RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00895
BRANCH OF SERVICE:  AIR FORCE	SEPARATION DATE:  20051128

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Utility Systems) medically separated for “recurrent deep venous thrombosis,” with a disability rating of 0%.  

CI CONTENTION:  “Review all conditions.”  The CI’s 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 or non-compensable.  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 panel 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 - 20050831	VARD - Service Treatment Records (STR)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Recurrent Deep Venous Thrombosis…(Associated with Factor V, Leiden Deficiency)	7199-7704-7121	0%	Deep Vein Thrombosis, Factor V Leiden Deficiency, Left Lower Extremity	7121	0%	STR	
			Deep Vein Thrombosis, Factor V Leiden Deficiency, Right Lower Extremity	7121	0%	STR	
Tobacco Habituation	Cat III	No VA Placement	
RATING:  0%	RATING:  0%	

ANALYSIS SUMMARY:  

Recurrent Deep Venous Thrombosis (DVT).  According to service treatment records (STRs) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s recurrent deep venous thrombosis condition began in July 2003 after a long trip.  On 29 July 2003, the CI reported right leg swelling and pain, which began 8 days earlier.  The diagnosis of a deep venous thrombosis was confirmed by an ultrasound examination and treatment consisted of Lovenox (enoxaparin, an anticoagulant) initially and Coumadin (warfarin, an anticoagulant) with regular monitoring of the INR (international normalized ratio to evaluate the clotting status potential) and dose modification as needed thereafter.  A follow-up Doppler examination on 18 November 2003 revealed there was still a clot and relatively minimal flow in the right superficial femoral vein whereas in the popliteal vein, satisfactory flow was reestablished.  In February 2004, the CI still had leg pain and cramping.  On 27 February 2004, an Internist felt it was appropriate to stop the Coumadin after 7 months of use and for the CI to take aspirin and to recheck laboratory studies. Vascular surgery evaluation recommended anticoagulation for life along with compression treatment as well as stopping smoking.  Laboratory results revealed a Factor V Leiden deficiency and Coumadin was continued.  In October 2004, the CI reported left leg pain and an ultrasound confirmed a deep vein thrombosis of the popliteal/superficial femoral vein network.  On examination there was 1+ edema of the left leg and tenderness to palpation of the popliteal area of the thigh.  Treatment consisted of a short course of Lovenox, life-long Coumadin with regular monitoring, and the use of compression hose.  

Despite treatment, the recurrent deep vein thrombosis condition could not be adequately rehabilitated such that the CI required life-long Coumadin therapy and could not to meet the physical requirements of the CI’s military specialty and he was referred for a MEB.  The MEB forwarded “recurrent DVT” for PEB adjudication.  At the MEB NARSUM, the CI denied shortness of breath, dyspnea on exertion, cough, nausea, vomiting, diarrhea, palpitations, chest pain, vision changes, eye pain, weight loss, numbness, paresthesias, rashes, or depression.  On examination the skin was noted to be normal and his chest was clear to auscultation bilaterally; however, no notation was present pertaining to the lower extremities.  The examiner noted that because of the Factor V Leiden deficiency with recurrent deep venous thrombosis, the CI would need life-long Coumadin therapy to prevent further events or more dangerous life threatening events such as stroke, myocardial infarction or pulmonary embolism. No VA Compensation and Pension (C&P) examination was performed.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 0% rating under an analogous 7199-7704-7121 code (Polycythemia vera-Post-phlebitic syndrome of any etiology), citing “recurrent deep venous thrombosis resolved but requiring Life-long anticoagulation (associated with Factor V, Leiden Deficiency).”  The VA assigned a 0% rating using the 7121 code (Post phlebitic syndrome of any etiology) based on the diagnosis of deep vein thrombosis, Factor V Leiden Deficiency, left lower extremity in the STRs.  The VA also assigned a 0% rating using the 7121 code (Post phlebitic syndrome of any etiology) based on the diagnosis of deep vein thrombosis, Factor V Leiden Deficiency, right lower extremity in the STRs.  

The PEB combined the left and right deep venous thrombosis conditions when it determined the rating.  A 0% rating using code 7121 requires “asymptomatic palpable or visible varicose veins,” while a 10% rating requires “intermittent edema of extremity or aching and fatigue in leg after prolonged standing or walking, with symptoms relieved by elevation of extremity or compression hosiery.”  However, at the time of separation, although each lower extremity had a history of a deep vein thrombosis, there was no mention of the physical status of either lower extremity in the undated NARSUM examination or any of the many clinic visits when the CI’s Coumadin was monitored, and there was no VA examination.  What the record did note was that the CI was advised to wear compression hose, which is a component of the 10% rating (appropriate for a single extremity) as noted previously.  Therefore, the Board believed that each lower extremity was reasonably justified as separately unfitting, as each extremity had a DVT which required life-long anti-coagulation therapy.  Thus, each extremity is separately ratable and a 10% rating for each leg is appropriate.  There was no documentation in the STRs that the CI met the requirements for a 20% rating for either leg, which requires “persistent edema, incompletely relieved by elevation of extremity, with or without beginning stasis pigmentation or eczema.”  Board members then considered whether an analogous rating using code 6899-6817 (Pulmonary Vascular Disease) was reasonable based on the requirement of lifelong anticoagulation since a 60% rating mentions chronic pulmonary thromboembolism requiring anticoagulant therapy.  Against that position is that the CI had deep vein thromboses of the lower extremities, but did not have any pulmonary symptoms or imaging evidence to support a diagnosis of either an acute pulmonary embolus or chronic pulmonary emboli.  Nevertheless, he was advised to take life-long Coumadin to prevent recurrent venous thromboses and the consequences of non-treatment.  However, the VASRD does not address life-long anticoagulation for rating purposes for a DVT of an extremity despite the requirements of regular laboratory monitoring, dietary precautions, dose modifications, caution in regard to drug interactions, and clinical monitoring for internal and/or external bleeding.  Therefore, it is appropriate to use the analogous code 7199-7121 to rate each separately unfitting lower extremity IAW with the VASRD and DoDI 6040.44 at 10%.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board majority recommends a disability rating of 10% for the right leg deep venous thrombosis condition, coded 7199-7121 and a disability rating of 10% for the left leg deep venous thrombosis condition, coded 7199-7121.  

Contended PEB Condition-Tobacco Habituation.  The Board’s main charge is to assess the fairness of the PEB’s determination that tobacco habituation condition was not unfitting. Tobacco habituation is not a condition that constitutes a physical disability.  After due deliberation, and in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB determination for the tobacco habituation.  

BOARD FINDINGS:  In the matter of the right lower extremity deep venous thrombosis condition, the Board majority recommends a disability rating of 10%, coded 7199-7121 IAW VASRD §4.104.  In the matter of the left lower extremity deep venous thrombosis condition, the Board majority recommends a disability rating of 10%, coded 7199-7121 IAW VASRD §4.104.  In the matter of the contended tobacco habituation condition, the Board unanimously recommends no change from the PEB determination as not unfitting.  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, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	RATING	
Right Lower Extremity Deep Venous Thrombosis 	7199-7121	10%	
Left Lower Extremity Deep Venous Thrombosis 	7199-7121	10%	
COMBINED RATING	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150608, 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-2015-00895.

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 not appropriate under the guidelines of the Veterans Affairs Schedule for Rating Disabilities.  Accordingly, the Board recommended modification of your assigned disability rating without re-characterization of your separation with severance pay. 

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding, accept their recommendation and direct that your records be corrected as set forth in the attached copy of a Memorandum for the Chief of Staff, United States Air Force.  The office responsible for making the correction will inform you when your records have been changed.

							Sincerely,

XXXXXXXXXXXXXXXXXX
Director
Air Force Review Boards Agency

Attachments:
1. Directive
2. Record of Proceedings

cc:
SAF/MRBR