RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX		CASE:  PD-2014-03767
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060221

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Petroleum Supply Specialist, medically separated for asthma rated at 20%.  Diabetes mellitus type II was determined as existed prior to service (EPTS) and was not rated.

CI CONTENTION:  “The issues were more severe than stated at time of separation.”  His 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 - Dated 20050921	VARD - 20060707	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Asthma…	6602	20%	Asthma	6602	60%	20060707	
Diabetes Mellitus Type II	7913	---% (EPTS)	Diabetes Mellitus	7913	20%	20060707	
COMBINED RATING:  20%	COMBINED RATING OF ALL CONDITIONS:  90%	

ANALYSIS SUMMARY:  

Asthma Condition.  The military enlistment physical in January 2002 noted as history of asthma as a child and although the CI did not report current respiratory symptoms or use of asthma medication and the DD Form 2808, Report of Medical Examination, noted a normal lung examination, the CI was referred to pulmonary for a waiver for asthma.  A pulmonary function test on 8 February 2002 was normal before bronchodilator (BD) medication and the waiver was approved.  The narrative summary (NARSUM) noted the CI developed shortness of breath (SOB) while running in basic training in June 2002.  He was diagnosed with exercise induced asthma by pulmonary function tests after exercise and treated with a BD inhaler.  While the CI was located overseas the asthma condition worsened and, despite the addition of an anti-inflammatory inhaler (Advair), the asthma attacks continued.  A methacholine challenge test (test to demonstrate reactive airways disease) was positive in March 2004.  It was recommended that the CI be returned to the continental United States and a Medical Evaluation Board (MEB) was initiated.  

The MEB pulmonary consult on 7 December 2004, 14 months before separation, noted the CI had a history of SOB with sports that began during high school, although he successfully played sports.  The CI’s current asthma symptoms were triggered by exercise, fumes, multiple allergies, and weather changes.  The CI reported compliance with Advair inhaler twice daily and use of his rescue BD inhaler two to three times every day, as well as before exercise, and allergy medications daily and as needed.  The physical examination was normal, but pulmonary function test results showed a forced expiratory volume in one second (FEV1) of 47% predicted normal (PRED) and an FEV1/forced vital capacity (FVC) ratio of 63% PRED with a significant response to BD medication and the FEV1 PRED after BD was 59%.  At the MEB examination on 29 December 2004, the CI reported asthma and the MEB physical examination cited the MEB pulmonary consult.  

At the MEB examination the CI reported asthma with SOB and wheezing for which he was given multiple inhalers and oral medication and that he had an asthma attack since his most recent evaluation.  The MEB physical examination noted a normal lung examination, without wheezes or other abnormal findings.  

The CI submitted a rebuttal to the MEB findings and noted that his medications had been changed since the MEB pulmonary consult and his symptoms were still not well controlled.  The USAPDA requested clarification regarding whether the asthma condition was EPTS and if so, whether it was service aggravated or not.  The pulmonary specialist responded that the CI did have respiratory symptoms prior to entry into the military, but did not have a diagnosis of asthma, and that in the specialist’s medical opinion chemical exposures as a fuel handler aggravated and exacerbated the CI’s asthma.  

Notes in the service treatment record (STR) after the MEB examination indicated the CI was placed on short courses of oral steroids for asthma exacerbations in August and September 2005.  In November 2005, the CI was started on daily oral steroids and as the dose was gradually tapered below 10mg per day, he reported increased difficulty breathing and the last pulmonary visit in the STR on 23 January 2006, 1 month before separation, indicated the CI remained on a 10mg daily dose.  Prescription of Xolair was also noted, an injectable medication (monoclonal antibody) which selectively inhibits IgE immunoglobulin to reduce allergic contributions to asthma.  At this visit the PFT test after BD-medication showed an FEV1 of 59% PRED and FEV1/FVC of 76% PRED. 

At the VA Compensation and Pension (C&P) General examination on 7 July 2006, 4 months after separation, the CI reported being on steroids for his breathing for the past 18 months and he reported his SOB gets worse if the oral steroid is tapered down.  He reported monthly asthma attacks and visits to a physician as often as once per month.  Daily medications noted included 20mg prednisone (oral steroids) and anti-inflammatory and bronchodilator inhalers.  The examination noted scattered wheezing in the lungs.  The chest X-ray was normal.  The PFT before BD medication was FEV1 of 46%, with an FEV1/FVC ratio of 78% and results were worse post-BD medication.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB adjudicated the asthma condition as existed prior to service (EPTS), but with permanent service aggravation, rated 30% and applied a 10% EPTS deduction for a combined rating of 20%, coded 6602 (asthma).  The VA initially rated the asthma condition 60%, also coded 6602, based on FEV1 of 47% PRED at the C&P examination.  The VA Rating Decision dated 11 October 2007 increased the asthma rating to 100% citing daily use of high dose steroids, with an effective date of 22 February 2006, the day after the date of separation.  The Board agreed that the evidence in record supports that the disability due to asthma condition at the time of separation met the 60% rating IAW VASRD §4.97 (respiratory conditions) for at least three courses of intermittent systemic (oral or parenteral) corticosteroids per year as the CI was on continuous oral steroids proximate to separation.  The Board reviewed to see if the evidence supports the next higher evaluation of 100%, but there was no evidence of FEV1 or FEV1/FVC less than 40% predicted or episodes of respiratory failure.  The Board noted that the 100% criteria include daily use of “high dose” oral steroids, but the Board considered 10 to 20mg prednisone daily was consistent with a “moderate dose” of steroids and not “high dose,” usually attributed to doses of prednisone of 40 mg/day or greater.  The Board also discussed if (for disability rating purposes) the use of Xolair was equivalent to the use of an immunosuppressive medication of the type in use when the VASRD rating criteria were developed, such as methotrexate or cyclosporine, which are not selective in their effects on the immune system, and judged it was not based upon Xolair’s targeted effect on immunoglobulin E.  The Board next considered if a deduction for the disability due to the asthma condition at the time of enlistment was appropriate in this case.  The Board noted at the enlistment physical the CI was not on any medications and the PFT was normal.  Therefore, at the time of enlistment the evidence supports a 0% rating for the asthma condition.  Thus, the Board determined that the evidence supports the asthma condition met the 60% rating at separation and no higher, with a 0% EPTS rating applied, resulting in a 60% rating at separation.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 60% for the asthma condition.  

Contended PEB Conditions.  

Diabetes Mellitus (DM) Type II.  The NARSUM notes that the CI was diagnosed with diabetes DM in March 2004.  He was treated with diet, oral diabetes medications and insulin.  The MEB endocrinology consult 14 January 2005 noted that the CI was on oral medications at the time with good blood sugar control and no evidence of diabetic complications.  The ophthalmologist noted no retinopathy, but indicated the CI was experiencing blurry vision due to fluctuating high blood sugars.  Notes in the STR after the MEB consult indicated that the CI’s blood sugar levels were difficult to control and long acting insulin was added to his treatment.  The CI’s blood sugars were further exacerbated by use of oral steroid medications for the asthma condition and regular insulin on a sliding scale was added to his treatment regimen.

VA outpatient endocrinology evaluations in March, May, and 29 June 2006 noted no objective sensory abnormalities of the extremities or evidence of kidney disease.  VA ophthalmology evaluation noted no diabetic eye complications.  At the VA C&P General examination on 7 July 2006, 4 months after separation, the CI reported visiting the doctor once per week for his diabetes.  The CI had no history of diabetic ketoacidosis or hypoglycemic episodes.  The examination noted decreased sensation over both feet, with normal strength and reflexes.  The VA examiner remarked that the steroid use for the asthma condition contributed to the CI’s diabetes.  Outpatient VA endocrine and diabetes clinic visits within 12 months of separation noted the CI had no DM complications.  

The Board noted that at the time of enlistment the CI was not on any medications for DM.  After the initiation of treatment with oral diabetic medications and insulin, the CI’s blood sugars were reportedly in good control but became very difficult to control once oral steroids were added to his treatment for the asthma condition, with continued daily oral steroid use documented at the post-separation C&P examination.  The Board considered this evidence of service aggravation of the DM II condition during active duty and therefore the Board recommends that the DM II condition was service aggravated and eligible for rating.  

The Board next directed attention to its rating recommendation based on the above evidence.  The VA rated the DM condition 20%, coded 7913 (diabetes mellitus).  The Board agreed that the evidence supports a 20% rating of the DM condition based upon “requiring insulin and restricted diet” and did not meet the next higher evaluation of 40% because there was no evidence of physician prescribed restriction of activities to manage the DM condition.  The evidence in record also did not support a higher rating based on episodes of ketoacidosis or hypoglycemia, or other diabetic complications.  Thus, the Board determined that the evidence supports a 20% rating for the DM condition and no higher.  After due deliberation, considering all of the evidence the Board concluded the DM condition was permanently aggravated by service and recommends a disability rating of 20%, coded 7913.  

BOARD FINDINGS:  In the matter of the asthma condition, the Board unanimously recommends a disability rating of 60% with a 0% EPTS deduction, coded 6602 IAW VASRD §4.97.  In the matter of the contended unfitting, but EPTS, DM condition, the Board unanimously agrees that it was service aggravated and unfitting and unanimously recommends a disability rating of 20%, coded 7913 IAW VASRD §4.119.  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; 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	
Asthma 	6602	60%	
Diabetes Mellitus Type II	7913	20%	
RATING	70%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140603, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR Commander

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXXXXX AR20160009344 (PD201403767)

1.  Under the authority of Title 10, United States Code, section 1554(a), I approve the enclosed recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) pertaining to the individual named in the subject line above to re-characterize the individual’s separation as a permanent disability retirement with the combined disability rating of 70% effective the date of the individual’s original medical separation for disability with severance pay.  

2.  I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum:

	a.  Providing a correction to the individual’s separation document showing that the individual was separated by reason of permanent disability retirement effective the date of the original medical separation for disability with severance pay.

	b.  Providing orders showing that the individual was retired with permanent disability effective the date of the original medical separation for disability with severance pay.

	c.  Adjusting pay and allowances accordingly.  Pay and allowance adjustment will account for recoupment of severance pay, and payment of permanent retired pay at 70% effective the date of the original medical separation for disability with severance pay.

	d.  Affording the individual the opportunity to elect Survivor Benefit Plan (SBP) and medical TRICARE retiree options.

3.  I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

BY ORDER OF THE SECRETARY OF THE ARMY:

			       
						      					
Enclosure
					
CF: 
(  ) DoD PDBR
(  ) DVA