RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03932
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040601

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve E5, Ammunition Specialist, medically separated for “type 1 diabetes mellitus,” with a disability rating of 20%.

CI CONTENTION:  The CI contends for a higher rating for her diabetes.  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 on 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 - 20040323	VARD - 20050114	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Type 1 Diabetes Mellitus	7913	20%	Diabetes, Type 1	7913	20%	20041220	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Diabetes Mellitus Type 1.  The service treatment record (STR) documents that the CI presented to the emergency room in October 2003 complaining of increased thirst, increased fluid consumption, increased urination, and a 30-pound weight loss over 4 months.  Labs revealed hyperglycemia (high blood glucose) and she was hospitalized and treated with insulin (hormone that regulates blood glucose) and oral hydration.  Further testing confirmed autoantibodies to the pancreatic islet beta cells which produce insulin.  The CI was diagnosed with diabetes mellitus Type 1 (DM1) which is characterized by autoimmune (immune response against own tissue) destruction of the pancreatic islet beta cells.  A 14 November 2003 optometry evaluation confirmed no evidence of diabetic retinopathy (retinal blood vessel damage).  Podiatry found no evidence of diabetic peripheral neuropathy (vascular and metabolic nerve damage) and labs revealed no evidence of diabetic nephropathy (kidney structural and functional damage).  Despite treatment, the diabetes mellitus condition 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 “adult onset diabetes mellitus” for PEB adjudication.  The MEB NARSUM examination on 26 January 2004, 4 months prior to separation, noted that the CI had been prescribed pre-meal (Lispro) and basal (Lantus) insulin.  The MEB physician noted an optometry exam revealing “nothing that needed to be treated.” The MEB physician did not indicate the avoidance of strenuous occupational and recreational activities was medically necessary.  The MEB physician agreed with the profile written by endocrinology which allowed for the standard physical fitness test and unlimited walking, running, bicycling and swimming.  Assignment limitations were listed to include: no extended consumption of MRE’s [meal, ready to eat] and availability of three meals a day.  Quarterly visits to internal medicine or endocrinologist within reasonable distance of these services was noted along with no operation of heavy machinery/trucks/aircraft, working at heights, and no scuba diving.  Precautions for no formal physical training when blood glucose was < 80 or > 250 mg/dL was also recommended.  After the initial presentation, the STR contained no evidence of episodes of ketoacidosis (life threatening hyperglycemia, elevated ketoacids, electrolyte disturbances, and dehydration) or hypoglycemic (low blood glucose) reactions requiring hospitalizations.  There was also no evidence of twice monthly visits to a diabetic care provider or diabetic complications.  

The VA Compensation and Pension (C&P) examination on 20 December 2004, 7 months after separation, reported that the CI was taking insulin.  The CI reported episodic left arm tingling and unusual sensations of the entire left side of her body, but stated the tingling did not interfere with daily activities and was only “an annoyance.”  The examiner did not indicate that avoidance of strenuous occupational and recreational activities was medically necessary.  The examiner stated “her only restriction is a voluntary avoidance of prolonged driving as she fears a hypoglycemic reaction might occur.”  At the VA C&P eye examination on 20 December 2004, the CI reported blurred vision when her blood sugars were high and had right eye pain described as throbbing.  These symptoms were noted to be documented side effects of her condition.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 20% rating under the 7913 code (diabetes mellitus), citing requirement for insulin and restricted diet.  The VA also assigned a 20% rating using 7913 code based on the VA C&P examination 7 months after separation, citing the requirement for insulin and restricted diet.  The Board agreed that the requirement for treatment with insulin and restricted diet justified a 20% rating.  There was no evidence of medically prescribed regulation of activities.  Board members thus concluded that the “regulation of activities” stipulation was not met in this case, and therefore the next higher 40% rating was not justified.  Furthermore, there was no requirement for frequent visits to a diabetic care provider, nor were there episodes of ketoacidosis, hypoglycemic reactions, hospitalizations, or diabetic complications that could support higher ratings.  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 diabetes mellitus condition.  

BOARD FINDINGS: In the matter of the diabetes mellitus condition and IAW VASRD §4.119, 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 20140905, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB						

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 
XXXXXXXXXXXXXXXXXX, AR20160017235 (PD201403932)

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