RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX		CASE:  PD-2014-01445
BRANCH OF SERVICE:  AIR FORCE		SEPARATION DATE:  20080615

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve E-6, Utility Systems Craftsman, medically separated for “coronary artery disease, status-post subendocardial myocardial infarction and stent placement,” “asthma,” and “obstructive sleep apnea (OSA) requiring use of CPAP” rated 10%, 10% and 0%, respectfully, with a combined disability rating of 20%.

CI CONTENTION:  He believes he should have been medically retired from the service.  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 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 - 20070822	VARD - 20090406	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Coronary Artery Disease	7005	10%	Coronary Artery Disease	7005	0%	20081224	
Asthma	6602	10%	Asthma, with Bronchitis	6600-6602	30%	20081224	
Obstructive Sleep Apnea	6847	0%	Sleep Apnea	6847	50%	20081224	
COMBINED RATING:  20%	COMBINED RATING FOR ALL VA CONDITIONS:  90%	

ANALYSIS SUMMARY:

Coronary Artery Disease (CAD).  In September 2002, at the age of 42, this CI experienced jaw pain and arm pain during a physical fitness test.  He was diagnosed with a myocardial infarction (MI) or heart attack.  A stent was placed in one of his coronary arteries.  After surgery, he underwent cardiac rehabilitation, and he did well.  In July 2006, the CI had a cardiac evaluation. The treadmill stress test revealed that his exercise tolerance was normal.  He achieved a peak workload of 10.6 METS [metabolic equivalents].  The electrocardiogram (ECG) response to exercise was negative for ischemia (inadequate blood to the heart).  The ECG showed mild left ventricular hypertrophy (LVH) (thickening of left pumping chamber wall), and mild left atrial dilatation (enlargement of the left atrium which collects oxygen rich blood).  The left ventricular ejection fraction (LVEF) (blood leaving the heart) was 65%.  Due to the severity of his heart condition, the CI was profiled and referred for a Medical Evaluation Board (MEB).

At the MEB narrative summary (NARSUM) in May 2007, 13 months before separation, the CI reported occasional shortness of breath and dizziness with exercise. Physical examination of the heart showed regular rate and rhythm, with normal heart sounds and no murmur.  A repeat treadmill stress test dated 1 May 2007 revealed his METS dropped to 9.6 which indicates slightly worse exercise tolerance.  Another second ECG test was negative for ischemia.

During the VA Compensation and Pension (C&P) examination in December 2008, 6 months after separation, the CI was not employed.  The physical examination of the heart showed regular rate and rhythm, with normal heart sounds, and no murmur or gallop.  The VA examiner referenced:  the July 2006 ECG which was negative for ischemia and the July 2006 TST which showed the CI’s peak workload of 10.6 METS.  The examiner did not reference the more recent May 2007 TST, which showed a peak workload of 9.6 METS.

The Board directed attention to its rating recommendation based on the evidence.  The PEB assigned a 10% rating coded 7005 (coronary artery disease).  The VA assigned a 0% rating also coded 7005, citing the July 2006 cardiac evaluation which showed normal LVEF (65%), and TST workload of 10.6 METS.  For the reader’s convenience, the VASRD §4.104 language for diagnostic code 7005 (coronary artery disease) is excerpted below:

Workload of greater than 5 METs but not greater than 7 METs results in
dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac
hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray..........30 

Workload of greater than 7 METs but not greater than 10 METs results in
dyspnea, fatigue, angina, dizziness, or syncope, or; continuous medication
required……………..………………………………………………………………..................................10 

The Board carefully reviewed all the data, and determined that the July 2006 echocardiogram clearly showed evidence of mild left ventricular hypertrophy (LVH) and mild left atrial dilatation.  Therefore, IAW VASRD §4.104, a disability rating of 30% was warranted based on the CI’s evidence of cardiac hypertrophy and dilatation on echocardiogram.  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 coronary artery disease condition, coded 7005.

Asthma.  According to the service treatment record and MEB NARSUM, the CI had a long history of childhood asthma symptoms, which was documented at enlistment.  On 7 November 2007, 7 months before separation, the CI presented for mild wheezing.  He reported that he was using an Albuterol inhaler about 1-3 times per day.  He was not using inhaled steroids.  On 19 November 2007, pulmonary function tests (PFTs) were done.  The forced vital capacity (FVC) was normal.  The forced expiratory volume (FEV-1) was also normal.  The FEV-1 divided by FVC was normal.  After inhalational bronchodilator therapy, there was no objective or significant improvement.  These PFTs were interpreted as normal.  

During the VA Compensation and Pension (C&P) examination in December 2008, 6 months after separation, the CI reported using Albuterol daily without inhaled steroids.  He denied any problems with dyspnea (difficulty breathing).  He denied any history of chronic, productive cough, incapacitation or hospitalization due to asthma.  He reported that his asthma was more noticeable during windy days.  On physical examination, his lungs were clear to auscultation (no wheezing or other abnormal breath sounds).

On 29 January 2009, repeat PFTs were done.  The FEV-1 was 119% of predicted.  The FEV-1 divided by FVC was 67%.  There was slight improvement after inhalation bronchodilator therapy.  The FEV-1/FVC ratio went up to 73%.  These PFTs were interpreted as consistent with a mild obstructive lung defect. 

The Board directed attention to its rating recommendation based on the evidence.  The PEB assigned a 10% rating coded 6602 (asthma).  The VA assigned a 30% rating analogously coded 6600-6602 (chronic bronchitis - asthma), citing daily Albuterol inhaler use.  A 30% rating stipulates “FEV-1 of 56 to 70 percent predicted, or; FEV-1/FVC of 56 to 70 percent, or; daily inhalational or oral bronchodilator therapy, or; inhalational anti-inflammatory medication.”  

The Board determined that the examinations in evidence reported prescription and daily use of Albuterol.  Albuterol is a short-acting inhalational bronchodilator.  Board members agreed that the VASRD §4.97 threshold for a 30% rating was reasonably satisfied in this case, based on the CI’s daily inhalational bronchodilator therapy.  A 60% rating was not justified in the absence of at least monthly visits to a physician for required care of exacerbations, or intermittent (at least three per year) courses of systemic corticosteroids.  There was no PFT evidence to support the next higher 60% rating.  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 asthma, coded 6602.

Obstructive Sleep Apnea (OSA).  In November 2005, this CI had a polysomnography study and was diagnosed with OSA.  He was placed on nocturnal continuous positive airway pressure (CPAP).  The CPAP therapy caused a significant improvement in his OSA symptoms.  During an ear, nose and throat clinic visit in July 2006, his OSA condition was documented as stable.  He was using nightly CPAP at a setting of 13 cm of water.  During a CPAP clinic visit in July 2008, 1 month after separation, the examination documented OSA was stable and CPAP therapy was working well.

The Board directed attention to its rating recommendation based on the evidence.  IAW VASRD §4.97, diagnostic code 6847, a 50% disability rating is warranted when a sleep apnea syndrome requires use of a breathing assistance device such as CPAP.  Therefore, the Board determined that a 50% rating was appropriate for the unfitting OSA condition.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 50% for OSA, coded 6847.

BOARD FINDINGS:  In the matter of the coronary artery disease, the Board unanimously recommends a disability rating of 30%, coded 7005 IAW VASRD §4.104.  In the matter of the obstructive sleep apnea (OSA), the Board unanimously recommends a disability rating of 50%, coded 6847 IAW VASRD §4.97.  In the matter of the asthma condition, the Board unanimously recommends a disability rating of 30%, coded 6602 IAW §4.97.  However, IAW VASRD §4.96 (Special provisions regarding evaluation of respiratory conditions), ratings under diagnostic codes 6600 through 6817, and 6822 through 6847 will not be combined with each other.  A single rating will be assigned under the diagnostic code which reflects the predominant disability.  In this case, the predominant respiratory disability is OSA (6847), rated at 50%.  There were no other conditions within the Board’s scope of review for consideration.

The Board, therefore, 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 his prior medical separation:

CONDITION	VASRD CODE	RATING	
Obstructive Sleep Apnea	6847	50%	
Coronary Artery Disease	7005	30%	
Asthma	6602	---%	
RATING	70%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140321, w/atchs
Exhibit B.  Service Treatment Record
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

PDBR PD-2014-01445

MEMORANDUM FOR THE CHIEF OF STAFF

	Having received and considered the recommendation of the Physical Disability Board of Review and under the authority of Title 10, United States Code, Section 1554a (122 Stat. 466) and Title 10, United States Code, Section 1552 (70A Stat. 116) it is directed that:

	The pertinent military records of the Department of the Air Force relating to XXXXXXXXXXXXXXXXXXXXX, be corrected to show that:

		a.  The diagnoses in his finding of unfitness were Obstructive Sleep Apnea, VASRD code 6847 was rated at 50% rather than 0%; and Coronary Artery Disease, VASRD code 7005, rated at 30% rather than 10%, with a combined disability rating of 70%.

		b.  On 14 June 2008, he elected spouse-and-child Survivor Benefit Plan coverage, based on full retired pay. 

		c.  He was not discharged on 15 June 2008 with entitlement to disability severance pay; rather, on that date he was released from active duty and on 16 June 2008 his name was placed on the Permanent Disability Retired List.

XXXXXXXXXXXXXXXXXXXXX
Principal Deputy Assistant Secretary 
(Manpower and Reserve Affairs