RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00833
BRANCH OF SERVICE:  Army
DATE PLACED ON TDRL:  XXXXXXXXX
DATE REMOVED FROM TDRL:  XXXXXXXXX

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve E3, Infantryman, medically separated from the Temporary Disability Retired List (TDRL) for “idiopathic thrombocytopenic purpura” with a disability rating of 0%.

CI CONTENTION:  The CI contends that the TDRL removal rating should be higher.  The 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 – 20020807/20040518	VA	
Condition	Code	Rating	Condition	Code	Rating
Proximate	
		TDRL
Placement	TDRL Removal			TDRL
Placement	TDRL
Removal	
Idiopathic Thrombocytopenic Purpura	7705	70%	0%	No VA Examination in Evidence	
COMBINED RATING:  70% → 0%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:

Idiopathic Thrombocytopenic Purpura (ITP).  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s ITP condition began with a severe rash and blood in his urine in the summer of 2001 after training.  He was hospitalized with a 0 platelet count (normal 130,000-380,000).  Following treatment, his platelet count increased on medication.  The MEB forwarded “ITP, which is stabilized with medication” for PEB adjudication and the CI was initially placed on TDRL at 70%.

The 11 February 2002 MEB NARSUM examination, 7 months prior to TDRL placement, noted a December 2001 hospital discharge diagnosis of ITP, with a platelet count of 31,000 on Danazol (a synthetic steroid).  Physical examination showed normal skin and mucosal exams.

During the TDRL examination on 20 March 2004, 3 months prior to TDRL removal, the CI reported continuing on daily Danazol and being followed by a hematologist and primary physician.  He complained of easy bruising and recurrent mild epistaxis (nose bleeds) on an average of once a week.  He denied recurrent skin rashes or blood in his urine or stool.  Physical examination was positive only for non-palpable “minimal scattered purpuric rashes present over the lower part of the neck and shoulder areas as well as the anterior aspects of both thighs.”  [Purpuric rash is a purplish discoloration of the skin produced by small bleeding vessels near the surface and it is indicative of an underlying cause of bleeding that is not equivalent to easy bruising].  Clinical and diagnostic tests showed a platelet count of 115,000 (normal 130,000-380,000), increased bleeding time 5.0 (normal 1-3), increased clotting time 20.5 (normal 8-14), with a white blood cell count of 4.3 (normal 4.8-10.8) and a normal urinalysis and no anemia.  There was no VA Compensation and Pension evaluation performed.

At TDRL removal, the PEB rated the ITP condition 0%, coded 7705 (thrombocytopenia, primary, idiopathic or immune), citing a platelet count of 115,000 on medication with easy bruising and mild epistaxis (nose bleeds) …“appears to be in nearly complete remission, but remains at risk for relapse.”  

At TDRL removal, the Board deliberated between the 0%, 30% and 70% criteria.  Platelet count, requirement for treatment, and bleeding were the ratable criteria evaluated.  Although the CI’s platelet count was 100,000 or more, the CI did have at least weekly minor bleeding (with abnormal bleeding time, clotting time, and purpuric rashes) which was adjudged by the Board consensus as supporting bleeding rather than supporting the “without bleeding” criteria, and the CI required treatment with medication.  The Board consensus agreed these findings did not support that the CI was “in nearly remission.”  The Board consensus determined at TDRL removal, the CI’s disability picture more nearly represented the 30% criteria under code 7705.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 30% for the idiopathic thrombocytopenic purpura condition, coded 7705.

BOARD FINDINGS:  In the matter of the idiopathic thrombocytopenic purpura condition, the Board majority recommends a disability rating of 30% at TDRL removal, coded 7705 IAW VASRD §4.117.  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 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	
Idiopathic Thrombocytopenic Purpura	7705	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150603, w/atchs
Exhibit B.  Service Treatment Record

MINORITY OPINION:  The minority dissent is with the majority’s interpretation of VASRD guidelines with regards to code 7705 as indicated:  

7705 Thrombocytopenia, primary, idiopathic (ITP) or immune: 
Platelet count of less than 20,000, with active bleeding, requiring 
treatment with medication and transfusions ....................................................100 
Platelet count between 20,000 and 70,000, not requiring treatment, 
without bleeding .................................................................................................70 
Stable platelet count between 70,000 and 100,000, without bleeding .............................30 
                                   Stable platelet count of 100,000 or more, without bleeding ...............................................0

The minority voter is of the firm opinion that the PEB correctly rated the CI’s condition at 0%.  According to the TDRL examination, the stable platelet count was 115,000.  The CI reported that he gets nose bleeds on average of once a week, which doesn’t constitute active bleeding.  He denied any recurrence of the skin rash, petechiae, blood in his urine or stool, no recurrence of hematuria, and he is not receiving frequent platelet or blood transfusions.  Additionally, at the time of the TDRL examination in December of 2003, the CI reported that he has been on daily medication since December 2001 and has only followed up with the hematologist on and off on an average of once or twice a year.  Lastly, radiologic evidence on 30 December 2003 showed “no active intrathoracic disease demonstrated.”  

There was no evidence of the CI seeking treatment from the VA since his separation and since his TDRL removal examination on 2 December 2003.

There was no evidence to support a rating higher than 0% as adjudicated by the PEB.  The platelet count was above 100,000 and there was no active bleeding.  The PEB noted that the condition “appears to be in nearly remission.”

The interpretation of VASRD guidelines provided ample support for a conclusion that the PEB’s adjudication of the unfitting thrombocytopenia purpura, idiopathic, condition was reasonable and fair, and consistent with the VA rating decision.

The Secretary is respectfully requested to consider the minority recommendation that there be no recharacterization of the CI’s service disability determination.

AR20170005112, XXXXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXXXX:

	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 record of proceedings, majority recommendation, and minority opinion (copy enclosed).  I regret to inform you that I reject the Board’s recommendation and your application to the DoD PDBR is denied.  There is insufficient justification to support the Board’s recommendation in accordance with Army and Department of Defense regulations.

	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,
						     
Enclosure