RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02255
BRANCH OF SERVICE:  Army	BOARD DATE:  20150305
SEPARATION DATE:  20081128

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty National Guard (AGR) E-7 (Health Care Specialist) medically separated for systemic lupus erythematosus (SLE).  The condition could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty.  She was issued a permanent P3 profile and referred for a Medical Evaluation Board (MEB).  The “lupus erythematosus, cutaneous involvement” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other condition was submitted by the MEB.  The Informal PEB adjudicated “lupus erythematosus, systemic” as unfitting, rated 10%, citing criteria of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI appealed to the Formal PEB (FPEB), which affirmed the PEB finding and rating, 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 FPEB – Dated 20080925	VA* (~1 Mos Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Lupus Erythematosus, Systemic	6350	10%	SLE with Discoid Lesions	6350-7806	60%	20081217	
			Pancytopenia…with Persistent Leucopenia	7799-7716	10%	20081217	
Other x 0 (Not In Scope)	Other x 3	
RATING: 10%	RATING:   70%	
*Derived from VA Rating Decision (VARD) dated 20090309 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

SLE Condition.  The service treatment record (STR) documented that the CI had a sudden onset of a diffuse itchy rash after outdoor training in July 2007 (16 months prior to separation).  She experienced an extensive cutaneous eruption involving sun-exposed face, scalp, ears, neck, palms, arms, and legs.  She was initially diagnosed with eczema and prescribed a 5-day burst of oral steroids (corticosteroids).  The rash was followed by patchy non-scarring alopecia (hair loss), weight loss, and malaise.  She subsequently developed generalized lymphadenopathy (enlarged lymph nodes) and pancytopenia (decreased formed elements in blood; i.e., red blood cells [RBCs], white blood cells [WBCs], and platelets) which were concerning for malignancy.  While the rash, lymphadenopathy, and pancytopenia responded to the first course of oral steroids, there was incomplete resolution of her rash.  No transfusions or other directed treatment was required for the pancytopenia.  Malignancy was ruled out by imaging and biopsies; and, SLE was ultimately diagnosed in January 2008 (11 months prior to separation).  At that time, “significant improvement of rash and lymphadenopathy” was noted and steroids were being tapered.  The CI ultimately responded to a 10-day, followed by a 21-day, taper of decreasing doses of oral steroids.  A subsequent dermatology consultation from March 2008 (8 months prior to separation) described the previous “extensive papular eruption” but noted “these lesions have largely faded over the past several months.” The exam also recorded “patchy hyperpigmentation [skin darkening, more akin to permanent discoloration (or scar) than dermatitis] ... over the ears and malar [cheek, typical of SLE] region ... [and] ... over the forearms and neck.” At that time, steroids were discontinued (the last prescription in the medication profile for oral steroids was 11 months prior to separation) and the CI remained only on maintenance treatment with the anti-rheumatoid drug Plaquenil (continued through to separation).  The final STR entry (September 2008, 2 months prior to separation) documented “slowly resolving” alopecia (hair loss) and mild leukopenia (decreased WBCs only) as the only active manifestations of SLE other than the above skin findings.

The narrative summary (NARSUM) was conducted on 5 August 2008 (4 months prior to separation) and detailed the above clinical course, noting “the patient has continued to improve with no significant reoccurrences of her dermatitis and with normalization of her cell blood count.”  The NARSUM physical exam detailed the “original dermatitis” and its distribution as above; and, then stated that, with treatment (specifying Plaquenil, topical steroid cream, and avoidance of sun exposure), “almost all of these lesions have resolved with only a slight bit of post-inflammatory hyperpigmentation in a similar distribution.”  The examiner noted that SLE “can be a multi-organ disease that can cause significant morbidity and mortality,” and opined that long term Plaquenil maintenance and sun avoidance would be likely.  In a follow-up memorandum, the NARSUM dermatologist clarified that the disease had thus far been manifested by a single “initial flare” which “I would characterize ... as severe and it lasted approximately 3 months ... [with] ... no way to predict when her next flare will be or how long it will last.”

A VA Compensation and Pension (C&P) exam was conducted on 17 December 2008 (a month after separation), and documented that the previous rash had “faded over several months with areas of remaining hyperpigmentation.”  The alopecia was described as “very minimal hair loss any longer.”  The VA examiner recorded a complaint of significant “fatigue 60% of the time” interfering with function and requiring frequent naps.  That complaint did not surface in the STR, and was specifically denied in separate entries.  Blood counts by the VA labs were normal.  The CI denied “any flares like her initial one.”  The VA physical exam documented “diffuse post-inflammatory hyperpigmentation ... no evidence of rash at present” with an estimated 60% body surface involvement (21% of exposed areas).  The VA examiner opined that there were “no significant effects” on occupational functioning by the SLE or any of its manifestations; noting the reported fatigue and need to cover exposed areas as the only impacts on daily activities.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB provided a 10% rating under code 6350 (specific for SLE).  The VASRD §4.88b criteria for a 10% rating under 6350 specify “exacerbations [note that ‘flare’ is not the terminology] once or twice a year or symptomatic during the past 2 years”; and, the next higher rating jumps to 60% for “exacerbations lasting a week or more, 2 or 3 times per year.”  The code, however, specifies, “Evaluate this condition either by combining the evaluations for residuals under the appropriate system, or by evaluating 6350, whichever method results in a higher evaluation.”  The Board must therefore consider: first, if a higher rating under 6350 is supported; and, second (in compliance with above), whether a higher rating can be supported by combining residuals.  Other than the skin findings, the only ratable residuals at separation were related to the resolving (apparently resolved at the time of the VA exam) pancytopenia and the resolving alopecia.  Members agreed that the fatigue issue reported to the VA examiner was not reasonably a factor for disability rating, given the lack of service evidence for its presence or any attendant disability.

The Board first considered whether the 60% rating under code 6350 was justified.  This issue was likely the reason for the NARSUM dermatologist’s clarification memo preceding the FPEB.  There was considerable deliberation as to what constitutes an “exacerbation” for purposes of VASRD rating.  Clinical comments in the STR evidence used the term “flare” for various cycles of rebounding symptoms (specifically the early rash and lymphadenopathy) which required higher dosing or repeat dosing of steroids.  It is clear that the early clinical diagnosis and treatment phase (characterized as the “initial flare” by the NARSUM dermatologist) in this case followed a waxing and waning course.  Distinguishing these cycles as “exacerbations” for rating purposes is a viable argument; and, if applied, would satisfy the 60% criteria of 6350.  Final consensus, however, was that these cycles were most reasonably construed as integral to the single overall presentation of the disease itself; and, that the opinion of the NARSUM dermatologist validly and fairly supported a conclusion that there had not been multiple exacerbations subject to rating.  Member consensus, therefore, was that a recommendation for a rating higher than 10% under code 6350 criteria was not sufficiently justified (with consideration of reasonable doubt).

The Board next considered whether a higher rating under 7806 for the skin residuals was reasonably justified.  The VA justified its 60% rating, citing the C&P skin findings, by rating residuals under code 7806 (dermatitis or eczema) and conferring 60% for “more than 40 percent of the entire body or more than 40 percent of exposed areas affected, or; constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12-month period.”  It must be noted, however, that the lesions at separation represented asymptomatic skin discoloration (likely permanent), and not an active rash or other dermatologic process.  The treatment in effect (Plaquenil) would help suppress future skin flares, but there is no indication that it was directed at active treatment of skin manifestations.  Members agreed, therefore, that a disability rating based on the skin residuals was not reasonably justified in this case.  The skin involvement was also considered for rating under a VASRD §4.118 scar code; but, there were no “unstable or painful” scars subject to rating under 7804; and, members agreed that rating under one of the other scar codes (burn scars and others) was likewise not reasonably justified.  It is also relevant that scars without any functional consequences are not easily defended for disability rating since there is no link to fitness.  Members agreed, therefore, that no higher rating for SLE could be recommended on the basis of the skin residuals.

Finally the Board considered whether a higher rating could be recommended on the basis of the pancytopenia and alopecia residuals.  The appropriate code for the pancytopenia would be analogous to 7716 (aplastic anemia) which confers 10% if “requiring continuous medication for control”; the next higher rating (30%) requires “transfusion of platelets or red cells at least once per year.”  Given that the blood count was near normal at separation and normal a month later per the VA evaluation, this is a dubious residual for rating; and, although the 10% rating might be justified, no higher rating is supported.  The code for rating alopecia is 7381 which confers only 0% for “loss of hair limited to scalp and face.”  Even if 10% for the pancytopenia was conceded, therefore, the resulting combined rating for residuals would not be favorable to the 10% primary rating under code 6350.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board consensus was that there was insufficient cause to recommend a change in the PEB adjudication of the SLE 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.  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 systemic lupus erythematosus condition and IAW VASRD §4.88b, the Board recommends no change in the PEB adjudication.  There were no other conditions within the Board’s scope of review for consideration.  The single voter for dissent did not elect to submit a minority opinion.

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 20140520, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

XXXXXXXXXXXXXXXXXXXX
President
Physical Disability Board of Review

SAMR-RB

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 XXXXXXXXXXXXXXXXXXXX, AR20150014929 (PD201402255)

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:

Encl						     XXXXXXXXXXXXXXXXXXXX
						     Deputy Assistant Secretary of the Army
						          (Review Boards)