RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00928
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20081127

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E5, Wheeled Vehicle Mechanic, medically separated for “recurrent perianal abscesses,” with a disability rating of 10%.

CI CONTENTION:  Her conditions continue to worsen and negatively impact her daily activities.  She was not evaluated for TBI.  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 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 - 20080827	VARD - 20090107	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Recurrent Perianal Abscesses	7820	10%	Residuals of Chronic Perianal Abscess and Ischiorectal Fistula	7332	10%	20090203	
Migraines	Not Unfitting	Migraine Headaches	8100	30%	20081107	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Recurrent Perianal Abscesses.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s recurrent perianal abscess condition began in 2005.  The CI underwent multiple incision and drainage (I&D) procedures.  A civilian surgeon noted that the CI was “status post drainage and fistula formation” at a visit on 3 May 2007.  The NARSUM noted the CI’s last abscess I&D was in November 2007.  Subsequent general surgery evaluations found no evidence of a fistula and a colonoscopy with biopsies was negative for Crohn’s disease (inflammatory bowel disorder).  Despite treatment, the perianal abscess condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for a MEB.  The MEB forwarded “multiple perianal abscesses” for PEB adjudication.  At the MEB NARSUM examination on 30 April 2008, 7 months before separation, the CI reported anorectal pain.  The physical exam of the rectum showed multiple scars from the perianal abscess drainage procedures, without evidence of a current abscess or fistula.  A MEB General surgery addendum dated 8 August 2008, 4 months before separation, indicated the CI had a history of recurrent perianal abscesses with multiple evaluations for intermittent recurrent pain, without evidence of a recurrent abscess or fistula.  The CI had last been evaluated by surgery in December 2007.  The surgeon noted that the CI reported recurrent episodes of pain in the area of the previous surgical procedures, without evidence of abscess or fistula.  He noted the CI requested a MEB due to “constant need of medical care and requirement for numerous rest periods.”

At a VA Compensation and Pension (C&P) Rectum and Anus examination on 2 February 2009, 2 months after separation, the CI reported pain with bowel movements, itching, burning, difficulty passing stool and rectal spasms, with episodes of fecal leakage, but no frank bowel incontinence.  The physical exam noted an anorectal fistula with drainage and tenderness.  There was no stricture, rectal prolapse or impaired sphincter tone noted.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the perianal abscesses condition 10%, coded 7820 (infections of the skin not listed elsewhere).  The VA Rating Decision dated 20 February 2009 rated the perianal abscess condition 10%, coded 7332 (impairment of sphincter control of the rectum and anus [7335 – fistula-in-ano is rated according to 7332 criteria]).  There was evidence of constant slight or occasional moderate leakage noted at the C&P exam to support a 10% rating, coded as 7332,   but there was no evidence of episodes of bowel incontinence to support a higher evaluation.  The PEB coded the condition as an infection of the skin and under 7820, there was no evidence to support the next higher 30% rating based on the extent of the infection or duration of use of immunosuppressive medications (or treatment which could be analogized to such courses of medication) to support a higher rating.  There is therefore no route to a rating higher than the 10% adjudicated by the PEB under any applicable VASRD code.  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 recurrent perianal abscesses condition.  

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the migraine condition was not unfitting.  The Board’s threshold for countering fitness determinations requires a preponderance of evidence, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  

Notes in the STR and the MEB neurological addendum indicated the CI had a history of migraine headaches.  A brain CT performed on 15 November 2007 was negative.  The MEB neurology addendum 17 June 2008 noted headaches which occurred two to three times per month and use of an abortive migraine medication (Imitrex) was usually effective.  The CI had been prescribed an antidepressant medication for migraine prevention in the past, but she stopped taking it on her own.  The neurological examination was normal.  The neurologist indicated the migraine headaches were moderately well controlled and added a prescription for preventive migraine medication and increased the dosage of Imitrex for treatment of an acute migraine.  The neurologist determined that the migraine headaches were medically acceptable.  

The migraine headache condition was not profiled.  The commander’s statement noted the CI was unable to perform her duties due to “constant need of medical care” and her “medical condition requires numerous rest periods.”  However, the Board noted that these were the words used by the surgeon with regard to the CI’s residual pain related to the perianal abscesses condition.  There was no evidence in the STR that the rest periods were due to “prostrating” migraine headaches and there was no performance based evidence from the record that the migraine condition significantly interfered with satisfactory duty performance.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for migraine headaches condition and so no additional disability ratings are recommended.

BOARD FINDINGS:  In the matter of the recurrent perianal abscesses condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended migraine headaches condition, the Board unanimously recommends no change from the PEB determination as not unfitting.  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 20140202, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB						

MEMORANDUM FOR Commander

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXX, AR20160007266 (PD201400928)

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