RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01908
BRANCH OF SERVICE:  Army	                        SEPARATION DATE:  20080611

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Cavalry Scout, medically separated for “chronic vascular headaches” and “postoperative painful scar” conditions, with a disability of 10% and 10%, respectively, with a combined disability rating of 20%.

CI CONTENTION:  “Veteran was not evaluated for PTSD w/anxiety & depression which the veteran was treated for while on active duty.”  The CI’s 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:  

SERVIC PEB  - 20080523	VARD -20090203  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Postoperative Painful Scar	8003-7804	10%	Residual Scar Secondary to…	8003-7800	30%	20081030	
Migraine Headaches	8022-8100	10%	Migraines…Meningioma…	8003-8100	50%	20081030	
PTSD	Not Unfitting 	Post-Traumatic Stress Disorder…also Anxiety/Depression	9411	10%	20081103	
Anxiety and Depression	Not Unfitting 					
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  90%	

ANALYSIS SUMMARY:  

Postoperative Painful Scar.   The CI underwent craniotomy with resection of a meningioma in April 2006.  The MEB physical examination, dated July 2007, noted a 7-inch surgical scar over the left parietal area and a 2.5 ml. scar in the left forearm.  The narrative summary (NARSUM) physical examination noted scars on the head consistent with a history of surgery.  A letter from his neurologist, dated October 2007, noted the CI had satisfactory recovery but some persistent headaches and some tenderness over his incisions.  The doctor noted he could perform desk work or other less strenuous activities.  

The VA Compensation and Pension (C&P) examination performed 4 months after separation, noted the CI had a surgical scar on the left temporal and upper scalp area of the scalp that was > 0.6 cm. wide x 16 cm length.  The scar was linear with mild depression and tissue loss, slightly darker/pinker than the surrounding skin and without hair growth or adherence.  There was tenderness but no breakdown of the skin.  There was no limitation of motion due to surgical scalp scar.  Neurological examination noted sensory loss in the form of tenderness in a portion of the surgical scar and numbness of the area just surrounding the scar.  The examiner noted a residual large tender scar with dysesthesias and hardware/screws still in place from the surgery.   

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB rated the postoperative painful scar condition 10%, coded 8003-7804 (benign, minimum residuals -scar, unstable or painful, one or two), citing no underlying soft tissue damage and residual condition of surgery for meningioma.  The VA rated the residual scar due to surgical excision, meningioma condition 30% coded 8003-7800 (scar of head, face, or neck with visible or palpable tissue loss or disfigurement), based on the VA C&P examination showing the length of the scar exceeding 13 cm and the width exceeding 0.6 cm.  The VA also rated the scar 10%, coded 7804, due to tenderness.  A higher 20% rating under the 7804 code would require 3-4 unstable or painful scars and a 30% rating would require 5 or more unstable or painful scars.  The Board noted there was no apparent deformity or disfigurement related to the scar and agreed the unfitting characteristic of the scar was the tenderness, appropriately rated at 10%.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the postoperative painful scar condition.  

Migraine Headaches.  According to service treatment records (STR), the CI deployed to Iraq from April 2003-August 2004.  He had a history of headaches prior to deployment but after his return, he reported worsening headaches, blurred vision, sometimes nausea, and dizziness. Imaging studies showed a large meningioma with significant compression of the brain.  The May 2006 post-craniotomy neurology note indicated headaches persisted, localized in the left region and independent of the area of surgical intervention.  Four months later he reported a daily headache and a more severe headache twice a week associated with nausea, photophobia, and with aggravation on movement.  The neurologist rendered a diagnosis of migraine headaches.  The commander’s statement noted the CI was constantly surrounded by the things that could trigger his seizure condition and chronic headaches.  He was not performing duties in his occupational specialty and was working in the training room.  When he exerted himself, it triggered his headaches which made it difficult for him to accomplish missions assigned to him.  

At the December 2007 narrative summary (NARSUM) the CI reported headaches twice weekly and received medication.  He claimed they were prostrating and the intractable pain interfered with work performance.  He could not wear a Kevlar helmet or participate in strenuous physical activity.  No recent emergency room (ER) visits were in evidence.  The pain was rated as slight and occasional.  At the VA Compensation and Pension (C&P) examination, the CI reported he had a chronic low level headache at all times and sometimes he had severe debilitating headaches about once per week occurring with photo/phonophobia and nausea with vomiting and lasting about 2-3 hours.  He had to lay down in a dark room and they were prostrating.  He received a medication to prevent headaches and he received a medication for headaches every 8 hours as needed.     

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB initially assigned a 0% disability rating for the headaches analogously under the 8022-8100 code (migraine attacks due to minimal residuals), noting they did not meet criteria for “prostrating headaches,” defined as extreme weakness and incapacitation.  The PEB noted the CI did not use his medication daily and his headaches were relieved by abortive medication and rest.  The CI appealed the PEB’s rating decision on 7 April 2008 with the request the headaches be defined as prostrating and a 30% rating be awarded.  The US Army Physical Disability Agency supported the initial PEB recommendations but the PEB changed the rating to 10%.  The VA assigned a 30% rating for migraines due to meningioma, coded analogously to 8003-8100 (migraines due to residuals of meningioma) based on frequent, prostrating and prolonged attacks productive of severe economic inadaptability.  The Board noted the NARSUM rated the headaches as slight and occasional.  His neurosurgeon noted he should be able to perform desk work or other less strenuous activities.  There were no recent ER visits and he was receiving prophylactic medication and medication to treat acute episodes.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the migraine headache condition.  

Contended PEB Conditions.  
 
PTSD, Anxiety and Depression.  The psychiatric NARSUM examination noted the CI’s depressive symptoms were reactive to the diagnosis of brain tumor, perceived as a loss of his military career.  The mental status examination (MSE) showed a “blah” mood and sad affect associated with grieving when discussing the loss of his military career.  He was taking anti-depression medication but he had no individual therapy.  A diagnosis of major depressive disorder was rendered with a Global Assessment of Functioning (GAF) score 60 (moderate bordering on mild symptoms, impairment.)  The MEB DD Form 2808, Report of Medical Examination, listed a diagnosis of anxiety disorder and assigned an S1 profile.  The C&P examination rendered a diagnosis of PTSD with a GAF score of 65 (mild symptoms, impairment.)

The PTSD, anxiety and depression were not profiled or implicated in the commander’s statement and were not judged to fail retention standards.  All were reviewed and considered by the Board.   There was no performance based evidence from the record that any of these conditions 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 PTSD, anxiety and depression contended conditions and so no additional disability ratings are recommended.

BOARD FINDINGS:  In the matter of the migraine headache condition and IAW VASRD §4.124, the Board recommends no change in the PEB adjudication.  In the matter of the postoperative painful scar condition and IAW VASRD §4.118, the Board recommends no change in the PEB adjudication.  In the matter of the contended PTSD, anxiety and depression conditions, the Board recommends no change from the PEB determinations as not unfitting.  There were no other conditions within the Board’s scope of review for consideration.  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 20140502 w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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 XXXXXXXXXXXXXXXXXXXXXXX AR20160010873 (PD201401908)

I have reviewed the enclosed Department of Defense Physical Disability Board of
Review (DoD PDBR) recommendation and record of proceedings pertaining to the
subject individual. Under the authority of Title 10, United States Code, section 1554a,
I accept the Board's recommendation and hereby deny the individual's application.

This decision is final. The individual concerned, counsel (if any), and any Members of
Congress who have shown interest in this application have been notified of this decision
by mail.

BY ORDER OF THE SECRETARY OF THE ARMY:

Enclosure

CF:
( ) DoD PDBR
( ) DVA