RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03081
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070608

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E6, Cavalry Scout, medically separated for “atherosclerotic heart disease” with a disability rating of 10%.

CI CONTENTION:  “Please consider all conditions.” The CI’s complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  It is limited to those conditions determined by the Physical Evaluation Board (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 based upon a 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:  

SERVICE PEB - 20070405	VARD - 20071129	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Atherosclerotic Heart Disease	7005	10%	Coronary Artery Disease	7005	10%	20070712	
Diabetes Mellitus (DM), Type II	Not Unfitting 	DM, Type II	7913	20%		
Obstructive Sleep Apnea (OSA)		OSA	6847	50%		
Hypertension (HTN)		HTN	7101	0%		
Hyperlipidemia		Hyperlipidemia	7099-7007	NSC		
Dyslipidemia		No VA Placement	
Obesity		No VA Placement	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY:  

Atherosclerotic Heart Disease Diagnosis.  The record shows that the CI presented to the emergency room on 13 October 2005 complaining of chest pain following exercise.  He was diagnosed with a heart attack and treated with coronary artery dilation and stenting.  An exercise tolerance test showed excellent tolerance with over 12 METS achieved.  An echocardiogram was unremarkable with a normal ejection fraction (over 60%).  He was put into cardiac rehabilitation with unsatisfactory results; compliance was an issue.  In fact, he gained over 80 pounds over the course of the following year.  On 16 August 2006, a repeat echocardiogram showed mild dysfunction in the resting phase of the heart (when it fills with blood), but the ejection fraction remained normal.  A perfusion scan on 14 September 2006 demonstrated good perfusion.  The ejection fraction was low at 36% (normal 50-70%), but the medical officer noted that the echocardiogram is a better study to measure the ejection fraction.  The Medical Evaluation Board (MEB) narrative summary (NARSUM) was dated 29 September 2006, 8 months prior to separation.  The CI reported that he still experienced shortness of breath with exercise.  It was noted that the CI was being treated for diabetes mellitus and lipid abnormalities (dyslipidemia).  He had been diagnosed with OSA and hypertension.  These are discussed below in the contended conditions section.  A cardiology note dated 2 July 2007, 4 weeks after separation, documented that the CI had lost over 60 pounds from his peak weight and had no cardiac symptoms.  He denied the use of rescue medications (nitroglycerin).  At the VA Compensation and Pension (C&P) examination on 12 July 2007, performed 5 weeks after separation, the CI reported no current cardiac symptoms.  The cardiac examination was normal and the examiner estimated the METS capacity at 14.  A repeat echocardiogram, on 19 July 2007, 6 weeks after separation, showed normal ventricular function and an ejection fraction of 66% (normal).  An exercise tolerance test on 7 August 2007 demonstrated good exercise tolerance at 10 METS and a normal response to exercise.  

The Board directed attention to its rating recommendation based on the above evidence. The PEB and VA both assigned a 10% rating under 7005 code (arteriosclerotic heart disease) for the use of continuous medication.  Absent a workload of less than 10 METS or cardiac symptoms, the Board found no route to a higher rating.  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 arteriosclerotic heart disease condition.  

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that contended dyslipidemia, DM, mild OSA, hyperlipidemia, HTN, and obesity conditions were 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 dyslipidemia, DM, and OSA were judged to fail retention standards.  The DM and OSA were profiled and implicated in the commander’s statement.  The dyslipidemia is a laboratory finding and not a ratable condition.  It was treated with medications and lifestyle changes as was the DM.  Control of both was compromised by poor compliance with treatment as manifested by weight gain and a poor diet high in fat and sugar.  The OSA was treated with continuous positive airway pressure (CPAP); however, compliance was an issue in control of this condition as well.  All three conditions are commonly found to be not unfitting and typically controlled with proper diet, lifestyle, and (for dyslipidemia and DM) medications.  Obesity is a condition not constituting a physical disability, IAW DoDI 1332.38.  Therefore, the Board has no basis for recommending it as unfitting.  The hyperlipidemia and hypertension conditions met retention standards and were not profiled.  The commander did not specifically address these, but noted that his “metabolism and exercise tolerance has declined significantly resulting in weight gain…”  All were reviewed and considered by the Board.  The record shows that the CI was losing weight in the months leading up to separation and had dropped from his peak (self-reported) weight of 320 pounds to 265 pounds.  Improvement in control of all the contended conditions would be expected with this degree of weight loss.  The PEB determined that his conditions could be controlled with treatment and that they were not unfitting as a consequence.  He was noted to have good exercise tolerance which would aid in further weight loss and continued improvement in the control of these conditions.  After due deliberation, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the contended dyslipidemia, DM, mild OSA, hyperlipidemia, HTN, and obesity conditions and so no additional disability ratings are recommended.  
BOARD FINDINGS:  In the matter of the arteriosclerotic heart disease condition and IAW VASRD §4.104, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended dyslipidemia, diabetes mellitus (DM), mild obstructive sleep apnea (OSA), hyperlipidemia, hypertension (HTN), and obesity conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting.  There were no other conditions within the Board’s scope of review for consideration.  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 20140618, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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 XXXXXXXXXXXXXXXXXXXXXXX AR201600111 06 (PD201403081)

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