RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00485
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070703

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Multiple Launch Rocket System Crewmember, medically separated for “vasovagal syncope” with a disability rating of 0%.

CI CONTENTION:  “Review all conditions.”  The CI’s 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 - 20070525	VARD - 20110606	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Vasovagal Syncope	8299-8210	0%	Vasovagal Syncope	8199-8108	NSC	20110118	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:  

Vasovagal Syncope.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI suffered a possible concussion in July 2006 and subsequently began experiencing frequent episodes of pre-syncope (feeling faint) with occasional syncope (passing out).  Cardiac and neurologic examinations were normal, but a tilt table test was positive, and the final diagnosis was vasovagal syncope.  Empiric medication trials, including Dilantin for the possibility of atypical seizures, were not helpful. 

As confirmed by the commander’s performance statement, the CI functioned satisfactorily with routine duties, but his condition was considered a hazard for various military requirements.  The 15 November 2006 cardiology NARSUM, 8 months prior to separation stated, “In total he has actually passed out only four or five times, but the pre-syncope is an almost daily occurrence.  
The CI was noted to claim if he lied down “the symptoms will almost always get better.”  The physical examination was normal, and the examiner expressed hope that the condition would resolve in the near term.  A VA Compensation and Pension (C&P) examination was not conducted until 6 June 2011, 4 years after separation, and it related that the symptoms had been resolved since 2007.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the vasovagal syncope condition 0%, coded 8299-8210 (analogous to vagus nerve impairment) but did not clarify the rationale.  The VA applied code 8199-8108 (analogous to narcolepsy), but did not service-connect the condition based on the absence of current symptoms.  The VASRD does not offer a code specific to syncope or pre-syncope.  Since vagus nerve dysfunction was the presumptive etiology of the condition in this case, 8210 was a reasonable analogous code on clinical grounds.  The only additional codes applicable for analogous rating in this case are the VA’s 8108 or, similarly, 8911 (petit mal epilepsy).  Both of these codes default to the VASRD §4.124a general seizure formula and would entail rating the events as equivalent to minor seizures.  Under those criteria, if even the near daily pre-syncopal events were conceded as minor seizure equivalents, the 40% criterion (5-8 weekly) would be satisfied.  The usual application of this analogous rating is for full syncopal events, and, by that standard only the 20% criterion (at least 2 in the last 6 months) could be defended.  

Members ultimately agreed, however, that the option of analogous rating as minor seizures was not sufficiently justified in this case.  The prerogative for analogous rating under the provisions of VASRD §4.20 (analogous ratings) calls for closely related “anatomical localization” that is much more applicable to code 8210 in this case, as established above.  The analogous default to minor seizures is commonly reserved for syncope or other significant alterations in mental status without a specific diagnosis or known etiology.  Members were also in agreement that, even if analogous rating under the seizure formula were conceded, only the limited number of full syncopal events captured in the NARSUM could be justified for rating; thus, this alternate analogous rating option would be of no practical benefit to the CI.  

Having agreed that rating under code 8299-8210 was more appropriate, members deliberated whether a rating higher than the PEB’s 0% could be justified.  Members agreed that the 30% criterion for severe impairment was not satisfied by the evidence but also agreed that the moderate 10% criterion was fairly conceded. After due deliberation, considering all of the evidence and conceding VASRD §4.3 (reasonable doubt), the panel recommends a 10% rating for the vasovagal syncope condition under code 8299-8210.

BOARD FINDINGS:  In the matter of the vasovagal syncope condition, the panel unanimously recommends a disability rating of 10%, coded 8299-8210 IAW VASRD §4.124a.  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	
Vasovagal Syncope	8299-8210	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150601, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170005974, XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found that your disability rating should be modified but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed) and I accept its recommendation.  This will not result in any change to your separation document or the amount of severance pay.  A copy of this decision will be filed with your Physical Evaluation Board records.  I regret that the facts of the case did not provide you with the outcome you may have desired.
  
	This decision is final.  Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction. 

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

Sincerely,	 
Enclosure