RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	 CASE:  PD-2014-04275
BRANCH OF SERVICE:  Army                                                              SEPARATION DATE:  20041215

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve E4, Healthcare Specialist, medically separated for “recurrent deep vein thrombosis [DVT], left lower extremity [LLE],” with a disability rating of 20%.  

CI CONTENTION:  “Please consider all conditions.”  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 – 20041102	VARD - 20051102   	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Recurrent DVT, LLE	7121	20%	Residuals, DVT LLE	7199-7121	0%	20050428	
Low Back Pain	Not Unfitting	Lumbar Spine Strain	5237	NSC		
Intermittent Migraine Headaches		Migraine Headaches	8199-8100	0%		
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Recurrent DVT, LLE.  According to service treatment records (STRs) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s LLE DVT condition began in 1998, shortly after giving birth.  She was treated with Coumadin (warfarin, an anticoagulant).  After being off the Coumadin for 2 weeks she had a pulmonary embolus in April 1998.  In July 2003, she had pleuritic chest pain.  A VQ (ventilation-perfusion) scan was interpreted as an intermediate probability for pulmonary embolus; however, a computed tomographic (CT) angiogram done on the same day, showed no evidence of a pulmonary embolus or a lower extremity DVT.  She was placed on anticoagulation because of her history and elevated D-dimer (a test for pulmonary embolus), although a hypercoagulable workup was normal.  In December 2003, the CI had shortness of breath, but no pulmonary embolus or DVT was detected.  Anticoagulation, which was sub-therapeutic with Coumadin, was switched to Lovenox (low molecular weight heparin).  The CI had repeated occasions of left calf pain.  On 19 March 2004 a non-occlusive thrombus, likely old, was seen while a 22 March duplex study showed no evidence of DVT; however, a study on 26 May 2004, showed an acute deep vein thrombosis of the left popliteal vein, which was occlusive and new, despite therapeutic anti-coagulant levels.  On examination she denied any shortness of breath at rest or chest pain, but reported dyspnea (shortness of breath) upon climbing stairs, which she felt was chronic and stable.  A CT angiogram on 27 May 2004 showed no evidence of a pulmonary embolus.  A CT scan in June 2004 showed no evidence for a malignancy.

At the MEB examination (recorded on DD Form 2807 Report of Medical History and DD Form 2808 Report of Medical Examination) dated June 2004, 6 months prior to separation, the CI reported shortness of breath and chest pain from pulmonary embolism.  The examiner noted the CI’s heart had a regular rate and rhythm without murmurs and her lungs were clear to auscultation.  Clinical evaluation of the lower extremities was checked as normal.  At the NARSUM examination dated 11 August 2004, the CI’s lungs were clear and the heart rate and rhythm were normal without murmurs, rubs or gallops.  A factor VIII level was 239% of normal.  The CI remained asymptomatic from her thromboembolic disease while continuing long-term anticoagulation.  She was able to perform her daily duties despite the history of DVT and the anticoagulation therapy; however, she remained at a high risk for recurrent thromboembolic disease and required long term anticoagulation.  Despite treatment, the CI’s condition did not improve.  The MEB forwarded “recurrent DVT of LLE with recurrent embolus” for the PEB adjudication.  

On 16 November 2004, the CI presented to the emergency room with increasing shortness of breath, chest pain and bilateral leg pain.  Workup revealed no evidence of a DVT or a pulmonary embolism. Treatment consisted of Morphine (a narcotic) and Vicodin (hydrocodone, a narcotic and acetaminophen, a pain reliever) for pain.  At an internal medicine clinic on 23 November 2004, the CI reported constant pain in her left calf which came and went and which hurt more when it rained.  Additionally, she noted the left leg was chronically swollen and that she could not wear her stocking because it was too tight.  On examination there was minimal left lower extremity edema and minimal left calf pain to palpation.  She was referred to vascular surgery for refit of Jobst (compression) stockings to help with the chronic problem.  For cold induced bronchospasm and nocturnal dyspnea, she was diagnosed with asthma and was started on Advair (fluticasone/salmeterol).  

At the VA Compensation and Pension (C&P) examination on 28 April 2005, performed 4 months after separation, the CI reported being diagnosed with a left lower extremity DVT in January 1998 shortly after giving birth in December 1997.  She took Advair daily and albuterol 1-2 times a week and was still taking the anticoagulant medication (Lovenox and aspirin).  On examination her gait was normal as were her heart and lungs.  Both the left and right lower extremities revealed no tenderness over the calves.  Left calf circumference was 39.5 cm and the right was 38 cm.  There was no erythema in the calves and Homan’s sign (to determine a DVT) was negative bilaterally.  On pulmonary function testing her FEV1/FVC (forced expiratory volume at 1 second/forced vital capacity) was 76%, which most accurately reflected the CI’s symptoms.  The examiner’s impression was reactive airway disease secondary to pulmonary embolus, recurrent left lower extremity DVT, and pulmonary embolus of unclear etiology with a negative hypercoagulable workup. 

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 20% rating under the 7121 code (post-phlebitic syndrome of any etiology/persistent edema, incompletely relieved by elevation of extremity, with or without beginning stasis pigmentation or eczema), citing recurrent DVT with history of pulmonary embolism and persistent edema in the extremity despite compression stockings and no chronic skin changes.  The VA assigned a 0% rating using an analogous 7199-7121 code based on the VA C&P examination 4 months after separation, citing residuals, DVT, left lower extremity.  The VA also assigned a 30% rating using the code 6817 (pulmonary vascular disease-symptomatic, following resolution of acute pulmonary embolism), citing residuals pulmonary embolism, and a 10% rating using an analogous 6899-6604 code (chronic obstructive pulmonary disease), citing reactive airway disease associated with residuals, pulmonary embolism.  

Board members noted the PEB assigned a 20% rating based on the recurrent DVT, but the condition did not rise to a 40% rating in the absence of persistent edema and stasis pigmentation or eczema, with or without intermittent ulceration.  However, the PEB did not take into account a rating for the history of the pulmonary emboli or the long term anticoagulant therapy, which although the reported workup did not find a cause for the hypercoagulable state, in actuality the CI had a markedly elevated Factor VIII that had been described not long before the CI’s separation as a contributor to a hypercoagulable state, as well as to the development of the venous thrombosis.  Furthermore, the Board noted the VA rating likewise did not address the anticoagulant therapy, which the CI was still taking at the time of the VA C&P examination.  The Board therefore determined that in view of the CI’s history of recurrent left lower extremity DVT and at least two documented episodes of pulmonary emboli, as well as the need for continuous anticoagulant therapy, the most appropriate rating would be 7121-6817, which identifies the recurrent DVT and history of the pulmonary emboli as well as the requirement for long term anticoagulant therapy.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 60% for the recurrent DVT with a history of pulmonary embolism condition, coded 7121-6817.  

Contended PEB Conditions-Low Back Pain and Intermittent Migraine Headaches.  The Board’s main charge is to assess the fairness of the PEB’s determination that low back pain and intermittent migraine headaches were not unfitting.  The low back pain and intermittent migraine headaches were not permanently profiled or implicated in the commander’s statement and were not judged to fail retention standards.  There was no performance-based evidence from the record that the LBP and the intermittent migraine headache conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, and 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 the LBP and intermittent migraine headaches conditions; and so, no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the recurrent venous thrombosis, left lower extremity condition, the Board unanimously recommends a disability rating of 60%, coded 7121-6817 IAW VASRD §4.104 and §4.97.  In the matter of the contended LBP and intermittent migraine headache conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting.  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	
Recurrent Venous Thrombosis, Left Lower Extremity	7121-6817	60%	
The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140723, 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

27 DEC 2016

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
XXXXXXXXXXXXXXXXXX, AR20160018331 (PD201404275)

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 re-characterize the individual’s separation as a permanent disability retirement with the combined disability rating of 60% 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 than 120 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 60% 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