RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02796
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20061230

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an Active Guard Reserve E-5 (Construction Equipment Repairer) medically separated for Type I diabetes.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS). The profile allows for an alternate aerobic event to satisfy physical fitness standards.  He was issued a permanent P3 profile and referred for a Medical Evaluation Board (MEB).  The “diabetes, Type 1” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded one other condition, “post-traumatic stress disorder,” for PEB adjudication.  The Informal PEB adjudicated “diabetes mellitus, type 1 requiring insulin” as unfitting, rated 20%.  The remaining condition was determined to be not unfitting.  The CI made no appeals and 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 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 20060726	VA* - (~13 Mos. Post-Separation) 	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Diabetes Mellitus, Type 1	7913	20%	Diabetes Mellitus, Type I	7913	20%	20080125	
Post-Traumatic Stress Disorder	Not Unfitting	Post-Traumatic Stress Disorder	9411	70%	20080118	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 12 (equals SC, NSC & deferred)	
RATING:  20%	RATING:  100%	
*Derived from VA Rating Decision (VARD) dated 20080616 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:  

Diabetes Mellitus, Type I, Requiring Insulin Condition.  The narrative summary (NARSUM) noted the CI was diagnosed with diabetes mellitus (DM) Type I in December 2005 and was treated with insulin therapy.  According to the NARSUM the DM Type I was in good control.  The permanent profile listed DM and alternate physical fitness testing was allowed. The comments section noted no extended consumption of MREs and “no PT or carrying or firing of weapons when blood glucose >250 or <70 milligrams/deciliter [mg/dL].”  The commander’s statement noted that the CI was capable of performing the duties of his MOS but listed the profile limitations as noted above and indicated that if the CI was able to be reclassified into another MOS his retention was supported, but that if not and he was found non-deployable, military separation was recommended.  The CI’s performance evaluation report (NCOER) for the period March 2005 to February 2006 noted that the CI passed his physical fitness test, was “extremely dedicated to physical fitness” and “performed group physical fitness training whenever possible.”

At the MEB exam 15 May 2006, the CI reported DM Type I and tingling in his feet.  The MEB physical exam noted normal eye and skin exams and normal sensation of both feet.  The CI’s current hemoglobin AIC (HAIC-test which measures long term blood sugar control) was 6.7 percent, improved from 9.7 at diagnosis. (normal HAIC level < 5.7).  The diagnosis was “Type I diabetes requiring insulin with dietary and exercise regulation.”  The MEB examiner noted that the CI’s present condition included a profile with no “extended MRE consumption and some exercise limitations depending on glucose level,” with “no identified secondary complications.”  The CI appealed the findings of the MEB in a letter dated 14 July 2006 and indicated that he had maintained blood sugar levels less than 120 mg/dL, while performing his duties without “special consideration or medical profiles” and stated that he was “well in control of my diabetic condition, with the help of insulin I am capable of continuing my military duties and remain physically fit.”  

At the VA Compensation and Pension exam performed on 25 January 2008, 13 months after separation, the CI reported DM type I with no history of ketoacidosis or any problem with hypoglycemia.  He visited his doctor for control of the diabetes on average twice per year.  He also reported weakness of the upper and lower extremities and numbness and tingling of the fingers, legs, and feet bilaterally.  The CI reported he had been diagnosed with peripheral neuropathy.  He denied cardiovascular or kidney complications due to the diabetes, but reported blurred vision with high blood sugars.  The exam of the eyes and skin was normal.  There was decreased sensation noted in the bilateral feet, with normal lower extremity strength and reflexes.  The CI’s blood glucose level was 287 mg/dL and sugar was present in his urine.  The examiner noted that the diabetes did not “cause any restriction of activities” and there were no secondary complications of the cardiovascular system, eyes or kidneys, but that it was the peripheral neuropathy was “at least as likely as not a complication of diabetes.”  

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB and VA both rated the DM Type I condition 20% coded 7913 (diabetes mellitus).  The Board reviewed the 7913 rating criteria.  A 20% rating is specified as “requiring insulin and a restricted diet” and the next higher evaluation of 40% is specified as “requiring insulin, restricted diet, and regulation of activities.”  The Board noted that at the time of separation the permanent profile listed diet and exercise restrictions.  Following separation the VA Rating Decision stated there was “no noted need for activity restriction due to diabetes.”  Members deliberated whether the noted profile limitations during service regarding restricted activity if blood sugar was not in an acceptable range was sufficient support for the 40% rating   The CI did not have a history of ketoacidosis or problems with hypoglycemia and there was no evidence in record that exercise caused an abnormal blood sugar level, either increased or decreased.  The NCOER indicated the CI was physically fit and was a successful and superior performer in his MOS.  The CI noted in his appeal of the MEB in July 2006 that since his diagnosis he was able to maintain acceptable blood sugar levels and physical fitness and was capable of remaining in the military, despite the requirement of insulin to manage his DM.  The Board concluded from the evidence the comments on the permanent profile to be sufficient evidence that activity restrictions were “required” for management of the CI’s DM condition.  The Board therefore determined that the evidence in record supports the 20% rating and no higher.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the DM condition.  

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the posttraumatic stress disorder (PTSD) 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.  

PTSD Condition.  There were no primary mental health (MH) evaluations or treatment notes in record.  The CI wrote an appeal of the MEB findings and noted his MH history.  He indicated that he was diagnosed with PTSD in theater in 2005.  When he returned he was treated by behavioral health until June 2005.  The CI said that he was “in control” after that point, but relapsed after he was diagnosed with DM.  He indicated that he returned to Behavioral Health care and was attending a social work group therapy for men.  The CI concluded in the letter that he had proven to his chain of command that he could perform the duties of his MOS and indicated that he wished to remain in the military.  A psychiatric “statement of medical condition” 24 April 2006 indicated the CI was admitted 19 April 2006 to the inpatient psychiatric unit due to depression symptoms with suicidal ideation and was started on anti-depressant medication.  The examiner noted the CI was no longer suicidal.  The Axis I diagnosis was PTSD and the Global Assessment of Functioning was 55 (moderate impairment range).  The psychiatrist indicated the CI was receiving appropriate care and his condition did not warrant referral to an MEB and recommended that he remain on active duty with continued treatment on an outpatient basis.  The commander’s statement dated 15 May 2006 did not mention any MH symptoms or conditions and indicated that the CI was fit for duty unless the CI was judged to be non-deployable due to the DM condition, and in that case recommended the CI be re-classed to a different MOS and retained.  

The Board found neither the PTSD condition, nor any other MH condition was profiled or implicated in the commander’s statement and no MH condition was judged to fail retention standards.  There was no performance based evidence from the record that the PTSD or 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 a change in the PEB fitness determination for the PTSD condition and agreed that there was insufficient evidence 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.  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 DM Type I condition and IAW VASRD §4.119, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended PTSD condition, the Board unanimously recommends no change from the PEB determinations as not unfitting and agrees that it cannot recommend any MH condition for additional disability rating.  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 20140606 w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB

06 July 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 AR20160003435 (PD201402796)

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
( ) DVA