RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01149
BRANCH OF SERVICE:  AIR FORCE	BOARD DATE:  20150513
Separation Date:  20090827

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-6 (Security Forces Craftsman) medically separated for chest pain.  The condition could not be adequately rehabilitated to meet the physical requirements of his Air Force Specialty.  He was placed on light duty and referred for a Medical Evaluation Board (MEB).  The chest pain condition, characterized as “atypical chest pain” was forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123.  The MEB also identified and forwarded two other conditions (first degree A-V block and right lower lobe lung nodule) for PEB adjudication.  The Informal PEB adjudicated “exertional chest pain” as unfitting, rated 10% with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  Of the remaining conditions the right lower lobe lung nodule was determined to be Category II (conditions that can be unfitting but are not currently compensable or ratable).  The first degree A-V block was not specifically addressed by the PEB.  The CI made no appeals and was medically separated.

CI CONTENTION:  “The original diagnosis of coronary artery vasospasms by my primary care physician & cardiologist was changed to atypical chest pain by the medical treatment facility's Group Commander for medical board review.  Once the package was submitted, I was advised by the medical board's legal counsel that there was no classification for atypical chest pain and I could not petition the 10% finding.  Continued...  All medical issues must be categorized (sic) within the Title 38 classifications; which the VA classified my coronary vasospasms as an atrioventricular (AV) block.  According to Title 38, 4.104 (7015N) an AV block with a "left ventricular dysfunction with an ejection fraction (EF) of 30 to 50 percent" qualifies as a 60% disability.  My left ventricular EF is 46% placing it as a 60% disability if Title 38, 4. 7 is applied, "Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned" or 4.3 "a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant." Regardless, the VA has initially (sic) awarded a 30% rating for my disability based on laws and regulations (while the 60% claim is still under review).  The Air Force did not apply Title 38's guidelines and generalized my condition which restricted my ability to dispute any medical board findings (no classification, means no objective method for establishing severity of disability).  If the Air Force classified my disability according to the law, I should have received a 60% disability rating based on my 46% EF and been medically retired instead of separated for my 15.5 years of dedicated service.”

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 IPEB – Dated 20000501	VA - (~2.5 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Exertional Chest Pain	5399-5321	10%	First Degree Atrioventricular Block (Also Claimed as Coronary Artery Vasospasm)	7015	30%	20091106-7	
Other x1 (Not In Scope)	Other x15	
Combined:  10%	Combined:  50%	

ANALYSIS SUMMARY:  

Exertional Chest Pain.  The CI had a 5-year history of sharp left sided chest pain symptoms that usually presented about 3/4 of the way into a 1.5 mile run.  The CIs’ primary care provider (PCP) evaluated the CI for a cardiovascular clearance prior to initiation of a medication for attention deficit hyperactivity disorder.  The physical exam cardiac exam was normal.  The examiner noted that a prior electrocardiogram (EKG) showed a first degree heart block and the patient was asymptomatic; therefore, the examiner concluded that this could occur in healthy young patients and no further workup or treatment was required at that time.  A repeat EKG done on the same date confirmed the previous results.  The CI was seen a week later by his PCP and reported the 5-year history of left sided chest pain which lasted minutes during intense runs with lightheadedness.  A cardiac stress test was normal and the cardiologist opined that the chest pain was pleuritic in nature.  The CI had a repeat episode of chest pain and as he drove himself to the emergency room, the symptoms resolved and he drove back home.  He reported that he sometimes would experience tunnel vision and lightheadedness with the chest pain.  The civilian cardiologist noted mild shortness of breath, sharp retrosternal chest pain, localized, non-radiating which was transient and subsided in a few minutes.  The cardiac exam and EKG were normal.  An echocardiogram demonstrated minimal left ventricular hypertrophy, evidence of left ventricular diastolic dysfunction, preserved left ventricular systolic function with a normal left ventricular ejection fraction (LVEF), and mild valvular dysfunction.  An exercise cardiolite spect test demonstrated a mildly reduced left ventricle systolic function with an ejection fraction of 46% and decreased perfusion which was possibly reversible although motion artifact was also noted on the exam.  The exercise echocardiogram and EKG documented the CI achieved 17.2 METS and 100% predicted heart rate.  The cardiologist wrote that the CI was “safe to exercise up to a workload of 17 METS.  The civilian cardiologist saw the CI in follow-up documented that based on the findings of the cardiac testing that the he most likely had vasospasm of the coronary arteries which could occur secondary to a combination of over-exertion or exposure to cold.  The Duty Limiting Condition report noted that the CI could exercise up to 17 METS or until he began to experience chest pain.  The MEB narrative summary exam performed 7 months prior to separation documented that the CI had undergone a Cardiolite stress test which was abnormal because of a possible motion artifact; however, there was no comment made on the mildly reduced left ventricle systolic function with an ejection fraction of 46% which was not attributable to the possible motion artifact.  The cardiac exam was normal.  The examiner opined that the CI was not currently world-wide qualified because of the angina he would experience with exertion.  The VA Compensation and Pension exam was missing from the record.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB coded the exertional chest pain condition as 5399 analogous to 5321 (Group XXI. Function: Respiration. Muscles of respiration: Thoracic muscle group).  The VA coded the first degree atrioventricular block condition as 7015 (Atrioventricular block) and rated at 30% for evidence of cardiac hypertrophy echocardiogram.  The Board reviewed the VA’s rating decision and recognized the note for VASRD code 7015 contained the following statement, “Simple delayed P-R conduction time, in the absence of other evidence of cardiac disease, is not a disability.”  The Board noted that the CI did have a simple delayed P-R interval (first degree AV block) and no other evidence of cardiac disease.  The CI had excellent exercise tolerance of >17 METS (under code 7015 7-10 METS is rated at 10%) and the “minimal left ventricular hypertrophy” with preserved systolic function and normal ejection fraction was not abnormal for an avid exerciser which the CI was.  The results of the exercise cardiolite spect test were equivocal based on the noted motion artifact demonstrated on the exam along with the other cardiac data demonstrating otherwise normal cardiac function and the CI’s excellent exercise tolerance.  After deliberation, Board members agreed that the evidence present for review did not support any underlying cardiovascular disease.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends no change in the PEB adjudication for the exertional chest pain 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 exertional chest pain condition and IAW VASRD §4.71a, 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 20140301, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

XXXXXXXXXXXXXXXXXXXX
President
Physical Disability Board of Review

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

Dear XXXXXXXXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2014-01149.

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 appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.

Sincerely,

XXXXXXXXXXXXXXXXXXXX
Director
Air Force Review Boards Agency

Attachment:
Record of Proceedings

cc:
SAF/MRBR