ECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02372
BRANCH OF SERVICE:  NAVY 	BOARD DATE:  20150303
SEPARATION DATE:  20061115

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Navy Law Enforcement Specialist) medically separated for a sleep disorder.  The condition could not be adequately rehabilitated to meet the physical requirements of his Rating and he was referred for a Medical Evaluation Board (MEB).  The “hypersomnia, unspecified” was forwarded to the Physical Evaluation Board (PEB) IAW SECNAVINST 1850.4E.  No other condition was submitted by the MEB.  The Informal PEB adjudicated his condition as unfitting and rated it at 10%.  The CI requested that the condition be reconsidered and submitted a two page appeal document to the PEB.  The PEB reconsidered his case and increased the disability to 20%.  The CI was medically separated.  

CI CONTENTION:  The CI requested that the Board review all of his conditions.  His 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:  

Recon IPEB – Dated 20060914	VA* - (~7 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Hypersomnolence Syndrome	8108	20%	Narcolepsy	8108	10%	20070501	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 10 	
RATING:  20%	RATING:  20%	
*Derived from VA Rating Decision (VARD) dated 20070709 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:  

Sleep Disorder.  The first note available for review from the service treatment record dated 21 March 2006 was from a pulmonologist who indicated the CI’s significant history of daytime hypersomnolence (excessive sleepiness) with snoring raising the possibility of sleep apnea.  Examination showed crowded tonsils and a crowded posterior pharynx (back of the throat).  A sleep study performed on 26 March 2006 revealed no evidence of sleep-disordered breathing.  An elevated Epworth score (a subjective test) suggested daytime sleepiness; and a Mean Sleep Latency Test (MSLT) was positive for narcolepsy (a sleep disorder characterized by overwhelming daytime drowsiness).  Treatment with Provigil (modafinil) was instituted on 10 July 2006; and a neurologist noted the CI did not have cataplexy (sudden and transient episode of muscle weakness accompanied by full conscious awareness).  On 6 September 2006, the CI stated he had episodes of numbness/paralysis twice a week during the prior year with episodes of shaking on awakening but without seizures.   

The MEB narrative summary dated 10 July 2006 indicated the CI was referred for evaluation of possible narcolepsy since he noticed worsening daytime sleepiness approximately 2 years earlier.  The symptoms increased in severity over the prior 8 months, and the CI experienced sleep paralysis about three times per week and more snoring.  Additionally, he fell asleep while driving, at his desk, at a nightclub and at a family cookout.  His Epworth sleepiness score was markedly elevated.  He had no difficulty initiating or maintaining sleep even after taking afternoon naps.  However, he did admit to one or two episodes of hypnagogic hallucinations (dream-like images and sounds experienced at REM (rapid eye movement) sleep onset) and denied cataplexy.  His mother and sister had severe daytime sleepiness, but have not sought medical attention.  His sleep efficiency was 90%, oxygen saturations were normal, and his MSLT latency was 4 minutes indicating narcolepsy.  Medication (Ritalin) was introduced to control his symptoms, but it was not tolerated because of headaches and nausea.  As a result of the daytime sleepiness, he was at risk for job-related accidents.  A wakefulness-promoting medication, modafinil, was prescribed in place of the Ritalin.  At the MEB examination dated 13 June 2006, the CI reported “when I sleep sometimes my leg or arm is almost like it has no feeling” and “very sleepy throughout the day and snore at night.”  The non-medical assessment dated 15 August 2006 indicated in June 2006, that once the diagnosis of narcolepsy was made, the CI was restricted to deskwork, but noted the CI never complained of narcolepsy in the past nor did it affect his patrol duties October 2003 through November 2005.

At the VA Compensation and Pension (C&P) examination dated 26 April 2007, performed 5 months after separation, the CI reported he had been suddenly falling asleep without warning and had symptoms of not only the sleep attacks, but also numbness in arm and legs, decreased libido and shortness of breath.  The effect the symptoms contributed to his inability to find a job.  Neurological examination of the lower extremities was unremarkable.  The CI was alert and oriented with normal behavior; his affect was appropriate; his comprehension was normal; his memory was intact; and he was free of any signs of tension.  A post-separation note suggested an antidepressant may provide some benefit for cataplexy and Celexa (citalopram) was prescribed along with scheduled daytime naps.  Additionally, he was educated about sleep hygiene and the avoidance of medications that cause excessive sleepiness and was referred to psychiatry for symptoms of depression.  A note dated 22 June 2007 indicated the CI had one episode of cataplexy 3 months earlier (approximately 4 months after separation), while a note dated 31 August 2007 indicated the cataplexy was brought on by heightened emotions.  The medication the CI was prescribed was not effective; and he did not take any medications at the time of the examination.  Temporally remote VA C&P examinations were reviewed; however, they offered very limited or no probative post-separation evidence of any significant value other than noting episodes of narcolepsy increased as did cataplexy in the absence of medication. 
The Board directed its attention to its rating recommendation based on the above evidence.  The PEB assigned a 20% rating using code 8108 (narcolepsy) for the hypersomnolence syndrome, which was noted to be most likely narcolepsy without cataplexy and less likely  idiopathic central nervous system hypersomnolence, while the VA assigned a 10% rating and also used code 8108 for narcolepsy.  However, narcolepsy is rated using the schedule for petit mal, which is rated as a minor seizure.  A rating of 40% requires an average of at least five to eight minor seizures weekly.  Approximately three episodes of sleep paralysis were reported weekly as were twice a week episodes of numbness/paralysis, both of which are less than needed for a 40% rating, but significantly more than the two minor seizures in the prior 6 months.  While a 40% rating was a viable option that the Board considered, the Board concluded that there was insufficient objective evidence from any independent observer or observers to support that rating.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the hypersomnolence 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.  In the matter of the hypersomnolence (narcolepsy) condition and IAW VASRD §4.124a, the Board unanimously recommends no change in the PEB adjudication.  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 20140513, 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 2 Dec 15

      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 USN
- XXXXXXXXXXXXXXXXXXXX former USN
- XXXXXXXXXXXXXXXXXXXX former USN
- XXXXXXXXXXXXXXXXXXXX former USN
- XXXXXXXXXXXXXXXXXXXX former USN
- XXXXXXXXXXXXXXXXXXXX former USN
- XXXXXXXXXXXXXXXXXXXX former USN

						  XXXXXXXXXXXXXXXXXXXX
	     				  Assistant General Counsel
						  (Manpower & Reserve Affairs)