RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	 CASE:  PD-2014-01495	
BRANCH OF SERVICE:  AIR FORCE	 BOARD DATE:  20141218
SEPARATION DATE:  20091228		   

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty TSgt (Aerospace Maintenance Craftsman) medically separated for narcolepsy.  The condition could not be adequately rehabilitated to meet the physical requirements of his Air Force Specialty (AFS).  He was placed on duty and mobility restrictions and referred for a Medical Evaluation Board (MEB).  “Narcolepsy with cataplexy” was forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123.  One other condition, “obstructive sleep apnea” was submitted by the MEB.  The Informal PEB adjudicated “narcolepsy associated with cataplexy” as Category I condition (unfitting condition which is compensable and ratable), rated at 10%, and “obstructive sleep apnea (OSA) requiring use of CPAP” as Category II condition (can be unfitting but is not currently compensable or ratable), citing application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) and DOD guidance.  The CI made no appeals and was medically separated.  

CI CONTENTION:  “VA rated my combined service-connected evaluation at 80%.  I continue to experience symptoms from service-connected disabilities”.   

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 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 IPEB – Dated 20090827	VA - (2 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Narcolepsy Associated With Cataplexy	8108-8911	10%	Narcolepsy With Cataplexy, Also Claimed As Organic Sleep Disorder And Insomnia	8108	40%	20100226	
Obstructive Sleep Apnea (OSA) Requiring Use Of CPAP	6847	Category II	Obstructive Sleep Apnea	6847	50%	20100226	
Other x 0 (Not In Scope)	Other x 3	
Rating:  10%	Combined:  80%	
Derived from VA Rating Decision (VARD) dated 20100625 (most proximate to date of separation [DOS]).  

ANALYSIS SUMMARY:  

Narcolepsy Condition.  The diagnosis of obstructive sleep apnea (OSA) mild was established by sleep study.  After successful treatment of the OSA, the CI continued to complain of excessive daytime sleepiness, sleep attacks, insomnia, and episodes of cataplexy.  He underwent additional sleep studies that did not confirm the condition of narcolepsy with cataplexy (sudden and transient episode of loss of muscle tone; he did not have the required REM episodes); however, due to the clinical presentation his condition was treated as narcolepsy with cataplexy.  The narcolepsy was treated with medications with excellent control of his cataplexy.  However, he required multiple adjustments and changes to his medication due to excessive daytime sleepiness that eventually improved and stabilized.  On 11 March 2009, approximately 9 months prior to separation, the sleep specialist prepared a letter that indicated there was no need to restrict activities including work.  Specifically, the CI could operate vehicles and engage in all work related activities.  His profile was lifted and indicated he had no limitations other than he was not deployable until cleared by MEB.  The treatment records did not record frequency of sleep attacks, or frequency of cataplexy episodes; however, a February 2009 physician note recorded the CI was not having episodes of cataplexy and stated “his daytime sleepiness has improved hugely.”  The last recorded treatment entry on 28 July 2009 noted that although he took his medications intermittently, the CI “continues to have excellent control of his cataplexy.”  The physician noted he continued to have some issues with daytime sleepiness. 
The MEB NARSUM dated 8 May 2009, approximately 7 months prior to separation, noted the CI denied further episodes of cataplexy since he started taking Xyrem (February 2009).  His excessive daytime sleepiness and insomnia had improved significantly with medications.  The CI indicated he wanted to remain in the military.  The VA Compensation and Pension (C&P) examination completed on 26 February 2010, 2 months after separation, recorded the report of sleep attacks at least one to two times per day and cataplexy where either the CI’s leg will suddenly go out or an arm will give out, every few days.  The CI noted he took his stimulant medication only as needed (prescribed for daily use), and there was no evidence that he continued the medication that treated his cataplexy.  The PEB applied the VASRD directive to rate narcolepsy as epilepsy: petit mal, under the general rating formula for minor seizures.  The PEB appears to have recognized the cataplexy episodes as equivalent to minor seizure episodes in arriving at a 10% rating (condition controlled by medication).  The VA rated the condition at 40% based on cataplexy “every few days”.  The Board acknowledges VASRD 8911 Note (2) which states, “a minor seizure consists of a brief interruption in consciousness or conscious control…) as adequate to encompass cataplexy as a minor seizure equivalent.  The higher rating of 20% requires evidence of at least two minor seizures in “the last six months.”  The Board noted the CI’s profile was lifted 9 months prior to separation.  The CI’s letter dated 13 May 2009, approximately 7 months prior to separation stated, “Currently, I have stabilized to the point where I am only minimally experiencing affects [sic] of the conditions” identified as cataplexy and narcolepsy.  The CI also stated that out of precaution he was restricted to not drive government vehicles or operate heavy machinery.  The commander’s statement dated approximately 6 months prior to separation, stated “while drug treatment has been very effective, the member still experiences periods of excessive daytime drowsiness (no mention of sleep attacks) and cataplexy.”  He was not allowed to perform his duties without restrictions, limitations or workarounds.  The Board noted the last treatment entry approximately 4 months prior to separation, documented “he continues to have excellent control of his cataplexy”, although he took Xyrem intermittently.  All Board members agreed the evidence best reflected the 10% level of impairment and did not support a 20% rating at the time of separation.  All evidence considered there is not reasonable doubt in the CI’s favor supporting a change from the PEB’s rating decision for the narcolepsy condition.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the condition of OSA was not unfitting.  The Board’s threshold for countering fitness determinations is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  The OSA was not profiled or specifically implicated in the commander’s statement and was not judged to fail retention standards.  The condition was reviewed and considered by the Board.  There was no performance based evidence from the record that this 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 the OSA condition and so no additional disability ratings are recommended.

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 narcolepsy associated with cataplexy condition and IAW VASRD §4.124a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended obstructive sleep apnea condition, the Board unanimously recommends no change from the PEB determination of not unfitting.  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 20140313, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

		
	           XXXXXXXXXXXXXXXXXXXX
	           President
	           DoD 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 (Title 10 U.S.C. § 1554a), PDBR Case Number PD-2014-01495.

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