RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02070
BRANCH OF SERVICE:  Navy 	SEPARATION DATE:  20091126

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty O-2, Explosive Ordnance Disposal Officer, medically separated for “Type I Diabetes Mellitus,” with a disability rating of 20%.  

CI CONTENTION:  He believes he is entitled to a higher rating and was not evaluated for other conditions.  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 - 20090604	VARD – 20100316	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Type I Diabetes Mellitus	7913	20%	Diabetes Mellitus, Type I	7913	10%	20091130	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Diabetes Mellitus, Type I.  According to the service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI developed diabetes mellitus type 1 (DM type 1) in January 2008 which was treated with dietary restrictions and insulin.  There were scant records for treatment of the DM condition in record.  An addendum to the Joint Disability Evaluation Tracking System (JDETS) dated 31 March 2009 (further discussed below) referenced three treatment visits in 2008 and the original notes from these visits are not in record.  Reportedly an internal medicine clinic visit dated 30 June 2008 noted the CI was training for a marathon race; another visit dated 3 October 2008 described the CI’s DM condition as well controlled; and a diabetic clinic visit 27 October 2008 noted “insulin pump for active lifestyle.”  Three visits dated 2-5 February 2009, are also in record at the time treatment was initiated with an insulin pump (shortly after the MEB NARSUM examination summarized below) which reflected that blood sugars were elevated at the start of pump use, before insulin dosage was titrated.  The NARSUM noted that the CI’s DM condition was well controlled and that the CI “has done well in managing his diabetes,” with the most recent A1c (blood test which reflects blood sugar control over a period of the last few months) recorded as 6.2%, “reflecting excellent control” (non-diabetic normal value less than 5.7%)  Despite treatment, the diabetes condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for an MEB.  The MEB forwarded “diabetes mellitus without mention of complication, type I” for PEB adjudication.

A Limited Duty (LIMDU) Board dated 10 January 2008 and the final LIMDU dated 10 January 2009 listed limitations of “no deployments” and the requirement to be stationed near a medical treatment facility with internal medicine providers.  The non-medical assessment (NMA) dated 4 February 2009 indicated the CI “is only constrained by the uncertainty of medical care within the austere environments our forces routinely operate.”  The NMA went on to say that the medical care the CI required had “minimal impact” on his duty performance within the parameters of his LIMDU, which included a deployment within the continental United States.  The JDETS dated 18 February 2009 noted the same facts as the NMA, indicating that the CI’s condition minimally impacted shore command duties, but the CI was unfit because he “will be constrained in future activities.” 

The MEB NARSUM examination on 6 January 2009, 11 months prior to separation, noted that the CI was on long acting and short acting insulin (Lantus and Aspart) at the time of the examination.  In the history of present illness, the MEB examiner summarized, the CI’s “medical condition limits the performance of his duties due to the need for frequent fingerstick glucose checks, as well as frequent insulin injections, although the patient is able to do many of the day-to-day activities required by his command. He is not deployable due to the frequent need for insulin.  In addition, he is not able to do some of the activities required by his command such as diving” and later the MEB examiner re-iterated that the CI’s duty performance was impaired because he “requires multiple daily injections of insulin, and due to that requirement is not capable of performing his assigned duties.  On that basis, this case is referred to the Physical Evaluation Board for fitness for duty determination.”  

A NARSUM addendum dated 20 March 2009, prepared for the CI’s rebuttal and PEB reconsideration by the same NARSUM examiner, noted the CI “can no longer perform occupational tasks such as diving.  While he has been encouraged to continue aerobic exercises, he now must regulate this activity in several ways, including aborting exercise when his blood sugar is too low, as well as constantly having both a glucose source and insulin on his person while engaged in exercise.  These limitations have impaired his ability to participate in the strenuous exercise he previously performed.”

An NMA dated 26 March 2009 by another commander (dated after the initial PEB), noted that the CI’s medical condition “forced his early departure from active duty service, which is a true loss to both his command and nation which urgently need…qualified personnel.  Furthermore, he is ineligible to continue military service at all because, he cannot perform even normal occupational and recreational activities.”  The March 2009 JDETS addendum listed the three treatment visits in 2008 as noted above and indicated the CI exercised and had been deployed.  A notation indicated that an insulin pump [was] recommended for an “active lifestyle” and the CI carried carbohydrates, a cell phone, and a glucometer “when he runs or bikes.”  The JDETS concluded that the additional information provided did not “reflect anything O/T [other than] that inherent to the disease of insulin dep. Type 1 DM management,” which includes daily multiple blood sugar checks and adjustment of insulin to diet and exercise. 
 
At the VA Compensation and Pension (C&P) examination in November 2009, performed 4 days after separation, the CI denied diabetic ketoacidosis or hypoglycemia requiring hospitalization. He stated he treated his diabetes with diet control and an insulin pump.  Physical examination reported no findings regarding the skin, eyes, heart, arteries, or kidneys.  No neurologic findings were noted.  The examiner noted activity restrictions of no swimming because the insulin pump could not get wet.  

At the VA C&P examination 19 August 2010, 10 months after separation, the CI reported the same treatment for the DM condition, without episodes of ketoacidosis or “hypoglycemia requiring hospitalization.”  Physical examination was again normal.  The VA examiner noted that there were no activity restrictions due to diabetes, however, the CI was “limited in jobs he can work in as employers are concerned about potential hypoglycemic reactions.”  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 20% rating under the 7913 code (diabetes mellitus).  The VA assigned a 10% rating using the 7913 code based on the VA C&P examination 4 days after separation and then increased the rating to 20%, citing dietary restrictions and the use of insulin with no associated activity restrictions due to diabetes.  

Review of the STR showed no hospitalizations for treatment of ketoacidosis or hypoglycemia.  There was also no evidence of twice monthly visits to a diabetic care provider and diabetic complications.  The Board agreed that the requirement for treatment with insulin and restricted diet justified a 20% rating, and carefully examined the evidence regarding the requirement for “regulation of activities” (avoidance of strenuous occupational and recreational activities) in this case, since this stipulation justifies the higher 40% rating.  Although the CI’s diagnosis of DM on insulin precluded his participation in safety sensitive occupational activities such as diving, the record reflects the CI remained a very active individual following the type 1 DM diagnosis with routine accommodations recommended for the diagnosis of type 1 DM.  There was no evidence in record of frequent hypoglycemic episodes provoked by activity, although precautions for prevention or treatment of hypoglycemia during activities were recommended.  Neither LIMDU in record documented any limitations to participation in physical activities.  Although the NMA in March 2009 indicated the CI could not perform “even normal occupational and recreational activities,” this contention was not corroborated by the majority of the evidence in record.  Board members thus concluded that the “regulation of activities” stipulation was not met in this case, and therefore the next higher 40% rating was not justified.  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 diabetes mellitus condition. 

BOARD FINDINGS:  In the matter of the diabetes mellitus condition and IAW VASRD §4.119, the Board unanimously recommends no change in the PEB adjudication.  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 20140512, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR DIRECTOR, SECRETARY OF THE NAVY COUNCIL OF REVIEW
               BOARDS 

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS
 
Ref:   (a) DoDI 6040.44
       (b) CORB ltr dtd 24 Jun 16

      In accordance with reference (a), I have reviewed the cases forwarded by reference (b), and, for the reasons provided in their forwarding memorandums, approve the recommendations of the PDBR that the following individual’s records not be corrected to reflect a change in either characterization of separation or in the disability rating previously assigned by the Department of the Navy’s Physical Evaluation Board:

		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USMC 

						XXXXXXXXXXXXXXXXXXXX
	     				  	Assistant General Counsel
						(Manpower & Reserve Affairs)