RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00950
BRANCH OF SERVICE:  AIR FORCE	SEPARATION DATE:  20080121

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Security Forces Journeyman) medically separated for an ulcerative colitis condition.  The condition could not be adequately rehabilitated to meet the physical requirements of her Air Force Specialty (AFS).  She was issued a temporary P4 profile and referred for a Medical Evaluation Board (MEB).  Ulcerative proctitis was forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123.  No other conditions were submitted by the MEB.  The Informal PEB adjudicated ulcerative colitis as unfitting, rated 10% citing application of the Department of Defense and Veterans Affairs Schedule for Rating Disabilities (VASRD) guidelines.  The CI appealed to the Formal PEB, which affirmed the PEB findings and rating.  The CI made no further appeal and was medically separated.

CI CONTENTION:  Her condition continues to worsen and negatively impact her daily activities.  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:  

FPEB - Dated 20071108	VA* - (~21 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Ulcerative Colitis	7399-7323	10%	Ulcerative Colitis	7323	30%	20091010	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 9	
RATING:  10%	RATING:  40%	
*Derived from VA Rating Decision (VARD) dated 20091110 (most proximate to date of separation [DOS])

ANALYSIS SUMMARY:  

Ulcerative Colitis Condition.  According to service treatment records and the MEB narrative summary (NARSUM), the CI’s ulcerative colitis condition began in Korea in January 2009 after a bowel infection (Salmonella).  Bowel symptoms did not resolve following antibiotics and colonoscopy in January 2006, sigmoidoscopy in March 2006, and colonoscopy in June 2006 confirmed ulcerative colitis primarily in the rectum (chronic ulcerative proctitis with cecal involvement).  Oral medication (Sulfasalazine/Asacol) and suppository medication (Mesalamine) had decreased the CI’s symptoms.

The MEB NARSUM exam on 18 June 2007 (7 months prior to separation) noted the CI’s complaints of ulcerative proctitis.  The history indicated that the CI reported marked improvement in symptoms in May 2006 following changes in how she took her medications.  The CI’s profile restrictions were decreased and she was permitted to PCS to Germany.  On 16 October 2006, in Germany, the CI was seen for results for her June 2006 colonoscopy, current symptoms (blood and mucus with diarrhea), and was referred for MEB.  Physical exam on 21 February 2007 was cited as showing hyperactive bowel signs with diffuse abdominal tenderness to palpation.

A gastroenterology note (referenced in the FPEB) dated 13 July 2007 (6 months prior to separation), summarized the CI’s history and noted the CI was taking only oral medications.  Examination documented the CI was well appearing and well nourished.  The assessment was ulcerative proctitis and the examiner stated “She has never missed work, not required IV medications.  Currently she is on oral medications which have a low delivery to the rectum.  If her symptoms were to increase then needs suppositories to tx [treat] the rectum.  This is a deployable condition.  Unsure why MEB initiated because AHLTA does not document recurrent visits, severity of disease.  Recommend retention and change to a deployable position.”  On 23 August 2007 (5 months prior to separation), an update to the NARSUM stated:  “(The CI) is currently asymptomatic on medication; per gastroenterology evaluation 13 July 2007 no MEB warranted.  (The CI) is currently performing all duties without restrictions except for those recommend while undergoing MEB.”  No new physical exam was accomplished.  The 21 September 2007 IPEB cited “inability to deploy” for their 10% unfit determination.  The CI appealed for an FPEB.  The CI had a sigmoidoscopy on 26 October 2007 (3 months prior to separation) with moderate active proctitis (terminal rectum) and hemorrhoids.  The same gastroenterologist recommended addition of suppository medication (Mesalazin).  On 31 October 2007 the CI was placed on 72 hours of quarters.

The FPEB dated 8 November 2007 (2 months prior to separation) included testimony from the CI that she was taking oral and suppository medications and “had an increase in the number and intensity of bowel movements, mostly unplanned, on an almost daily basis.  Pain from cramp frequency and intensity she rates as 10/10 without medication and 6/10 on medication.  … even with the medication she has unpredictable flares on a four to six episodes basis monthly.  The member testified that she has at no time gone more than a week without symptoms.”  The FPEB remarks summarized the 13 July 2007 and 26 October 2007 gastroenterology notes referenced above.

Gastroenterology note dated 22 November 2007 (2 months prior to separation), noted CI complaints of burning to itching pains during and shortly after defecation.  The CI had 5-6 bowel movements per day of varying consistency and abdominal complaints “from time to time.”  Exam showed a painful rectal exam with hemorrhoidic skin tag and an anal fissure (break or tear in the skin of the anal canal).  On 27 November 2007, the CI had surgery for excision of a chronic anal fissure.  The gastroenterologist noted that during surgery there was significant evidence of “Morbus Crohn” activity (Crohn’s disease-type inflammatory findings) and recommended addition of rectal corticosteroid foam.

At the VA Compensation and Pension (C&P) examination on 10 October 2009, performed 21 months after separation, the CI reported similar remote history as well as losing 20 pounds over the prior 6 months; with symptoms of nausea and vomiting, diarrhea and alternating constipation, abdominal pain with distress and cramps, and intermittent as often as 2 times per month lasting up to 2 weeks with fair response to medication of Sulfasalazine.  She complained of anal itching and pain, frequent hemorrhoids, and a nagging feeling to empty bowel, swelling and perianal discharge and bleeding.  Physical exam showed the CI was well developed and well-nourished with tenderness to palpation of the abdomen.  Rectal exam showed both external and internal hemorrhoids (reducible) with thrombosis.  There was no evidence of excessive redundant tissue.  Laboratory testing showed no anemia.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under an analogous 7399-7323 code (Colitis, ulcerative), citing treatment records with few entries, “currently symptom free,” and no missed work.  The VA assigned a 30% rating using the 7323 code for moderately severe symptoms with frequent exacerbations.  The Board considered that the service records had the highest probative value for rating as the VA exam was 21 months remote from separation and indicated post-separation worsening.  The crux of the Board’s deliberation focused on the code 7323 rating criteria of 30% “moderately severe; with frequent exacerbations,” versus 10% “moderate; with infrequent exacerbations.”  The FPEB’s remarks noted that 6 months prior to separation (July 2007) the CI was reported as symptom free and that 3 months prior to separation (October 2007) gastroenterology notes indicated moderately active proctitis.  The CI’s FPEB testimony was 2 months prior to separation and indicated that she had increased severity and frequency of her abdominal and bowel symptoms.  Following the FPEB, but prior to separation, the CI had anal fissure surgery and the gastroenterologist indicated significant evidence of inflammatory disease and recommended additional medication for treatment.

Given the evidence of pre-separation worsening of the CI’s disease severity and frequency, the Board adjudged that her condition more nearly approximated the disability picture of the 30% criteria.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (Reasonable doubt), the Board recommends a disability rating of 30% for the ulcerative colitis 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.  As discussed above, PEB reliance on DoD guidelines for rating the ulcerative colitis condition was operant in this case and the condition was adjudicated independently of those guidelines by this Board.  In the matter of the ulcerative colitis condition, the Board unanimously recommends a disability rating of 30%, coded 7399-7323 IAW VASRD §4.114.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  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 her prior medical separation:

CONDITION	VASRD CODE	RATING	
Ulcerative Colitis	7399-7323	30%	
RATING	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140224, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD  20762

Dear XXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2014-00950.
 
After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was not appropriate under the guidelines of the Veterans Affairs Schedule for Rating Disabilities.  Accordingly, the Board recommended your separation be re-characterized to reflect disability retirement, rather than separation with severance pay.

I have carefully reviewed the evidence of record and the recommendation of the Board.    I concur with that finding, accept their recommendation and determined that your records should be corrected accordingly.  The office responsible for making the correction will inform you when your records have been changed.

As a result of the aforementioned correction, you are entitled by law to elect coverage under the Survivor Benefit Plan (SBP).  Upon receipt of this letter, you must contact the Air Force Personnel Center at (210) 565-2273 to make arrangements to obtain an SBP briefing prior to rendering an election.  If a valid election is not received within 30 days from the date of this letter, you will not be enrolled in the SBP program unless at the time of your separation, you were married or had an eligible dependent child, in such a case, failure to render an election will result in automatic enrollment.

Sincerely,

Attachment:
Record of Proceedings

cc:
SAF/MRBR  
DFAS-IN