RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00780
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20070207

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Patient Admin Specialist) medically separated for chronic pelvic pain.  The condition could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty (MOS).  She was issued a permanent P3 profile and referred for a Medical Evaluation Board (MEB).  The diagnosis “chronic pelvic pain as a result of multiple adhesions and scarring within the pelvic cavity, unresponsive to all available treatment modalities to include total abdominal hysterectomy” was forwarded as the sole submission to the Physical Evaluation Board (PEB) IAW AR 40-501.  The Informal PEB adjudicated “chronic pelvic pain ... [identical to MEB language]” as unfitting, rated 10%, citing application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI made no appeals and was medically separated.    

CI CONTENTION:  The CI referenced additional conditions of bladder incontinence, depression, bipolar disorder, and post-traumatic stress disorder.  Her 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/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 

IPEB - Dated 20061026	VA* - (~2 Mos. Pre-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pelvic Pain ...	7399-7301	10%	Hysterectomy w/ Pelvic Adhesions	7614-7618	30%	20061212	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 8 (6 Not Service Connected)	
RATING:  10%	RATING:  40%	
*Derived from VA Rating Decision (VARD) dated 20071205 (most proximate to date of separation [DOS]).  

ANALYSIS SUMMARY:   

Pelvic Condition.  The service treatment record (STR) corroborates the history in the narrative summary (NARSUM) of an onset of pelvic pain in 2004 (2+ years pre-separation).  A laparoscopy in March 2005 did not identify any significant pathology.  The CI continued to experience pelvic pain, now with abnormal bleeding; and, in September 2005 (17 months pre-separation) she underwent a therapeutic hysterectomy.  The operative note described lysis of “dense severe” adhesions which involved the uterus and bladder, but noted normal Fallopian tubes and ovaries.  The pain was initially resolved (bleeding, of course, remedied), but subsequently recurred.  A gynecology note in May 2006 documented “intermittent” pain rated 4/10, and an MEB was initiated.  The last outpatient entry in the STR was a month later (7 months pre-separation) and documented that the CI was pain free at the time of the visit, but still suffered “recurrent” pain. 

The NARSUM was conducted 25 September 2006 (5 months pre-separation) and documented “constant” pelvic pain rated 5/10 “on a good day” with exacerbations to 8/10 “2-3 times per month;” and, aggravated by “going to a standing position from a sitting position, performing sit-ups, running for long distances [but 4 mile walking tolerance], and negotiating stairs.”  The examiner did not reference medications or response to treatment.  The physical examination recorded bilateral inguinal tenderness.  

A VA Compensation and Pension (C&P) examination was conducted 12 December 2006 (2 months pre-separation) and documented “continued” pain since surgery which “only responded somewhat to Naprosyn [anti-inflammatory] and Percocet [narcotic].”  Naprosyn was listed on the MEB’s DD Form 2807-1 medical history, but the last prescription per the medication profile was 15 months earlier, and the last prescription for Percocet (20 tablets) was 5 months earlier.  The VA physical examination recorded no acute distress and “mild” diffuse lower abdominal tenderness.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB cited the “moderate” criterion for 10%, rating under the analogous code 7301 (peritoneum, adhesions of).  The 30% rating under code 7301 requires “moderately severe” symptoms with partial obstruction (not in evidence).  The VA rated under 7614-7618 (fallopian tube adhesions rated as removal of the uterus), with 7618 conferring 30% as a permanent rating three months after removal of the uterus.  Code 7614 (fallopian tube, disease, injury, or adhesions) itself confers 10% for “symptoms that require continuous treatment” and 30% for “symptoms not controlled by continuous treatment.”  The only other applicable code under VASRD abdominal or gynecologic listings is analogous application of 7629 (endometriosis); but, the 10% and 30% criteria are equivalent to those of 7614 (PEB code), and the highest 50% rating is for features specific to endometriosis which are not applicable to this case (bleeding, etc.).

Members first considered the VA option of analogous rating under 7618 for which the clinical history unequivocally matches the 30% criterion.  It must be noted, however, that 7618 clearly rates for loss of reproductive capability since no symptoms or other criteria are encompassed by the rating language.  The DoD directive in effect for this case (DoDI 1332.39 [E2.A1.3.2.15.2], as reflected in AR 635-40 [B-80]) stipulates that “anatomical loss of procreative organs shall not be rated.” The Board, IAW DoDI 6040.44 (4.d), must comply with “all applicable statutes and any directives in effect ... to the extent they do not conflict with the VASRD;” and, members agreed that these directives were not countermanded by the VASRD which does not address policy of this nature.  Deliberation then ensued as to whether a 30% rating recommendation was supported by analogous application of code 7614 (the only option more favorable than the PEB code and rating).  As above, recommending 30% under 7614 necessitates a conclusion that the condition required continuous treatment and that the symptoms were not controlled.  Although it is possible that the CI required continuous medication to manage her pain, the medication profile suggests only sporadic use of the anti-inflammatory and it is clear that she did not require frequent use of the narcotic at separation.  Furthermore, although the VA examiner noted that the pain was “only ... somewhat” controlled, the STR evidence indicates that the pain was intermittent and could reasonably be characterized as fairly well controlled.  It should also be considered that code 7614 is not clinically aligned with the pathology in this case, since there was no fallopian tube disease; and, its application, even analogously, is tenuous.  The PEB’s code 7301 for general peritoneal adhesions is the best clinical fit.  Members concluded, therefore, that neither the 30% rating criteria nor the analogous application of code 7614 were sufficiently supported.  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 of the pelvic 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 pelvic condition and IAW VASRD §4.114, 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 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 XXXXXXXXXXXXXXXXXX, AR20160002532 (PD201400780)

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:

Enclosure

CF: 
(  ) DoD PDBR
(  ) DVA