RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03708
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20020220

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an AGR National Guard E6, Personnel NCO, medically separated for “arteriosclerotic coronary heart disease,” with a disability rating of 10%.

CI CONTENTION:  “For 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 - 20011105	VARD - 20020219	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Coronary Disease 	7005	10%	Coronary Disease 	7005	10%	20020131	
Retropatellar Pain Syndrome	Not Unfitting	RPS, Right Knee	5299-5014	10%	20020131	
		RPS, Left Knee	5299-5014	10%	20020131	
Thoracic Outlet Syndrome, Right 	Not Unfitting	Right Thoracic Outlet Syndrome	8510	0%	20020131	
Major Depressive Disorder	Not Unfitting	Major Depression	9434	10%	20020131	
Status Post Fusion of C6-C7	Not Unfitting	Status Post Fusion of C6-C7	5290	10%	20020131	
Neck Pain w/ Degenerative Joint	Not Unfitting					
Reflux Esophagitis	Not Unfitting	Hiatal Hernia, Reflux Esophagitis 	7346	10%	20020131	
Adenoid Hypertrophy	Not Unfitting	Adenoid Hypertrophy	6599-6516	0%	20020131	
Hyperlipidemia	Not Unfitting	No VA Placement	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY:  

Arteriosclerotic Coronary Heart Disease.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM) the CI had a documented history of myocardial infarction in 1996 with stent placement (single lesion left anterior descending [LAD]), and stable coronary artery disease until a recurrence of chest pain in January 2001 (13 months before separation).  The CI was re-stented (new LAD lesion) and remained stable through separation.  There was STR evidence by ancillary studies that ventricular size and function were normal (no hypertrophy or dilatation, ejection fraction 55%).  By exercise stress test the CI achieved a workload tolerance of 10.7 METS (metabolic equivalent units applicable to VASRD rating).  There was no STR evidence for any active symptoms (dyspnea, fatigue, angina, dizziness, or syncope) after the 2001 intervention.  The CI was referred for an MEB, which in turn forwarded “atherosclerotic coronary artery disease, status post myocardial infarction, and preserved left ventricular function, status post angioplasty and stenting” to the PEB.

The NARSUM examination in July 2001, 7 months before separation, corroborated the above clinical course and findings, did not document any active symptoms, and noted that the CI was prescribed medication for control (atenolol and aspirin).  There were no pertinent findings on physical examination.  

A VA Compensation and Pension (C&P) examination in January 2002, 3 weeks before separation, documented sporadic angina “associated with stressful situations” four times since stenting.  It otherwise corroborated the above evidence.  There were no pertinent findings on physical examination.  

The Board directed attention to its rating recommendation based on the above evidence.  Both the PEB and the VA conferred 10% ratings under code 7005 (atherosclerotic coronary artery disease).  Code 7005 is specific to the condition and members agreed that no alternate code to achiever a higher rating was justified.  The 10% criteria of 7005 are “workload of greater than 7 METs but not greater than 10 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; continuous medication or a pacemaker required.”  The 20% criteria are “workload of greater than 5 METs but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray.”  There was no evidence in support of any of the 20% criteria.  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 the atherosclerotic coronary artery disease.

Contended PEB Conditions.  The Board’s main charge was to assess the fairness of the PEB’s determination that the remaining conditions submitted by the MEB were not unfitting: retropatellar pain syndrome [RPPS], thoracic outlet syndrome [TOS] of the right shoulder, major depressive disorder [MDD], status post fusion of C6-C7, doing well, reflux esophagitis [GERD], adenoid hypertrophy, and hyperlipidemia and neck pain with degenerative joint.

The RPPS, TOS, and MDD conditions were forwarded as failing retention standards on the MEB DD Form 3947 submission; and, the remaining conditions were considered medically acceptable.  The permanent P3/U3/S3 profile, in addition to the heart condition, listed the cervical, MDD, and TOS conditions.  The commander’s performance statement was primarily focused on the heart disease, although a past history of cervical disc disease was mentioned.  None of the other conditions were referenced and none of the documented physical limitations specifically implicated any of the contended conditions. 
 
The CI had a history of bilateral knee pain, subsequently diagnosed as RPPS, dating to 1995.  An orthopedic addendum to the NARSUM documented pain “with descending stairs and prolonged standing,” but there was no gait disturbance, instability, impingement (locking) or significant range of motion (ROM) limitation.  The TOS was diagnosed in 1996 and was surgically addressed (bilateral 1st rib and scalene muscle resections) at that time.  The orthopedic addendum documented that it “continued to bother him ... with overhead work or lifting.”  Bilateral shoulder ROM was normal without evidence of instability or impingement.  The CI underwent surgery for cervical disc disease (C6/7 discectomy) in 1996.  The orthopedic addendum stated, “He says he has had no problems with the neck since then with no pain and no radiation of any pain to the upper extremities.”  Cervical ROM was normal, as were neurological findings (5/5 strength) for both upper extremities.  The MEB orthopedist opined that, although these conditions did not meet retention standards, the “permanent profile for no running and no sit-ups for the past two years [issued for the cardiac condition] ... is an adequate profile for his condition.”  The STR did not indicate that there was any clinical escalation of any of these chronic conditions during the MEB period; and, the CI passed his last Army Physical Fitness Test (APFT) with alternate events in April 2001 (during MEB proceedings).  The VA C&P examiner corroborated the history and findings in the orthopedic addendum.  The GERD, adenoid hypertrophy, and hyperlipidemia were incidental conditions recorded in the NARSUM.  All were chronic and stable, and none were clinically active at separation.

The CI, with no history of preceding mental health (MH) issues, was diagnosed with depression in 1997 in the aftermath of his cardiac diagnosis.  He responded well to treatment with an anti-depressant (Prozac) and subsequently discontinued treatment.  There were no interim MH developments until his symptoms resurfaced after the 2001 recurrence of coronary artery disease.  A psychiatric addendum to the NARSUM stated, “In spite of how well he responded to Prozac in the past, he did not have sufficient hopefulness, energy, or drive to re-initiate treatment.”  At the time of the addendum, the psychiatrist documented “remains depressed ... sleep is poor ... [and] ... concentration somewhat impaired.”  The mental status examination (MSE) was normal except for depressed mood with congruent affect.  The MEB psychiatrist diagnosed MDD “recurrent, moderate”, assigned a Global Assessment of Functioning (GAF) score of 57 (moderate impairment), and restarted Prozac.  The commander’s statement and final NCO evaluation indicated good performance within the constraints of the physical limitations.  A VA C&P evaluation for mental disorders on the same day as the above general C&P, 3 weeks before separation, documented a favorable response to Prozac, stating that the CI “looks at the future with a whole new outlook” and described healthy social functioning.  The MSE was normal except for an “anxious” mood, and the GAF assignment was 70 (mild to slight impairment).  The VA rating based on the C&P evidence was 10%.  

The Board directed attention to its recommendations based on the above adjudication standards and evidence.  Although some of the orthopedic conditions were profiled and judged to fail retention standards, the orthopedic addendum indicated that they were satisfactorily managed within the constraints of the profile; an opinion corroborated by the CI’s APFT record.  The only one mentioned by the commander was the cervical condition, which the MEB orthopedist indicated was not clinically active at the time of separation.  All of these conditions (and the others) were subject to DoDI 1332.38 (E3.P3.3.3 - Adequate Performance Until Referral); which stipulates, “If the evidence establishes that the Service member adequately performed his or her duties until the time the Service member was referred for physical evaluation, the member may be considered fit for duty even though medical evidence indicates questionable physical ability to continue to perform duty.”  Although the MDD was moderately acute at the time of the MEB psychiatric evaluation, this was in an untreated state.  The C&P evidence established that the MH condition was well controlled with treatment, as it had been in the past without necessitating separation.  Members thus agreed that there was a lack of performance based evidence indicating that any of the above conditions interfered with duty requirements to an extent that would have resulted in MEB referral and termination of service.  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 fitness determinations for any of the above conditions; thus, none were eligible for Service rating.  

BOARD FINDINGS:  In the matter of the atherosclerotic coronary artery disease and IAW VASRD §4.104, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended knee, thoracic outlet syndrome, major depressive disorder, cervical disc disease, reflux esophagitis, adenoid hypertrophy, and hyperlipidemia 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, 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 20140706, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB						

MEMORANDUM FOR Commander

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
XXXXXXXXXXXXXXXXXX, AR20160017207 (PD201403708)

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