RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXX	CASE:  PD-2014-03333
BRANCH OF SERVICE:  AIR FORCE	SEPARATION DATE:  20030423

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-3 (Ground Radio Communications) medically separated for a sleep disorder condition.  The condition could not be adequately rehabilitated to meet the physical requirements of his Air Force Specialty or satisfy physical fitness standards.  He was issued P4 profile and referred for a Medical Evaluation Board (MEB).  The sleep condition, characterized as “narcolepsy,” was forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123.  No other conditions were submitted by the MEB.  The Informal PEB adjudicated “narcolepsy” as unfitting, rated 10%, citing criteria of Department of Defense (DoD) and the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The PEB also adjudicated an “overweight” condition as Category III (not separately unfit & compensable/ratable).  The CI made no appeals and was medically separated.

CI CONTENTION:  The CI requests consideration of all 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/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:

Service IPEB – Dated 20030305	VA - (2 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Narcolepsy	8108	10%	Narcolepsy and Cataplexy	8108	20%	20030617	
Other x 1 (In Scope)	Other X 0	
Combined:  10%	Combined:  20%	
Derived from VA Rating Decision (VARD) dated 20030718 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Narcolepsy Condition.  The CI first reported sleep difficulty in October 2001 that was treated effectively within 2 months with Elavil.  The service treatment records regarding sleep problems were silent until August 2002.  At that time, he reported breath holding that aroused him from sleep, loud snoring and daytime fatigue for over a year.  He said he had problems with sleep for the past 3 years.  Two sleep studies between September-December 2002 did not reveal sleep apnea.  A Multiple Sleep Latency Test (MSLT) in December 2002 diagnosed narcolepsy.  A Neurology consult January 2003 noted he had sleep paralysis, excessive dreamlike activity, and sleeping at inappropriate times.  Neurology exam in January 2003 showed normal gait and posture, including the power, bulk, and tone of upper and lower extremity muscles.  Diagnoses of narcolepsy and overweight were rendered with a recommendation for treatment with Adderall XR.  He was advised to not be close to water, avoid heights and heavy machinery, and avoid being near moving parts.

The narrative summary, dated 30 January 2003, 3 months prior to separation, noted the CI had symptoms of cataplexy, a sudden and transient episode of muscle weakness accompanied by full conscious awareness.  He had a loss of muscle tone when laughing, which caused him to fall down at times.  He had limited activity with electronics, could not work with dangerous machinery, and could not work at high levels of elevation.  He slept seven to eight hours per day intermittently, broken up into sleep at night and naps during the day.  He still had some fatigue during the late afternoon and evening even while taking Adderall.

The VA Compensation and Pension exam, dated 17 June 2003, performed 2 months after separation, noted the CI was about to start technical training and had not worked since his discharge a month previously.  A review of medical records revealed the CI had symptoms diagnostic for narcolepsy and suggestive for cataplexy, although he had not been given the medications used for cataplexy.  There was a reference to the last visit to his neurologist in February 2003, noting he was receiving Adderall that allowed him to get through the day without difficulty and allowed him to sleep at night.  The CI reported that when alone or as a passenger in a moving vehicle, he could easily fall asleep in daytime but he did not fall asleep during repetitive activities, like eating or driving.  When he occasionally felt sleepy while driving, he would pull over, sleep for a few minutes to a half hour and awake refreshed.  An episode of cataplexy might occur after waking when his legs were wobbly.  On occasion when laughing, he had to sit down before falling down.  He had components of narcolepsy that included sleep-related hallucinations, sleep paralysis (awakening but unable to move), and remaining asleep for a relatively long time, though not as long as others with narcolepsy.  Physical and neurological exam was normal.  He had only slight cataplexy but had other elements of narcolepsy: sleep related hallucinations, sleep paralysis, and sleeping for a long time though not as long as others.  There was no history of seizures.  Physical exam revealed no abnormalities of gait, power, tone, or coordination of muscle movements.  During 1.25 hours of clinical contact, he did not appear to become drowsy when standing and displayed no abnormality of trunk posture or evidence of paravertebral muscle spasms.  The examiner noted convincing evidence that the CI suffered from narcolepsy and had “only slight cataplexy.”  The VA assigned a disability rating of 20%.

The Board directed attention to its rating recommendation based on the above evidence.  The VASRD directs that narcolepsy (8108) is to be rated as epilepsy: petit mal, under the general rating formula for minor seizures (8911).  A minor seizure consists of a brief interruption in consciousness or conscious control associated with staring or rhythmic blinking of the eyes or nodding of the head, or sudden jerking movements of the arms, trunk, or head (myoclonic type), or sudden loss of postural control (akinetic).  The CI did lose postural control during untreated cataplexy episodes.  He did not have a seizure disorder that would cause a major seizure (generalized tonic-clonic convulsion with unconsciousness).  The Board noted both the PEB and the VA listed the 8108 code.  The PEB assigned a 10% rating, noting a diagnosis of narcolepsy with “mild social and industrial adaptability impairment” which is language IAW DODI 1332.39 (in effect at separation, but since rescinded) rather than the VASRD 8108 criteria.  The VA assigned a 20% rating for narcolepsy and cataplexy (which assumes at least two minor seizure episodes in the last 6 months).  The rating options under 8108 for Narcolepsy which are open to consideration in this case, rely on the frequency and timing of “seizures.”  The Board adjudged that episodes of cataplexy or unplanned falling asleep could be considered analogous to minor seizures for analogous rating.  The Board carefully considered the frequency and timing of the CI’s narcolepsy episodes including objective evidence and corroborating subjective evidence.  The Board deliberated on the 40% (averaging at least 5 to 8 minor seizures weekly), 20% (at least 2 minor seizures in the last 6 months), or the 10% rating criteria (fewer than 2 events in the last 6 months).

The VA exam was more proximal to separation, more comprehensive and detailed and therefore of greater probative value than the MEB exam.  Treatment records reflected medication was working well, but not completely, for daytime drowsiness and the CI reported symptoms of cataplexy persisted.  The VA examiner noted the cataplexy symptoms had not been treated with the recommended medications.  Although both the MEB and VA examiners acknowledged the presence of symptoms of cataplexy, they vaguely defined their frequency as, “occasional, at times, and may follow waking.”  Since the VA examiner noted the CI was able to get through the day without difficulty and was able to sleep at night, one might reasonably conclude the episodes of cataplexy were infrequent.  There was insufficient evidence to support a higher 40% rating which requires five to eight minor seizures per week.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 20% for the narcolepsy and cataplexy condition.

Contended PEB Condition.  The Board’s main charge is to assess the fairness of the PEB’s determination that the overweight was not compensable.  Obesity is a condition or circumstance not constituting a physical disability IAW DoDI 1332.38, E5 and therefore the overweight condition is not compensable.  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 Category III determination (not compensable) for the contended overweight 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.  As discussed above, PEB reliance on DoDI 1332.39 for rating Narcolepsy was operant in this case and the condition was adjudicated independently of that instruction by this Board.  In the matter of the narcolepsy and cataplexy condition, the Board unanimously recommends a disability rating of 20%, coded 8108 IAW VASRD §4.71a.  In the matter of the contended overweight 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, effective as of the date of his prior medical separation:

UNFITTING CONDITION	VASRD CODE	RATING	
Narcolepsy	8108	20%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140791, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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

XXXXXXXXXXXX
XXXXXXXXXXXX
XXXXXXXXXXXX

Dear XXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2014-03333.

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 modification of your assigned disability rating without re-characterization of your 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 direct that your records be corrected as set forth in the attached copy of a Memorandum for the Chief of Staff, United States Air Force.  The office responsible for making the correction will inform you when your records have been changed.

Sincerely,

XXXXXXXXXXXX
Director
Air Force Review Boards Agency

Attachment:
Record of Proceedings