RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX		CASE:  PD-2015-00376
BRANCH OF SERVICE:  Army 		SEPARATION DATE:  20030702

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Light Wheel Vehicle Mechanic, medically separated from the Temporary Disability Retirement List (TDRL) for “Crohn’s disease” and “chronic low back pain (LBP) ” rated at 10% each, with a combined disability rating of 20%.

CI CONTENTION:  The CI asked to review all conditions.  The 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 review of disability ratings assigned 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 or non-compensable.  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 determination 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(s) 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 - 20030529	VARD - 20030827	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Crohn’s Disease	7399-7323	10%	Crohn’s Disease	7399-7323	30%	20020916	
Chronic LBP	5293-5299-5295	10%	DJD at the Level of L4-5, L5, S1 and S/P Diskectomy L4-5	5293	20%	20020916	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  40% 	

ANALYSIS SUMMARY:  

Crohn’s Disease.  According to the service treatment record (STR) and Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s Crohn’s disease was diagnosed in 1995 under civilian care (records not in evidence).  In February 1997, the CI was hospitalized for a partial intestinal (small bowel) obstruction.  There was evidence of iron deficiency and anemia.  Multiple specialized radiographic evaluations documented a distal small intestinal stricture (narrowing).  Systemic anti-inflammatory medication (prednisone) was used for treatment, however, the CI was readmitted for a recurrent small intestinal obstruction 10 days later.  

At the 19 March 1997 MEB examination (documented on Standard Forms 93 and 88), 17 months prior to TDRL placement, the CI reported having indigestion and liver disease since his diagnosis, and a 20-pound weight loss due to his Crohn’s disease.  There was no laboratory evidence of anemia (low blood count).  His medication list included iron, folic acid, and prednisone.  In June 1997, surgical resection of the intestinal stricture was performed as there was no response to conservative treatment.  In a 15 July 1997 NARSUM examination, 13 months prior to TDRL placement, the CI reported good appetite and good weight gain with relatively normal bowel movements with minimal or no pain.  There were no symptoms of bowel obstruction.  At the 13 March 1998 NARSUM examination, 5 months prior to TDRL placement, the CI reported abdominal pain and multiple bowel movements after each meal and on a daily basis.  The physical examination showed a weight of 160 pounds, with a nontender, nondistended abdomen.  Laboratory findings documented iron deficiency and no anemia.  The CI was placed on TDRL with a disability rating of 30%, citing the need for chronic immunosuppressive therapy.  

At a 20 November 1998 VA Compensation and Pension (C&P) examination, 3 months after TDRL placement and 2 years prior to TDRL removal, the CI reported chronic episodic abdominal pain and loose stools/diarrhea, occurring twice weekly, with nausea and vomiting.  He reported that his medications (prednisone and mesalamine [Asacol] )prevented recurrence “in some ways.”  On physical examination, his weight was 175 pounds, and there was no abdominal tenderness.  There was no evidence of anemia on laboratory examinations.  At a 22 April 1999 TDRL reevaluation, 8 months after TDRL placement, the CI reported continued diarrhea occurring 3 to 4 times daily with blood, and abdominal pain 1 to 2 times weekly.  The physical examination showed a weight of 177 pounds, a nontender abdomen, with normal bowel sounds, normal liver size, and well healed abdominal scars.  At a 9 May 2003 gastroenterology visit, 2 months prior to TDRL removal, the CI reported abdominal pain after eating, blood with diarrhea, and a 20 pound weight loss in the previous weeks.  The physical examination showed abdominal tenderness with a weight of 142 pounds.  Conservative treatment did not resolve his symptoms and another surgical resection (ileocecectomy) was performed in June 2003, 2 weeks prior to TDRL removal.  At a follow-up visit, 3 weeks later, the CI reported “feeling much better, eating well, and gaining some weight back.”  The CI was removed from TDRL and separated with a permanent disability disposition of separation with severance pay at 10%.  There were no C&P examinations in evidence for review within 12 months after TDRL removal.  

In accordance with DoDI 6040.44, the panel is required to recommend a rating IAW the VASRD in effect at the time of separation.  The panel directed attention to the rating recommendation based on the above evidence. The panel considered its rating recommendation for permanent disability at the time of TDRL removal.  The STR shows that, prior to TDRL removal, there was documentation of increasing severity of symptoms (bloody diarrhea and general debility), greater than 35 pound weight loss (malnutrition), and abdominal tenderness, which resulted in another abdominal surgery for complications of Crohn’s disease.  This evidence would support the higher rating of 30% coded 7323.  After surgery and at separation, there was no evidence of ‘numerous attacks a year and malnutrition’ with the health ‘only fair during remissions;’ and no ‘definite interference with absorption and nutrition’ or ‘severe impairment of health’ that would support higher ratings under codes 7323 and 7328, respectively.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a permanent disability disposition rating of 30% at TDRL removal.  

Chronic Low Back Pain Status Post Status Post L4-L5 Discectomy.  According to the STR and MEB NARSUM, the CI had back surgery (left sided hemi-laminotomy, discectomy, and foraminotomy at the L4 and L5 vertebral levels) for a herniated disc and an L5 radiculopathy in July 1996 (2 years prior to TDRL placement).  
At the 19 March 1997 MEB examination the CI reported pain with forward bending or prolonged standing.  The physical examination showed pain radiating to the left lower extremity with toe touch.  According to a 7 July 1997 MEB addendum the CI reported inability to lift greater than 25 pounds, run, or perform push-ups or sit-ups without significant lower extremity radicular pain.  The physical examination showed flexion to 85 degrees (normal 90), normal bilateral side bending, and normal strength, sensation, and reflexes.  There was pain with nerve tension testing.  The CI was separated and placed on TDRL with a disability rating of 20%, citing recurrent attacks of moderate intervertebral disc syndrome.  

At a 20 November 1998 VA C&P examination the CI reported progressive pain with numbness into the left lower extremity and inability to lift more than 30 pounds, or walk/run for prolonged periods.  The physical examination showed lumbar flexion of 45 degrees (normal 60-90), and bilateral side bending to 20 degrees (normal 30), without painful motion.  Lumbar radiographs (X-rays) documented degenerative joint disease at L4-L5 and loss of intervertebral spacing between L5 and S1.  Radiographic evaluation (MRI) in July 2001 documented a recurrent L5 herniated disc with severe spinal canal narrowing.  Further studies in 2002 documented no significant progression.  At neurosurgical appointments in November 2001 and March 2002, 20 and 16 months prior to TDRL removal, the CI reported back pain radiating to the right lower extremity.  The physical examinations showed normal gait, strength, reflexes, and sensation.  ROM was documented as “limited” and “diminished,” respectively.  At a 16 September 2002 VA C&P examination the CI reported constant pain to the right lower extremity, and bed rest and treatment by a physician.  The physical examination showed evidence of tenderness, spasm, and radiation of pain on movement.  Nerve tension testing showed no signs of radiculopathy.  Flexion was to 90 degrees (normal), bilateral flexion was to 30 degrees (normal); all with painful motion.  There was a normal gait without assistive devices, and normal sensation, strength, and reflex testing.  At a 21 November 2002 neurosurgery visit for TDRL reevaluation the CI reported no improvement in the intermittent low back and leg pain and denied right leg symptoms.  The physical examination showed no spinal tenderness, no signs of nerve tension (negative straight leg raise), and normal gait, strength, and reflexes.  The CI was removed from TDRL with a permanent disability disposition of separation with severance pay at 10%, citing painful motion, intermittent radicular symptoms, without chronic muscle spasm or neurologic abnormality.   

The panel directed attention to the rating recommendation based on the above evidence.  At the time of TDRL entry in August 1998, the 2002 VASRD standards for rating were subject to the rater’s opinion regarding degree of severity.  At the time of TDRL removal, in July 2003, the 2003 VASRD standards were in effect.  The panel must correlate the above clinical data with the 2003 rating schedule; applicable diagnostic codes include: 5292 (limitation of lumbar spine motion); 5293 (intervertebral disc syndrome, based on incapacitating episodes); and 5295 (Lumbosacral strain).  There was no STR evidence of moderate limitation of motion of the lumbar spine in support of a higher 20% rating under 5292.  There was no STR evidence of incapacitating episodes having a total duration of at least 2 but less than 4 weeks during the prior 12 months in support of a higher 20% rating under 5293.  Likewise, there was no STR evidence of consistent muscle spasms on extreme forward bending, or loss of unilateral lateral spine motion in support of a higher rating.  There was, however, evidence of painful motion in support of the 10% rating adjudicated by the PEB.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded that there was insufficient cause to recommend a change in the PEB adjudications for the low back at TDRL removal.  

BOARD FINDINGS:  In the matter of the Crohn’s disease condition, the panel majority recommends a disability rating of 30% at TDRL removal, coded 7399-7323 IAW VASRD §4.114.  In the matter of the low back condition and IAW the 2002 and 2003 VASRD, the panel unanimously recommends no change in the PEB adjudication.  The single voter for dissent recommends a rating of 40% for the Crohn’s disease condition and elected not to submit a minority opinion.  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; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of his prior medical separation:  

CONDITION	VASRD CODE	RATING	
			
Crohn’s Disease	7399-7323	30%	
Low Back Pain	5293-5299-5295	10%	
RATING	40%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150530, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170005966, XXXXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXXXX  

Dear XXXXXXXXXXXXXXXXXXXXX:

	I accept the recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) to re-characterize your separation as a disability retirement with the combined disability rating of 40% effective the date of your medical separation for disability with severance pay.  Enclosed is a copy of the Board’s recommendation and record of proceedings for your information.

	The re-characterization of your separation as a disability retirement will result in an adjustment to your pay providing retirement pay from the date of your original medical separation minus the amount of severance pay you were previously paid at separation.
 
	The accepted DoD PDBR recommendation has been forwarded to the Army Physical Disability Agency for required correction of records and then to the U.S. Defense Finance and Accounting Service to make the necessary adjustment to your pay and allowances.  These agencies will provide you with official notification by mail as soon as the directed corrections have been made and will provide information on your retirement benefits.  Due to the large number of cases in process, please be advised that it may be several months before you receive notification that the corrections are completed and pay adjusted.  Inquiry concerning your correction of records should be addressed to the U.S. Army Physical Disability Agency, (AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557.

	A copy of this decision has also been provided to the Department of Veterans Affairs.

Sincerely,					      
Enclosure