RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00713
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20060620

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E2, Aircraft Armament Systems Helper, medically separated for “postural orthostatic tachycardia syndrome (POTS) with chest pain and normal coronary arteries,” 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 - 20060504	VARD - 20061004	
Condition	Code	Rating	Condition	Code	Rating	Exam	
POTS with Chest Pain and Normal Coronary Arteries	8299-8210	10%	POTS	7099-7010	NSC	20060916	
			Chest Pain	7099-7005	NSC		
			Dizziness	6299-6204	NSC		
			Recurrent Syncope	7099-7015	NSC		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:  

POTS.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s POTS condition began in June 2005.  The CI experienced multiple episodes of chest pain and shortness of breath (SOB) with brief loss of consciousness.  He underwent a comprehensive cardiopulmonary work-up including pulmonary function testing (PFT), exercise treadmill testing (achieved 15 METS), heart rhythm monitoring, and heart catheterization, all of which were within normal.  Tilt table testing testing was positive and the CI was diagnosed with POTS.  He was placed on appropriate medication for the condition (Midodrine) and following treatment the CI did not have any recurrent syncopal episodes, but still experienced occasional dizziness.  The MEB forwarded “POTS syndrome; chest pain with normal coronary arteries” for adjudication by the PEB.  The MEB NARSUM examination on 14 February 2006, 4 months prior to separation, noted complaints of a history of recurrent syncope with postural dizziness despite treatment.  The physical examination cited a comprehensive physical examination on 13 February 2006, which was normal.  

At the 16 September 2006 VA Compensation and Pension (C&P) General medical evaluation, performed 3 months after separation, the CI reported wheezing, chest pain, and fatigue with moderate exertion.  Physical examination showed a normal steady gait.  Examination of the heart and lungs was normal.  Neurological examination was normal.  Pulmonary function testing on 5 November 2005 noted mild obstructive lung disease without improvement after bronchodilator medication and an electrocardiogram showed normal heart rhythm.  The examiner noted “NYHA [New York Heart Association] Classification of Heart Disease: Class II.”  (The NYHA classification is used to describe functional capacity due to heart failure.  Class II is “mild symptoms and slight limitation during ordinary activity.”)  The C&P Heart examination was performed on the same day by the same VA examiner as the General examination.  The history noted current symptoms of chest pain and shortness of breath with less than 5 minutes of exercise and one to two episodes per week of chest pressure and SOB that last 10 minutes or less.  The CI was on a beta–blocker medication daily for the condition.  The physical was the same.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the POTS condition 10%, coded 8299-8210 (analogous to incomplete paralysis of the tenth cranial [vagus] nerve) an analogous code for vasovagal syncope or syncope, not otherwise specified.  The VA did not service connect the condition, and cited that the first POTS episode occurred 1 week after entering active duty and was a pre-existing condition with no evidence of service aggravation.  At the time of separation, the CI was without symptoms and had not experienced recurrent syncope since being placed on appropriate medication.  The evidence supports no higher than 10% rating for the POTS condition for “moderate” incomplete paralysis of the vagus nerve, coded 8299-8210 IAW VARSD §4.124a (neurological conditions).  There was no evidence to support characterizing the incomplete vagus nerve paralysis as “severe” based on the extent of sensory or motor loss to the heart.  The Board considered if rating the POTS condition IAW VASRD §4.104 (cardiovascular system) supported a higher rating than 10%.  There was no evidence of a cardiomyopathy with a workload not greater than 10 METS (7020), or paroxysmal atrial fibrillation or other supraventricular tachycardia, with more than 4 episodes per year documented by ECG or Holter (7010) to support higher rating with the applicable codes.  The Board also considered alternative VASRD cardiovascular and analogous codes, but all were less applicable and not advantageous to rating.  There was no path to a higher rating than 10% as adjudicated by the PEB.  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 for the neurocardiogenic syncope condition.  

BOARD FINDINGS:  In the matter of the POTS condition and IAW VASRD §4.124a, 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 20150603, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD  20762

Dear XXXXXXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2015-00713.

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,

Director
Air Force Review Boards Agency

Attachment:
Record of Proceedings