RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00533
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050413

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E6, Personnel Service Specialist, medically separated for “chronic fatigue” and “chronic right upper quadrant abdominal pain” rated 10% and 0% respectively, with a combined disability rating of 10%.  

CI CONTENTION:  The CI contends that his conditions should have received a higher rating.   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 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 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 - 20050322	VARD - 20051122	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Fatigue 	7528-7524-6354	10%	Testicular Cancer Status Post Orchiectomy with Chronic Fatigue	7528-7524	0%	STR	
Chronic Right Upper Quadrant Abdominal Pain	5099-5003	0%	Gastroesophageal Reflux with Hiatal Hernia and Status Post H. Pylori Treatment	7346	0%		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Chronic Fatigue.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s fatigue condition started after he completed treatment for left testicular cancer.  Surgical removal of the left testis was performed in June 2003, but after completing chemotherapy in October 2003 the CI complained of persistent fatigue.  There was no subsequent evidence of cancer recurrence, and extensive evaluation failed to identify a cause of the fatigue.  The function of the remaining right testis was normal and urinalysis testing was unremarkable.  The fatigue condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and he was referred for MEB. The MEB forwarded “testicular cancer” and “persistent fatigue” for PEB adjudication.  

The permanent profile on 5 August 2004 limited duty to not more than 8-hour shifts.  It permitted unlimited walking, biking, swimming and weight training.  In addition to citing the profile’s duty shift and physical training limitations, the commander’s statement on 10 August 2004, 8 months prior to separation, also referred to the inability to move a fighting load and dig a fighting position as impediments to duty performance.  At the MEB examination (recorded on DD Forms 2807 and 2808) dated 16 August 2004, 8 months prior to separation, the CI reported shortness of breath due to fatigue.  On the attached DD Form 2697 (Report of Medical Assessment) the CI wrote that “chemotherapy, cancer, severe pain in abdomen” caused him to miss duty for longer than 3 days.

The MEB NARSUM examination on 4 February 2005, 2 months prior to separation, noted complaints of feeling “tired all the time and … no energy.”  The fatigue limited his ability to work for extended periods and he required frequent breaks.  He could not run without having significant fatigue.  An anti-depressant medication (Zoloft) “moderately” helped his symptoms.  He denied bladder dysfunction.  The physical examination showed a blood pressure of 134/86 and no evidence of lower extremity swelling.  An MEB addendum on 16 February 2005 noted that the CI’s wife of 3 years was expecting their first child in August 2005.  The CI endorsed unhappiness about his medical circumstances, and reported that he was discontinuing the antidepressant medication because it was “not…doing anything for him.”  A mental status examination was normal.  The examiner stated there was no psychiatric diagnosis.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic fatigue condition 10% under a code combination 7528-7524-6354 (malignant neoplasms of the genitourinary system; testis removal; chronic fatigue syndrome), citing “symptoms controlled by continuous medication” as a rationale.  Based on the STR, the VA rated “testicular cancer…with chronic fatigue” at 0% coded 7528-7524 (malignant neoplasm of the genitourinary system; testis, removal), for loss of one testicle.  The Board noted that the unfitting condition in this case was the fatigue, which was properly rated under the 6354 base code.  Since treatment of testicular cancer led to this unfitting residual, inclusion of the 7528 and 7524 codes in combination with 6354 was reasonable.  However, the PEB appropriately did not consider those codes for rating purposes since the conditions those codes reflected were not unfitting.  Even conceding applicability of 7528 or 7524 for rating purposes however, neither code resulted in a rating advantage.  Under the 7524 code, removal of one testis warrants 0% in the presence of a normally functioning remaining testis.  Under the 7528 code, a rating is based on residuals of voiding dysfunction or renal dysfunction.  Since there was no evidence of constant albuminuria, recurrent hyaline or granular casts, blood cells in the urine, edema or hypertension, a rating higher than 0% was not justified for renal dysfunction.  There was no evidence of voiding dysfunction to support rating via this alternate stipulation under the 7528 code.  Finally, under the 6353 pathway, the 10% rating is justified by symptoms “which wax and wane but result in periods of incapacitation of at least one but less than two weeks total duration per year, or symptoms controlled by continuous medication.”  Incapacitation, which is also an alternative stipulation in the next higher 20% and 40% ratings, is defined as requiring bedrest and treatment by a physician.  Since there was no evidence of incapacitation, it cannot be used as a basis for the higher ratings in this case.  Since Board members did not conclude that continuous medication “controlled” the fatigue, the next higher ratings were carefully examined.  The 20% rating is justified by symptoms “which are nearly constant and restrict routine daily activities by less than 25 percent of the pre-illness level” and the 40% rating by symptoms “which are nearly constant and restrict routine daily activities to 50 to 75 percent of the pre-illness level.”  Board members agreed that symptoms “which are nearly constant” stipulation was satisfied.  However, there was no evidence that “routine daily activities” appeared to be restricted by 50-75%, and Board members concluded that the 20% criteria most accurately described the clinical picture in this case. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 20% for the chronic fatigue condition, coded 6354.  

Chronic Right Upper Quadrant Abdominal Pain.  The CI’s abdominal pain condition also started after completion of testicular cancer treatment.  Exhaustive evaluation discovered a hiatal hernia variably associated with reflux symptoms, and an infection of the stomach (Helicobacter pylori), but treatment of these conditions did not provide significant relief, and no clear etiology of the pain was established.  The abdominal pain condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty.  The MEB forwarded “idiopathic right upper quadrant pain” for PEB adjudication.  

At a gastroenterology evaluation on 21 May 2004, 11 months prior to separation, the CI reported that the right upper quadrant abdominal pain was intermittent, and sharp or cramping in nature. At times it could be extremely severe.  Body movements or exercise did not aggravate the pain. The CI denied heartburn, vomiting or difficulty swallowing (dysphagia).  The gastroenterologist subsequently performed an upper endoscopy which showed some inflammation of the duodenum (first section of intestine), but not the stomach.

At the MEB examination the CI reported severe, chronic abdominal pain that required frequent emergency room visits and interfered with sleep.  Examination of the abdomen was normal.  

At an emergency room visit on 18 October 2004 (6 months prior to separation), the CI complained of a 2-day history of intermittent 8/10 right upper quadrant abdominal pain associated with nausea.  Examination documented that the CI appeared well, calm and in no acute distress.  The abdomen was tender in the right upper quadrant.  At a 25 October 2004 primary care clinic evaluation, the CI complained of a 9 day history of burning pain in the chest, nausea and episodes of vomiting.  Treatment for Helicobacter pylori infection was started, but was stopped several days later due to worsening symptoms.  

The MEB NARSUM examination noted that current medications (which included a narcotic, and medications for gastritis and reflux) “only moderately” controlled his right upper quadrant abdominal pain.  He described episodes of pain which were stabbing, colicky and radiated to his back.  Significant reflux symptoms were present, but nausea and vomiting were denied.  Physical examination showed “slight” tenderness in the right upper abdominal quadrant.  The examiner rendered a diagnosis of idiopathic right upper quadrant pain.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the abdominal pain condition 0%, analogously coded 5099-5003 (arthritis, degenerative), with likely application of the US Army Physical Disability Agency (USAPDA) pain policy.  The VA also rated the abdominal condition 0% coded 7346 (hernia hiatal) based on the STR.  In debating the appropriate coding and rating for the abdominal pain condition, Board members acknowledged that no code ideally described the condition and associated disability. However, the 5003 code is a poor choice given the impossibility of assessing relevant and ratable range of motion in this case (a key element in VASRD §4.71a rating criteria).  Under the 7346 code a 30% rating requires “persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health.”  The 10% rating stipulates “two or more of the symptoms for the 30 percent evaluation of lesser severity.”  It was agreed that the 30% rating was not supported by the evidence, but the presence of epigastric distress and variable reports of reflux or substernal pain was reasonably conceded as fulfilling the 10% rating requirements.  The 7307 (gastritis, hypertophic), 7301 (peritoneum, adhesions of) and 8530 (ilio-inguinal nerve) codes were also considered but were inapplicable or did not result in a rating higher than 0%.  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 abdominal pain condition, coded 7346.  

Contended PEB Conditions:  Hyperlipidemia, Depression.  The Board’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  Neither of the conditions were profiled or implicated in the commander’s statement or judged to fail retention standards.  There was no performance-based evidence from the record that either of the conditions significantly interfered with satisfactory duty performance at separation. After due deliberation, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for either of the contended conditions and so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the chronic fatigue condition, the Board unanimously recommends a disability rating of 20%, coded 6354 IAW VASRD §4.88b.  In the matter of the chronic right upper quadrant abdominal pain condition, the Board unanimously recommends a disability rating of 10%, coded 7346 IAW VASRD §4.114.  In the matter of the contended hyperlipidemia and depression conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting.  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	
Chronic Fatigue 	6354	20%	
Chronic Right Upper Quadrant Abdominal Pain	7346	10%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150602, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB																		

MEMORANDUM FOR Commander

06 MAR 2017

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
XXXXXXXXXXXXXXXXXX, AR20170000677 (PD201500533)

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 30% 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 30% 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