RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03396
BRANCH OF SERVICE:  Army	
DATE OF PLACED ON TDRL:  20071029	
DATE OF REMOVED FROM TDRL:  20091112 

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E6, Human Resources Specialist, medically separated from the Temporary Disability Retired List (TDRL)for “Crohn’s 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 – 20070718/20091102	VARD - 20080522	
Condition	Code	Rating	Condition	Code	Rating
Proximate	
		TDRL
Placement	TDRL Removal			TDRL
Placement	TDRL Removal	
Crohn’s Disease	7399-7323	30%	10%	Crohn’s Colitis ...	7399-7323	30%	30%	
COMBIEND RATING:  30% → 10%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Crohn’s Disease.  The service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM) documented an initial onset on abdominal pain in late 2006 which resulted in hospital admission with a concern of appendicitis.  The evaluation yielded a suspected diagnosis of Crohn’s disease, which was eventually confirmed over the remaining clinical course.  The CI was re-admitted to the hospital in March 2007 (7 months before TDRL placement), with prompt response to treatment.  There were no other hospital admissions prior to TDRL placement.  A brief flare resulting in an emergency room visit and 24-hour quarters transpired in May 2007.  Outpatient STR entries reflected a regular complaint of abdominal pain and intermittent diarrhea (10 times per day in one note), with no persistent vomiting or other acute features.  There was treatment with a dietary regimen and routine gastrointestinal (GI) mediations (Colazal, Entocort, Imodium), and pharmacy records identified three courses of prednisone (oral steroid).  A nutritional note documented a 19-pound gain from the CI’s base weight (recorded as 186 at the time of diagnosis).  Laboratory results over the clinical course revealed a consistent mild (values just below normal) iron deficiency anemia, but no organ dysfunction (liver and kidney indices) or indication of malnutrition.  Surgery was not indicated; conservative treatment did not result in sufficient improvement to allow unrestricted duty; and, the CI was referred for an MEB which in turn forwarded “Crohn’s disease” to the Physical Evaluation Board (PEB).

The NARSUM (5 months before TDRL placement) documented “regular diarrhea, occasional blood in stool, regular nausea and crampy abdominal pain.”  The weight gain was attributed to steroid use, and the medication list noted “not currently taking but requires frequent bursts of prednisone.”  The physical examination recorded “mild” diffuse tenderness with no distention or other abnormalities.

A VA Compensation and Pension (C&P) examination on 12 December 2007 (6 weeks after TDRL placement, 23 months before permanent separation) documented “significant symptoms ... daily diarrhea of at least three stools a day...has lost [emphasis added] approximately 40 pounds ... chronic abdominal cramping....”  It was noted that the VA examiner’s calculated weight loss was premised on a history that the weight went from 225 to 186 pounds, in marked contrast with the STR nutritional note based on actual weights.  The physical examination recorded a “soft and nontender” abdomen.  

A review of STR entries during the 2-year period of TDRL revealed sporadic visits, continued dispensing of the above GI medications with no dispensing of prednisone, and stable laboratory values consistent with those described for the initial course.  There were no relevant outpatient entries or C&P examinations from the available VA file, or from civilian providers, during the period of TDRL. 

An examination for TDRL reassessment was conducted on 6 October 2009 (5 weeks before permanent separation), at which time the CI reported “that her condition is about the same.”  She was working full time and “able to perform her activities of daily living as well as household chores.”  The examiner documented “approximately four to six stools per day without [blood]... [crampy abdominal] pain once or twice per week ... weight has increased in the last three months, approximately 11 to 12 pounds...on no special diet.”  The examiner also documented that the CI had been hospitalized “for two days in 2008” and “has had two exacerbations of her condition requiring steroid therapy in the last year.”  The physical examination was normal without abdominal tenderness or other abnormalities.  The TDRL examiner’s contemporary STR entry contained an automated medication list with multiple active prescriptions, but no GI medications or steroids.  Contemporary laboratory reports were normal except for a borderline anemia.  The TDRL examination also recorded an opinion from a recent gastroenterology consultant that the “soldier’s condition appears to be well-controlled,” and implied that it was the superimposition of “multiple other issues” that prohibited continued active duty.  

The next C&P examination from July 2011 (20 months after permanent separation) and documented relatively mild and “stable” Crohn’s disease “with irritable bowel syndrome” that was not being treated; although, the VA’s initial 30% rating has remained unchanged. 

The Board directed attention to its rating recommendations based on the above evidence.  Both the PEB and the VA rated under the standard analogous code for Crohn’s disease, 7399-7323 (ulcerative colitis), and the Board agreed that no alternate code was justified.  The 10% criteria for 7323 are “moderate; with infrequent exacerbations,” and those for 30% are “moderately severe; with frequent exacerbations.”  Higher ratings require numerous attacks and malnutrition with other complications, none of which were in evidence.  The primary rationalization from the PEB’s DD Form 199 decision for the 30% rating required to place the CI on TDRL was, “This condition has not stabilized to the point that a permanent degree of severity can be determined.”  The VA’s 30% rating decision cited the C&P evidence (including weight loss), opining that “your limitations most closely equate [to] moderately severe impairment.”  The PEB’s 10% rating for permanent separation summarized the findings from the TDRL examination, including the frequency of exacerbations (two in past year) and the above specialty opinion; opining “moderate [severity] with infrequent exacerbations.”

With regard to the TDRL rating, all members agreed no rating higher than the PEB’s (and VA’s) 30% was supported.  The main focus of deliberations was a 10% (no change) versus 30% recommendation for rating at permanent separation.  The most probative, and almost exclusive, source of evidence for this recommendation was the above TDRL examination, corroborated somewhat by the STR.  Although the CI perceived no change in her symptoms, the objective evidence from the TDRL examination was consistent with a significant improvement from the severity evidenced at the time of TDRL placement.  At TDRL entry, the exacerbations were spaced about 3 months apart and treatment included two hospitalizations, a controlled diet, maintenance medications, and cyclical steroids.  At permanent separation there had been only one hospital admission in 2 years; exacerbations were at 6-month intervals (as best as can be extrapolated); there were no dietary restrictions and little or no medication requirements (as best as can be ascertained from available records); and, there was no significant occupational or other functional impairment.  The specialist’s opinion that the condition was well controlled was corroborated by the post-separation course reflected in the later C&P evidence.  The members concluded the evidence at the time of permanent separation was better aligned with the 10% criteria than with those for 30%.  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 of Crohn’s disease for the period of TDRL at permanent separation.

BOARD FINDINGS:  In the matter of the Crohn’s disease and IAW VASRD §4.114, the Board unanimously recommends no change in the PEB adjudications for the period of TDRL and at permanent separation.  There were no other conditions within the Board’s scope of review for consideration.  The Board recommends that there be no re-characterization of the CI’s temporary retirement or permanent disability and separation determinations.

The following documentary evidence was considered:
Exhibit A.  DD Form 294, dated 20140704, 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 XXXXXXXXXXXXXXXXXXXXX AR20160014202 (PD201403396)

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