RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	      CASE:  PD-2015-00139
BRANCH OF SERVICE:  Army                                                                   SEPARATION DATE:  20021229 

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Cavalry Scout, medically separated for “idiopathic nausea and vomiting…” with a disability rating of 0%.  

CI CONTENTION:  The CI requested consideration of all conditions.  His complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The panel’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 panel’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 panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The panel’s assessment of the PEB rating determinations is based on 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 panel 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 panel 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 - 20050601	VARD - 20060307	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Idiopathic Nausea And Vomiting…	7299-7204	0%	Idiopathic Nausea, Vomiting ... Gastroesophageal Reflux Disease and Irritable Bowel Syndrome	7399-7346	10%	20031007	
Gastroesophageal Reflux	Not Unfitting					
Left Hearing Loss	Not Unfitting	Bilateral Hearing Loss	6100	0%	20031007	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  90%	

ANALYSIS SUMMARY:    

Idiopathic Nausea and Vomiting.  The service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM) documented an onset of epigastric distress with exertion in basic training.  The symptoms progressed and the CI first presented for medical evaluation in March 2002 (9 months before separation) reporting epigastric pain, nausea, and vomiting with attempts at running or other strenuous activity.  An exhaustive gastrointestinal work-up was negative except for “mild reflux without any mucosal abnormality” on endoscopy.  The symptoms did not improve with various medication trials.  The MEB forwarded “idiopathic physical training associated nausea and vomiting” for PEB adjudication.  

The 30 October 2002 NARSUM examination, 2 months before separation, stated, “His current status is that he wakes up at night twice a week with reflux and still gets reflux with nausea aggravated by moderate levels of exertion such as climbing several flights of stairs.  Running and other strenuous exertion and even fast walking for > 30 minutes causes abdominal pain, nausea, and emesis.”  The physical examination was normal.  

A 7 October 2003 VA Compensation and Pension (C&P) examination, 10 months after separation, noted “extremely nauseated in the morning when he does physical activity such as running, pushing the lawn mower, and extended climbing or walking.”  The CI was employed but had been unable to return to his previous occupation in construction.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB’s 0% rating under code 7299-7204 (analogous to esophageal spasm) cited failure to meet the minimum compensable criteria, referencing VASRD §4.31 (no-percent rating).  The VA’s 10% rating under code 7399-7346 (analogous to hiatal hernia) was based on the C&P evidence and cited the 10% criteria elaborated below.  There is no available code in VASRD §4.114 (digestive system) that is specific to this condition and analogous rating is unavoidable.  The PEB’s analogous code 7204 defaults to rating for esophageal stricture, e.g., obstruction.  This clinical analogy was incongruent with the pathology in that there was no element of esophageal obstruction; and, in fact, the reflux feature would have had the opposite effect.  The resulting 0% rating was therefore driven by the selected code more than the functional impairment.  The VA’s analogous code 7346 provides for a 10% rating “with two or more of the symptoms for the 30 percent evaluation of less severity;” and, the 30% rating lists “dysphagia [difficulty swallowing], pyrosis [heartburn], and regurgitation, accompanied by ... pain.”  Since the VA subsumed the reflux diagnosis in its rating, there was no question that at least the pain and regurgitation criteria were satisfied in justification of a 10% rating.  The panel however must assess the regurgitation criterion in light of the need to separately address the gastroesophageal reflux disease (GERD) that was determined to be not unfitting by the PEB (see below).   Members agreed, however, that in fairness and considering the VASRD coding constraints, the 10% criteria of 7346 should be conceded.  Although GERD must be considered independently for fitness, the overlap of symptoms with the unfitting diagnosis (combined effect) should not be entirely discredited for rating.  There is no other code offered by §4.31 that is analogously applicable; thus, there was no reasonable path to a rating higher than 10%.

After due deliberation, considering all of the evidence and conceding VASRD §4.3 (reasonable doubt), the panel recommends a 10% rating for the idiopathic nausea and vomiting condition under code 7399-7346.

Contended PEB Conditions:  GERD and Hearing Loss.  The panel’s main charge was to assess the fairness of the PEB’s determinations that these conditions were not unfitting.  The co-existing, but separately adjudicated, GERD was judged to meet retention standards by the MEB.  A mild high-frequency hearing loss was detected during MEB screening that did not require a hearing aid and was judged to meet retention standards.  Neither GERD nor hearing loss was profiled, and the commander’s performance statement referenced only the physical restraints imposed by the idiopathic nausea and vomiting.

Members agreed that there was no performance-based evidence indicating that either of these conditions significantly interfered with duty requirements, acknowledging that some impairment from GERD was subsumed in the rating for the unfitting condition.  After due deliberation, and in consideration of the preponderance of the evidence, the panel concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the GERD or hearing loss conditions; thus, neither was separately eligible for disability rating.  

PANEL FINDINGS:  In the matter of the idiopathic nausea and vomiting condition, the panel unanimously recommends a disability rating of 10%, coded 7399-7346, IAW VASRD §4.31.  In the matter of the contended GERD and hearing loss conditions, the panel unanimously recommends no change from the PEB determinations as not unfitting.  There were no other conditions within the panel’s scope of review for consideration.

The panel recommends that the CI’s prior determination be modified as follows, effective as of the date of his prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Idiopathic Nausea and Vomiting Secondary to Physical Exertion and Exacerbated by Gastroesophageal Reflux	7399-7346	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140918, 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

10 Apr 2017

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for
XXXXXXXXXXXXXXXXXX, AR20170004770 (PD-2015-00139)

1.  I have reviewed the enclosed Department of Defense Physical Disability Board of Review (DoD PDBR) recommendation and record of proceedings pertaining to the subject individual.  Under the authority of Title 10, United States Code, section 1554a, accept the Board’s recommendation to modify the individual’s disability rating to 10% without re-characterization of the individual’s separation.  This decision is final.  

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.   

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:

CF: 
(  ) DoD PDBR
(  ) DVA