profiled and judged to fail retention standards; however, it was not implicated in the commander’s statement.  There was no performance-based evidence from the record that this condition significantly interfered with satisfactory duty performance. Additionally, adjustment disorder is not a physical disability and is not ratable IAW DoDI 1332.38.  

Anxiety Disorder NOS. The Board next reviewed the evidence for the anxiety disorder NOS and noted this condition was not profiled nor implicated in the commander’s statement and was not judged to fail retention standards.  There was no performance-based evidence from the record that any mental health condition significantly interfered with satisfactory duty performance. 

After due deliberation, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the any of the contended conditions and so no additional disability ratings are recommended.

BOARD FINDINGS:  In the matter of the posttraumatic headache condition, the Board unanimously recommends a disability rating of 50%, coded 8045-8100 IAW VASRD §4.124a.  In the matter of the contended left superior visual field defect, cognitive disorder NOS with adjustment disorder,  and anxiety disorder NOS conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting.  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	
Posttraumatic Headaches 	8045-8100	50%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140201, 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 XXXXXXXXXXXXXXXXXXXXX, AR20160010865 (PD201400670)

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 (000 PDBR) pertaining to the individual named in the subject line above to recharacterize
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