RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03672
BRANCH OF SERVICE:  Marine Corps 	SEPARATION DATE:  20081129

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E3, Field Artillery Cannoneer, medically separated for “presyncopal syndrome” with a disability rating of 10%.  

CI CONTENTION:  The CI believes he should have been awarded a higher rating for his 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 confined to 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 - 20080729	VARD - 20090303	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Presyncopal Syndrome	
8299-8210
	10%	Heart Murmur	7000	0%	20090113	
Anxiety due to a Medical Condition	Cat II	Anxiety Not Otherwise Specified Variously Diagnosed as Pre Syncopal Syndrome/Neurocardiogenic Syndrome, Neurogenic Vasovagal Syndrome	9413	10%	20090113	
						
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Presyncopal Syndrome.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s pre-syncopal syndrome began in July 2007.  The CI reported “black outs” during and after exercise, usually associated with an increased heart rate.  He reported a history of a heart murmur and “black outs” after consumption of alcohol, even in adolescence.  At the NARSUM examination the CI denied actually passing out with the episodes, but noted the episodes were associated with heart palpitations, confusion, and falling down several times.  The episodes occurred intermittently, mainly with exertion.  The CI underwent cardiac evaluation and metabolic testing with no cause being identified.  Tilt table testing on 30 January 2008 was interpreted as “extremely suggestive” of neurocardiogenic syncope.”  High dose salt loading and fluid administration were recommended, as well as a trial of treatment with Florine (mineralocorticoid), which causes salt retention.  The CI reported the medication was not helpful, but a high salt diet helped prevent symptoms, however, he reported continued episodes of light headedness with physical exertion such as lifting something off the ground or standing quickly.  During the tilt table testing, the CI experienced anxiety and shortness of breath (SOB).  He sought treatment for the anxiety a week later and was referred to mental health (MH) and was started on an antidepressant medication (Zoloft).  At a primary care visit on 29 May 2008, the CI reported the anxiety was improved on the antidepressant medication.  Despite treatment, the pre-syncopal syndrome could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for a MEB.  The MEB forwarded “syncope and collapse” and “other anxiety states” for PEB adjudication.  

At the MEB NARSUM examination performed on 7 March 2008, 4 months before separation, physical examination showed normal respiratory rate, regular heart rhythm, low but within normal heart rate, and normal blood pressure.  His mood and affect were reportedly normal.

At the VA C&P Mental disorders examination on 30 December 2008, 1 month after separation, the CI reported no history of MH treatment prior to the “tilt table test” in the Service which caused dizziness, SOB, lightheadedness, and confusion.  Following this episode, the CI was treated by MH with a variety of medications for his anxiety, irritability, and difficulty with his temper.  The CI reported continued episodes of dizziness, that caused him to become anxious, and he feared having another attack like the one precipitated by the testing maneuvers.  The CI reported his symptoms were much improved on antidepressant medication.  The MSE was normal, including insight and judgement, with the exception of the CI’s perception that all of his current difficulties were related to the tilt test.  The Axis I diagnosis was anxiety disorder, not otherwise specified (NOS), mild intensity, with a global assessment of functioning assignment of 70-75, which is in the mild, if any , impairment range on this scale.  The VA examiner noted that the degree to which the CI had “vasovagal” syndrome was outside of his expertise, but raised questions of psychophysiological manifestation of anxiety, hypochondriasis or a conversion disorder.  The examiner stated “the overall clinical impression that makes any sense…is that of an anxiety disorder, not currently otherwise specified, that is of mild intensity…treated with a low average dose of Zoloft.”

At the VA Compensation and Pension (C&P) examination on 13 January 2009, 2 months after separation, the CI reported that when he physically strained he would feel lightheaded and records indicated the history of dizziness with running, but the VA examiner noted that there had been no falls or head injuries as a consequence.  The CI had sought care at the VA in December 2008 to obtain prescription for his antidepressant medication which had run out.  The CI’s history of a heart murmur with a negative cardiac evaluation was also noted.  The CI did not report any dizziness, nausea, vertigo, syncope, chest pain, or headaches at the examination.  Blood pressure and pulse were normal.  Pertinent physical examination was normal, including cardiac examination, except for the previously noted heart murmur.  The VA examiner noted that thyroid testing in the Service was normal and repeat electrocardiogram and thyroid testing at the C&P examination were normal.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under the analogous 8210 code (vagal nerve, incomplete paralysis) for presyncopal syndrome.  The PEB also adjudicated “anxiety due to a medical condition” as a related Category II condition.  The VA also assigned a 10% rating using 9413 code (anxiety disorder, not otherwise specified) based on the VA C&P examinations 1  month after separation, citing that the VA examiner though the diagnosis was anxiety disorder, NOS, which may have had physical manifestations that were medically evaluated as pre-syncope/syncope.  The Category I condition of “pre-syncopal syndrome” and the Category II condition of “anxiety due to a medical condition” were considered to represent the same disability by the Service and the VA, and Board members agreed.  IAW VASRD 4.14 (Avoidance of pyramiding more than one rating may not be provided for the same set of symptoms.  There was evidence of reported persistent pre-syncopal episodes of light headedness with exertion at the MEB NARSUM examination, with the last episode described as a “black out” documented in August 2007 before medical evaluation and treatment.  At the C&P examination, the examiner noted no associated falls and did not mention any interim pre-syncopal or anxiety episodes since military separation of greater severity 

The Board consensus was that the evidence supports a 10% rating analogous to “moderate” incomplete paralysis of the vagus nerve, coded as 8299-8210.  Consideration of an alternative coding option of 8199-8108 (analogous to narcolepsy), an analogous code for syncope, NOS or vasovagal syncope, also rendered a 10% rating and no higher rating is obtained rating analogously to a confirmed diagnosis of epilepsy controlled with medication.  The Board noted that if alternatively rating the condition IAW VASRD §4.130 as a mental disorder, a 10% rating and no higher was supported for anxiety symptoms controlled with continuous antidepressant medication.  There was therefore no higher rating available with any applicable VASRD code. 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 “presyncopal syndrome” condition.  

BOARD FINDINGS:  In the matter of the “presyncopal syndrome,” and IAW VASRD §4.124a, the Board unanimously recommends no change in the PEB adjudication.  There were no other conditions within the Board’s scope of review for consideration.  The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140805, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR DIRECTOR, SECRETARY OF THE NAVY COUNCIL OF REVIEW
               BOARDS 

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS
 
Ref:   (a) DoDI 6040.44
       (b) CORB ltr dtd 9 Aug 16

      In accordance with reference (a), I have reviewed the cases forwarded by reference (b), and, for the reasons provided in their forwarding memorandums, approve the recommendations of the PDBR that the following individual’s records not be corrected to reflect a change in either characterization of separation or in the disability rating previously assigned by the Department of the Navy’s Physical Evaluation Board:

		- XXXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXXX, former USMC

						XXXXXXXXXXXXXXXXXXXX
	     					Assistant General Counsel
						  						(Manpower & Reserve Affairs)