RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-04250
BRANCH OF SERVICE:  Air Force	SEPARATION DATE:  20080527

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E4, Security Forces, medically separated for “pulmonary embolism resolved,” with a disability rating of 0%.  

CI CONTENTION:  My pulmonary embolism should have been rated 30% based on Department of Defense Instruction.  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 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 - 20080219	VARD - 20081124	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Pulmonary Embolism Resolved	6817	0%	Residuals, Pulmonary Embolism and Pleurisy	6817-6845	10%	20001015	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:

Pulmonary Embolism.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI was hospitalized in May 2007 for multiple small peripheral pulmonary emboli in both lungs.  No cause for the emboli was found and testing was negative for known hypercoagulable conditions, although there was a family history of unspecified clotting disorders.  The CI was placed on chronic anticoagulant therapy and referred for an MEB.  The MEB forwarded “pulmonary embolus” for PEB adjudication.  At the pulmonologist’s evaluation in June 2007 (12 months prior to separation), the examiner noted a slight pleural rub with clear lung sounds, that the CI was on anticoagulant medication (Coumadin), and that he had persistent pleuritic right chest pain with diagnostic imaging showing a small right pleural effusion.  The examiner’s diagnoses included pulmonary emboli and persistent pleuritic right chest pain due to pleural inflammation and pulmonary infarct.  

The MEB NARSUM examination in October 2007, 8 months before separation, noted that the CI was taking Coumadin for his history of pulmonary embolism and family history of unspecified clotting disorders.  Review of systems indicated no shortness of breath, cough or wheeze, chest pain, dyspnea (difficult or labored breathing) on exertion, orthopnea (difficult breathing with laying down), or PND [breathing problems at night].  Relevant medications included Coumadin and Indocin (a nonsteroidal anti-inflammatory medication for pain) as needed (PRN).  Examination documented the chest as normal to auscultation (normal lung sounds) without wheezing, rales, rhonchi or retractions.  The examiner’s summary stated that the CI was “currently stable on his current regimen with coumadin for anticoagulation Indocin prn for pain control of pleurisy.  Pulmonary has recommended long term anticoagulation due to strong family history.”  

According to the Formal PEB (FPEB) in February 2008, 3 months before separation, the CI testified that he still experienced “shortness of breath and sharp pain upon exertion;” the FPEB stated that the medical record did not show a post symptomatic state.  The FPEB also indicated that the preponderance of the evidence did not support a hereditary or congenital pulmonary embolism condition or hypercoagulable state (NOTE:  The thrust of the CI’s appeals were for a 30% rating using application of DoDI 1332.39 for hypercoagulable states requiring chronic anticoagulation with episodes of emboli in the past year).  The SECAF Personnel Council’s (SAFPC) response to appeal in April 2008, 2 months before separation, referenced the NARSUM review of systems (ROS), which was negative for lung or chest symptoms, and the FPEB testimony of occasional chest pain or shortness of breath with exertion, and concluded that “the medical reports suggest that he has completely recovered from the episode [pulmonary embolism].”  A hematologist’s evaluation in April 2008, the same month as separation, confirmed a negative evaluation for congenital hypercoagulability.  A subsequent treatment note in May 2008 indicated that the CI’s coumadin was discontinued.  

At the VA Compensation and Pension (C&P) examination in October 2008, performed 5 months after separation, the CI reported a similar history of pulmonary embolism with chest pain since that time, but no recurrence of pulmonary embolism and he was no longer on coumadin.  His right sided chest pain had been diagnosed as pleurisy after his pulmonary embolism with recurrent sharp stabbing chest pain worsened with any sort of movement.  Pain frequency had decreased (from a couple of times every week) at the time of the VA examination to 1-2 times a month.  The CI was on no pain medication and treatment involved breathing and relaxation techniques that were taught to him by a psychiatrist.  The CI indicated that when these attacks came on they did affect his activities of daily living in that he didn’t feel like moving around.  Physical examination showed lungs clear to auscultation.  The examiner’s reporting of pulmonary function testing (PFTs) indicated “FVC of 74%, an FEV1 of 71% suggesting a possible restricted ventilatory defect but no evidence of an obstructive ventilatory defect.”  Diagnostic imaging showed blunting of the right costophrenic angle (right lower lung corner near chest wall) “that can be seen with pleural thickening or pleural effusion.”  There was also “mild elevation of the right hemidiaphragm.”  Diagnoses included both pulmonary embolism and pleurisy, and indicated that there was no evidence of pneumonia/acute bronchitis or chronic obstructive pulmonary disease.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB (including FPEB and SAFPC appeal) assigned a 0% rating using code 6817 (pulmonary vascular disease), citing that the condition was asymptomatic, following resolution of pulmonary thromboembolism warranting a zero percent rating.  The VA assigned a 10% rating using codes 6817-6845 (pulmonary vascular disease analogous to chronic pleural effusion or fibrosis), based on the VA C&P examination 5 months after separation, citing an “FEV-1 of 71 to 80 percent of predicted value.”  The CI’s pulmonary emboli were documented as resolved by diagnostic imaging.  There was no evidence of chronic or recurrent pulmonary thromboembolism, pulmonary hypertension, right ventricular hypertrophy, or cor pulmonale, or inferior vena cava surgery for any rating higher than 30%.  The Board deliberated if there was adequate evidence of the CI being “symptomatic, following resolution of acute pulmonary embolism” to support a 30% rating under code 6817.  

The NARSUM specialist indicated the CI was taking pain medication as needed for pleurisy and the FPEB and SAFPC rationale included the CI’s complaints of occasionally suffering from chest pain or shortness of breath when he exerted himself.  While the NARSUM ROS did not align with the examiner’s summary statement of a diagnosis of pleurisy (chest pain or symptoms with breathing), the Board placed greater weight in the examiner’s summary assessment of pleurisy diagnosis, the NARSUM summary indicating medication use for pain control of pleurisy, and the CI’s testimony at the FPEB; and, therefore conceded that there was reasonable doubt that the CI more closely met the code 6817 30% disability picture of being symptomatic, following resolution of acute pulmonary embolism.  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 pulmonary embolism condition, coded 6817.  

BOARD FINDINGS:  In the matter of the pulmonary embolism condition, the Board unanimously recommends a disability rating of 30%, coded 6817 IAW VASRD §4.97.  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	
Pulmonary Embolism	6817	30%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140720, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAF/MR
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD  20762

Dear XXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2014-04250.

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was not appropriate under the guidelines of the Veterans Affairs Schedule for Rating Disabilities.  Accordingly, the Board recommended your separation be re-characterized to reflect disability retirement, rather than separation with severance pay.

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding, accept their recommendation and determined that your records should be corrected accordingly.  The office responsible for making the correction will inform you when your records have been changed.

As a result of the aforementioned correction, you are entitled by law to elect coverage under the Survivor Benefit Plan (SBP).  Upon receipt of this letter, you must contact the Air Force Personnel Center at (210) 565-2273 to make arrangements to obtain an SBP briefing prior to rendering an election.  If a valid election is not received within 30 days from the date of this letter, you will not be enrolled in the SBP program unless at the time of your separation, you were married or had an eligible dependent child, in such a case, failure to render an election will result in automatic enrollment.

Sincerely,

Attachment:
Record of Proceedings 
cc:
SAF/MRBR
DFAS-IN