RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02928
BRANCH OF SERVICE:  Army	BOARD DATE:  20150522
SEPARATION DATE:  20040527

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (MLRS Crewmember) medically separated for paroxysmal atrial fibrillation and asthma.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty or satisfy physical fitness standards.  He was issued a permanent P3 profile and referred for a Medical Evaluation Board (MEB).  The “Paroxysmal atrial fibrillation” and “Asthma” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded one other condition (hypertension) for PEB adjudication.  The Informal PEB adjudicated “Paroxysmal atrial fibrillation” and “Asthma” as unfitting, rated 10% and 10%.  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 20040330	VA* - (~at-Separation) 	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Paroxysmal Atrial Fibrillation	7010	10%	Paroxysmal Atrial Fibrillation	7010	10%	20040514	
Asthma	6602	10%	Asthma	6602	10%	20040514	
Hypertension	Not Unfitting	Hypertension	7101	10%	20040514	
Other x 0 (Not In Scope)	Other x 0	
RATING:  20%	RATING:  30%	
*Derived from VA Rating Decision (VARD) dated 20040913 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Paroxysmal Atrial Fibrillation Condition.  The CI was first diagnosed with atrial fibrillation (A-fib) during an emergency room work-up after he experienced a near-syncopal (fainting) episode while standing in formation in June 2003.  He was hospitalized for observation and cardiac evaluation as to rule out an underlying heart attack as well as to define the etiology of the sudden A-fib.  Laboratory analysis did not reveal that a heart attack occurred and during other invasive testing, the CI spontaneously converted from the abnormal A-fib heart rhythm to a normal heart rhythm on his second day of hospitalization.  A post-rhythm conversion echocardiogram was normal as was a thyroid function test.  Although the CI endorsed 4-5 similar symptom episodes in the previous 6 months, none were documented in the records.  Specialty consultations of cardiology and pulmonary indicated the CI was at risk for A-fib related complications and was also diagnosed with asthma, respectively.  He was placed on anti-coagulant (Coumadin) therapy and referred to a MEB.  At the MEB narrative summary (NARSUM) of 5 March 2004 (3 months prior to separation), The CI’s chief complaint was “My heart doesn't beat properly and I have to take Coumadin.”  His cardiopulmonary focused physical examination (PE) was normal.  His diagnosis remained as sudden A-fib.  The condition was listed on the permanent profile and implicated in the commander’s letter noting a greater risk for bleeding as being incompatible with military service.  At the VA Compensation and Pension (C&P) examination of 14 May 2004 (2 weeks prior to separation), the CI’s history was unclear in that it described his initial presenting symptoms of lightheadedness and passing out and then stated, “The symptoms described occur constantly.”  The PE remained normal.  He maintained the ability to perform all activities of daily living to include driving a car.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB and VA both coded the condition as 7010 (supraventricular dysrhythmia), and rated it 10%.  While the CI reported frequent episodes of symptoms, only the initial hospitalization episode of A-fib was actually documented in the records in evidence.  The cardiac evaluations by both the MEB and VA examiners were normal and no abnormal cardiac rhythm was noted.  The Board considered if a higher, 30% rating was supported.  The difference between 10% and 30% impairment is that the latter requires documentation by electrocardiogram (ECG) or Holter monitor (a continuous ECG) of A-fib of five or more times a year.  The record did not show that level of documented episodes during his time in military service.  The diagnosis of lone A-fib at the NARSUM clearly is supported at the 10% impairment level.  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 A-fib condition.

Asthma Condition.  In February 2004, the CI had a positive methacholine challenge test (asthma definitive test), noting a 20% drop in FEV1 which was consistent with asthma.  The CI had no past history of asthma or allergic reactions.  Although individual record encounters do not specifically state medication use for this condition, medication profiles do reveal the CI was prescribed daily use of inhalational steroids in early 2004; however, a pulmonary function test (PFT) dated 14 May 2004 (2 weeks prior to separation) clearly listed “none” under the heading of “medications.”  The CI was permanently profiled in March 2004 and referred for a MEB with the diagnosis of asthma.  At the NARSUM examination the CI’s present condition included shortness of breath and dyspnea (labored breathing) on exertion.  Symptom triggers included smoking, cold exposure, moderate exertion, performing outdoor activities, or the wearing of NBC protective equipment.  His PE revealed few wheezes in the upper lung fields, but the examiner stated “otherwise, they were clear.”  Advair, an inhaled corticosteroid was listed as a current medication.  His PFT dated 5 February 2004, (approximately 3 months prior to separation) was interpreted as a normal variant of lung function.  At the VA C&P examination the CI’s reported history remained confusing and nonsensical.  The clinical encounter noted that the asthma condition has “existed for two months,” “…has asthmatic attacks three times per week” and requires “physician [assistance] to control the attacks as often as once per year”; additionally, the CI denied shortness of breath.  His medications remained unchanged noting continued use of Advair.  The PFT results as referenced above, with additional §4.97-ratable treatment criteria, are summarized in the chart below.

Pulmonary Exam	MEB ~3 Mo. Pre-Sep
(20040205) 	VA C&P ~2 week Pre-Sep
(20040514) 	
FEV1 (% Predicted)	95%	201%	
FEV1/FVC	82%	82%	
Meds	Advair; Albuterol	Advair; Albuterol 	
§4.97 Rating	30%	30%	

The Board directed attention to its rating recommendations based on the above evidence.  The unequivocal VASRD code for rating asthma is 6602.  VASRD §4.97 defines both PFT-derived criteria and clinical treatment criteria for rating under 6602.  The non-PFT derived criteria are: “intermittent inhalational or oral bronchodilator therapy” for 10%; “daily inhalational or oral bronchodilator therapy, or; inhalational anti-inflammatory medication” for 30%; and, “intermittent (at least three per year) courses of systemic (oral or parenteral) corticosteroids” for 60%.  In this case, the Board members were confronted with two prior to separation examinations each indicating the use of both inhalation bronchodilator and corticosteroid medications.  Board members deliberated if the CI’s condition supported the 30% criteria level.  Clearly, the record documentation and medication lists supported the use of inhalation steroids thus supporting the 30% criteria level under VASRD code 6602.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 30% for the asthma condition.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the hypertension 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.  The hypertension condition was not profiled or implicated in the commander’s statement and was not judged to fail retention standards.  The condition was reviewed and considered by the Board.  There was no performance based evidence from the record that the hypertension 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 hypertension condition 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 A-fib condition and IAW VASRD §4.104, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the asthma condition, the Board unanimously recommends a rating of 30% coded 6602 IAW VASRD §4.97.  In the matter of the contended hypertension condition, the Board unanimously agrees that it cannot recommend it for additional disability rating.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  The Board recommends that the CI’s prior determination be modified as follows and that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of his prior medical separation:

UNFITTING CONDITION	VASRD CODE	RATING	
Asthma	6602%	30%	
Paroxysmal Atrial Fibrillation	7010	10%	
COMBINED	40%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140619, 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

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXX, AR20160003767 (PD201402928)

1.  Under the authority of Title 10, United States Code, section 1554(a), I approve the enclosed recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) pertaining to the individual named in the subject line above to re-characterize the individual’s separation as a permanent disability retirement with the combined disability rating of 40% effective the date of the individual’s original medical separation for disability with severance pay.  

2.  I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum:

	a.  Providing a correction to the individual’s separation document showing that the individual was separated by reason of permanent disability retirement effective the date of the original medical separation for disability with severance pay.

	b.  Providing orders showing that the individual was retired with permanent disability effective the date of the original medical separation for disability with severance pay.

	c.  Adjusting pay and allowances accordingly.  Pay and allowance adjustment will account for recoupment of severance pay, and payment of permanent retired pay at 40% effective the date of the original medical separation for disability with severance pay.

	d.  Affording the individual the opportunity to elect Survivor Benefit Plan (SBP) and medical TRICARE retiree options.

3.  I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

BY ORDER OF THE SECRETARY OF THE ARMY:
						      					
Enclosure
					
CF: 
(  ) DoD PDBR
(  ) DVA