RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02202
BRANCH OF SERVICE:  AIR FORCE	BOARD DATE:  20150303
Separation Date:  20080528

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Security Forces Journeyman) medically separated for a pulmonary thromboembolism condition.  The condition could not be adequately rehabilitated to meet the physical requirements of his Air Force Specialty.  He was placed on duty and mobility restrictions and referred for a Medical Evaluation Board (MEB).  The pulmonary thromboembolism condition, characterized as “recurrent deep venous thrombosis (DVT) and pulmonary embolus (PE), paroxysmal atrial fibrillation (PAF)” was forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123.  No other conditions were submitted by the MEB.  The Informal PEB (IPEB) adjudicated “deep venous thrombosis and pulmonary embolus” as unfitting, rated 10%.  Additionally the IPEB adjudicated the “paroxysmal atrial fibrillation as Category II (condition that can be unfitting but is not currently compensable or ratable).  The CI appealed to the Formal PEB which changed the DVT condition rating to 0% and increased the atrial fibrillation condition to 10%.  The CI appealed this decision to the Secretary of Air Force Personnel Council (SAFPC) which changed the DVT condition to “pulmonary thromboembolism” with a 0% rating and determined that the PAF did not contribute to the CI’s unfitness and therefore, did not warrant a disability rating.  The CI made no appeals and was medically separated.

CI CONTENTION:  “Please Consider All Conditions.”

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 Formal PEB – Dated 20080415	VA - (2 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Pulmonary Thromboembolism	6899-6817	0%	Recurrent Venothromboembolic Disease	6817	60%	20080721	
PAT	Category II	Atrial Fibrillation	7010	10%	20080721	
Other x0	Other x8	
Combined:  0%	Combined:  80%	
Derived from VA Rating Decision (VARD) dated 20090202 (most proximate to date of separation [DOS])

ANALYSIS SUMMARY:  SAFPC coded the paroxysmal atrial tachycardia (PAT) condition as a Category II condition (“Conditions that can be unfit, but not compensable or ratable”) will be discussed below under the unfitting condition.

History of DVT and PE Requiring Lifelong Anticoagulation Condition.  The CI was seen in a civilian emergency room (ER) with symptoms of some pleuritic pain with deep breathing and some bruising on the top of his foot and toes.  There were physical exam findings of clear chest, and left leg tenderness in the popliteal fossa and in the lower posterior calf.  A left leg ultrasound demonstrated a DVT involving the left popliteal vein.  He was admitted and started on heparin (anticoagulant) intravenously.  The pulmonologist noted that the CI denied any lengthy trips or prolonged periods of sitting and no specific left lower extremity injury.  The examiner confirmed the physical exam findings of a clear chest and left popliteal tenderness and increased calf diameter.  A ventilation perfusion scan was indeterminate for pulmonary emboli.  The examiner opined that the CI had a left lower extremity DVT and his lung scan very likely reflected PE.  The examiner further recommended a transition to Lovenox (an injectable anticoagulant for 5 days, then transition to Coumadin (an oral anticoagulant).  The CI was seen in follow-up by the family practitioner who noted that the CI reported that the left leg was doing better and there was no pleuritic pain.  There were physical exam findings of left calf mild tenderness in the posterior popliteal fossa.  The examiner recommended that the CI could return to work with desk work only and to continue Coumadin and continue lab work to monitor Coumadin effectiveness.  The Internal Medicine examiner in a memo to the family practitioner examiner documented that the CI underwent a hypercoagulable workup in which all testing was negative.  The CI continued to report decreased stamina with vigorous activity (he would get more short of breath and worn out after approximately 30 minutes of basketball, whereas prior to his DVT/PE he could easily play for an hour).  The left leg physical exam findings were normal.  The examiner recommended 6 months of Coumadin with follow-up and the CI was given extensive education regarding DVT/PE.  The CI was seen in the civilian ER on 24 February 2004 for chest pain.  A chest X-ray performed in the ER was normal along with a normal bilateral lower extremity ultrasound.  A lung scan performed the next day for difficulty breathing showed indeterminate PE while a chest CT scan showed left lower lobe pneumonia.  The CI deployed and was seen in-theater on 27 May 2007 for throbbing right calf pain for 2 weeks.  The physical exam findings were right calf pain with compression.  The examiner suspected DVT and the CI was medevac'd to Landstuhl Army Medical Center (LAMC) for evaluation.  The examiner at LAMC diagnosed a right lower lobe PE on CT scan and a right calf DVT and restarted the CI on Lovenox.  The civilian hematologist documented that the CI was asymptomatic with a normal physical exam.  The examiner diagnosed recurrent venothromboembolic disease and noted that the CI was at “high risk for recurrent thrombosis without indefinite anticoagulation due to the unprovoked nature of both clots.”  The civilian cardiologist documented the CI as asymptomatic with a normal physical exam.  The examiner diagnosed recurrent DVT with pulmonary emboli.  The examiner opined that the CI understood the “risk of recurrent DVT and PE is significant at his age and as he gets older.”  The civilian 
pulmonologist noted the diagnosis of recurrent PE and recommended more pulmonary testing.  On 30 august 2007, the CI was admitted to the hospital for the development of atrial fibrillation.  An echocardiogram was negative for valvular heat disease or cardiomyopathy.  Electrocardiogram was suggestive of pericarditis and the CI did have a possible virus syndrome prior to admission.  He was started on cardiac medication to control the atrial fibrillation.  He had done very well since then and remained in sinus rhythm.  The civilian cardiologist documented that the CI had two spontaneous DVTs and PE with normal hyper-coagulopathy testing and that the CI required lifelong Coumadin.  The MEB narrative summary exam performed approximately 6 months prior to separation documented that the CI was previously evaluated by hematology, cardiology and pulmonary specialists who recommended lifelong therapy with Coumadin given the “recurrent nature of his venothromboembolic disease.”  The MEB examiner filed a duty limiting condition report and stated that because the CI was on blood thinners, that he could not participate in any high risk activities that would predispose him to bleeding.  The VA Compensation and Pension exam accomplished almost 2 months after separation documented that the CI continued on Coumadin and cardiac medications.  The CI was asymptomatic and the physical exam findings for the chest and extremities were normal.  The examiner diagnosed recurrent DVT/PE and atrial fibrillation secondary to the DVT/PE.

The Board directed attention to its rating recommendation based on the above evidence.  The SAFPC coded the pulmonary thromboembolism condition as 6899 analogous to 6817 (Pulmonary Vascular Disease) and rated at 0% (asymptomatic, following resolution of pulmonary thromboembolism) with specific mention that treatment for the condition (continuous anticoagulant medication) and not the condition itself is what rendered the CI unfitting.  The VA coded the condition as 6817 code (Recurrent Venothromboembolic Disease) rated at 60% for chronic pulmonary thromboembolism requiring anticoagulant therapy.  It is well documented throughout the service treatment record that the CI had recurrent DVT/PE and required lifelong anticoagulation therapy.  The VASRD criteria for the 0%, 30%, and 60% rating are copied below for the reader’s convenience:

Chronic pulmonary thromboembolism requiring anticoagulant therapy, or; following inferior vena cava surgery without evidence of pulmonary hypertension or right ventricular dysfunction…...... 60

Symptomatic, following resolution of acute pulmonary embolism……………………………………………….30

Asymptomatic, following resolution of pulmonary thromboembolism………………………………….……….0

There was no evidence of any residual pulmonary complications due to his recurrent PE and no evidence that suggest anything other than complete resolution of the PE.  The evidence supports that the CI did not have any symptoms after resolution of his recurrent PE; therefore, he did not met the 30% rating criteria.  Additionally, the evidence does not support that the CI had chronic pulmonary thromboembolism, evidence of pulmonary hypertension, right ventricular dysfunction, or inferior vena cava surgery as required for the 60% rating.  Considering the totality of the evidence and mindful of VASRD §4.3 (reasonable doubt), members agreed that a disability rating of 0% for the pulmonary thromboembolism condition was appropriately recommended in this case.

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 pulmonary thromboembolism condition and IAW VASRD §4.100a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended PAT condition, the Board unanimously recommends no change from the PEB determinations as not unfitting.  There were no other conditions within the Board’s scope of review for consideration.
RECOMMENDATION:  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 20140429, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

			
XXXXXXXXXXXXXXXXXXXX
President
DoD Physical Disability Board of Review

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

Dear XXXXXXXXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Title 10 U.S.C. § 1554a), PDBR Case Number PD-2014-02202.

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 appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

	I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.

							Sincerely,

XXXXXXXXXXXXXXXXXXXX
Director
Air Force Review Boards Agency

Attachment:
Record of Proceedings

cc:
SAF/MRBR