RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-04308
BRANCH OF SERVICE:  Air Force 	
DATE PLACED ON TDRL:  20010703	
DATE REMOVED FROM TDRL:  20020915

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Security Forces Journeyman, medically separated from the Temporary Disability Retired List (TDRL) for “major depressive disorder,” with a disability rating of 10%.  

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 – 20010424/20020730	VARD - 20010911	
TDRL Placement – 20010701	Code	Rating	Condition	Code	Rating
Proximate	
Condition		TDRL
Placement	TDRL Removal			TDRL
Placement	TDRL Removal	
MDD	9434	30%	10%	Depression	9434	70%	70%	
Diabetes Mellitus	Category II	Diabetes Mellitus	7913	40%	40%	
COMBINED RATING:  30% → 10%	COMBINED RATING OF ALL VA CONDITIONS:  80%	

ANALYSIS SUMMARY:  

Major Depressive Disorder (MDD).  According to service treatment records (STR) and the mental health (MH) Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s MDD condition began in August 2000 after being diagnosed with diabetes.  The CI reported mild to moderate depressive symptoms for years which became much worse after his diabetes diagnosis and subsequent duty restrictions.  Following the diabetes diagnosis the CI was restricted from weapons bearing and his Security Forces position was changed to one he did not like (customer service in the Visitor’s Center) , which he cited as an additional stressor.  Prior to this, the NARSUM indicated CI was a “distinguished member of the Security Forces” and an Enlisted Performance Review (EPR) for the period 21 December 1999 to 20 December 2000 rated the CI highly in all categories and he was unanimously recommended for immediate promotion.  The CI was evaluated by a psychiatrist in August 2000 and reported sleep problems, changes in interest and pleasure in activities, decreased concentration, and decrease appetite.  The psychiatrist initially deferred diagnosis on Axis I, but noted a rule-out diagnosis of adjustment disorder with anxiety and depression.  In October 2000, the CI’s case was closed from a psychiatry standpoint.  

The CI continued to be seen by the psychologist and his depressed mood continued and he was non-compliant with treatment for diabetes mellitus (DM).  He was evaluated again by a psychiatrist in December 2000.  The mental status examination (MSE) noted the CI was well-groomed.  His mood and affect were depressed and passive suicidal ideation (SI) was noted.  The remainder of the examination was unremarkable.  The CI was diagnosed with dysthymia and started on antidepressant medication. Psychologist visits noted the CI’s mood remained depressed and he expressed concerns about death related to his DM condition.  At a psychiatry evaluation in April 2001, the MSE noted the CI’s mood was “brighter than initial presentation,” though continued passive SI was noted, and the examination was otherwise unremarkable.  The Axis I diagnosis was changed to MDD, single episode, severe, without psychotic features.  The MEB forwarded “major depressive disorder, single episode, severe, without psychotic features” for PEB adjudication.  

The MEB NARSUM examination, 6 April 2001, 3 months prior to separation, noted continued complaints of depressive symptoms with variable compliance with DM treatment, despite some improvement on antidepressant medication.  He denied alcohol abuse or illicit drug use.  The MEB MSE was performed 2 months before the NARSUM on 14 February 2001 (4 months before separation) and showed a dysphoric mood and guarded affect.  The CI reported frequent thoughts and worries about death related to his diabetes with occasional passive SI, but the CI denied active SI, intent, or planning.  The Axis I diagnosis was MDD, single episode without psychotic features, with a Global Assessment of Functioning (GAF) of 60, which is in the moderate range of impairment on this scale.  The MH MEB NARSUM listed a profile for MDD.  The MH MEB examiner noted the CI was being presented to the MEB because his MH symptoms continued and interfered with his medical compliance with treatment for his DM, despite the CI’s active participation in MH treatment which included therapy and antidepressant medication.  

The PEB on 24 April 2001 placed the CI on the Temporary Retired Disability List for the MDD condition on 30 June 2001, noting that the condition was not yet stabilized and a re-evaluation in 1 year was indicated.

At the 16 August 2001 VA Compensation and Pension (C&P) evaluation, performed 2 months after TDRL placement, the CI reported he was on an antidepressant medication (Wellbutrin) prior to separation, both for his depression and to help him stop smoking.  He was able to cut down on his smoking but stopped the medication because he did not find it helpful for his depression.  He reported depression over his inability to work in his career field of law enforcement or have a romantic relationship and expressed it was useless to continue his life.  He reported sleep problems, decreased interest and enjoyment, and decreased concentration, but felt he got along well with coworkers.  The CI noted his DM remained not well controlled because he forgot to take his medication at times.  He indicated he thought he was feeling better on a previous antidepressant and maybe he should get back on it.  The MSE noted a “mildly” dysphoric mood and the remainder of the examination was unremarkable.  The VA MH examiner indicated the CI’s difficulties with concentration were related to his DM and also to his reaction to living with a chronic illness.  The Axis I diagnosis was “mood disorder (depression) due to onset of diabetes mellitus” and “MDD, single, secondary to his experience of chronic illness.  This continues to a moderate degree with earlier treatment of depression, but not currently.”  The GAF was 52 “in response to both of his Axis I, diagnoses,” which is in the moderate range of impairment on this scale.

The Board directed its attention to the rating recommendation for the MDD condition at TDRL placement.  The PEB rated the MDD condition 30% at TDRL placement.  The VA rated the depression condition 70%, based on the C&P examination 2 months after separation.  All Board members agreed that the evidence of the record did not support a traumatic stressor as the cause of the mental condition for which application of VASRD §4.129 would be appropriate.  However, the PEB placed the CI on TDRL because the MDD condition was not considered stable, but there is no mandatory minimum requirement for a 50% rating at TDRL placement in this case.  The Board considered whether the evidence at the time of TDRL placement supported a rating higher than the 30% rating adjudicated by the PEB.

At TDRL placement there was evidence of depression symptoms including depressed mood, chronic sleep impairment, and decreased concentration supportive of the 30% rating specified as “occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal).”  There was no evidence of symptoms such as abnormal thought processes; impaired speech; panic attacks more than once a week; difficulty in understanding complex commands; or impairment of short-term and long-term memory that are indicated by the VASRD as supportive of the 50% rating or other symptoms which reflect this level of impairment.  The commander noted the CI was working a full 8-hour duty day in an administrative position at the time without any issues noted.  Board consensus was that a 30% rating for the MDD condition at TDRL entry was appropriate.

At the TDRL MH examination on 12 July 2002, the CI reported that since military separation he had a few jobs from which he was either fired or quit.  He reported he was not taking his antidepressant medication.  The CI reported drinking to intoxication every week and “as often as possible,” but denied illicit drug use.  The CI reported that his MDD condition had not changed since discharge.  He reported continued depression with sleep problems and endorsed feelings of hopelessness and worthlessness, decreased interest, and fluctuating appetite and concentration.  He continued to report intermittent, fleeting passive SI, but denied any intent and contracted for safety during the TDRL evaluation.  He also denied any symptoms of mania, panic or psychosis.  The TDRL examiner noted the CI was “marginally compliant” with his DM medications.  The examiner also indicated the CI was not cooperative throughout the MSE.  The MSE noted the CI was hostile and belligerent to the examiner.  The CI indicated he did not know why he was there for a “mandatory” evaluation and asked “what is TDRL.”  He was well groomed.  The MSE was notable only for a “hostile and angry” mood and “somewhat labile” affect.  His speech was slow and halting.  There was no active suicidal ideation, delusional or hallucinatory symptoms, or other symptoms suggestive of psychosis, speech disturbance, objective cognitive impairment, or other abnormality.  His insight and judgment were considered poor.  The Axis I diagnosis remained the same; MDD, single episode, severe, without psychotic features.  The GAF assignment was 40-50, which is in the serious range of impairment on this scale.  The TDRL examiner noted the CI was “essentially noncompliant” with the interview.  The TDRL examiner’s recommendations are excerpted below.

Given his attitude toward his illness and his behavior, his prognosis is poor.  His use of alcohol appears to be a maladaptive contributing factor to his situation.  He is recommended for permanent medical retirement.

The Board directed attention to its rating recommendation at TDRL removal (permanent separation) based on the above evidence.  The PEB rated the MDD condition 30%, coded 9434, indicating the CI’s condition was unchanged since being placed on the TDRL, but subtracted 20% for contributing/aggravating factors, citing alcohol abuse and non-compliance.  The VA continued the 70% rating.

The PEB deducted 20% for aggravating factors, however, while non-compliance with generally acceptable medical standards of care can affect the severity of a ratable condition, once a condition is determined to be unfitting, the Board must rate the condition IAW VASRD guidelines.  The VASRD rating criteria for the MDD condition does not incorporate non-compliance as a deduction for rating.  Therefore, the members agreed no less than a 30% rating at permanent separation as adjudicated by the PEB was at issue in this case.  The Board therefore considered whether the evidence at the time of TDRL placement supported a rating higher than 30%.  

At the TDRL re-evaluation, the psychiatrist assessment was that the CI was “essentially noncompliant” with the evaluation.  Even so, at the evaluation the CI did not report and there was no evidence of symptoms, such as abnormal thought processes; panic attacks more than once a week; active SI, difficulty in understanding complex commands; or impairment of short- and long-term memory, which indicated a level of impairment due to the MDD condition supportive of the 50% rating.  

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 30% at the time of TDRL placement and a permanent 30% rating at the time of removal from the TDRL for the MDD condition, coded 9434.  

Contended PEB Conditions:  Diabetes mellitus (DM) Type II.  The Board’s main charge is to assess the fairness of the PEB’s determination that the contended DM Type II condition was not unfitting.  The CI was diagnosed with DM in August 2000 while deployed.  The CI had a blood sugar of 660 mg/deciliter (dL) (normal less than 100 mg/dL) without ketoacidosis.  He was treated with fluids and insulin and medically evacuated.  As noted above, the CI also became depressed after his DM diagnosis to the point of being diagnosed with MDD, though he did report pre-existing depressive symptoms of a lesser intensity prior to the DM diagnosis.  The CI was diagnosed with DM Type II and prescribed daily insulin, oral diabetic medication, and a diabetic diet.  Throughout treatment visits the CI was noted to be non-compliant with treatment recommendations and his DM remained poorly controlled.  The CI’s non-compliance was attributed significantly to the co-morbid MDD and lack of acceptance of and poor coping with having a chronic illness.  Notes by the diabetes specialist through the end of February 2001 noted extremely poor control of the CI’s blood sugar and the CI reported missing doses of insulin and not regularly checking his blood sugar

The commander’s statement dated 20 February 2001 noted that the CI’s profile “stipulates insulin dependent/Non-worldwide deployable” and noted that the CI’s “condition” also prevented him from meeting the annual physical fitness requirements.  

The DM MEB NARSUM was written 2 April 2001, but indicated that the NARSUM was based upon a visit on 13 November 2000.  At that visit the CI reported being out of long acting insulin and his blood sugar was 251 mg/dL.  According to the NARSUM the CI was doing “fairly well,” taking his medications, without any symptoms of DM, but blood sugars were still in the 200 to 300 range.  There was no evidence of heart, kidney or vision complications of DM on examination.  The diabetic specialist indicated the CI should be on a Class C restriction regarding deployability, but otherwise saw no need for restrictions on his “current duty” in the Security Forces, which as noted above was a position working in the Visitor’s Center which the CI was transferred to as a consequence of his illnesses.  

The diabetic specialist saw the patient again for follow-up on 23 April 2001 and the CI’s blood sugar was 433 mg/dL.  In the past week the CI reported he had taken a few doses of his oral diabetic medication, but not insulin.  He reported symptoms of uncontrolled DM of increased thirst and urination and reported periods of mild confusion and lethargy.  On examination his mental status seemed “okay.”  The CI was noted to be thinner and his medications were restarted and explained to him again.  The examiner noted that he thought the CI’s dysthymia would improve if the DM was better controlled.  

The diabetic specialist wrote an addendum to the MEB NARSUM on the same date.  He noted the CI’s had significant DM symptoms with a weight loss of 37 pounds in 4 to 5 months and that the CI was non-compliant with treatment, which was attributed to his depressed mood.  The examiner re-iterated that the plan was to transition the CI off insulin to only oral diabetic medications in the future, if possible.  The examiner indicated the CI seemed to understand the need for compliance with treatment and control of his DM.  The examiner amended his earlier assessment that no work restrictions were indicated and recommended that the CI was “not currently fit to perform his usual duties with the Security Forces” and suggested that the CI be cross-trained in another career field.  Medical follow-up in a month was planned.

The DM condition was profiled with a limitation of “not world-wide deployable.”  The commander’s statement implicated the DM condition as impairing the CI’s successful performance of the duties of his military specialty and meeting physical fitness requirements.  In the MEB NARSUM addendum, dated the day before the date of the PEB, the diabetic specialist noted that the DM was poorly controlled, required insulin, and impacted the CI’s mental status and rendered him currently unfit to perform in his career field.  

After due deliberation, the Board agreed that the preponderance of the evidence with regard to the functional impairment of DM condition favors its recommendation as an additionally unfitting condition for disability rating.  It is appropriately coded 7913 and meets the VASRD §4.119 (endocrine system) criteria for a 20% rating at the time of TDRL placement based on DM requiring insulin or oral hypoglycemic agent and restricted diet for control.  

An internal medicine clinic visit on 11 July 2002 with the same physician who co-signed the TDRL evaluation that follows, noted the CI was on oral DM medication and insulin for the DM condition and was poorly compliant with treatment recommendations.

The TDRL DM evaluation on 12 July 2002 noted the CI reported finger stick blood sugars between 100 and 400 mg/dL and symptoms of urinary frequency.  He admitted non-compliance with monitoring, medications, and lifestyle interventions to control the DM.  The physical examination was unremarkable.  The TDRL examiner counseled the CI on the need for control of his DM.  The examiner noted that the CI’s compliance was unlikely to improve until his psychiatric problem “has been addressed” and recommended another year of TDRL.

The Board directed attention to its rating recommendation at TDRL removal (permanent separation) based on the above evidence.  At the TDRL evaluation the CI’s blood sugar remained uncontrolled with highly elevated blood sugar readings reported and continued symptoms of uncontrolled DM and he was still recommended oral diabetic medication, insulin, and restricted diet to control the DM.  The evidence supports a 20% rating but there was no evidence of “regulation of activities” for a higher rating.  

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 20% at the time of TDRL placement and a permanent 20% rating at the time of removal from the TDRL for the DM Type II  condition, coded 7913.  

BOARD FINDINGS:  In the matter of the MDD the Board unanimously recommends an initial TDRL rating of 30% and a 30% permanent rating IAW VASRD §4.130.  In the matter of the contended DM, type II condition, the Board unanimously recommends it as unfitting at TDRL placement with a 20% rating and a 20% permanent rating IAW VASRD §4.119.  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	RATING	
		TDRL	PERMANENT	
Major Depressive Disorder	9434	30%	30%	
Diabetes Mellitus, Type II	7913	20%	20%	
COMBINED	40%	40%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20141127, w/attachments
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-2014-04308.

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 direct that your records be corrected as set forth in the attached copy of a Memorandum for the Chief of Staff, United States Air Force.

The office responsible for making the correction will inform you when your records have been changed.  Corrected documents will involve a retirement order to place you on the retired rolls by reason of physical disability and, if appropriate, a new DD Form 214, Certificate of Release or Discharge from Active Duty.  Once you receive these documents, you may proceed to the nearest military personnel flight to secure a military identification card for you and any eligible dependents.  If you require assistance for matters not involving military pay actions, please contact the PDBR Intake Unit at Randolph AFB, (210) 565-3256.  Any inquiry concerning your pay may be addressed to DFAS – Indianapolis Center, Department 3300 (ATTN:  Correction of Records/Claims), 8899 East 56th Street, Indianapolis IN 46249-3300.

Sincerely,

Attachments:
1.  Directive 
2.  Record of Proceedings 

cc:
SAF/MRBR 
DFAS-IN