RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02813
BRANCH OF SERVICE:  Army	BOARD DATE:  20150623
SEPARATION DATE:  20040816

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Bradley Fighting Vehicle System Maintainer) medically separated for asthma.  The condition could not be adequately rehabilitated to meet the requirements of his Military Occupational Specialty (MOS) but a permanent P3 profile, referring him for a Medical Evaluation Board (MEB), also authorized him to perform an alternate physical fitness test. “Mild intermittent asthma” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other condition was submitted by the MEB.  The Informal PEB adjudicated “asthma mild and intermittent that does not require the use of daily controller medications” as unfitting, rated 10%, with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  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 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 20040614	VA* - based on Service Treatment Records (STR)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Asthma	6602	10%	Asthma	6602	30%	STR	
Other x 0 (Not In Scope)	Other x 4	
RATING:  10%	RATING:  30%	
*Derived from VA Rating Decision (VARD) dated 20040917 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Asthma Condition.  The narrative summary notes the CI was evaluated on 9 February 2004 by a pulmonary specialist for shortness of breath (SOB).  Chest X-rays on 8 January 2004 were normal.  At the pulmonary evaluation, the CI reported SOB every day and at night, aggravated by exercise.  He reported twice a week awakening with asthma symptoms and daily use of a bronchodialator (BD) inhaler.  The CI reported a history of smoking cigarettes and seasonal allergies.  The pulmonary specialist prescribed anti-inflammatory inhaler medication (Advair) twice daily and a BD inhaler as needed.  Pulmonary function testing on 17 February 2004 after BD medication showed forced expiratory volume (FEV) of 88% predicted normal (PRED) and FEV1/forced vital capacity (FVC) of 74%, with an increase in the FEV1/FVC ratio of 7% after BD use, which was below the standard improvement of 12% or more used for asthma diagnosis.  A methacholine challenge test (“gold standard” test for asthma diagnosis) on 19 February 2004 was positive.  At a follow-up pulmonary visit on 25 February 2004 the CI reported no response to what the examiner termed “controller meds” and reported continued exertional SOB.  The pulmonary specialist indicated the CI should discontinue the “controller meds” and use the BD inhaler as needed.  Treatment visits dated 26 March 2004 and 13 April 2004 continued to indicate asthma medications as oral and inhaled anti-inflammatory medications and a BD inhaler as needed.  A medication profile in record indicated an albuterol inhaler was filled on 1 December 2003; a 10-day course of oral steroids was filled on 9 February 2004; and prescriptions for montelukast (Singulair – oral anti-inflammatory medication), a BD inhaler, and, a steroid-containing inhaler were filled on 28 April 2004.  The last four medications were all filled by prescriptions from the pulmonary specialist.  The undated commander’s statement noted that the CI’s condition “should not prevent him from accomplishing any of the tasks given to him as a soldier and indicated the CI passed an alternate APFT on 8 April 2004.  The commander noted that the profile limitation of “no wearing of a PROMASK” made the CI non-deployable.”

At the MEB examination on 5 April 2004, 4 months prior to separation, the CI reported SOB.  The physical exam noted a normal lung exam.  The examiner indicated there had been no response to “controller medications” and the CI did not require “controller medications” for “mild intermittent asthma” but he did not meet retention standards because he could not wear a protective mask or run, and his symptoms were chronic.  The MEB examiner recommended that the CI “is to use albuterol [BD inhaler] 2 puffs every 4 hours as needed for exertional activities and be forwarded to the PEB for further adjudication.”

The original VARD was based upon service medical records.  The VARD stated the service medical records showed that the CI had been treated for asthma and took “daily doses of Advair for the condition as well as frequent doses of albuterol as needed.”  The earliest VA C&P examination available in the record is dated 16 June 2009, 5 years after separation.  The examination provides no information relating back to the period following military separation, except that the CI commented his asthma worsened after separation.  He reported significant asthma symptoms and was being treated with a steroid inhaler and a BD inhaler as needed, but the exam indicated that the CI was using this medication only for the past 3 months.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the asthma condition 10%, coded 6602 (asthma), and noted on the DD Form 199 that the CI did not “require the use of daily controller medications.  Inhaler to be used for exertional activities.”  The VA rated the asthma condition 30%, coded 6602.  The Board noted that the PEB also referenced the commander’s statement which indicated that the only factor making the CI unfit for continued military service was the fact that he was non-deployable due to being unable to wear a protective mask.  However, the Board considered that the CI was adjudicated as unfit due to the asthma condition and according to VASRD rules for rating asthma in effect at the time of separation, the salient rating criteria are: pulmonary function test results, frequency and type of medication use, and for higher evaluations, the frequency of oral immunosuppressive medications, or the frequency and severity of asthma attacks.  Therefore, the Board reviewed the evidence to see if a rating higher than 10% was supported.  The Board determined the evidence does not support the higher evaluations of 100% or 60%; there was no evidence of asthma attacks requiring treatment by a physician monthly, or at least three courses of immunosuppressive medications in the past year.  The pulmonary function test met the criteria for a 10% rating and no higher.  The discriminating factor between the 10% and 30% ratings based on medications is the type and frequency of medication use.  The evidence in record supports that the CI took a course of oral steroids in February 2004, after which the pulmonary specialist advised him to cease use of steroid medications and use a BD inhaler as needed, since the CI reported no change with use of the steroids.  Treatment visits in March and early April 2004 listed medications of Singulair, Advair, and albuterol.  However, according to the medication profile the CI filled these prescriptions from the pulmonary specialist in late April 2004 which was several months after his early February evaluation.

The Board engaged in lengthy deliberations regarding the conflicting evidence in record regarding medication usage.  The Board consensus was that the evidence does not provide support for asthma requiring the daily use of a BD medication or use of an anti-inflammatory inhaler medication.  Although the CI eventually filled the prescriptions written by the pulmonary specialist, the CI’s decision to fill them appeared to have been well after the pulmonary specialist rescinded the prescription for lack of efficacy.  There is no documentation in the record of any worsening of the asthma condition and there were no treatment notes from the MEB examination to the date that the CI filled the rescinded prescriptions.  Member consensus was that the evidence in record supports the 10% rating, coded 6602 based upon pulmonary function test results and intermittent use of BD medication, and no higher.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded there was insufficient cause to recommend a change in the PEB adjudication for the asthma 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 asthma condition and IAW VASRD §4.97 the Board unanimously recommends no change in the PEB adjudication.

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 20140602, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB

MEMORANDUM FOR Commander, US Army Physical Disability Agency
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557

06 July 2016

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation
for, AR20160003436 (PD201402813)

I have reviewed the enclosed Department of Defense Physical Disability Board of
Review (000 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