RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-04101
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060530

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Wheel Vehicle Mechanic, medically separated for “Crohn’s disease,” with a disability rating of 10%.

CI CONTENTION:  Crohn’s-related arthralgias should have been evaluated and rated.  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 - 20060307	VARD - 20061108	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Crohn’s Disease	7399-7323	10%	Crohn’s Disease with Gastroesophageal Reflux Disease and Erectile Dysfunction	7346-7323	10%	20060516	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Crohn’s Disease.   According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s Crohn’s condition began in October 2002 after experiencing bloating, abdominal cramping and increased fullness sensation with nausea and vomiting.  Due to a disease exacerbation, medical evacuation from a deployed location was required in February 2005, 15 months prior to separation.  Subsequent treatment did not result in improvement sufficient to allow return to unrestricted duty.  The MEB forwarded “Crohn’s disease” for PEB adjudication.

From the time of return from deployment until separation, medical management consisted of oral steroids and anti-inflammatory agents.  The CI experienced a brief flare-up of abdominal pain, nausea, vomiting and diarrhea in June 2005.  On 12 September 2005, 9 months prior to separation, the CI was hospitalized for 2 days for a flare-up of Crohn’s disease characterized by nausea, vomiting and abdominal pain due to a partial small bowel obstruction.  He also complained of 2 months of diffuse arthralgias (joint pain).  The exacerbation occurred in the context of tapering off oral steroids 6 weeks previous, and it was necessary to re-start them.  At an evaluation by a surgeon on 28 September 2005, the CI reported a main complaint of abdominal pain after every meal “on a daily basis.”  He experienced diarrhea every 3-4 days.  The examiner indicated that there was no history of anemia.  Surgery was considered but postponed since a sufficient response to oral steroids was seen. 
  
At the MEB examination (recorded on DD Form 2807 Report of Medical History and DD Form 2808 Report of Medical Examination) dated 31 October 2005, the CI denied recent weight loss but complained of joint pains for one year that included pain from a previously injured right ankle.  He checked “no” for “impaired use of arms, legs, hands, or feet.”  Examination of the abdomen was normal, and all joints of the upper and lower extremities showed full range of motion without tenderness or swelling.  The profiling section of the DD Form 2808 included “multiple arthralgia (painful joints) by history and normal examination.”  

The commander’s statement on 10 November 2005, 7 months prior to separation, reported that joint pain prevented performance of some duties required of the CI’s job.  At a gastroenterology follow-up visit on 19 December 2005 the CI reported diffuse arthralgias, weight gain, and intermittent non-bloody diarrhea.  The examiner cited recent laboratory values that indicated no anemia or malnutrition. 

The NARSUM examiner on 23 January 2006, 4 months prior to separation, indicated that the Crohn’s condition “stabilized and improved” since restarting prednisone in July 2005.  The CI reported that he was “totally incapacitated” during a flare-up.  Arthralgias in the hands and wrists, thought to be related to the Crohn’s disease, rendered him unable to effectively turn wrenches.  Physical examination noted a normal abdominal examination.  All joints of the upper and lower extremities were normal.

On 9 February 2006 the CI was hospitalized for 10 days for an exacerbation of Crohn’s disease manifested by severe stabbing abdominal pain and 2 days of non-bloody diarrhea.  At the time of hospital discharge he was given oral narcotic pain medication for control of polyarthropathy and instructions for tapering off the steroids.  A permanent profile on 14 February 2006 listed Crohn’s disease (P3) and right ankle pain (L2), and allowed running at own pace and distance, unlimited walking, swimming and biking, and upper and lower body weight training.  On 23 April 2006, 1 month prior to separation, the CI was hospitalized for a 3-4 day history of increasing abdominal pain, nausea and inability to eat or drink.  Laboratory evaluation for anemia was negative.  The discharge summary indicated that the severity of the inflammatory bowel condition was “more than mild.”

At the 16 May 2006 VA Compensation and Pension (C&P) examination, performed 14 days before separation, the CI reported nausea, vomiting, chronic constipation, diarrhea and alternating diarrhea and constipation that occurred constantly.  He also reported multiple joint pains for 2 years.  Painful joints were precipitated by a flare-up of Crohn’s, and limited his ability to perform daily functioning.  Physical examination showed no abdominal tenderness.  The gait was normal, the spine exhibited no abnormalities, and other joints were normal.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under an analogous 7323 code (ulcerative colitis), acknowledging that repeated exacerbations prevented effective duty, but cited “infrequent exacerbations” as a rating rationale.  The VA also assigned a 10% rating using a 7346-7323 code (hiatal hernia/ulcerative colitis) based on the VA C&P examination 14 days before separation, citing infrequent exacerbations.  Board members agreed that the 60% rating described by “numerous attacks a year and malnutrition, the health only fair during remissions” was not reflected in the evidence.  In deliberating between the 10% (moderate; with infrequent exacerbations) and the 30% rating criteria (moderately severe, with frequent exacerbations) Board members considered that three hospitalizations were required during the 9 months prior to separation.  Despite intensive treatment with steroids and anti-inflammatory agents, the CI still experienced intermittent symptoms including diarrhea and abdominal pain.  The Board concluded that the evidence at the time of separation described the presence of gastrointestinal symptoms best depicted by “moderately severe, with frequent exacerbations.”  The Board also noted that the only other applicable coding pathway under VASRD §4.114 (7319; irritable colon syndrome) does not provide a rating higher than 30%.  

The Board deliberated if arthralgia related to the Crohn’s disease condition justified a separate rating.  The VA’s initial rating decision did not service connect arthralgia because of the absence of objective evidence of disability.  In 2010 the VA included multiple arthralgias in the rating for Crohn’s disease, which was increased to 30%.  This contended condition was not listed by the MEB or adjudicated by the PEB, but as a residual of the Crohn’s condition warranted Board review.  Although the commander and NARSUM identified job-related limitations imposed by multiple painful joints, the final permanent profile in evidence only specified right ankle pain (from a previous injury) as a cause for an L2 designation.  There were no upper extremity profile limitations (U1); and unlimited walking, biking and swimming, and upper and lower body weight training, were permitted.  The Board also considered that examinations consistently showed normal joint findings, and that the VA examiner stated that painful joints were precipitated by Crohn’s disease exacerbations.  Board members concluded that there was not a preponderance of evidence that arthralgia was unfitting, separate from Crohn’s disease, and agreed with the VA that they were properly subsumed under the 7323 code.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 30% for the Crohn’s disease condition, coded 7399-7323.

BOARD FINDINGS:  In the matter of the Crohn’s disease condition, the Board unanimously recommends a disability rating of 30%, coded 7399-7323 IAW VASRD §4.114.  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 the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Crohn’s Disease	7399-7323	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated w/attachments
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 AR20160018239 (PD201404101)

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 recharacterize the individual’s separation as a permanent disability retirement with the combined disability rating of 30% 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 than120 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 30% 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