RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02112
BRANCH OF SERVICE:  MARINE CORPS	BOARD DATE:  20150408
SEPARATION DATE:  20051231

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-3 (Rifleman) medically separated for narcolepsy.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty.  He was placed on limited duty (LIMDU) and referred for a Medical Evaluation Board (MEB).  The condition characterized as “cataplexy and narcolepsy” was forwarded to the Physical Evaluation Board (PEB) IAW SECNAVINST 1850.4E.  No other conditions were submitted by the MEB.  The Informal PEB adjudicated “narcolepsy” as unfitting, rated at 10% with likely application of SECNAVINST 1850.4E.  The CI made no appeals and was medically separated.

CI CONTENTION:  The CI elaborated no specific contention in his application.

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 20051027	VA* - (~13 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Narcolepsy 	8108	10%	Obstructive Sleep Apnea with Narcoleptic Traits and Daytime Somnolence	8108-6847	30%	20070212	
Other x 0 (Not in Scope)	Other x 3 (Not in Scope)	20070212	
Rating:  10%	Combined: 30%	
*Derived from VA Rating Decision (VARD) dated 20070828 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Narcolepsy.  The narrative summary (NARSUM) dated 27 September 2005, approximately 3 months prior to separation, and the service treatment record noted the CI was evaluated for excessive sleepiness due to trouble staying awake and “had fallen asleep several times on post.”  He had two UCMJ actions for falling asleep on post (June 2004 and February 2005).  An emergency department note 9 months prior to separation indicated the CI “passes out daily” (“he falls asleep vs passes out”), that “buddies have noticed that he would witness him falling asleep in class,” and that “he notices himself 15-20 yards in front of where he remembered himself while walking.”  The CI denied sleepwalking, seizures or drop attacks.  Exam was essentially normal.  Pulmonary specialist evaluation indicated the CI slept for long periods and was still tired during the day with symptoms of sleep paralysis without hypnagogic hallucinations or cataplexy.  The impression was hyper-somnolence with possible obstructive sleep apnea (OSA) versus atypical narcolepsy, or idiopathic hyper-somnolence related to an old head injury.  Polysomnogram (sleep study) and multiple sleep latency testing documented a few respiratory disturbances consistent with upper airway resistance syndrome and pathologic sleepiness.  A trial of a continuous positive airway pressure (CPAP) machine was reported as making the CI’s symptoms worse.  Physical exam was normal.  The final NARSUM diagnosis was “Narcolepsy supported by the multiple sleep latency test with pathologic sleepiness and two sleep onset rapid eye movements.”

At the VA Compensation and Pension exam dated 12 February 2007, performed approximately 13 months after separation, the CI reported onset of symptoms of snoring and prolonged respiratory pause and daytime somnolence in 2005.  Sleep study from 2005 was reviewed by the examiner and read as demonstrating an obstructive sleep apnea condition with prolonged respiratory pause, with mild to moderate restless leg syndrome (RLS).  The CI’s initial treatment with CPAP was discontinued due to an increase in symptoms of RLS and daytime somnolence.  The CI “related hypersomnolence only during periods of nonactivity.  If the (CI) is busy going about his chores, duties or other activities that require attention and alertness, he states that he stays awake and can concentrate fairly well.”  He was not on any treatment and exam was normal.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB 10% rating for code 8108 (Narcolepsy) may have been with application of SECNAVINST 1850.4E (in effect at the time) for mild industrial impairment; however, the PEB worksheet (JDETS) continuation was not in record.  The VA rating of 30% (coded 8108-6847; “Obstructive Sleep Apnea with Narcoleptic Traits and Daytime Somnolence”) applied the analogous rating criteria for OSA which was diagnosed by the VA examiner based on the service sleep study from 2005.  Sleep Apnea and narcolepsy were LIMDU diagnoses and the LIMDU was signed by the sleep specialist who interpreted the original sleep study and an additional sleep specialist.

The rating options under 8108 for narcolepsy, which are open to consideration in this case, rely on the frequency and timing of “episodes.”  The Board adjudged that episodes of unplanned falling asleep could be considered analogous to minor seizures for analogous rating.  The Board carefully considered the frequency and timing of the CI’s narcolepsy episodes including objective evidence and corroborating subjective evidence.  The Board deliberated on the 40% (averaging at least 5 to 8 minor seizures weekly), 20% (at least 2 minor seizures in the last 6 months), or the 10% rating criteria (fewer than 2 events in the last 6 months).  The most detailed note specifying the number and frequency of episodes of unplanned falling asleep indicated daily episodes at 8 months prior to separation.  There was no indication of any improvement in the CI’s condition through his date of separation, but there were no further details or restating of the number or frequency of unplanned falling asleep episodes.

The Board also considered analogous rating to code 8108-6847 (narcolepsy - sleep apnea syndromes obstructive, central, mixed).  Although the CI had been prescribed and had a trial of CPAP, he was no longer using any breathing device as it made his symptoms worse.  The CI had hypersomnolence that persisted through the after separation VA exams.

The CI’s narcolepsy symptoms were predominately unplanned falling asleep during the day and his evaluation supported sleep apnea and persistent day-time hypersomnolence.  The CI’s disability picture proximate to separation was best aligned with the 30% rating coded analogously as 8108-6847.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 30% for the narcolepsy condition.

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.  As discussed above, PEB reliance on SECNAVINST 1850.4E for rating narcolepsy was likely operant in this case and the condition was adjudicated independently of that instruction by the Board.  In the matter of the narcolepsy condition, the Board unanimously recommends a disability rating of 30%, coded 8108 6847 IAW VASRD §4.124a and §4.97.  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:

UNFITTING CONDITION	VASRD CODE	RATING	
Narcolepsy	8108-6847	30%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140423, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR COMMANDER, NAVY PERSONNEL COMMAND
	         DEPUTY COMMANDANT, MANPOWER & RESERVE AFFAIRS	
	                          
Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR)
       RECOMMENDATIONS          

Ref:  (a) DoDI 6040.44
      (b) PDBR ltr dtd 27 Aug 15 ICO XXXXXXXXXXXXXXX
      (c) PDBR ltr dtd 28 Aug 15 ICO XXXXXXXXXXXXXXX
	(d) PDBR ltr dtd 31 Aug 15 ICO XXXXXXXXXXXXXXX

1.  Pursuant to reference (a) I approve the recommendations of the Physical Disability Board of Review set forth in references (b) through (d).

2.  The official records of the following individuals are to be corrected to reflect the stated disposition:

     a. XXXXXXXXXXXXXXX, former USMC: Placement on the Permanent Disability Retired List with a 30 percent disability rating (increased from 10 percent) effective date of discharge.

     b. XXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 30 percent disability rating (increased from 10 percent) effective date of discharge.

     c. XXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 30 percent disability rating (increased from 20 percent) effective date of discharge.

3.  Please ensure all necessary actions are taken to implement these decisions, including the recoupment of disability severance pay, if warranted, and notification to the subject members once those actions are complete.