RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00654
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20031215

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an Air National Guard E7, Security Forces Craftsman, medically separated for “dyspnea associated with paralyzed right hemidiaphragm,” with a disability rating of 10%.  

CI CONTENTION:  “Review 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 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 - 20031003	VARD - 20040803	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Dyspnea Associated with Paralyzed Right Hemidiaphragm	6602-6699	10%	Sleep Apnea S/P Somnoplasty, Uvulectomy and Tonsillectomy and Idiopathic Paralyzed Right Hemidiaphragm with Insomnia and Dyspnea	6840-6847	50%	20040403	
Sleep Apnea	6847	Cat II					
Insomnia	Cat III					
Obesity		No VA Placement	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY:  

Dyspnea Associated with Paralyzed Right Hemidiaphragm.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s chest pain and shortness of breath (dyspnea) began acutely in November 1999 while running.  During evaluation he was found to have a paralyzed right hemidiaphragm of unclear etiology (confirmed by fluoroscopy). 
 
At the 20 August 2002 pulmonary specialist evaluation, the CI was evaluated for dyspnea.  Pulmonary function tests (PFT) revealed mild to moderately severe, irreversible, restrictive ventilator impairment and mildly decreased FEV1 and flow rates, with no changes after a bronchodilator.  Pulse oximetry testing showed no evidence of baseline resting or exercise-induced hypoxemia.  X-rays showed a right apical calcified nodule, an elevated right hemidiaphragm, and Chilaiditi Syndrome (portion of intestines located between the liver and the diaphragm), with no change from a July 2001 X-ray of July 2001.  The specialist’s impression was of idiopathic unilateral phrenic nerve paralysis.  The CI was evaluated by multiple specialists without resolution of the hemidiaphragm paralysis.  

The 2 April 2003 MEB NARSUM examination, 8 months prior to separation, noted the CI reported difficulty with physical activity as causing more shortness of breath and increased fatigue.  Dyspnea was chronic and “also complicated by difficulty sleeping, snoring, daytime sleepiness and recurrent sinus infections.”  The physical examination showed the lungs were clear to auscultation bilaterally and respirations were not labored.  The examiner referred to the PFTs done 20 August 2002 (above), but no spirometry values were listed.  PFTs dated 19 June 2003 showed three trials with FEV1 of 72%, 72%, and 70% predicted and all trials had FEV1/FVC of over 80%.  The source evaluator’s interpretation was:  “Acceptable test with good reproducibility in both FEV1 and FVC as well as a total expiratory time greater than 6 seconds in duration.  Baseline spirometry is significant for mild airway restriction with an FVC of 68% expected.  Further testing with TLC and DLCO is recommended.”  

At the 3 April 2004 VA Compensation and Pension (C&P) evaluation, 4 months after separation, the CI reported shortness of breath and a paralyzed right hemidiaphragm since collapsing during a run in 1999.  He took albuterol inhaler as needed approximately once a week.  The physical exam showed lungs were clear to auscultation.  The diagnosis was “symptom of dyspnea secondary to partial paralyzed hemidiaphragm, essentially of an insignificant clinical significance.”  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the dyspnea associated with paralyzed right hemidiaphragm condition 10%, coded analogously to 6602 (asthma).  The VA rated all combined pulmonary-related conditions as “sleep apnea s/p somnoplasty, uvulectomy and tonsillectomy and idiopathic paralyzed right hemidiaphragm with insomnia and dyspnea” at 50%, coded 6840-6847 (diaphragm paralysis -- sleep apnea syndrome), based on the C&P examination 4 months after separation, citing requirement for continuous airway pressure (CPAP).  

There was no evidence of requirement for medications beyond occasional inhaled bronchodilator medication (albuterol) for any rating higher than 10% based on medication use under code 6602.  The 10% and 30% criteria for code 6840 that were deliberated contain the same FEV-1 and FEV-1/FVC values as code 6602, and are:  

			FEV-1 of 56- to 70-percent predicted, or; FEV-1/FVC of 56 to 70 
				percent, or; DLCO (SB) 56- to 65-percent predicted	30  
			FEV-1 of 71- to 80-percent predicted, or; FEV-1/FVC of 71 to 80 
				percent, or; DLCO (SB) 66- to 80-percent predicted	10 

Regarding code 6840, there was no (DLCO (SB)) testing in evidence [diffusion capacity of the lung for carbon monoxide by the single breath method].  There was no right ventricular hypertrophy, or; pulmonary hypertension (shown by Echo or cardiac catheterization), or; episode(s) of acute respiratory failure in evidence.  The CI’s use of oxygen at night was not considered to equate to “requires outpatient oxygen therapy” noted in the 100% criteria for code 6840.  

The Board deliberated on the PFTs in evidence and noted that the third trial of testing indicated an FEV-1 of 70% predicted with good effort and slightly irregular flow loop.  Although the first two trials, and the average, indicated an FEV-1 of 72% predicted, the CI’s paralyzed hemidiaphragm (muscle/phrenic nerve) and symptoms indicating increased dyspnea on activity, raised the issue of decreased endurance of the respiratory muscles.  The Board considered the provisions of the VASRD Revised FAST Letter 97-67, Pulmonary Function Tests in the Evaluation of Respiratory Conditions (in effect at the time and similar to the current VASRD §4.96), para 4: “When there is a disparity between the results of different tests (FEV-1, FVC, etc.), so that the level of evaluation would differ depending on which test result you use, the examiner should tell you which test result most accurately reflects the level of disability.”  The Board noted that the FEV1/FVC ratio for the three tests were all greater than 85% predicted.  These results could reasonably be characterized as “mild.”  Further, the examiner’s impression was noted as a “mild airway restriction” on the three PFTs. The Formal PEB noted that the CI had missed no work but did testify to some limits in the activities of daily living.  At the C&P evaluation 4 months after separation the VA examiner stated the “symptom of dyspnea secondary to partial paralyzed hemidiaphragm, [is] essentially of an insignificant clinical significance.”  The Board noted that these statements corroborated the NARSUM examiner’s impression of “mild airway restriction” and supported the majority’s opinion that the FEV1 of 72% predicted, most accurately reflected the level of disability, and that the PEB accurately and fairly rated the condition at 10% based on an FEV-1 of 71- to 80-percent predicted.  

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board majority concluded that there was insufficient cause to recommend a change in the PEB adjudication for the dyspnea associated with paralyzed right hemidiaphragm condition.  

Contended PEB Conditions:  Sleep Apnea, Obesity, and Insomnia.  The Board’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  None of the conditions were profiled, implicated in the commander’s statement or judged to fail retention standards.  There was no performance-based evidence from the record that any of the conditions significantly interfered with satisfactory duty performance at separation.  The Formal PEB specifically addressed the sleep apnea with required night-time oxygen use as not unfitting.  Routinely, sleep apnea is not considered unfitting solely on the basis of field and operational impediments to the use of night-time treatments.  There is no evidence in this case that sleep apnea was associated with any functional impairments that were not corrected by night-time treatment with oxygen or a breathing device (such as CPAP).  Obesity and insomnia are not physical disabilities and are not compensable.  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 dyspnea associated with paralyzed right hemidiaphragm condition and IAW VASRD §4.97, the Board majority recommends no change in the PEB adjudication.  In the matter of the contended sleep apnea, obesity, and insomnia conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting.  The single voter for dissent submitted the appended minority opinion.  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 20150603, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

	

MINORITY OPINION:  

In the matter of the dyspnea associated with paralyzed right hemidiaphragm condition, the minority voter recommends a disability rating of 30%, coded 6840 IAW VASRD §4.97.  

The CI had increased dyspnea with activities, he used home oxygen at night, and had some limits in the activity of daily living.  Although recommended for more comprehensive pulmonary testing (TLC and DLCO), none was accomplished.  The Formal PEB statement that “the member is appropriately rated at 10 percent, based on his level of functionality in a sedentary job,” did not align with any VASRD rating criteria.  

PFT evaluations had indicated that there was no significant response to bronchodilators, and the paralyzed right hemidiaphragm (muscle) should also be considered as an impairment (paralysis) of the right phrenic nerve.  There was no clear statement from the examiner which indicated which value of the PFTs best described the CI’s disability.  

Ratings for conditions impacting muscle use consider lack of endurance as a significant component for rating.  The minority voter adjudged that the CI’s PFTs of FEV-1 of 70% following repetition and dyspnea symptoms were most likely due to lack of endurance, and that the CI’s disability picture more nearly approximated the 30% criteria under code 6840 for; “FEV-1 of 56- to 70-percent predicted.”  

The minority voter 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	
Dyspnea Associated with Paralyzed Right Hemidiaphragm	6840	30%	

SAF/MRB
XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2015-00654.

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.  I accept their recommendation that your application be denied.

Sincerely,

Director
Air Force Review Boards Agency

Attachment:
Record of Proceedings