RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-04023
BRANCH OF SERVICE:  Navy 	SEPARATION DATE:  20080506

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Mass Communications Specialist, medically separated for the overall effect of “endometriosis,” “gastroesophageal reflux disease (GERD),” and “pain disorder associated with psychological and physical factors,” with a disability rating of 0%.  

CI CONTENTION:  Her conditions continue to worsen and negatively impact her daily activities.  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 - 20080221	VARD - 20080714	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Endometriosis	Overall Effect	0%	Endometriosis	7629	10%	20080207	
GERD	Overall Effect		Gastroesophageal Reflux	7399-7346	10%	20080207	
Pain Disorder Associated with Psychological and Physical Factors	Overall Effect		Pain Disorder Associated with Psychological and Physical Factors	9422	10%	20080207	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Endometriosis, GERD, and Pain Disorder Associated with Psychological and Physical Factors.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s chronic pelvic pain condition began in 2005.  The CI underwent laparoscopic surgery in May 2007 and was diagnosed with endometriosis (biopsies negative).  
Despite treatment, the endometriosis condition could not be adequately rehabilitated to meet the physical requirements of the CI’s rating and the CI was referred for an MEB.  The MEB forwarded “endometriosis, site unspecified” for PEB adjudication.  

The MEB NARSUM examination on 30 November 2007, 5 months prior to separation, noted the CI was on her second LIMDU for chronic pelvic pain.  The CI had complaints of continued pelvic pain escalating to the “severe range, 7-8/10 at worst times.”  Pain was noted as controlled by narcotic medications, but the examiner indicated that “despite further consultation with psychiatry and gastroenterology, unable to alleviate patient's chronic pelvic pain to a state that would allow her to be deployable.”  Diagnostic imaging was essentially normal.  Physical examination showed the CI was well appearing and in no acute distress.  Pelvic and abdominal exam showed lower abdominal tenderness to deep palpation and diffuse pelvic tenderness.  There was no guarding, rebound, or masses.  The psychiatric NARSUM addendum the same day, indicated the CI was on chronic psychoactive medications with good results.  Mental status exam was essentially normal.  The diagnosis was “AXIS I:  Pain disorder associated with psychological and physical factors” and the military impairment was assessed as minimal with a global assessment of functioning of 85 (Absent or minimal symptoms) with 80 during the past year (If symptoms are present they are transient and expectable reactions to psychosocial stressors).  The psychiatrist indicated that the condition had improved with treatment and the CI was “considered psychiatrically fit for return to full duty.”  

STRs indicated GERD had worsened in November 2007 due to use of nonsteroidal anti-inflammatory medications (NSAIDS).  Upper GI endoscopy performed in November 2007 showed mild to moderate reflux esophagitis, mild gastritis, and mild duodenitis.  There were over 20 clinic visits or consults related to pelvic pain in the year preceding separation, with most episodes related to pain medication management.  

The non-medical assessment (NMA) dated 4 December 2007 indicated that the CI could “perform all facets of her rating while in CONUS ashore, her medical condition precludes her from serving aboard a ship, overseas or as an Individual Augmentee.”  

At the 7 February 2008 VA Compensation and Pension (C&P) evaluations, performed 3 months before separation, the CI reported chronic severe pelvic pain not responsive to medication (including narcotic) and had symptoms of menopause and bladder urgency and frequency.  She had GERD symptoms of heartburn, epigastric pain, scapular pain and reflux and regurgitation of stomach contents, with symptoms described as occurring constantly despite treatment of Nexium and Zantac twice a day.  An upper GI series and abdominal X-ray with esophagram done in February 2008 showed gastroesophageal reflux without other lesions.  Physical exam showed a normal non-tender abdominal exam and normal rectal exam.  At the 15 February 2008 VA C&P psychiatrist’s exam the CI complained of depression and pain.  She was taking Cymbalta which had been effective in relieving her symptoms.  The mental status exam showed affect and mood were abnormal with disturbance of motivation and mood (annoyed) and was otherwise normal.  The diagnosis was pain disorder associated with psychological and physical factors, and the Global Assessment of Functioning was “60-70, some mild symptoms, difficulty in social and occupational functioning, generally functioning pretty well has meaningful personal relationships.”  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB dated 31 December 2007 found the CI fit to continue duty.  The CI requested reconsideration and the PEB dated 22 February 2008 found the CI unfit for overall effect with the diagnoses of endometriosis, GERD, and pain disorder associated with psychological and physical factors.  There was no VA disability coding or rating of any individual condition, and the combined disability was 0%.  
The Board approach to conditions combined under the provision for overall effect (DoDI 1332.38 E3.P3.4.4.) is that each condition has been determined by the PEB to be separately not-unfit, but that the overall effect considered together creates a condition of unfitness.  Each condition remains separately not-unfit unless a preponderance of evidence shows the condition to be unfitting.  

The VA individually rated each condition at 10% based on the VA C&P examination 3 months before separation.  The VA rating for endometriosis was coded 7629 (Endometriosis), citing for pelvic pain requiring continuous treatment.  The VA rating for GERD was coded 7399-7346 (Hernia hiatal), citing symptoms of heartburn, epigastric pain, scapular pain and reflux and regurgitation of stomach contents.  The VA rating for pain disorder associated with psychological and physical factors was coded 9422 (Pain disorder), citing symptoms being controlled with continuous medication.  

There was insufficient evidence to indicate that the GERD condition was separately unfitting.  There were a large number of clinic contacts for pain management due to pelvic pain.  There was a preponderance of evidence supporting a finding of unfitness for the endometriosis condition, with insufficient evidence of an unfitting mental health condition.  Regarding rating of the endometriosis condition, the evidence supported a 10% rating coded 7699-7629 for pelvic pain requiring continuous treatment, but did not more nearly approximate the 30% criteria for “pelvic pain or heavy or irregular bleeding not controlled by treatment.”  After due deliberation, considering all of the evidence the Board recommends a finding of unfit for the endometriosis condition and a disability rating of 10%, coded 7699-7629.  

BOARD FINDINGS:  In the matter of the overall effect of the endometriosis, GERD, and pain disorder associated with psychological and physical factors condition, the Board unanimously recommends an unfitting endometriosis condition with a disability rating of 10%, coded 7699-7629 IAW VASRD §4.116.  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, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Endometriosis	7699-7629	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR COMMANDER, NAVY PERSONNEL COMMAND
	         DEPUTY COMMANDANT, MANPOWER & RESERVE AFFAIRS	
	                          
Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS          

Ref:  (a) DoDI 6040.44
	(b) PDBR ltr dtd 19 Sep 16 ICO XXXXXXXXXXXXXXXXXXXX   
	(c) PDBR ltr dtd 20 Sep 16 ICO XXXXXXXXXXXXXXXXXXXX
	(d) PDBR ltr dtd 26 Sep 16 ICO XXXXXXXXXXXXXXXXXXXX
	(e) PDBR ltr dtd 19 Sep 16 ICO XXXXXXXXXXXXXXXXXXXX
	(f) PDBR ltr dtd 16 Sep 16 ICO XXXXXXXXXXXXXXXXXXXX
	(g) PDBR ltr dtd 29 Jul 16 ICO XXXXXXXXXXXXXXXXXXXX
	(i) PDBR ltr dtd 20 Sep 16 ICO XXXXXXXXXXXXXXXXXXXX

1.  Pursuant to reference (a), the recommendations of the Physical Disability Board of Review set forth in references (b) through (i) are approved.

2.  The official records of the following individuals are to be corrected to reflect the stated disposition:
     
     a. former USN: Retroactive placement on the Permanent Disability Retired List with a 40 percent disability rating (increased from 20 percent) effective date of discharge.  

     b. former USN: Retroactive placement on the Permanent Disability Retired List with a 30 percent disability rating (increased from 10 percent) effective date of discharge.  

     c. former USN: Entitlement to disability severance pay with a 10 percent disability rating (increased from 0 percent) effective date of discharge.  

     c. former USN: Entitlement to disability severance pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge. 

     d. former USN: Entitlement to disability severance pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge. 

     e. former USMC: Retroactive placement on the Permanent Disability Retired List with a 30 percent disability rating (increased from 10 percent) effective date of discharge.  

     f. former USN: Retroactive placement on the Permanent Disability Retired List with a 50 percent disability rating (increased from 20 percent) effective date of discharge.

3.  Please ensure all necessary actions are taken to implement these decisions, including the recoupment of disability severance pay, if warranted, and notification to the subject members once those actions are complete.