RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03744
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20050929

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Bridge Crew Member, medically separated for “chronic bilateral breast pain” with a disability rating of 10%.

CI CONTENTION:  Contends bilateral breast with associated scars, asthma, foot, migraine headaches and depression 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 – 20050726	VARD - 20070512	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Breast Pain...	5099-5003	10%	Scar…Left Breast Reduction	7626-7804	10%	20070320	
			Scar…Right Breast Reduction	7626-7804	10%		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Bilateral Breast Condition.  The PEB combined the right and left breast conditions as a single unfitting condition analogously coded 5003 (arthritis, degenerative) and rated 10% with application of the USAPDA pain policy AR 635-40 B24.f.  The PEB’s 10% rating was supported by the USAPDA pain policy, but was not consistent with the VASRD for non-musculoskeletal conditions.  The PEB’s bilateral rating of 10% analogously to code 5003 (degenerative arthritis) does not comport with the VASRD §4.71a stipulation for a 10% rating under 5003 for “2 or more major joints”, the latter without regard to ROM limitation or other factors.  The approach by the PEB not uncommonly reflected its judgment that the constellation of conditions was unfitting, and there was no need for separate fitness adjudications or implied adjudication that each condition was separately unfitting.  The Board’s initial charge in this case was therefore directed at determining if the PEB’s approach of combining conditions under a single rating was justified in lieu of separate ratings.  When considering a separate rating for each condition, the Board considers each bundled condition to be reasonably justified as separately unfitting.  When the Board recommends separate fitness recommendations in this circumstance, its recommendations may not produce a lower combined rating than that of the PEB.  The evidence for the right and left breast conditions are presented together, with attendant recommendations regarding separate unfitness and rating in the rating discussion.

According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the bilateral breast pain symptoms began approximately 3 years prior to referral for MEB.  At a 5 February 2004 general surgery encounter the CI complained of macromastia (abnormally large breasts) with associated back pain, poor posture, and difficulty performing physical training.  The surgeon referred the CI for reduction mammoplasty (breast reconstructive surgery).  In the 14 June 2005 MEB NARSUM, 4 months before separation, the CI complained of a history of bilateral breast enlargement (size increase from 36C to 44DD probably due to hormone imbalance) with associated pain and nipple discharge.  She underwent bilateral breast reduction on 3 June 2004.  The post-operative course was complicated by bilateral slow wound healing (surgical incisions closed 5 months after surgery) and breast sinus tract drainage.  The CI experienced a right breast sinus tract infection that was treated with antibiotics (March 2005).  She underwent a second surgery on 28 April 2005 for scar revision and right nipple reconstruction.  The CI complained the post-operative pain was worse than pre-operative symptoms.  Pain was characterized as 6/10, constant, sharp, and aching.  It was exacerbated to 10/10 pain by breast contact (clothing), direct pressure over breast (flak vest and LBE), and activity (lifting, running, and jumping) and incompletely relieved by medication.  There was episodic swelling over the bilateral surgical scars and right nipple with a large area of anesthesia (loss of sensation) over the right nipple.  The general physical examination was normal except for breast findings.  The focused breast examination revealed large and pendulous breasts, healed surgical scars (inferior with midline extension to periareolar areas), and an absent right nipple.  There was bilateral breast and scar tenderness, right periareolar tenderness, and an area of right periareolar anesthesia.  The diagnoses listed bilateral breast pain (particularly in the areas of the surgical scars), status post bilateral breast reduction complicated by prolonged surgical scar healing, prolonged sinus tract drainage, and right breast infection.

The 20 March 2007 VA Compensation and Pension (C&P) examination, 18 months after separation, recounted the history and interventions.  The CI complained of progressively worsening painful breasts and areas of numbness on the nipples.  The focused breast examination revealed residuals of breast surgery (wide local excision including lumpectomy partial mastectomy), tenderness, diffuse nodularity, asymmetry, and retraction of the nipples.  The right breast showed areas of thickening.  The diagnoses listed residual bilateral breast scars and nipple deformity secondary to breast reduction surgery.

The Board directed attention to its rating recommendation based on the above evidence.  As previously elaborated, the Board must first consider whether each breast condition remains separately unfitting, having been de-coupled from a combined PEB adjudication.  The PEB rated the bilateral breast condition 10%, analogously coded 5003 (degenerative arthritis) citing application of the US Army Physical Disability Agency pain policy.  The VA rated each breast condition 10%, analogously coded 7626-7804 (breast, surgery of-scar[s], unstable or painful) based on the VA C&P examination 18 months after separation, citing painful superficial scars.

The Board agreed the CI underwent bilateral reduction mammoplasty for the expressed purpose to reduce breast size and form.  There was no disability associated with significant alteration of size or form for consideration under 7626.  The post-surgical scars were consistent with the 10% rating (1 or 2 scars that are unstable or painful) under 7804.  The higher 20% rating would require three or four scars that are unstable or painful.  The Board carefully considered the option of rating both breasts together, noting that the VA rated each breast separately.  The Board concluded that the evidence did provide sufficient grounds for recommending separate breast disability ratings in this case.  A rating of 10% for the right and 10% for the left, coded 7804, is a good analogy to both the pathology and disability.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the right breast condition and 10% for the left breast condition.

Contended PEB Conditions:  Asthma, Foot, Migraine Headaches and Depression.  The Board’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  The contended conditions were not profiled or implicated in the commander’s statement and were not judged to fail retention standards.  All were reviewed and considered by the Board.  There was no performance based evidence from the record that any of these conditions significantly interfered with satisfactory duty performance.  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 determination for the any of the contended conditions and so no additional disability ratings are recommended.

BOARD FINDINGS:  In the matter of the chronic bilateral breast pain condition , the Board unanimously recommends a disability rating of 10% for both the right and left breast conditions, coded 7804 IAW VASRD §4.118.  In the matter of the contended asthma, foot, migraine headaches, and depression 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.  

he 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	
Chronic Right Breast Pain	7804	10%	
Chronic Left Breast Pain	7804	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140811, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20160017214,  XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found that your disability rating should be modified but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability.   I have reviewed the Board's recommendation and record of proceedings (copy enclosed) and I accept its recommendation.  This will not result in any change to your separation document or the amount of severance pay.  A copy of this decision will be filed with your Physical
Evaluation Board records.  I regret that the facts of the case did not provide you with the outcome you may have desired.

This decision is final.  Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction.

A copy of this decision has also been provided to the Department of Veterans Affairs.

Sincerely,

Enclosure