RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX		CASE:  PD-2014-00938
BRANCH OF SERVICE:  Army		DATE OF SEPERATION:  20071002

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an activated National Guard E-5, Heavy Construction Equipment Operator, medically separated by the Informal Physical Evaluation Board from the Temporary Disability Retired List (TDRL) for “non-ischemic dilated cardiomyopathy with dilated right ventricle”; with a disability rating of 10%.

CI CONTENTION:  The applicant makes no specific contention in his application.  His 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 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

SERVICE PEB – 20070823	VARD – 20040908	
Condition	Code	Rating	Condition	Code	Rating
Proximate	
		TDRL
Placement	TDRL Removal			TDRL
Placement	TDRL Removal	
Cardiomyopathy	7020	30%	10%	Non-Ischemic Idiopathic Dilated Cardiomyopathy	7020	10%*	None	
COMBINED RATING:  30% → 10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	
* Rating increased to 60% based on STR showing left ventricular systolic function (ejection fraction of 44%)

ANALYSIS SUMMARY:

Cardiomyopathy.  The service treatment record (STR) and narrative summary (NARSUM) documented chest pain that began while on deployment to Bosnia in early 2003.  Electrocardiograph (ECG) changes were documented in February 2003 (15 months pre-TDRL placement) and prompted a referral to cardiology in March 2003 (14 months pre-TDRL placement).  A cardiac stress test was performed and stopped after 11 minutes for fatigue and dyspnea without ECG changes but frequent premature ventricular contractions (abnormal heart rhythm) on recovery.  An ultrasound (echocardiograph) exam documented a reduced ejection fraction of 43% (normal 50-75%).  The examiner diagnosed “early” idiopathic cardiomyopathy.  A cardiac perfusion scan in May 2003 (12 months pre-TDRL placement) documented “no definite evidence of reversible ischemia;” decreased movement (hypokinesis) of the inferior heart wall with “borderline” dysfunction; and left ventricular dilation, with an ejection fraction of 49%.  During a perfusion stress test in November 2003 (6 months pre-TDRL placement), the CI achieved a peak workload of 13 METs with “good exercise tolerance.”  The test was stopped due to “fatigue with no reported symptoms” and no ischemic ECG changes.  The cardiologist documented a normal perfusion study with “no…perfusion defects,… no chamber dilation,…and normal contractility” with a “borderline low-normal” left ventricular systolic function (ejection fraction of 44%).  At a cardiology visit in December 2003 (5 months pre-TDRL placement), an echocardiogram documented “mild” global dysfunction, left ventricular enlargement, fixed inferior wall defect, and hypokinesis of posterior wall.  The ejection fraction was 40-50%.  The examiner diagnosed “non-ischemic idiopathic dilated cardiomyopathy” and medications (ACE inhibitor and Beta Blocker) were started.

The Medical Evaluation Board (MEB) NARSUM exam was dated 3 March 2004 (2 months pre-TDRL placement).  The CI reported daily chest pain with exercise and continued the medications as prescribed.  The examiner documented a normal physical exam and referenced the studies done previously.  On the MEB DD Form 2807-1 Report of Medical History, dated 9 March 2004, the CI reported taking medications and still having chest pain, but did not elaborate.  On the MEB DD Form 2808, Report of Medical Examination, dated 9 March 2004, the examiner documented a normal exam, ECG, and chest x-ray.

At the VA Compensation and Pension (C&P) exam dated 26 April 2004 (1 month pre-TDRL placement), the CI reported chest pain and fatigue that worsened with exertion, and continued medication usage.  He denied shortness of breath and lower extremity swelling.  He reported difficulty pushing a lawnmower, climbing stairs and walking.  The examiner documented a normal heart exam, no signs of enlarged heart or heart failure, and no edema of the lower extremities.  In an undated C&P addendum, the examiner added the stress test findings:  “Veteran complaining of chest pain and fatigue.  ECG showed [evidence of myocardial infarction (lack of blood flow to the heart)].  Stress test showed chest tightness [indicating] angina.  Estimated METs of 4-5.”

The Board directed attention to the rating recommendation at TDRL Placement based on the above evidence.  The PEB adjudicated the “non-ischemic cardiomyopathy with dilated right ventricle” as unfitting and rated 30% coded 7020 (cardiomyopathy).  The VA rated the “angina claimed as idiopathic dilated cardiomyopathy” at 10% analogously coded 7099-7005 (atherosclerotic or coronary heart disease) citing angina with no symptoms and no evidence of heart disease (cardiomegaly, congestive heart failure, cardiomyopathy).  A subsequent VA Rating Decision increased the rating to 60% based on the STR (perfusion stress test in November 2003) showing left ventricular systolic function (ejection fraction of 44%).

The Board considered the evidence for a higher than 30% rating.  There was evidence of cardiomyopathy and two separate tests documenting ejection fractions of 30-50% in support of a 60% rating.  There was also evidence of exercise testing that documented a workload of 4-5 METs that resulted in angina symptoms in support of a rating of 60%.  There was no evidence of congestive heart failure, workload of 3 METs or less, or left ventricular dysfunction with an ejection fraction of less than 30% percent in support of a higher rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a TDRL placement disability rating of 60% for the cardiac condition. 
Radiologic imaging in October 2005 (24 months pre-separation) documented the resting ejection fraction as 46%.  There was moderate dilation of the left ventricle.  At a cardiology visit for exercise testing in October 2005, a stress test induced no symptoms and documented no stress induced evidence of heart disease.  The TDRL MEB NARSUM/reevaluation exam was performed on 4 January 2006 (21 months pre-separation).  The CI reported left sided intermittent chest pain, with no shortness of breath, fatigue or nocturnal symptoms.  The examiner documented a normal blood pressure and a normal cardiac exam (regular heart rate without murmur or edema).  Review of the exercise testing from October 2005 revealed a maximum workload of 7 METs (“stopped due to severe knee pain”).  The examiner recommended continued medications and continued TDRL status.

At a TDRL reevaluation visit with cardiology in March 2007 (7 months pre-separation), the CI reported left sided chest pain that occasionally radiated to the left arm and was not always related to exertion.  He reported the ability to walk about 10-15 minutes regularly, and denied lower extremity edema, syncope, and shortness of breath.  He had continued his medications.  The examiner documented normal lung, cardiac and extremity exams.  Cardiac imaging documented an ejection fraction of 56%, normal heart size, and good cardiac wall motion throughout.  After 8 minutes of exercise testing, a workload of 10 METs was achieved with normal cardiac electrical activity (normal ECG) and “non-limiting chest pain and shortness of breath” was documented.  The examiner opined improved heart function on medications with no limitations on exercise testing; and that the chest pain was not of cardiac origin.  There were no VA C&P exams within 12 months post-separation in evidence for review.  

The Board directed attention to the rating recommendation at TDRL Removal/Separation based on the above evidence.  The PEB adjudicated the cardiac condition at 10% coded 7020, citing an ejection fraction of 56% with appropriate medications, and no limitation on graded exercise testing (10 METs) which was not limited by chest pain or shortness of breath.  The VA did not reevaluate the CI’s cardio condition; and thus, did not consider changing the current rating.

The Board considered the evidence for a higher than 10% rating.  There was no evidence of an ejection fraction that persisted between 30-50% in support of a higher rating.  The ejection fraction improved to normal (56%) by the time of separation.  There was no evidence of persistent left ventricular dilation (cardiomyopathy) or dysfunction in support of a higher rating, as heart size and function was normal by the time of TDRL removal.  All stress testing performed induced no symptoms and documented no stress induced evidence of heart disease (ECG changes) in the year prior to separation and did not support a higher rating.  There was evidence of a workload of 10 METs achieved without associated cardiac symptoms that resulted from continuous medications usage in the 2 years pre-separation which supported a 10% 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 cardiac condition at separation.  

BOARD FINDINGS:  In the matter of the cardiac condition, the Board unanimously recommends a rating of 60%, coded 7020 IAW VASRD §4.104 at TDRL placement; and no change in the PEB adjudication (10%) at permanent separation.  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, effective as of the date of his prior medical separation:

CONDITION	VASRD CODE	RATING	
		TDRL	PERMANENT	
Cardiomyopathy	7020	60%	10%	
RATING	60%	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140221, 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, AR20160005441 (PD201400938)

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 (DoD PDBR) pertaining to the individual named in the subject line above to  constructively place the individual on the Temporary Disability Retired List (TDRL) at 
60% disability rather than 30% for the period 1 August 2004 to 1October 2007 and then following this period no recharacterization of the individual’s separation or modification of the permanent disability rating of 10%.

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 as follows:

	a.  Providing a correction to the individual’s separation document showing that the individual was separated by reason of temporary disability effective the date of the original medical separation for disability with severance pay.

	b.  Providing orders showing that the individual was separated with a permanent combined rating of 10% effective the day following the TDRL period with no recharacterization of the individual’s separation.

	c.  Adjusting pay and allowances accordingly.  Pay and allowance adjustment will provide 60% retired pay for the temporary disability retired period effective the date of the individual’s original medical separation and adjusting severance pay as necessary.

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:

Enclosures

CF: 
(  ) DoD PDBR
(  ) DVA