RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03148
BRANCH OF SERVICE:  AIR FORCE	BOARD DATE:  20141030
SEPARATION DATE:  20060710

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SrA/E-4 (2A553B/Aircraft Instrument and Flight Controls) medically separated for asthma.  Due to her asthma condition, she could not meet the physical requirements of her Air Force Specialty or satisfy physical fitness standards.  She was issued a P4 profile and referred for a Medical Evaluation Board (MEB).  The asthma condition was the only condition forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123.  The Informal PEB adjudicated “asthma” as unfitting, rated 10% with application of the VA Schedule for Rating Disabilities (VASRD).  The CI non concurred with the PEB findings and requested a formal hearing; however, upon recommendation of counsel, withdrew her request, concurring with the PEB findings.  

CI CONTENTION:  “Developed pulmonary disease while deployed to Afghanistan.  Have thinning vertebrae and ruptured disc due to car accident while TDY to Las Vegas.  Suffer from major depression due to deployments.  Have severe back problems and chipped tooth.”

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 those conditions identified but not determined to be unfitting by the PEB when specifically requested by the CI.  The rating for the unfitting asthma condition is addressed below.  No other conditions, to include the contended depression and back are within the defined purview of the Board.  Any conditions outside the Board’s scope of review may be eligible for consideration by the Board for Correction of Military Records.

RATING COMPARISON:

Service IPEB – Dated 20060426	VA - (4 Months Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Asthma	6602	10%	Asthma	6602	30%	20061114	
Other x 0	Other x 4 		
Rating:  10%	Combined:  70%	
Derived from VA Rating Decision (VARD) dated 20070306 (most proximate to date of separation [DOS])

ANALYSIS SUMMARY:  The Board acknowledges the CI’s contention that she suffers from other conditions in addition to the pulmonary disease (asthma).  It is noted for the record that the Board is subject to the same laws for disability entitlements as those under which the Disability Evaluation System operates.  While other conditions and diagnoses may have been present during military service, compensation can only be offered for those conditions that cut short a member’s career and then only to the degree of severity present at the time of separation.  The pulmonary disease (asthma) was the only condition listed on AF Form 356.  The VA, however, is empowered to compensate for all service-connected conditions and to periodically re-evaluate conditions for the purpose of adjusting the Veteran’s disability rating should the degree of impairment change over time.
Asthma.  In April 2004, this CI was seen for possible dyspnea (difficulty breathing).  She was referred to a pulmonologist, but she failed to make the appointment.  In June 2005, while deployed to Afghanistan, she started having breathing difficulties and was given several nebulizer treatments.  Upon return to the US, her symptoms would come and go for several months.  She had an Albuterol inhaler which she used, and it gave her relief from the symptoms of dyspnea and wheezing.  On 27 February 2006, the CI presented to the emergency room (ER) complaining of wheezing and dyspnea.  She was treated, started on medications and released.  When she left the ER, her medications included oral Prednisone (a corticosteroid in tablet form), Atrovent (an inhaled anticholinergic bronchodilator) and Albuterol (a short-acting beta adrenergic agonist).

The CI saw her primary care manager on 1 March 2006, and an MEB was initiated.  Pulmonary examination was normal.  The CI was pleasant, cooperative and in no acute distress.  Respiratory rate was 16 breaths per minute.  Lungs were clear to auscultation in all fields, with no rales or wheezes and good airflow throughout.  The examiner’s diagnosis was mild, persistent asthma.  He started her on Advair (an inhaled combination drug containing corticosteroid) and continued the Albuterol as a “rescue” inhaler.  The following day, pulmonary function tests (PFTs) were performed.  The forced expiratory volume in the first second (FEV-1) was 83% of predicted, and did not improve with bronchodilator.  The FEV-1 divided by forced vital capacity (FVC) was 90%, which was normal.

As noted above, the CI was found unfit by the Air Force PEB, and separated from service in July 2006.  Four months later, in November 2006, she had a VA Compensation and Pension (C&P) exam.  She reported that her asthma attacks were occurring at least weekly.  She denied any history of bronchitis, pneumonia, or hospitalizations.  At that time, her medications included Formoterol (a long-acting beta adrenergic agonist), Albuterol (a short-acting beta adrenergic agonist), and Mometasone (an inhaled corticosteroid).  On physical exam, she was healthy and fit appearing, and her lungs were clear to auscultation.

The PFTs which the Board weighed in arriving at its rating recommendation, are summarized below.
        
PFTs	MEB ~ 4 mos. Pre-Sep 
(20060302)	VA C&P ~ 4 mos. Post-Sep
(20061114)	
FEV-1 (% of Predicted)	83% pre-drug,
81% post-drug	89%	
FEV-1/FVC	90% pre-drug,
89% post-drug	88%	
Medications	Meds included daily dose of oral corticosteroid	Meds included daily use of inhaled corticosteroid	
§4.97 Rating	30%*	30%*	
 		* 30% based on medication, not the PFT thresholds

The Board carefully reviewed all evidentiary information available, and directs attention to its rating recommendation based on the evidence above.  Both the Air Force PEB and the VA coded the pulmonary condition 6602 (Asthma).  The PEB rated it 10%, and the VA rated it 30%.  In the VASRD §4.97, the rating guidance for asthma is based on clinical exacerbations, type & frequency of medications used, and results of PFTs.  For the reader’s convenience, the VASRD §4.97 language for the 10% and 30% ratings (diagnostic code 6602) is excerpted below:

FEV-1 of 56 to 70-percent predicted, or; FEV-1/FVC of 56 to 70 
percent, or; daily inhalational or oral bronchodilator therapy, 
or; inhalational anti-inflammatory medication .....................................................30 

FEV-1 of 71 to 80-percent predicted, or; FEV-1/FVC of 71 to 80 
percent, or; intermittent inhalational or oral bronchodilator therapy .................10

IAW VASRD §4.97, a 10% rating is warranted when there is satisfactory evidence of intermittent inhalational bronchodilator therapy.  A 30% rating is warranted when there is satisfactory evidence of daily inhalational bronchodilator therapy, or inhalational anti-inflammatory medication.  Therefore, the crux of the Board’s deliberation centered on the CI’s use of anti-asthma medications.

The 1 March 2006 MEB examination was just 2 days after an ER visit.  The CI was in the middle of a 5-day course of oral Prednisone.  At that MEB visit, the examiner started her on Advair (an inhaled combination drug containing corticosteroid).  At some point later, her inhaled corticosteroid was changed to Motametasone, because when she arrived for her 14 November 2006 C&P exam, she was using daily Motametasone.  The Board determined that it was clear, that the CI required inhalational anti-inflammatory medication.  First it was Advair, which contains the anti-inflammatory corticosteroid, Fluticasone proprionate.  Eight months later, she was using the anti-inflammatory corticosteroid Motametasone.  Following a thorough review of the evidence in the treatment record, the Board concluded that it was more likely than not that the CI was using inhalational anti-inflammatory medication at the time of separation from service.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (Reasonable doubt), the Board unanimously recommends a disability rating of 30% 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 a disability rating of 30%, coded 6602.  There were no other conditions within the Board’s scope of review for consideration.

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

UNFITTING CONDITION	VASRD CODE	RATING	
Asthma	6602	30%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140624, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

XXXXXXXXXXXXXXXXXX
President
Physical Disability Board of Review

SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD 20762

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXX:

	Reference your application submitted under the provisions of DoDI 6040.44 (Title 10 U.S.C. § 1554a), PDBR Case Number PD-2014-03148.

	After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was not appropriate under the guidelines of the Veterans Affairs Schedule for Rating Disabilities.  Accordingly, the Board recommended your separation be re-characterized to reflect disability retirement, rather than separation with severance pay.

	I have carefully reviewed the evidence of record and the recommendation of the Board.    I concur with that finding, accept their recommendation and determined that your records should be corrected accordingly.  The office responsible for making the correction will inform you when your records have been changed.

	As a result of the aforementioned correction, you are entitled by law to elect coverage under the Survivor Benefit Plan (SBP).  Upon receipt of this letter, you must contact the Air Force Personnel Center at (210) 565-2273 to make arrangements to obtain an SBP briefing prior to rendering an election.  If a valid election is not received within 30 days from the date of this letter, you will not be enrolled in the SBP program unless at the time of your separation, you were married or had an eligible dependent child, in such a case, failure to render an election will result in automatic enrollment.

							Sincerely,

XXXXXXXXXXXXXXXXXX
Director
Air Force Review Boards Agency

Attachment:
Record of Proceedings

cc:
SAF/MRBR
DFAS-IN