RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00779
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20071210

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Operating Room Specialist, medically separated for “recurrent uncontrolled neurocardiogenic syncope” with a disability rating of 10%.

CI CONTENTION:  “Review all conditions.”  The 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 review of disability ratings assigned 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 - 20071113	VARD – NA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Recurrent Uncontrolled Neurocardiogenic Syncope	8299-8210	10%	No VA examination in evidence	
Plantar Fasciitis	Not Unfitting 		
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:  

Recurrent Uncontrolled Neurocardiogenic Syncope.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI had a pre-enlistment history of syncope (abrupt loss of consciousness) and near-syncope (feeling faint without losing consciousness).  The ratable disability prior to service could not be determined.  She suffered one episode of syncope in September 2005 (26 months before separation) after prolonged standing while serving as an operating room technician.  A seizure work-up for that event was negative, and included a normal electroencephalograph (EEG).  She continued to experience frequent episodes of near-syncope that interfered with her duties (no additional episodes of syncope in evidence); and, underwent a thorough evaluation for cardiac or other causes of the condition (full laboratory investigation, cardiogram, ECHO, Holter, coronary catheterization, stress test, nuclear perfusion, other specialized imaging and angiography studies).  All results were normal; and, there was no evidence supporting any ratable criterion under VASRD cardiovascular codes (no arrhythmias, exercise tolerance was 11 METS, no hypertrophy, normal ejection fraction, etc.).  A trial of various treatment modalities did not result in sufficient improvement to allow unrestricted duty. 

The 12 October 2007 NARSUM examination, 2 months before separation, documented that the CI “continues to have near syncopal episodes 3 to 4 times per week” that were aborted by sitting and resting.  All findings were normal by physical examination. There was no VA claim, examination, or clinical notes on file; and, there was no other post-separation evidence in this case.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB’s rating under code 8299-8210 (analogous to vagus nerve impairment) cited “moderate” impairment as the criterion applicable to its 10% determination.  Code 8210 also offers a 30% rating for “severe” impairment.  The VASRD does not offer a code specific to syncope or near-syncope.  Since vagus nerve dysfunction mediates neurocardiogenic syncope, the PEB’s 8210 was a reasonable analogous code on clinical grounds.  The only other code that might be considered for analogous rating in this case is 8999-8911 (analogous to petit mal epilepsy).  This would default to the VASRD §4.124a general seizure formula and would entail rating the near syncopal events as equivalent to minor seizures.  Consideration of rating the single full syncopal event as equivalent to a major seizure was moot given the 2-year interval specified in the formula.  The applicable 20% criterion under the formula is “2 minor seizures in the last 6 months,” and the 40% criterion is “averaging at least 5 to 8 minor seizures weekly.”

The panel 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 more applicable to code 8210 in this case, as established above; and, a seizure etiology was excluded by EEG.  Furthermore, the analogous default to disability akin to minor seizures is commonly reserved for loss of consciousness or other significant alterations in mental status without a specific diagnosis or known etiology. Having agreed that rating under code 8299-8210 was appropriate, members further concluded that the “severe” criterion for a higher rating was not justified by the disability in evidence.  

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication of the recurrent uncontrolled neurocardiogenic syncope condition.

Contended PEB Condition:  Plantar Fasciitis.  The panel’s main charge was to assess the fairness of the PEB’s determination that the condition was not unfitting.  The STR noted a 2-year history of foot pain, and there was a single podiatry entry that diagnosed bilateral plantar fasciitis treated with orthotics.  The NARSUM did not address the condition, although it was forwarded on the MEB’s DA Form 3947 as meeting retention standards.  It was not profiled or mentioned in the commander’s performance statement.  There was no performance-based evidence that indicated the condition significantly interfered with satisfactory duty performance at separation.    After due deliberation, the panel concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition and so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the recurrent uncontrolled neurocardiogenic syncope condition and IAW VASRD §4.124a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the contended plantar fasciitis condition, the panel unanimously agrees that it cannot recommend it for additional disability rating.  There are no other conditions within the panel’s scope of review for consideration.  The panel, therefore, recommends that there be no modification or 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/attachments
Exhibit B.  Service Treatment Record

AR20170007028, XXXXXXXXXXXXXXXXXX. 

Dear XXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found your separation disability rating and your separation from the Army for disability with severance pay to be accurate.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed), and I accept its recommendation.  I regret to inform you that your application to the DoD PDBR is denied.  

	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.

Sincerely,