RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03409
BRANCH OF SERVICE: MARINE CORPS	BOARD DATE:  20150916
SEPARATION DATE:  20031215

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-3 (Trainee) medically separated for chronic bronchiectasis.  The bronchiectasis could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS).  He was placed on limited duty (LIMDU) and referred for a Medical Evaluation Board (MEB).  Chronic bronchiectasis idiopathic and asthma with evidence of reversible airflow obstruction were forwarded to the Physical Evaluation Board (PEB) IAW SECNAVINST 1850.4E.  No other condition was submitted by the MEB.  The Informal PEB adjudicated chronic bronchiectasis, idiopathic as unfitting, rated 10% with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The remaining asthma condition was determined to be category II (a condition contributing to the unfit condition).  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 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:

IPEB - Dated 20031017	VA* - (~3 Mos. Pre-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bronchiectasis, Idiopathic	6601	10%	Chronic Bronchiectasis with Asthma	6601	30%	20030909	
Asthma	Category II					
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 2	
RATING:  10%	RATING:  50%	
*Derived from VA Rating Decision (VARD) dated 20040326 (most proximate to date of separation [DOS])

ANALYSIS SUMMARY:

Chronic Bronchiectasis, Idiopathic (Includes Asthma).  The MEB narrative summary (NARSUM) noted the CI initially developed pneumonia in basic training.  The CI was seen in sick call for a productive cough and fever and chest X-rays showed bilateral lung infiltrates consistent with pneumonia.  Notes in the service treatment record indicated the CI was treated with a bronchodilator (BD) inhaler and several courses of different antibiotics with temporary improvement noted, but was eventually admitted to the hospital on 09 October 2002.  The CI improved and was returned to training, but his symptoms again worsened and he was re-admitted to the hospital in November 2002.  Pulmonary evaluations in February 2003 noted a history of recurrent pneumonia and sinus infections and the CI reported a history of wheezing and use of an inhaler with sports in high school, with current symptoms of persistent productive cough and malaise.  Specific testing for genetic causes of the CI’s symptoms (including cystic fibrosis and impaired immune function) was negative.  Pulmonary function tests showed a restrictive pattern, but a positive response to BD medication was noted consistent with an obstructive component.  High resolution computed tomography (CT) of the chest was consistent with chronic bronchiectasis (an abnormal stretching and widening of the airways due to mucus blockage) and CT of the sinuses noted mild chronic changes due to inflammation.  The CI was diagnosed with recurrent pneumonia and bronchiectasis.  A clinic visit in April 2003 noted the CI had recently been hospitalized but was now improved on antibiotics (Levaquin) and a BD inhaler, and oral Prednisone was added for persistent chest congestion.  The CI experienced symptom relapse after the antibiotics were completed and was placed on antibiotics again (Cipro) by the pulmonary specialist on 18 April 2003.  In May 2003 the pulmonary specialist noted frequent exacerbations and prescribed Advair (anti-inflammatory inhaler), a BD inhaler as needed, and courses of rotating antibiotics (10 days per month of one, and 10 days per month of another) and a device (vest) to help mobilize secretions.  A pulmonary follow-up on 17 July 2003 noted there was little improvement with rotating antibiotics.  The CI had persistent productive cough, with occasional blood-tinged sputum, and antibiotics were held pending sputum cultures.  The MEB NARSUM noted diagnoses of bronchiectasis of unknown etiology and asthma.

At the MEB NARSUM exam on 26 June 2003, 6 months before separation, the CI reported current symptoms of productive cough (purulent sputum) and difficulty breathing.  Medications included daily anti-inflammatory inhaler, rotating antibiotics, and as needed use of a BD inhaler.  The MEB physical exam noted sounds consistent with bronchiectasis (rhonchi and crackles) at the base of the left lung.  The exam was otherwise normal.

At the VA Compensation and Pension (C&P) exam on 9 September 2003, 3 months before separation, the CI reported daily productive cough with occasional blood, chest discomfort and difficulty breathing with exertion.  He reported he was not currently taking oral steroids or antibiotics, but was using Advair inhaler twice daily.

The pulmonary function tests (PFTs) in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.

DOS 20031215
Pulmonary Exam	PFT ~10 Mo. Pre-Sep
(20030220) p.81	VA C&P ~3 Mo. Pre-Sep
(20030909) p.49	
FEV1 (% Predicted)	73%	99%	
FEV1/FVC	108	90.34	
Meds	BD as needed	Advair 2x per day	
§4.97 Rating	10% (PEB 10%) 	30% (VA 30%)	
The Board directed attention to its rating recommendation based on the above evidence.  The PEB and VA both coded the respiratory condition 6601 (Bronchiectasis).  The PEB rated it 10% and the VA, 30%.  The PEB also adjudicated asthma as a related Category II condition.  The Board reviewed the 6601 rating criteria, which specify a 10% rating for “intermittent productive cough with acute infection requiring a course of antibiotics at least twice a year” and 30% for “daily productive cough with sputum that is at times purulent or blood-tinged and that requires prolonged (lasting four to six weeks) antibiotic usage more than twice a year”.  The Board reviewed the record for evidence of prolonged antibiotics use (lasting four to six weeks) more than twice a year.  The evidence indicates the CI was on near continuous antibiotics from September to mid October 2002 (6 weeks); mid-November to mid December 2002 (4 weeks); April 2003 (4 weeks) and on the rotating antibiotics 20 days per month from May to mid-July 2003 (11 weeks).  Additionally, between October 2002 and April 2003, the CI was hospitalized for treatment three times.  The Board noted that there were the gaps within the antibiotics treatment periods noted above, but Members agreed that this reflected changing medical practices regarding antibiotics prescription, but was equivalent to more than two “prolonged courses” of antibiotics.  The Board agreed that the evidence supports that the disability due to the bronchiectasis condition was most closely approximated by the 30% rating and reviewed to see if the next higher rating of 60% was supported.  However, although the CI did have a “near constant cough” and occasional blood tinged phlegm, there was no evidence of loss of appetite, weight loss, and hemoptysis, (coughing of frank blood) and there was no evidence of incapacitating episodes (defined as bed rest and treatment by a physician) of 4 weeks or more.  The Board considered alternatively rating the condition of bronchiectasis as 6600 (Bronchitis) as permitted by the VASRD.  However, the 6600 criteria for 10%, 30%, and 60% ratings are based upon PFT results and the PFT results in the STR and at the C&P exam both support a 10% rating.  Therefore, a higher rating than 30% is not achieved.

The Board next considered if the rating should be elevated IAW VASRD §4.96 which states that when rating with 6600 through 6817, which includes 6600 (Bronchitis) 6601 (Bronchiectasis) and 6602 (Asthma), that the ratings will not be combined, but “a single rating will be assigned under the diagnostic code which reflects the predominant disability with elevation to the next higher evaluation where the severity of the overall disability warrants such elevation.”  The Board agreed the predominate disability in evidence was bronchiectasis, but the CI was treated with BD inhalers and asthma was noted in the MEB NARSUM.  However, the Board noted bronchiectasis may include an obstructive component by itself and may be rated alternatively based upon PFT results coded as 6600, as noted above.  Moreover, the obstructive component of the respiratory condition was mild and well controlled with treatment as evidenced by PFT results in the STR and at the C&P exam.  For both reasons the Board agreed that elevation of the single rating was not warranted in this case IAW §4.14 (Avoidance of pyramiding).  However, Board discussion noted that the pulmonary condition could reasonably be alternatively rated according to rating criteria for asthma (6602).  The evidence supports the 30% rating based on use of an anti-inflammatory inhaler, but there was no evidence of moderate to severe obstructive disease on PFTs, monthly visits for care of asthma exacerbations, or three or more courses of steroids per year to support the next higher rating of 60%.  Therefore, the Board determined the evidence supports a 30% IAW VASRD §4.97, and no higher and chose to code as 6601, which was deemed the most medically appropriate code in this case.  The Board noted that the PEB adjudicated the asthma condition as a Category 2 condition - related to the unfitting bronchiectasis and not separately unfitting.  Members agreed that this is consistent with the Board’s rating rationale above that the asthma condition was an integral part of the bronchiectasis condition and could not be recommended for additional disability rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (Reasonable doubt) and §4.96, the Board recommends a disability rating of 30% for the bronchiectasis 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 bronchiectasis condition, the Board unanimously recommends a disability rating of 30%, coded 6601 IAW VASRD §4.97.  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:

CONDITION	VASRD CODE	RATING	
Chronic Idiopathic Bronchiectasis	6601	30%	
RATING	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140724, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR COMMANDER, NAVY PERSONNEL COMMAND
	         DEPUTY COMMANDANT, MANPOWER & RESERVE AFFAIRS	
	                          
Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS          

Ref:  (a) DoDI 6040.44
	(b) PDBR ltr dtd 2 Dec 15 ICO XXXXXXXXXXXXXXXXXXXX
      (c) PDBR ltr dtd 23 Nov 15 ICO XXXXXXXXXXXXXXXXXXXX
	(d) PDBR ltr dtd 19 Nov 15 ICO XXXXXXXXXXXXXXXXXXXX.
	(e) PDBR ltr dtd 19 Nov 15 ICO XXXXXXXXXXXXXXXXXXXX
	(f) PDBR ltr dtd 30 Nov 15 ICO XXXXXXXXXXXXXXXXXXXX
	(g) PDBR ltr dtd 20 Nov 15 ICO XXXXXXXXXXXXXXXXXXXX
	(h) PDBR ltr dtd 20 Nov 15 ICO XXXXXXXXXXXXXXXXXXXX
	(i) PDBR ltr dtd 18 Nov 15 ICO XXXXXXXXXXXXXXXXXXXX

1.  Pursuant to reference (a), the recommendations of the Physical Disability Board of Review set forth in references (b) through (i) are approved.

2.  The official records of the following individuals are to be corrected to reflect the stated disposition:

     a. XXXXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability retired pay with a 40 percent disability rating (increased from 10 percent) with placement on the Permanent Disability Retired List effective date of discharge.

     b. XXXXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability retired pay with a 30 percent disability rating (increased from 10 percent) with placement on the Permanent Disability Retired List effective date of discharge.

     c. XXXXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability retired pay with a 40 percent disability rating (increased from 20 percent) with placement on the Permanent Disability Retired List effective date of discharge.

     d. XXXXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability retired pay with a 40 percent disability rating (increased from 20 percent) with placement on the Permanent Disability Retired List effective date of discharge.

     e. XXXXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.

     f. XXXXXXXXXXXXXXXXXXXX, former USN: Placement on the Temporary Disability Retired List for six months beginning the date of separation with a 50 percent disability followed by placement on the Permanent Disability 

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS

Retired List at the conclusion of six months with a final rating of 30 percent and entitlement to disability retired pay.

     g. XXXXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability retired pay with a 30 percent disability rating (increased from 10 percent) with placement on the Permanent Disability Retired List effective date of discharge.

     h. XXXXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability retired pay with a 40 percent disability rating (increased from 10 percent) with placement on the Permanent Disability Retired List effective date of discharge.
     
3.  Please ensure all necessary actions are taken to implement these decisions, including the recoupment of disability severance pay, if warranted, and notification to the subject members once those actions are complete.

	XXXXXXXXXXXXXXXXXXXX
	Assistant General Counsel
	(Manpower & Reserve Affairs)