RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00769
BRANCH OF SERVICE:  Army	BOARD DATE:  20150616
SEPARATION DATE:  20080125

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-3 (Basic Trainee) medically separated for mental health (MH) and cardiovascular conditions.  These conditions could not be adequately rehabilitated to meet physical fitness standards, although he was authorized to perform alternate physical fitness testing.  He was issued a permanent P3 profile and referred for a Medical Evaluation Board (MEB).  Idiopathic hypertrophic subaortic stenosis status-post myectomy and mitral regurgitation conditions were identified, but the CI did not agree.  A second MEB was conducted that identified idiopathic hypertrophic subaortic stenosis status-post myectomy, mitral regurgitation and adjustment disorder with anxiety conditions, were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The Informal PEB (IPEB) adjudicated hypertrophic cardiomyopathy, with mitral regurgitation as unfitting, but existed prior to service (EPTS), not permanently service aggravated and not ratable with likely application of DoD 1332.39.  The CI appealed to the Formal PEB (FPEB) which adjudicated generalized anxiety disorder as unfitting, rated 10% with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The remaining hypertrophic cardiomyopathy with mitral regurgitation conditions were determined EPTS, not permanently service aggravated and not ratable with likely application of DOD 1332.39.  The CI made no further appeals and was medically separated.

CI CONTENTION:  The CI elaborated no specific contention in his application.

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/Naval 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:

Service FPEB – Dated 20080109	VA* - (~4 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Generalized Anxiety D/O	9400	10%	Adjustment Disorder with Mixed Anxiety and Depressed Mood	9440	10%	20080515	
Hypertrophic Cardiomyopathy with Mitral Regurgitation	7020	----	Hypertrophic Subaortic Stenosis with Mitral Regurgitation…	7099-7010	NSC	20080508	
Other x 0 (Not in Scope)	Other x 0	
Combined:  10%	Combined:  10%	
*Derived from VA Rating Decision (VARD) dated 20080618 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Generalized Anxiety Disorder Condition.  At an MEB exam on 7 May 2007 (9 months prior to separation) the CI wrote that he experienced frequent panic attacks and anxiety when he thought about his heart problem (see below) or when he was around others.  He also endorsed difficulty sleeping.  The CI presented to a primary care clinic on 11 September 2007 (4 months prior to separation) with a history of sleep difficulty for 2 weeks due to worry over family members who were deployed.  He denied depression.  A diagnosis of adjustment disorder with anxiety was rendered, and a medication for sleep and a psychotropic medication were prescribed.  A psychiatrist reviewed the case and concurred with the diagnosis.  An MEB addendum on 12 October 2007 indicated that the CI had developed an adjustment disorder due to worry over his family’s welfare and health.  It was considered an acceptable diagnosis that did not fail retention standards.  On 24 October 2007 (3 months prior to separation) the CI informed another primary care provider that he was having panic attacks “1-2 times per week in social situations” since his heart surgery.  This provider diagnosed panic disorder, but the following month rendered a diagnosis of adjustment disorder.  At a follow-up on 28 November 2007, the CI felt “like he is having a nervous breakdown,” and hadn’t slept or eaten for 2-3 days.  He complained of anxiety, persistent worry, depression and no energy.  The FPEB (2 weeks prior to separation) acknowledged the diagnosis of adjustment disorder forwarded by the MEB.  However, the CI’s anxiety symptoms, which reportedly included ongoing worry, difficulty concentrating, sleep problems, feeling on edge, and withdrawal from social activities, were sufficiently concerning that the FPEB was recessed.  Ultimately, the PEB concluded that a diagnosis of anxiety disorder was appropriate.

At the VA Compensation and Pension (C&P) exam on 15 May 2008 (approximately 4 months after separation), the CI reported he “always feels anxious.”  Symptoms began in March 2007 (weeks prior to heart surgery), the CI endorsed intermittent insomnia, and episodes of his heart racing and panic which lasted for 1-2 hours.  The CI indicated that he was unable to work because of physical disability.  Although he was prescribed an anti-anxiety medication, he was not currently in MH treatment.  He denied any history of interpersonal conflicts, reprimands or missed time from work due to mental illness.  He spent his time reading, listening to music and “hanging out with friends.”  He did not participate in sports due to his heart condition.  Mental status examination noted him to be calm with normal psychomotor activity.  Mood was “anxious and worried,” affect and speech was normal, and memory and judgment intact.  There was no evidence of hallucinations or thoughts of harm.  After review of the service treatment record (STR) (including the PEB document) the examiner rendered a diagnosis of adjustment disorder with mixed anxiety and depressed mood and assigned a Global Assessment of Functioning (GAF) of 60, connoting moderate symptoms or impairment.  The examiner opined that there were no major MH limitations which would preclude employment.

The Board directed attention to its rating recommendation based on the above evidence.  Under code 9400 (generalized anxiety disorder), the PEB cited occupational and social impairment due to “mild or transient symptoms” as the rationale for a 10% rating.  The VA used code 9440 (chronic adjustment disorder), and also assigned a 10% rating.  Application of VASRD §4.129 is considered by the Board for all cases of service-connected psychiatric conditions resulting in separation; but, all members agreed (member consensus was) that the “highly stressful event” requisite for §4.129 was not satisfied in this case.  The Board considered if a rating higher than 10% was warranted at the time of separation.  It was agreed that the 50% rating (“occupational and social impairment with reduced reliability and productivity”) was not described by the evidence, and deliberation settled on arguments between a 10% and 30% rating.  The §4.130 criteria for a 10% rating is “Occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication.”  A 30% rating requires “occupational and social impairment with occasional decrease in work efficiency and intermittent inability to perform occupational tasks.”

Because the C&P exam provided the only comprehensive assessment proximal to separation, it was assigned preponderant probative value in the Board’s deliberations.  While there were possibly two or three 30% threshold symptoms, board members considered that the GAF score reflected moderate impairment, symptoms were not apparently severe enough to prompt the CI to seek treatment after separation and there were no psychiatric hospitalizations or emergency room visits.  Although the CI complained of social withdrawal and unemployment, spending time with friends was an activity of engagement, and there was no history of interpersonal conflict; there was likewise no evidence that unemployment was related to MH symptoms.  All Board members agreed that the evidence presented above could not be reconciled with the 30% rating description, and concluded that the evidence at hand was most accurately depicted by the 10% rating criteria.  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 generalized anxiety disorder condition.

Hypertrophic Cardiomyopathy with Mitral Regurgitation Condition.  The requested hypertrophic cardiomyopathy condition is eligible for Board review to the extent that, although the Board does not have the authority to recommend a reversal of the service EPTS determination, it by precedent and prior legal/administrative opinion, may review the fairness of the PEB’s judgment that there was not permanent service aggravation (PSA).  Should the majority of members agree that there was PSA, a disability rating IAW the VASRD, with or without a deduction IAW VASRD §4.22 (Rating of disabilities aggravated by active service), will be recommended.

On 28 February 2007 (2 weeks after entry into the service and a week after beginning Basic Training) the CI presented for care of acute tonsillitis.  A thorough physical exam noted a heart murmur, and a chest X-ray noted enlargement of the heart (both ventricles and the left atrium).  He reportedly had participated in 3 days of physical therapy, and did not pass the running.  Within a week further evaluation established a diagnosis of hypertrophic cardiomyopathy (HCM; a genetic abnormality of heart muscle).  During the evaluation process, the CI denied any known history of heart disease, but acknowledged a history of occasional chest pain, a fast heart rate after running or walking, irregular heartbeats sometimes associated with lightheadedness and shortness of breath (SOB) at night.

A nuclear medicine test on 6 March 2007 (11 months prior to separation) noted an enlarged left ventricle and an ejection fraction of 44% (greater than 50% generally considered normal).  A cardiac stress test on the same day recorded an exercise capacity of 7.2 metabolic equivalents (METs).  The test was stopped due to chest pain and SOB.  During a civilian evaluation in early March 2007 the CI reported that he had experienced difficulties with basic training requirements, but “no more than anybody else.”  He “was able to tolerate a four mile march/run, but stopped secondary to a sprained ankle.”  He reported that he had “always been active, played church volley ball and basketball without any difficulty throughout high school.”  The author of the clinical entry noted that the current report of no history of symptoms was “at odds with the history in the medical records” from the service.  Echocardiography noted outflow tract obstruction from the left ventricle to the aortic valve, and also severe mitral regurgitation (abnormal backflow from the left ventricle towards the lungs) associated with abnormal movement of the mitral valve.  Severe left ventricular hypertrophy (enlargement) and severe left atrial enlargement were present.  Near the end of March 2007 the CI was hospitalized for 9 days for treatment of pneumonia.

At the narrative summary evaluation on 25 April 2007 the CI reported that he had been very physically active throughout his life, including playing basketball, volleyball and running.  At the current time, the CI reported tiring easily and SOB with exertion.  He could walk short distances at a slow pace, but could not walk prolonged distances.  Because of worsening of mitral regurgitation and enlargement of the left atrium, on 14 May 2007 the CI underwent a myectomy (surgical removal of part of the abnormally enlarged heart muscle) and repositioning of mitral valve leaflets.  Repeat echocardiography in August 2007 showed an ejection fraction of 80%.  Although hypertrophic cardiomyopathy was evident, mitral regurgitation was mild, there was no outflow tract obstruction and left atrial enlargement was moderate.  The previously identified abnormal movement of the mitral valve was no longer present.  Repeat exercise stress testing showed an exercise capacity of 5.2 METs.  A record entry by a cardiologist on 11 October 2007 (3 months prior to separation) noted that symptoms of exercise intolerance and SOB had improved mildly since surgery, and stated the following:

“This (HCM condition) is a chronic congenital condition that has been present for many years… (Which) is demonstrated by his severe left atrial enlargement, a chronic compensatory process to severe MR (mitral regurgitation).  In addition, acute severe mitral regurgitation is not tolerated well and would have resulted in acute pulmonary edema and an ICU admission, neither of which (the CI) had…Active duty service uncovered his condition…there is no evidence that his active duty service caused further heart damage.”

A cardiology addendum for the MEB on 12 October 2007 indicated that the condition had improved since surgery.  A chest X-ray on 27 November 2007 (2 months prior to separation) showed normal heart size.

At the VA C&P exam approximately 3 months after separation, the CI reported that he could not perform exertional work due to his heart condition.  He experienced SOB on a daily basis.  Walking 100 feet caused SOB, palpitations and chest tightness.  After reviewing the STR the examiner concluded that active duty service did not cause or aggravate the heart condition.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB and VA concluded the heart condition was not eligible for disability rating and compensation.  The Board does not challenge service EPTS determinations (nor is there any evidence for doing so in this case), but as previously elaborated does exercise the prerogative of assessing the PSA element IAW DoDI 1332.38 (E3.P4.5.2.3. - Presumption of Aggravation).  All members agreed that the evidence supports the PEB’s position.  The service cardiologist clearly described how compensatory mechanisms already in place (i.e. left atrial enlargement) could not have developed acutely; and that active duty did not cause further heart damage.  The Board debated if a week of Basic Training resulted in a permanently aggravated heart condition given that intensive physical training must be prolonged to possibly cause progression of heart damage in HCM1 (footnote refers to addended medical reference).  It was also considered that objective echo and radiographic findings showed obvious and significant structural improvement after surgery.  There is no objective evidence that the natural evolution of this condition was permanently affected by military activities.  After due deliberation, and mindful of DoDI 1332.38 (E3.P4.5.2.3 - Presumption of Aggravation), members agreed that there was insufficient cause to recommend a change in the PEB's determination that the hypertrophic cardiomyopathy with mitral regurgitation condition EPTS and was not permanently aggravated by service.

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 generalized anxiety disorder condition and IAW VASRD §4.130, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the hypertrophic cardiomyopathy with mitral regurgitation condition, 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 20140114, 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 XXXXXXXXXXXXXXXXXXXX, AR20150015756 (PD201400769)

I have reviewed the enclosed Department of Defense Physical Disability Board of Review (DoD PDBR) recommendation and record of proceedings pertaining to the subject individual.  Under the authority of Title 10, United States Code, section 1554a,   I accept the Board’s recommendation and hereby deny the individual’s application.  
This decision is final.  The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail.

 BY ORDER OF THE SECRETARY OF THE ARMY:

Encl						
						         
CF: 
(  ) DoD PDBR
(  ) DVA