RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03619
BRANCH OF SERVICE:  Navy	SEPARATION DATE:  20050630

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E4, Hospital Corpsman, medically separated for “chronic urticaria” rated at 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 - 20050421	VARD - 20050930	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Urticaria	7825	10%	Idiopathic Angioedema and Contact Urticaria with Dermatographism	7825-7118	10%	STR	
Contact Urticaria	Cat III					
Dermatographism						
Etiopathic Angioedema						
Extrinsic Asthma	EPTS	Asthma	6600	NSC		
Allergic Rhinitis		Allergic Rhinitis	6522	NSC		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:

Urticaria (includes Category III Contact Urticaria).  According to the service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI initially presented to the emergency room with a urticarial (itchy) rash that was considered to be an allergic reaction to a previously prescribed medication in June 2004.  Despite intermittent oral steroids and chronic antihistamine treatment, her condition could not be adequately controlled to meet the physical requirements of her military specialty and she was referred to an MEB.
At the MEB NARSUM in December 2004, 7 months before separation, the CI reported having a history of urticaria but never with symptoms consistent with anaphylactic shock, difficulty breathing, or throat swelling.  Absent actual physical examination (PE), the MEB provider diagnosed the CI with chronic urticarial and dermatographism (local skin eruption when scratched) by the CI’s subjective history.  There was no VA Compensation and Pension (C&P) examination proximate to separation as the CI failed to report to her 25 March 2005 appointment.  A VA dermatology examination performed 14 months after separation, documented the CI’s previous medication allergy.  The CI reported that her skin symptoms were fairly well-controlled on oral antihistamines.  Flare-ups would occur with extreme heat or cold exposure.  Such attacks would occur about 5 times per month and last 1 hour per episode.  Her PE did not reveal any skin eruptions.  The examiner opined that the CI’s urticarial symptoms were fairly controlled with use of medication and would erupt daily without such continued medical therapy.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under code 7825 (urticaria).  The VA also assigned a 10% rating using an analogous 7825-7118 codes (urticaria-angioneurotic edema), citing “available medical evidence establishes that you have had symptomatic dermal attacks that have responded well to medication and treatment.”  Board members agreed that the urticarial condition was properly coded under 7825 and in the absence of either debilitating episodes or the requirement for immunosuppressive therapy for control, the 30% impairment criteria was not supported.  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 urticarial condition.

Contended PEB Conditions.  Dermatographism and etiopathic angioedema (rapid swelling of underlying skin tissue) were adjudicated by the PEB as Category III conditions.  The Board unanimously agreed that both conditions were physical manifestations of the primary unfitting condition of chronic and contact urticaria and therefore, do not warrant consideration as separately unfitting conditions. 

Extrinsic Asthma and Allergic Rhinitis.  According to the STR, the CI was treated for asthma as well as allergic rhinitis in September 2004 through April 2005, 3 months before separation.  Despite inhaled medication treatment, her conditions could not be adequately rehabilitated to meet the physical requirements of her military specialty and she was referred to an MEB.  The MEB forwarded “extrinsic asthma” and “allergic rhinitis” to the PEB for adjudication.  At the MEB NARSUM, in December 2004, 7 months before separation, the CI admitted having asthma and allergic rhinitis as a young child.  The examiner opined that both conditions were linked to the CI’s primary urticarial condition.  The examiner forwarded the conditions to the PEB as existing prior to service (EPTS).

Inconsistent use of inhaled steroids was documented throughout the case file to include use in September 2004 followed by 7 months of no use and then more contradictions in April 2005, 2 months prior to separation, whereby the examiner documented the CI’s current medication as oral antihistamines and listed a diagnosis to include acute asthma exacerbation.  Two days later, records indicated daily use of inhaled steroid (flovent) medication.  There was no VA C&P examination proximate to separation as the CI failed to report to her 25 March 2005 appointment.  However, a 14 month remote VA C&P examination in August 2006, 14 months after separation, documented the CI had childhood asthma that went away until September 2004; after which the CI had persistent asthma and allergic rhinitis symptoms requiring medications.  The post-service VA spirometry measurements remained non-compensable and the CI’s medications included albuterol as needed and flovent twice a day. 

The Board directed attention to its rating recommendation based on the above evidence. Members first deliberated if the PEB’s determination that the two conditions were not permanently service aggravated (PSA) and therefore, considered for impairment ratings.  After extensive deliberation and review of the case file, the Board adjudged that the asthma was PSA by increased symptoms associated with increased military physical activities.  The allergic rhinitis condition was determined not to have been PSA by any portion of military service and no change from EPTS is recommended.  A 10% asthma rating stipulates “intermittent inhalational or oral bronchodilator therapy.”  Members agreed that a 10% rating was justified by the intermittent use of inhaled bronchodilator therapy reflected in multiple exams prior to separation as well as the VA examination 14 months after separation.  The single clinical record (April 2005) noting the use of an inhaled corticosteroid near the time of separation was not the observed and continued treatment seen throughout the entire case file.  This finding coupled with the significant inconsistency of medication documentation provided Board members doubt of the CI’s actual medication regime.  After deliberation, all Board members agreed the evidentiary totality of the STR exceeded a finding of continued use of inhaled corticosteroids at the time of separation.  Therefore, the Board recommends a disability rating of 10% for the extrinsic asthma condition, coded 6602. 

BOARD FINDINGS:  In the matter of the chronic urticaria/contact urticaria condition and IAW VASRD §4.118, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the allergic rhinitis condition and IAW VASRD §4.97, the Board unanimously recommends no change in the PEB adjudication as EPTS.  In the matter of the extrinsic asthma condition, the Board unanimously recommends a disability rating of 10%, coded 6602 IAW VASRD §4.97.  In the matter of the contended dermatographism and etiopathic angioedema 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 recommends that the CI’s prior determination be modified as follows, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Urticaria	7825	10%	
Extrinsic Asthma	6602	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140729, 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 27 Jul 16 ICO XXXXXXXXXXXXXXXXXXXX
	(c) PDBR ltr dtd 27 Jul 16 ICO XXXXXXXXXXXXXXXXXXXX
	(d) PDBR ltr dtd 27 Jul 16 ICO XXXXXXXXXXXXXXXXXXXX
	(e) PDBR ltr dtd 27 Jun 16 ICO XXXXXXXXXXXXXXXXXXXX

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

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

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

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

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