RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02486
BRANCH OF SERVICE:  Army	BOARD DATE:  20150616
SEPARATION DATE:  20050227

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Light Wheel Vehicle Mechanic) medically separated for chronic bilateral breast pain.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty.  He was issued a permanent P3 profile and referred for a Medical Evaluation Board (MEB).  The “complex regional pain syndrome” condition was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded one other condition (adjustment disorder) for PEB adjudication.  The Informal PEB adjudicated “chronic bilateral breast pain” as unfitting, rated 20%, citing application of application of the US Army Physical Disability Agency (USAPDA) pain policy.  The remaining condition was determined to be not unfitting.  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:

IPEB – Dated 20041222	VA* - (~2 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Breast Pain	5099-5003	20%	Residual Scar, Status Post Resection, Breast, Right	7804	10%	20050720	
			Residual Scar, Status Post Resection, Breast, Left	7804	10%	20050720	
Adjustment Disorder	Not Unfitting	Post Traumatic Stress Disorder	9411	NSC	STR	
Other x 0 (Not In Scope)	Other x 2	
RATING:  20%	RATING:  20%	
*Derived from VA Rating Decision (VARD) dated 20050819 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:  The PEB combined the right and left breast pain conditions as a single unfitting condition rated at 20%, coded 5099-5003 (analogous to arthritis).  The PEB relied on AR 635.40 (B.24 f.) and/or the USAPDA pain policy for not applying separately compensable VASRD codes.  The Board must apply separate codes and ratings in its recommendations if compensable ratings for each condition are achieved IAW VASRD rating guidelines.  If the Board judges that two or more separate ratings are warranted in such cases, however, it must satisfy the requirement that each “unbundled” condition was unfitting in and of itself.  Thus the Board must exercise the prerogative of separate fitness recommendations in this circumstance, with the caveat that its recommendations may not produce a lower combined rating than that of the PEB.

Chronic Bilateral Breast Pain.  The narrative summary (NARSUM) noted the CI was diagnosed with bilateral gynecomastia and underwent bilateral subcutaneous mastectomies to reduce the gynecomastia.  Following the surgical procedure the CI reported bilateral breast pain around the surgical scars.  The pain was thought to be neuropathic (nerve related) and the CI was prescribed medication for nerve related pain (Gabapentin).  An undated civilian pain management evaluation also diagnosed the pain as neuropathic and recommended thoracic epidural injections or possibly, a spinal cord stimulator.  The examiner referred the CI to a major medical center equipped to provide all treatment options for the rare condition.  The CI had injections of the scars by a pain specialist, but the pain continued.  At a follow-up visit the CI was prescribed antidepressant medications for the pain, as well as the Gabapentin.  Electrodiagnostic studies of the upper extremities were performed on 22 September 2004 to evaluate the reported arm pain and weakness and were normal.  The CI obtained a second civilian pain specialist opinion on 4 November 2004 and was diagnosed with possible complex regional pain syndrome (CRPS), Type I.  Intercostal nerve injections (nerves which travel from the thoracic spine to the anterior chest along the ribs) and a home transcutaneous electrical nerve stimulator (TENS) unit were recommended.

At the MEB examination performed on 19 November 2004, 5 months prior to separation, the CI reported bilateral breast pain with any activity.  The MEB physical exam was normal except for bilateral breast scars.  The MEB examiner noted that the CI was scheduled to have intercostal nerve injections by the pain specialist soon.  The NARSUM noted that the chronic pain impaired duty performance by impacting bilateral upper extremity activities such as lifting, reaching, and pulling.

At the VA Compensation and Pension examination on 20 July 2005, 5 months after separation, the CI reported constant breast pain.  The physical exam was normal except for bilateral breast scars that measured five centimeters long and one wide, without ulceration, adherence, or other abnormality.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral breast condition at 20%, coded 5099-5003 (analogous to degenerative arthritis) and cited the USAPDA pain policy.  The VA rated the residual breast scars at 10% each, coded 7804 (unstable or painful scars) for a combined 20% rating.  The Board first considered if the bilateral breast condition could be unbundled as right and left breast conditions and each remain reasonably justified as separately unfitting.  Chronic pain of both the right and left chest was noted in the service treatment record following the bilateral surgical procedure.  The permanent profile noted only complex regional pain syndrome, without specifying the right or left side.  There was no commander’s statement in the available record but the NARSUM implicated bilateral pain as impairing duty performance by limiting bilateral upper extremity use.  Therefore, the Board concluded that the evidence supports that the residual right breast condition and residual left breast conditions were each reasonably justified as separately unfitting for continued military service, and are therefore eligible for individual rating.
The Board next noted that the evidence supports that the CI was consistently diagnosed with nerve related chest pain following the bilateral breast surgeries.  The notes in the STR indicated the breast conditions were identical in cause, findings, and residual disability.  The Board considered rating the conditions IAW §4.124a for CRPS.  The Board noted there was not a VASRD code for incomplete paralysis of the intercostal nerves, implicated by the pain specialist, and deliberated which nerve code was the best analogous code for the anterior chest pain.  The anterior branches of the upper thoracic intercostal nerves supply sensation to the anterior chest skin and breasts.  The most similar nerve code in function and symptomology the Board noted was 8529 (external cutaneous nerve of the thigh), which supplies sensation to the upper outer thigh; compression/irritation of the nerve causes localized thigh pain.  The rating criterion of 8529 provides 0% for “mild” or “moderate” incomplete paralysis, and 10% for “severe.”  The Board agreed that the incomplete paralysis, which was wholly sensory could not achieve higher than a 0% rating with this code because according to the VASRD when the “involvement is wholly sensory the rating should be for the mild, or at most, the moderate degree.”  IAW DoDI 6040.44 the Board may not recommend a lower combined rating than that conferred by PEB, therefore, members looked to see if any other §4.124a code provided a higher evaluation than the PEB, but found none that were closely similar in anatomic location, function and symptomology to the CI’s disability IAW §4.20 (Analogous ratings).

The Board also discussed rating analogously IAW §4.71a (musculoskeletal conditions).  However, rating the anterior chest condition as bilateral chondritis (which was a good fit with consideration of §4. 20), according to 5003 rating criteria would also provide a maximum of 20% for the right and left breast conditions combined.  Thus, having unbundled the bilateral breast condition, the Board found it provided no ratings benefit to the CI.  The Board concluded that there was no path to a higher combined evaluation than that conferred by the PEB and the PEB’s reliance on the USAPDA pain policy for rating was not detrimental to arriving at the highest rating.  Therefore, no change to the code is recommended.  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 adjudication for the bilateral breast condition.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the adjustment disorder condition was not unfitting.  The Board’s threshold for countering fitness determinations requires a preponderance of evidence, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.

Adjustment Disorder.  The Board noted that there was no evidence in the STR that the CI was evaluated or treated for mental health (MH) symptoms.  At a follow-up pain specialist visit, the CI was prescribed antidepressant medications (for the pain), and the pain specialist also noted the CI appeared depressed and expressed concern that psychological symptoms may be affecting his physical condition.  A psychiatric evaluation on 27 September 2004 noted the CI reported “mild symptoms” with “nightmares (combat related), flashbacks, anger, and easy irritable.”  The examiner indicated the CI did not require psychotropic medications for the MH condition and had employment and continuing education plans for his future after military separation.  The MH examiner diagnosed adjustment disorder, but indicated there was little to no impairment of social and industrial adaptability and the CI met retention standards with an S1 profile.  No MH condition was profiled or judged to fail retention standards.  As noted above, there was no commander’s statement in the available record and there was no performance based evidence from the record that any MH condition significantly interfered with satisfactory duty performance.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend any MH condition as unfitting at separation and so no additional disability rating is recommended.

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 the USAPDA pain policy for rating the chronic bilateral breast pain was operant in this case and the condition was adjudicated independently of that policy by this Board.  In the matter of the bilateral breast condition, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended MH condition, the Board unanimously recommends no change from the PEB determination as not unfitting.

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 20140522, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB			0 6 JUL 2016 

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, AR20160003103  (PD201402486)

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:

Enclosure CF:
( ) DoD PDBR ( ) OVA