RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03831
BRANCH OF SERVICE:  Army  	
DATE OF TDRL PLACEMENT:  20080411 	
DATE OF TDRL REMOVAL:  20091204

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-6, Motor Transport Operator, medically separated from the Temporary Disability Retired List (TDRL) for “coronary artery disease,” with a disability rating of 10%. 

CI CONTENTION:  The CI was given a higher rating by the VA.  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 – 20080125/20091116	VARD - 20080417	
Condition	Code	Rating	Condition	Code	Rating
Proximate	
		TDRL
Placement	TDRL Removal			TDRL
Placement	TDRL
Removal	
Coronary Artery Disease	7005	30%	10%	CAD	7005	30%	30%	
Diabetes
	Not Unfitting 	DM, Type II 	7913	20%	20%	
		Diabetic Bladder…	7599-7517	20%	20%	
		Neuropathy, RUE	8515	10%	10%	
		Neuropathy , LUE	8515	10%	10%	
		Neuropathy, RLE	8520	10%	10%	
		Neuropathy, LLE	8520	10%	10%	
		Erectile Dysfunction	7599-7522	0%	0%	
Hypertension		Hypertension	7101	10%	10%	
Metatarsalgia		DJD Right Foot	5284	10%	10%	
COMBINED RATING:  30% → 10%	COMBINED RATING OF ALL VA CONDITIONS:  100%	

ANALYSIS SUMMARY:  

Coronary Artery Disease.  The service treatment records (STRs) and the Medical Evaluation Board (MEB) narrative summary (NARSUM) show the CI was first evaluated for chest pain on 18 April 2003 while between periods of activation.  A thallium stress test (ThST) showed no evidence of ischemia (decreased perfusion) with exercise or at rest and the electrocardiogram (ECG) was negative for cardiac hypertrophy.  An ECG on 8 September 2006, was concerning for a possible old anterior myocardial infarction (heart attack).  The CI was activated on 18 October 2006.  A subsequent ECG on 20 October 2006 was normal.  On 1 February 2007, the CI presented with a 1 week history of chest pain which was suggestive of cardiac ischemia.  An ECG the next day was suboptimal secondary to the obesity of the CI.  A repeat nuclear stress test on 13 February 2007 was non-diagnostic due to the underlying abnormal baseline ECG.  He was incidentally noted to have pneumonia 2 days later.  A trans-thoracic echocardiogram (TTE) on 23 February 2007 revealed a low normal ejection fraction (% of blood volume ejected from the left ventricle to the body each contraction) at 55-65%.  The left atrium and right ventricle showed mild hypertrophy (enlargement).  The study was suboptimal and the left ventricle could not be adequately assessed.  The CI continued with medical management, but his pain persisted.  Compliance with recommendations was an issue.  A cardiac catheterization on 31 July 2007 (per the NARSUM) showed coronary artery disease.  He was then entered into the MEB process noting multiple medical conditions.  The NARSUM dated 6 October 2007 noted the CI had multiple risk factors for heart disease including a family history, obesity, elevated lipids, diabetes, and hypertension (high blood pressure).  He reported continued chest pain despite treatment.  The physical examination was unremarkable other than obesity.  He was admitted for chest pain on 31 October 2007, but a myocardial infarction was excluded (rule-out).  A modified ThST on 14 November 2007 was negative for ischemic changes, but did not record the METS.  Another stress test was then accomplished on 13 December 2007 that showed good exercise tolerance at 12.8 METS and no ischemic changes.  The baseline ECG was noted to be normal.  

At the VA Compensation and Pension (C&P) examination performed on 11 January 2008, 3 months before placement on the TDRL, the CI reported continued chest pain.  He was noted to be 69 inches and 222 pounds (an 80 pound increase from initial enlistment).  The cardiac examination was unremarkable.  The CI was placed on the TDRL effective 11 April 2008.  

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB and VA both rated the cardiac condition at 30%, coded 7005 (coronary artery disease), citing the presence of hypertrophy on the echocardiogram supported the 30% rating.  The criteria for a higher rating were not present.  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 coronary artery disease condition at TDRL placement.  

While on the TDRL, the CI was evaluated in cardiology on 11 September 2008 where he reported continued pain.  His blood pressure was normal and the cardiac examination was unremarkable.  An ECG showed stable changes without documentation of hypertrophy.  The records then fall silent until a family practice evaluation on 24 July 2009 where he reported the placement of a cardiac stent the previous June (not in evidence).  He denied ongoing chest pain.  The CI was noted to have good control of his hypertension and diabetes.  The cardiac examination remained normal.  He was given medication refills and follow up in one month was advised.  No cardiac testing was accomplished at that time.  

A TDRL examination was accomplished 21 September 2009, just over 2 months prior to separation.  Progression of his coronary artery disease, hypertension, and diabetes since TDRL placement were documented.  No examination or testing was accomplished.  A memorandum for the PEB was dated 13 November 2009 and noted that the CI had a ThST the previous day with 12.9 METS and no ischemia evident on the tracings or images.  No comment was made on the presence or absence of hypertrophy.  The TDRL removal PEB was dated 16 November 2009 and noted both the above ThST and that the CI was on medication.  It specifically stated that there was “no evidence of chamber enlargement in heart” and that the CI was stable.  The Board found no evidence in the record to confirm or refute this statement.  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 coronary artery disease condition at TDRL removal.  

Contended PEB Conditions:  Diabetes, Hypertriglyceridemia, Obesity, Hypertension, and Metatarsalgia.  The MEB also forwarded diabetes, hypertriglyceridemia, obesity, hypertension, and metatarsalgia as medically acceptable conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that these conditions were not unfitting.  Obesity and hypertriglyceridemia are not ratable conditions.  The hypertension, and metatarsalgia were not profiled or implicated in the commander’s statement.  The diabetes was profiled, but determined to be medically acceptable.  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 at TDRL placement.  The TDRL removal examination also listed mood disorder, insomnia, gastro-esophageal reflux disease, and cervical spine degenerative disease.  The PEB observed that these appeared to be new conditions and not ratable.  These are also outside the scope of the Board for adjudication.  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 any of the contended conditions and so no additional disability ratings are recommended.

BOARD FINDINGS:  In the matter of the coronary artery disease condition and IAW VASRD §4.104, the Board unanimously recommends no change in the PEB adjudication at TDRL placement or removal.  In the matter of the contended diabetes, hypertriglyceridemia, obesity, hypertension, and metatarsalgia conditions, the Board unanimously recommends no change from the PEB determination as not unfitting.  In the matter of the contended mood disorder, insomnia, gastro-esophageal reflux disease, and cervical spine degenerative disease condition, the Board unanimously agrees that these are outside the scope of the Board.  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 20140821, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for AR20160013808 (PD201403831)

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