RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXXXXX	     CASE:  PD-2015-00198
BRANCH OF SERVICE: Army                                                                   SEPARATION DATE:  20050421

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Administrative Specialist, medically separated for “endometriosis…” rated 10% and “asthma” judged as unfitting, but not rated it as the condition was determined to have existed prior to service (EPTS).  The CI was medically separated with a combined rating of 10%.  

CI CONTENTION:  The CI contends for all of her conditions stating that she felt the process was extremely unfair.  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 - 20050301	VARD - 20050608	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Endometriosis	7629	10%	Endometriosis	7629	30%	20050224	
Asthma	6602	EPTS	Asthma	6602	NSC	20050224	
Migraines	Not Unfitting	Migraine Headaches	8100	30%	20050224	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Endometriosis.  According to service treatment records (STRs) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s pelvic pain condition began in November 2000.  The pelvic pain was followed by amenorrhea (absence of menstruation) in December 2000 and the CI experienced monthly pelvic pain thereafter. Treatment with Provera (medroxyprogesterone, a hormone) caused hot flashes and mood swings and birth control pills provided some relief, but had to be discontinued due to worsening of her migraine headaches (see below).  Menses occurred in February 2002, but pain and very irregular, heavy menses continued.  In November 2002 the CI underwent laparoscopy and the diagnosis of endometriosis (clusters of cells from the lining of the uterus) was made.  Lupron-Depo (leuprolide acetate) was tried to treat the endometriosis but the CI experienced night sweats and hot flashes.  Despite taking Clomid (clomiphene citrate) and Provera, she was unable to get pregnant.  In June 2004 the CI reported sharp pain in the lower left pelvic area and left back.  In July 2004 the CI underwent diagnostic laparoscopy, fulguration of sites of endometriosis implants and lysis of adhesions from omentum (covering of the bowel) to the anterior abdominal wall.  Following the procedure she continued to experience chronic pelvic pain and heavy bleeding, which was treated in the Emergency Room with Motrin (ibuprofen, a nonsteroidal anti-inflammatory drug (NSAID) and Tylenol #3 (codeine, a narcotic and acetaminophen, a pain reliever) and she had difficulty with functioning and performing her daily military duties.  The CI did not desire to undergo a hysterectomy because she wanted to become pregnant again. 

At the MEB examination on 4 November 2004, 5 months before separation, the CI reported endometriosis, painful periods, excessive and prolonged bleeding, and pelvic pain.  A pelvic examination was not performed and the examiner referred to the gynecology report. 

At the VA Compensation and Pension (C&P) examination on 24 February 2005, performed 2 months before separation, the CI reported irregular menstrual cycles and irregular bleeding not controlled by treatment.  Additionally, she had pelvic pain throughout the month that required continuous treatment; however, despite the treatment, she was functionally impaired by the pain which prohibited her from performing her daily routines.  The abdominal and pelvic examinations were normal.   

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under the 7629 code (endometriosis), citing endometriosis with chronic pelvic pain, confirmed by laparoscopy, required continuous treatment with NSAIDs and pain medication.  The VA assigned a 30% rating using the 7629 code (endometriosis) based on the VA C&P examination 2 months before separation, citing continuous pain and heavy and irregular menstruation that did not respond to medications or surgical procedures.  Board members noted the disparity in the ratings between the PEB and VA and determined that the CI’s symptoms required continuous treatment, but the pelvic pain or heavy or irregular bleeding was not well controlled by either surgical intervention or medication thereby warranting a 30% rating.  However, the CI did not report any bowel or bladder symptoms sufficient to achieve a 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% for the endometriosis condition, coded 7629.  

Asthma.  According to STRs and the MEB NARSUM, the CI’s allergy marked by nasal and sinus congestion, itchy eyes, coughing, and exercise induced dyspnea (shortness of breath) began during basic training in 2000.  She was treated decongestants and antihistamines initially.  In November 2000 she was treated with Zyrtec (cetirizine, an antihistamine), Sudafed (pseudoephedrine hydrochloride, a decongestant), cough medication, and Flonase (fluticasone, a steroid nasal spray) with minimal improvement.  In 2003 she had a tonsillectomy, which helped her chronic sinus infection and drainage.  The CI had aeroallergen skin testing in March 2003 that was positive for trees, grasses, ragweed, cat hair, and dust mites.  Avoidance, medication including Allegra (fexofenadine, an antihistamine) and Flonase spray were prescribed, and immunotherapy for desensitization was to be performed; however, the CI stopped twice and then decided not to continue taking three shots a week.  The CI had an exacerbation of allergic rhinoconjunctivitis (runny nose and inflammation of the eyes) in April 2003 that was treated with Allegra, Atrovent (ipratropium bromide, an anticholinergic medication) nasal spray, Patanol (olopatadine, an antihistamine) eye drops, and Benadryl (diphenhydramine, an antihistamine) at bedtime.  Treatment did not result in improvement sufficient to allow unrestricted duty. The MEB forwarded “reactive airway disease, allergy) for PEB adjudication.  At the MEB examination the CI reported allergic asthma and chronic sinusitis.  The examiner checked normal lungs and chest on the clinical evaluation.

A note in November 2004 indicated the CI was referred for pulmonary function testing (PFT) and was diagnosed with reactive airway disease.  The NARSUM dated 22 November 2004, performed 5 months prior to separation, indicated the CI used an albuterol inhaler.  She experienced exacerbations [of wheezing] with allergies especially around the pollen season, freshly cut grass, and other exposures.  She also had wheezing at times with running and never wore a gas mask more than 30 minutes.  A chest X-ray revealed no active chest disease.  The NARSUM also indicated the CI “required prednisone orally—about 3 times in the past 18 months.”  

At the VA C&P examination on 24 February 2005, performed 2 months before separation, the CI reported she had a loss of appetite, a cough with purulent (containing pus) sputum, orthopnea (shortness of breath when lying flat) and shortness of breath with walking two city blocks.  With change of seasons, she had asthma attacks yearly and saw a physician to control the attacks as often as three times a year.  She contracted infections easily which required antibiotics.  She did not report and any incapacitating episodes that required bed rest or treatment by a physician.  As a result of her condition, she could not engage in any strenuous activity.  Physical examination revealed symmetric breath sounds without rhonchi or rales (indicating obstruction or secretions in the lungs) and the expiratory phase of respiration was within normal limits.  The examiner concluded that a diagnosis was not possible because the reported PFT with old records reflected normal to poor results.  The CI did not have any complications secondary to her pulmonary disease.  PFTs were scheduled, but the CI did not report for the appointment.    

The Board directed attention to its recommendation based on the above evidence.  The PEB indicated there was compelling evidence to support a finding that the current condition existed prior to service (EPTS) and was not permanently aggravated beyond natural progression by such service.  A PEB reconsideration did not rate the condition but coded it 6602 (asthma, bronchial), citing “asthma with allergies.  FEV-1 greater than 100%.  The soldier’s wheezing episodes are related to environmental exposure and therefore constitute a reaction to the environmental allergens.  These allergies are long standing.”  The VA assigned a not service connected, no diagnosis using the 6602 code (asthma) based on the VA C&P examination 2 months before separation, citing no evidence of a confirmed diagnosis of asthma or evidence that the diagnosis was based on actual pulmonary function tests.  

The PEB’s determination was predicated on the position that the condition existed prior to service, although the diagnosis and treatment of the allergies and asthma occurred while the CI was on active duty.  The STRs presented for review did not contain PFT studies and the sole reference to a PFT was the FEV-1 being greater than 100% in the PEB reconsideration findings.  A 10% rating stipulates “FEV-1 of 71- to 80-percent predicted, or; FEV-1/FVC of 71 to 80 percent, or; intermittent inhalational or oral bronchodilator therapy.”  However, the sole PFT result in this case showed an FEV-1 greater than 80 percent predicted; therefore, a 10% rating could not be supported, but the CI did use intermittent inhalational or bronchodilator therapy warranting a 10% rating.  The CI did not use inhalation anti-inflammatory medication; therefore, a 30% rating was not warranted nor was a 60% rating warranted since the CI did not have at least monthly visits to a physician for required care of exacerbations and did not use at least three courses per year of systemic (oral or parenteral) corticosteroids.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the asthma condition, coded 6602.  

Contended PEB Condition: Migraines.  The Board’s main charge is to assess the fairness of the PEB’s determination that the migraines condition was unfitting.  The migraines condition was profiled and implicated in the commander’s statement, but was not judged to fail retention standards.  According to STRs and the NARSUM, the CI’s headaches, marked by nausea with pain over the posterior neck and face/temporal regions with blurred vision and photo/phonophobia, began in 2000 after receiving Lupron Depot (leuprolide acetate, a hormone) injections to treat her endometriosis.  She noted at a neurology consultation on 24 March 2003 that she was scheduled to get another injection, but chose not to, and had no headaches or significant abdominal discomfort for over 3 weeks.  She had taken Midrin (a combination of acetaminophen, dichloralphenazone, and isometheptene) and Imitrex (sumatriptan, a migraine abortive medication) in the past.  Neurological examination was unremarkable.  The neurologist’s diagnosis was migraine headaches related to the use of Lupron Depot and the CI was advised to avoid use of hormonal medications.  In October 2004 she had an Emergency Room visit for a migraine headache and was treated with Toradol (an NSAID) and Phenergan (promethazine, an antihistamine for nausea) and was started on Cafergot (ergotamine, to prevent migraine headaches) and Fioricet (acetaminophen, a pain reliever, butalbital, a barbiturate, and caffeine, a stimulant).  A neurology addendum dated 23 October 2004 indicated the CI had a good response to Cafergot for abortive therapy without significant side effects; however, she continued to have occasional migraine episodes, but were generally short-lasting and non-prostrating.  The examiner opined she remained medically acceptable.   
 
At the MEB examination the CI reported migraines.  The examiner checked off normal head, face, neck, and scalp on the clinical evaluation and listed migraines with the annotation of P3 [profile] in the summary of defects and diagnoses.  In November 2004, the CI had a protracted migraine headache for 3 days that was temporarily aborted with Fioricet.  Treatment consisted of prednisone for a 6-day taper.  The NARSUM dated 22 November 2004 indicated she used Cafergot and Fioricet on an as needed basis and still experienced headaches about twice a month and was disabled for 4-6 days when they occurred.  In April 2005 the CI reported being about 9 weeks pregnant.  She was counseled to discontinue the Cafergot, Fioricet and Midrin and to use Reglan (metoclopramide) or Phenergan for nausea and magnesium oxide for migraine prevention.  Percocet (oxycodone, a narcotic and acetaminophen, a pain reliever) was recommended for breakthrough pain. 

At the VA C&P examination on 24 February 2005, performed 2 months after separation, the CI reported migraines with associated nausea and vomiting for which she stayed in bed on the average of once every 3 weeks and the condition resulted in 9-10 times lost from work per year.  Neurologic examination was unremarkable and she was alert and oriented times three.  Behavior was normal; affect was appropriate; comprehension was intact; and there were no signs of tension.

After due deliberation, the Board agreed that the preponderance of the evidence with regard to the functional impairment of migraines condition favors its recommendation as an additionally unfitting condition for disability rating.  It is appropriately coded 8100 and meets the VASRD §4.124a criteria for a 30% rating with characteristic prostrating attacks occurring on an average once a month over last several months.

BOARD FINDINGS:  In the matter of the endometriosis condition, the Board unanimously recommends a disability rating of 30%, coded 7629 IAW VASRD §4.116.  In the matter of the asthma condition, the Board unanimously recommends a disability rating of 10%, coded 6602 IAW VASRD §4.97.  In the matter of the contended migraines condition, the Board unanimously agrees that it was unfitting and unanimously recommends a disability rating of 30%, coded 8100 IAW VASRD §4.124a.  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	
Endometriosis	7629	30%	
Asthma 	6602	10%	
Migraines	8100	30%	
COMBINED	60%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150311, 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

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXXXXX, AR20160018517 (PD-2015-00198)

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