RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXX						            CASE:  PD-2014-02023
BRANCH OF SERVICE:  AIR FORCE	SEPARATION DATE:  20020416

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-3 (Missile and Space Systems Electronic Maintenance Helper) medically separated for postural orthostatic tachycardia syndrome (POTS).  The POTS condition could not be adequately rehabilitated to meet the physical requirements of his Air Force Specialty (AFS).  He was referred for a Medical Evaluation Board (MEB).  “Psychological symptoms affecting POTS” was forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123.  The Informal PEB (IPEB) adjudicated “postural orthostatic tachycardia syndrome (POTS) associated with headaches” as Category II (can be unfitting, but not compensable or ratable) and “psychological symptoms affecting POTS, primary condition” as Category III (not separately unfitting and not compensable or ratable) and recommended the CI be unfit and separated under other than Chapter 61, Title 10 USC (non-medical disability separation) citing application of Department of Defense Instruction (DoDI) 1332.38 (existed prior to service [EPTS] and no permanent service aggravation).  The CI appealed to the Formal PEB (FPEB), which adjudicated “postural orthostatic tachycardia syndrome (POTS) associated with headaches” as unfitting, rated 10% but applied a 10% deduction citing “less contributing/aggravating factors.  “Psychological symptoms affecting POTS, primary condition” was determined to be Category III.  The CI was medically separated with a 0% rating.  

CI CONTENTION:  The CI contends the Postural Orthostatic Tachycardia Syndrome (POTS) was a misdiagnosis and that he actually suffers from atrial fibrillation.  The applicant’s 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 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:  

FPEB – Dated 20020114	VA* - Based on Service Treatment Records (STR)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Postural Orthostatic Tachycardia Syndrome (POTS) Associated with Chronic Headaches	8210-8299	0%	Postural Orthostatic Tachycardia Syndrome with Chronic Headaches	9210-8100	0%	STR	
Psychological Symptoms Affecting POTS, Primary Condition	Cat III 					
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 0	
RATING:  0%	RATING:  0%	
*Derived from VA Rating Decision (VARD) dated 20020813 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:  The unfitting POTS and the Category III condition of “Psychological Symptoms Affecting POTS” have significant overlap and are discussed together below.  

POTS and Psychological Symptoms Affecting POTS.  According to service treatment records and the MEB narrative summary (NARSUM) and specialist NARSUMs, the CI began having syncopal (sudden loss of consciousness-LOC-fainting) and pre-syncopal episodes with headaches in 2001 while at technical school.  There was no trauma and extensive medical specialty evaluations and testing (including two inpatient evaluations by cardiology and neurology) led to a diagnosis of POTS following an abnormal tilt table test in July 2001.  Inpatient hospital cardiac monitoring and testing did not document any other cardiac structural or electrical abnormalities; however, the CI “would become tachycardic upon standing and would occasionally become bradycardic while sleeping.”  An exercise tolerance test (ETT) was reported as electrically and clinically negative.  Medications were not effective in controlling the CI’s recurrent, unpredictable episodes of altered consciousness.  The final cardiology assessment was recurrent syncope of noncardiac origin.  The final neurology assessment was recurrent syncope of unclear etiology, possibly due to POTS or also possibly psychogenic.  There was no evidence of autonomic neuropathy.  The reported headaches were not considered to be migraines and there was no evidence of seizures.  

At the psychiatric NARSUM, the CI reported having “passed out” a total of 45 times over the past year which he attributed to POTS.  The duration of LOC had reportedly increased from 2 minutes to 15-60 minutes.  He had associated headache which was constant and right-sided without any aura and medication (Depakote) was effective.  The CI denied any depressive or anxiety symptoms and described being frustrated with “passing out” and the episodes were “bothersome” but had never put him in any dangerous situations.  Mental status exams were normal and the recommended profile was temporary S4.  The summary indicated that the CI’s “multiple and increasingly prolonged episodes of loss of consciousness cannot be fully explained by medical evaluation alone.  Given other factors and history, there appears to be some psychological factors involved.”  Psychiatry had considered a diagnosis of conversion disorder however the final diagnosis was “psychogenic factors affecting POTS.”  

The CI failed to show for a scheduled VA Compensation and Pension (C&P) examination proximate to separation.  The initial VA C&P noted in the records was from September 2012, over 10 years after separation.  

The Board directed attention to its rating recommendation based on the above evidence.  The FPEB assigned a 10% rating under an analogous 8210 code (tenth [pneumogastric, vagus] cranial nerve), with a 10% deduction for contributing/aggravating factors.  The FPEB remarks cited the CI having no LOC episodes or headaches for 3 months, being on no medications, and deduction for the “psychological factors diagnosis.”  The VA assigned a 0% rating using 9210-8100 coding (psychotic disorder, not otherwise specified [atypical psychosis] with migraine) based on the service treatment record, citing a non-compensable evaluation as the latest military treatment records did not show the condition was causing significant functional impairment and the CI failed to show for a scheduled VA exam.  

The Board therefore focused on rating the CI’s syncope/LOC episodes diagnosed as POTS associated with chronic headaches.  The condition was adjudged as compensable by the FPEB and the Service entry exam provided no ratable elements, so any EPTS factor would be undeterminable or 0%.  The Board considered that the headache component of the unfitting condition did not produce prostrating episodes and would not contribute to any rating over 0% analogously to code 8100 (migraine).  The Board discussed the various analogous coding and rating options for syncope given the CI’s specific history and VASRD §4.20 (analogous ratings).  Analogous coding under 8210 (vagus nerve), 8108 (narcolepsy), 7010 (supraventricular arrhythmias - atrial fibrillation), 7011 (ventricular arrhythmias) or 7015 (atrioventricular block) were considered.  There was scant evidence of cardiac arrhythmias on electrocardiograms (EKG) or Holter monitor, and no sustained dysrhythmias.  There was no structural cardiac abnormality and the CI underwent exercise tolerance testing (ETT) which was reported as normal and would not indicate workload less than 10 METS.  The criteria under code 8210 (paralysis of the vagus nerve) was adjudged to reach the 10% incomplete, moderate level and did not more nearly approach the picture of the 30% (incomplete, severe) rating level.  The Board discussed possible analogous rating using 8108 (narcolepsy - which is rated under the criteria for petit mal epilepsy 8911), however, there was insufficient alignment with this body system and insufficient evidence of episodes within the six months prior to separation to achieve a rating higher than 10%.  “Psychological Symptoms Affecting POTS, Primary Condition” is not a compensable Axis I mental health disorder IAW DoDI 1332.38, E5, in effect at the time and there was no compensable Axis I mental disorder for rating.  The Board next considered if the FPEB’s 10% rating deduction “due to the psychological factors diagnosis” was warranted.  

The crux of this case, although not definitively stated in the record, was if the CI had episodes of altered consciousness (syncope/LOC) or was feigning the episodes.  There was not a preponderance of evidence indicating the episodes were not due to a ratable condition.  Any impact from the “psychological factors” was adjudged as most likely related to the duration of episodes, and would not have reasonably decreased the frequency of episodes.  Recommended coding is 8100-8210, rated 10%.  

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the POTS associated with chronic headaches with no deductions.  

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.  In the matter of the POTS associated with chronic headaches condition, the Board unanimously recommends a disability rating of 10%, coded 8100-8210 IAW VASRD §4.124a.  In the matter of the contended “Psychological Symptoms Affecting POTS, primary condition,” the Board unanimously agrees that it cannot recommend it for additional disability rating.  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, effective as of the date of his prior medical separation:  

CONDITION	VASRD CODE	RATING	
Postural Orthostatic Tachycardia Syndrome (POTS) Associated with Chronic Headaches	8100-8210	10%	
RATING	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140508, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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

Dear XXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2014-02023.

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 not appropriate under the guidelines of the Veterans Affairs Schedule for Rating Disabilities.  Accordingly, the Board recommended modification of your assigned disability rating without re-characterization of your separation with severance pay. 

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding, accept their recommendation and direct that your records be corrected as set forth in the attached copy of a Memorandum for the Chief of Staff, United States Air Force.  The office responsible for making the correction will inform you when your records have been changed.

Sincerely,

Attachment:
1.  Directive 
2.  Record of Proceedings 

cc:
SAF/MRBR