RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01782
BRANCH OF SERVICE:  Army	DATE OF SEPARATION:  20061220

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-6, Aircraft Structural Repair, medically separated for asthma condition.  This condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty or satisfy physical fitness standards.  He was issued a permanent P3 profile and referred for an Medical Evaluation Board (MEB).  Asthma, moderate, persistent was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other condition was submitted by the MEB.  The Informal PEB (IPEB) adjudicated asthma as unfitting, rated 0% with application of the Veteran’s Affairs Schedule for Rating Disabilities (VASRD).  The CI appealed and was placed on the temporary retirement disability list (TDRL).  After reevaluation the PEB adjudicated the asthma condition as unfitting, rated 0%.  The CI made no further appeals and was medically separated.

CI CONTENTION:  He was not evaluated for PTSD and ankle conditions.  His 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 condition 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:

Final PEB – 20080909	VA Rating Decision1 - 20070817	
TDRL Placement – 20061221	Code	Rating	Condition	Code	Rating
Proximate	
Condition		TDRL
Placement	TDRL Removal			TDRL2
Placement	TDRL Removal	
Asthma	6602	30%	0%	Asthma	6602	10%	--	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 10	
RATING:  30% → 0%	RATING:  20%	
1. Most proximate to TDRL Placement
2. Rating derived from C&P exam dated 20070711, ~7 mos. pre-TDRL placement

ANALYSIS SUMMARY:

Asthma.  A noted dated 8 November 2005 indicated the CI had a several year history of shortness of breath with increasing symptoms since returning from deployment.  He had seasonal allergies and a family history of asthma.  Pulmonary function tests (PFTs) revealed the FVC (forced vital capacity) and FEV1 (forced expiratory volume at 1 second) were within normal limits and the FEV1/FVC ratio and FEF25-75 (forced expiratory flow at 1/4 to 3/4 of the FVC) were reduced.  With bronchodilators, FEV1 and FEF25-75 increased and airway resistance decreased.  The conclusion was that over inflation and response to bronchodilators was characteristic of reactive airways and the pulmonary function diagnosis was mild obstructive airways disease-reversible.  Advair Discus (salmeterol xinafoate, a bronchodilator and fluticasone, a steroid) was dispensed in February 2006.  An asthma action plan was established in March 2006 with a medication protocol based on symptoms.  The CI also had sinusitis and allergic rhinitis, which was treated with Claritin (loratadine, an antihistamine).  Montelukast (an oral indirect bronchodilator) was introduced to treat the asthma.  The CI had an initial visit for asthma on 20 March 2006 at which time he noted having symptoms for about 3 months of daily shortness of breath and chest tightness with wheezing “every day once or every other day.”  He used albuterol (a bronchodilator) at least once every day and Advair twice each day. By the end of a run, he was “sucking for air.”  PFT findings again were diagnosed as mild obstructive air disease-reversible.  With the use of Advair, albuterol, and Singulair (montelukast), PFTs were within normal limits.  In May 2006 further history indicated the CI was in the desert when deployed; he worked with resins for fiberglass; and he did painting in the past.  Three weeks prior to the May 2006 visit the CI had taken prednisone for the asthma.  His chest was clear on examination and there was no wheezing.  Allergy evaluation revealed positive tests for oak and grass pollen.  Flovent (fluticasone) was added to the protocol, if needed in July 2006.  In August 2006 the CI had shortness of breath and chest tightness for 2 weeks when he was not taking albuterol on a regular basis.  However, expiratory peak flow studies were above the 80% target, but below the average expected peak expiratory flow.  When the CI took the Advair and albuterol in October 2006, he still noted daytime and evening symptoms as well as cold air sensitivity, but in November 2006 he denied daytime or nighttime asthma symptoms.   

A permanent P3 profile was issued on 5 May 2006 with limitations of moving with a fighting load and wearing a protective mask and chemical defense equipment.  He was also precluded from running, taking an alternative physical fitness test, and engaging in activities in extreme temperatures of less than 40 degrees or greater than 90 degrees.  The commander’s statement dated 12 May 2006 indicated the CI’s assignment availability based on his profile was limited as were his functional activities and ability to perform MOS related tasks with a respirator or NBC (nuclear, chemical, biological) mask.  At the MEB examination on 9 May 2006 the CI reported on DD Form 2807-1 asthma, shortness of breath, wheezing, inhaler use, a chronic cough, sinusitis, and chest tightness.  On the DD Form 2808, Report of Medical Examination, dated 2 June 2006, approximately 7 months before TDRL placement, the examiner reported moderate persistent asthma, but he did not note any physical findings related to the CI’s lungs.  

At the MEB narrative summary (NARSUM) examination, dated 21 September 2006, approximately 3 months before TDRL placement, the CI reported symptoms of dyspnea (shortness of breath) on awakening and nocturnal symptoms approximately three to four times monthly and he continued to use Advair, albuterol, Flovent when more symptoms were present along with Zantac (ranitidine for reflux) and Flonase (fluticasone, for allergic rhinitis).  Examination revealed the CI’s lungs to be clear to auscultation bilaterally without wheezing or rhonchi (course, rattling respiratory sounds).    A chest X-ray in May 2006 was negative and pulmonary function testing on 1 May 2006 revealed an FEV1 106% predicted, FVC 113% predicted, and FEF 25-75 74% predicted with a 24% increase post bronchodilator.  The CI was unable to do any running without severe dyspnea, which occurred even with minimal exertion or at rest. There was no improvement despite aggressive therapy with bronchodilators, inhaled steroids, and two trials of prednisone tapers.

An Addendum to the MEB NARSUM dated 1 November 2006, approximately 7 weeks prior to separation, indicated the CI continued to experience symptoms of shortness of breath with even minimal exertion despite the use of the Advair.  He used medication prior to exercise and approximately three to four times weekly with symptoms of dyspnea.  He was unable to perform any physical fitness training or wear his protective mask due to shortness of breath. 

At the VA Compensation and Pension (C&P) examination, dated 11 July 2007, approximately 7 months after TDRL placement, the CI stated the asthma began when deployed in 2004.  He had dyspnea with wheezing approximately 2-3 times per week for which he took albuterol and Advair daily.  He did not require any emergency room management; he had no home oxygen; and he had no acute dyspnea on exertion that prevented him from performing his usual activities of daily living or his usual occupational activities. 

Pulmonary Exam	Army Com Hospital
~8 Mo. Pre-TDRL Placement
	MEB
~3 Mo. Pre-TDRL Placement
	MEB Addendum
~2 Mo. Pre-Sep
	VA C&P 
~7 Mo. Post-TDRL Placement
(	
FEV1 (% Predicted)	112*	113**	--	--	
FEV1/FVC	93*	94**	--	--	
Meds	Albuterol, Advair, Singular	Advair, Flovent	Advair	Advair	
§4.97 Rating	30%	30%	30%	30%	
	*Post bronchodilator	**Pre bronchodilator-	PEB 30%	VA 10%	

On 1 June 2008, 18 months post-separation, PFTs were normal, which indicated the absence of any significant degree of obstructive pulmonary impairment and/or restrictive ventilatory defect.  Advair and albuterol were refilled in May 2008 and examination revealed the CI had a history of   shortness of breath and difficulty taking a breath.  At the TDRL evaluation, dated 12 June 2008, approximately 3 months before TDRL exit, the CI reported that since the MEB in September 2006 he had been on Advair twice daily and continued the medication faithfully.  He also used albuterol as a rescue inhaler as needed and also took Flovent and Nasonex (mometasone, a nasal steroid).  He was able to work, but he awakened about every other night to use the inhaler.  He also had a low exercise tolerance and symptoms of gasping of breath when climbing stairs or performing vigorous activity.  He did not use oral prednisone for the asthma and had not been to the emergency room or was hospitalized.  He had a history of gastrointestinal reflux disease and allergic rhinitis and took Prilosec (omeprazole) and Claritin respectively.  On examination the CI’s ears, nose, and throat appeared normal; and his heart and lungs were normal.  PFTs pre- and post-albuterol revealed the FVC was 103%; the FEV1 was 97%, which increased to 100% post treatment; and the FEF 25-75 was 83%, which significantly increased to 101%.  He did have some irregular inspiratory loops noted on the PFT printout that could have been related to mild vocal cord dysfunction.  The diagnosis of moderate to severe asthma by history was made, which did not cause him to lose days of work or visit an emergency room.

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB initially assigned a 0% rating using code 6602; however, the CI did not concur.  After an Addendum to the MEB NARSUM was reviewed, the PEB assigned a 30% rating using code 6602 for asthma and noted the Addendum raised “some question about the consistency of medication use, but could be constructed [construed] to support regular use.”  The PEB added that “on follow-up TDRL examination, accurate and complete data on receipt of medication must be supplied.”  The VA assigned a 10 rating using code 6602 for asthma and noted a 30% rating required daily inhalation or oral bronchodilator therapy, or inhalational anti-inflammatory medication.  For removal from the TDRL, the PEB assigned a 0% rating using code 6602 for asthma and indicated the medication profile submitted did not support use of daily or rescue controller medications.  

The Board first addressed whether the 30% rating at placement on TDRL was appropriate.  Because the CI was regularly taking Advair, an inhalational anti-inflammatory medication and albuterol frequently, although not on a consistent daily basis, a 30% rating was reasonable and appropriate.  On removal from TDRL, the Board again noted the CI was taking Advair and albuterol, albeit not on a daily basis, thereby qualifying the CI for a 30% rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends no change to the disability rating assigned to the asthma condition at placement on TDRL and a disability rating of 30% upon removal from the TDRL.

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 asthma condition, the Board unanimously recommends no change at placement if TDRL and a disability rating of 30%, coded 6602 IAW VASRD §4.97 upon removal from the TDRL.  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 recharacterized to reflect permanent disability retirement, effective as of the date of his prior medical separation:  

CONDITION	VASRD CODE	RATING	
		TDRL	PERMANENT	
Asthma	6602	30%	30%	
RATING	30%	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140422, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

SAMR-RB																		

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXX, AR20160003387 (PD201401782)

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 re-characterize the individual’s separation as a permanent disability retirement with the combined disability rating of 30% effective the date of the individual’s original medical separation for disability with severance pay.  

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:

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

	b.  Providing orders showing that the individual was retired with permanent disability effective the date of the original medical separation for disability with severance pay.

	c.  Adjusting pay and allowances accordingly.  Pay and allowance adjustment will account for recoupment of severance pay, and payment of permanent retired pay at 30% effective the date of the original medical separation for disability with severance pay.

	d.  Affording the individual the opportunity to elect Survivor Benefit Plan (SBP) and medical TRICARE retiree options.

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:

			      
						      					
Enclosure
					
CF: 
(  ) DoD PDBR
(  ) DVA