RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00535
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20060313

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Aerospace Maintenance Craftsman, medically separated for “asthma,” with a disability rating of 10%.

CI CONTENTION:  The CI requests consideration of all conditions.  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 - 20060126	VARD - 20070105	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Asthma	6602	10%	Asthma	6602	NSC	STR	
Overweight	CAT III	No VA Entry	
Tobacco Habituation	CAT III	No VA Entry	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  None	

ANALYSIS SUMMARY:  

Asthma.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI developed episodes of wheezing commencing in 2004 and was subsequently diagnosed with asthma by pulmonary function tests (PFT).  His initial treatment was with albuterol (inhalational bronchodilator) as needed.  He was later started on Azmacort (inhalational steroid anti-inflammatory); and, in June 2005 (9 months before separation) the latter was switched to Advair (inhaled steroid with bronchodilator), with daily dosing prescribed.  There were multiple automated pharmacy lists in the STR which indicated that Advair was dispensed only one time on the day of the above visit, and there was no evidence to the contrary.  The quantity dispensed was not specified, but other entries indicated that a 30-day supply was the norm.  Albuterol was prescribed “as needed” (prn) and pharmacy data indicated that the last prescription had expired five months before separation.  There were continuing provider entries in the STR with medication listings (by history) of albuterol and Advair, but they did not address frequency of use or compliance.  The latter included the MEB’s DD Form 2697, Report of Medical Assessment (February 2006, 6 weeks before separation).  There were multiple pulmonary function test (PFT) results in evidence.  Measurements of FEV1 (some post-bronchodilator, some not) ranged from 71% to 76% predicted, and FEV1/FVC ratios ranged from 96% to 99%.  There was no significant change in PFT parameters with Advair (FEV1 76% on the day of the prescription, 74% six weeks later).  There was no STR evidence for respiratory failure, hospital admissions, continuous requirement for systemic corticosteroids, or monthly exacerbations requiring physician visits (criteria for VASRD ratings higher than 30%).  Continued treatment did not result in sufficient improvement to allow unrestricted duty, and the CI was referred for an MEB which in turn forwarded “asthma” to the PEB.

The NARSUM examination in January 2006 (2 months before separation) documented “does require Albuterol before his routine exercise but otherwise doing no exercise would generally only require his Albuterol 3 times per week ... very well controlled ....”  The NARSUM history indicated a positive response to Advair, without specifying compliance, and Advair at a twice daily dose was on the medication list.  The physical examination recorded clear lungs.  The CI failed to report for a scheduled VA examination and there was no post-separation evidence.

The Board directed attention to its rating recommendation based on the above evidence.  VASRD §4.97 defines both PFT-derived criteria and clinical treatment criteria for rating under code 6602 (asthma).  The 6602 criteria for a rating higher than 30% were not in evidence as above.  The criteria for the ratings under consideration are: 30% - “FEV-1 of [56-70%] predicted, or; FEV-1/FVC of [56-70%], or; daily inhalational or oral bronchodilator therapy, or; inhalational anti-inflammatory medication;” and, 10% - “FEV-1 of [71-80%] predicted, or; FEV-1/FVC of [71-80%], or; intermittent inhalational or oral bronchodilator therapy.”  A 10% rating is supported by the PFT criteria in this case.  This was presumably the basis of the PEB’s rating determination, although a rationale was not cited.  The VA did not service connect the condition, citing failure to forward requested records or present for examination.   

The Board deliberated whether the above medication criteria for a 30% rating were supported.  The pharmacy evidence and NARSUM established that there was not daily use of a bronchodilator (albuterol) to support that criterion.  It was less clear cut as to whether the evidence for the use of an inhalational anti-inflammatory (Advair) was sufficient to support a 30% recommendation premised on that criterion.  The rating language does not specify a daily requirement for inhalational anti-inflammatory, and members were left to judge in this case whether the evidence supported at least some regular use of Advair at the time of separation that would reasonably satisfy the criterion.  

Despite provider reports of ongoing treatment with Advair, the objective (and therefore more probative) pharmacy evidence indicated that the amount dispensed would not have covered more than very sporadic use of Advair over the period to separation; e.g., a 30-day supply (60 doses) for a 9-month period.  The serial PFT results did not reflect a therapeutic response consistent with sustained daily use of inhaled steroids.  It could be speculated that there was an undocumented supply of the medication, or conceded that the provider entries were sufficient evidence of its continuing regular use; but, members agreed that the compelling objective evidence to the contrary could not be overcome for concluding that the inhalational anti-inflammatory criterion was adequately satisfied in this case.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication of the asthma condition.
Contended PEB Conditions:  Overweight and Tobacco Habituation.  There were two contended Category III (conditions that are not separately unfitting and not compensable or ratable) adjudications in this case.  These are not subject to service compensation IAW DoDI 1332.38 and the VASRD.  After due deliberation, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for any of the contended conditions and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the asthma condition and IAW VASRD §4.97, the Board unanimously recommends no change in the PEB adjudication.  There were no other conditions within the Board’s scope of review for consideration.  The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.  

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

SAF/MR

Dear XXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2015-00535.

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.

Sincerely,

Attachment:
Record of Proceedings