RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01096
BRANCH OF SERVICE:  Navy 	SEPARATION DATE:  20080112

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Deep Dive Operator, medically separated for “post traumatic stress disorder (PTSD)” and “obstructive ventilatory defect,” rated 10% and 10% respectively, with a combined disability rating of 20%.

CI CONTENTION:  The CI requests the Board consider 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 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 determination 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(s) 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 - 20071102	VARD - 20081015	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Post Traumatic Stress Disorder (PTSD)	9411	10%	PTSD, Personal Trauma	9411	50%	20080910	
Obstructive Ventilatory Defect	6699-6604	10%	Pulmonary Edema	6600	NSC	20080910	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Post Traumatic Stress Disorder (PTSD).  According to service treatment records (STR) and the Medical Evaluation Board (MEB) mental health (MH) narrative summary (NARSUM), the CI was initially evaluated on 25 June 2007 for MH symptoms after passing out from possible oxygen toxicity during a dive in August 2006 where he had a brief loss of consciousness.  Neurological evaluation was normal, however, he spent 4 days in the hospital secondary to pulmonary edema subsequent to the near drowning experience.  Since then he was not able to dive.  
The CI developed nightmares, flashbacks, intrusive thoughts, and shortness of breath, poor memory, decreased concentration and agoraphobia.  He was diagnosed with PTSD and prescribed psychotropic medication to address anxiety and mood symptoms and sleep medication, but elected to take only the sleep medication.  Due to the CI’s inability to successfully perform his military duties, he was referred to the MEB.  

At the MEB NARSUM examination on 9 August 2007, 6 months prior to separation, the CI stated “I had a diving accident and do not want to dive anymore.”  It was noted that after the diving accident, the CI was able to return to work but was disqualified from diving and was performing non-diving duties.  The CI reported he had a good relationship with his wife of 6 months and he enjoyed spending time with her and walking his dogs.  The CI participated in three individual psychotherapy sessions and was evaluated twice for medications.  However, he agreed only to take Ambien.  The thought of diving continued to cause extreme anxiety and he was not able to complete work requirements expected of a diver.  The mental status examination (MSE) was unremarkable with the exception of “somewhat anxious” mood and affect.  The diagnosis of PTSD was recorded and the Global Assessment of Functioning (GAF) score indicated moderate symptoms and or impairment.

At the 10 September 2008 VA Compensation and Pension (C&P) evaluation, performed 9 months after separation, the CI reported since his discharge, he had been unable to find employment and  planned to relocate in search of better employment opportunities.  He applied for several jobs but was unsuccessful.  He and his wife had plans to go to Florida where he had acquaintances and had set up several interviews for possible job positions.  The CI reported symptoms of anxiety and depression, in addition to PTSD symptoms.  The MSE was unremarkable with the exception of notable anxiety.  He endorsed problems with sleep and panic attacks, however frequency of attacks was not recorded.  The diagnoses of PTSD and adjustment disorder with anxiety and depression were recorded, and the GAF score indicated borderline mild to moderate impairment and or symptoms.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the PTSD condition 10%, coded 9411 (post-traumatic stress disorder).  The VA rated the condition of PTSD, coded 9411 at 50%. For “Occupational and social impairment with reduced reliability and productivity due to panic attacks; impairment of short- and long-term memory; disturbances of motivation and mood; depression, anxiety, sleep difficulty, nightmares about the near drowning.”

The Board, IAW DoDI 6040.44 and DoD guidance will recommend a minimum 50% rating for a retroactive 6-month period on the Temporary Disability Retired List (TDRL).  The panel must then determine the most appropriate fit with VASRD 4.130 criteria at 6 months for its permanent rating recommendation, based on the facts in evidence which are most probative for that interval.  The Panel considered the record in evidence did not support a higher than 50% rating for TDRL placement. 

The panel next considered whether the evidence at the time of removal from TDRL and permanent disability disposition supported a rating higher than the 10% rating adjudicated by the PEB.  The 50% disability rating requires evidence of “Occupational and social impairment with reduced reliability and productivity due to symptoms such as: flat affect, panic attacks more than once a week, difficulty in understanding complex commands, impaired short and long-term memory and impairment in judgment and thinking…”  The C&P MH examination, 9 months after separation, documented that the CI was not working, but was actively seeking employment.  There was no evidence suggesting that if the CI had employment that he would have occupational impairment from his PTSD symptoms.  Although the C&P examination recorded the report of symptoms that were not recorded at separation, there was no report that the CI sought treatment in the ER for his panic attacks, and the CI was not hospitalized psychiatrically.  His PTSD symptoms had not worsen significantly and his symptoms were not treated.  

The panel considered the record in totality and noted that the CI had no history of hospitalization, ER visits, had minimal MH treatment, no history of suicidal or homicidal ideation, and no evidence of impairment in judgment at any time before or after separation.  Panel members concluded the evidence demonstrated the CI’s condition was stable at the time of separation, and that his disability was most reflective of the 10% level for “Occupational or social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication mild or transient”  After due deliberation, considering the totality of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a retroactive 6-month period of TDRL with a rating of 50% (in accordance with §4.129), and a permanent rating of 10% for PTSD. 

Obstructive Ventilatory Defect.  According to STR and the MEB NARSUM, the CI’s ventilatory defect began after the same near drowning incident during the dive in August 2006.  Upon surface ascent he was noted to seize and aspirate seawater, and developed pulmonary edema.  He was admitted to the ICU initially but required only minimal therapy and was transferred to a medical ward.  The CI was able to ambulate on room air by day 4 of hospitalization and was discharged.  In May 2007, the CI was medically cleared for dive duty, however was determined to be mentally unfit for dive duty.  He had pulmonary function tests documented in the mild range, and there was no evidence that intermittent or daily bronchodilator therapy was prescribed.  Due to the CI’s inability to dive he was referred to the MEB.  

The MEB NARSUM examination on 9 August 2007, 6 months prior to separation, noted the CI’s statement that he had no desire to dive after the accident.  The NARSUM noted that the CI was medically cleared for diving with 20% diminished lung capacity.  A physical diagnosis was deferred.  Ambien was the sole medication listed under current medications.  At the MEB examination (recorded on DD Forms 2807 and 2808) dated 10 September 2007, 5 months prior to separation, there was no mention of his pulmonary condition.

At the 10 September 2008 VA C&P evaluation the CI reported the diving accident but no current complaints were recorded.  Physical examination of the lungs was unremarkable.  The CI was not taking any medication with the exception of Ambien.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the obstructive ventilatory defect 10%, analogously coded 6604 (Chronic obstructive pulmonary disease (COPD)).  The VA did not service-connect the obstructive ventilatory defect based on the VA C&P examination 9 months after separation.  As noted above, the CI was placed on constructive TDRL, therefore, the panel first considered the rating at TDRL placement.  At the time of TDRL placement, the CI was not taking any medication related to COPD diagnosis.  Visits to the ER for respiratory complaints were absent, and there was no indication that his condition interfered with duty performance.  In fact, he was cleared for duty several months prior to separation.  The PFTs demonstrated values greater than 70%, FEV1/FVC, interpreted as mild obstructive defect.  The CI had a significant response to inhaled bronchodilator, but evidence of bronchodilator use in the months prior to separation was absent.  Panel members agreed, there was insufficient evidence to support a higher than 10% rating at constructive TDRL placement.  The panel next proceeded to the rating at the time of permanent separation, and all members agreed, there was not a path to a higher than 10% rating for the obstructive ventilatory defect.  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 for the lung condition.  

BOARD FINDINGS:  In the matter of the PTSD condition, the panel recommends an initial TDRL rating of 50% in retroactive compliance with VASRD §4.129 as DOD directed; and a 10% permanent rating at 6 months IAW VASRD §4.130.  In the matter of the obstructive ventilatory defect condition and IAW VASRD §4.97, the panel recommends no change in the PEB adjudication.  There were no other conditions within the panel’s scope of review for consideration.  

The panel 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	
		TDRL	PERMANENT	
PTSD	9411	50%	10%	
Obstructive Ventilatory Defect	6699-6604	10%	10%	
	60%	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150609, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

MEMORANDUM FOR DEPUTY COMMANDANT (Manpower and Reserve Affairs)
		   COMMANDER, NAVY PERSONNEL COMMAND	
	                          
Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS          

Ref:  (a) DoDI 6040.44
	(b) PDBR ltr dtd 13 Oct 17 ICO XXXXXXXXXXXXXXXXXXX
	(c) PDBR ltr dtd 20 Sep 17 ICO XXXXXXXXXXXXXXXXXXX  
	(d) PDBR ltr dtd 28 Sep 17 ICO XXXXXXXXXXXXXXXXXXX
	(e) PDBR ltr dtd 28 Sep 17 ICO XXXXXXXXXXXXXXXXXXX
	(f) PDBR ltr dtd 11 Apr 17 ICO XXXXXXXXXXXXXXXXXXX
	(g) PDBR ltr dtd 16 Jun 17 ICO XXXXXXXXXXXXXXXXXXX
	(h) PDBR ltr dtd 25 Sep 17 ICO XXXXXXXXXXXXXXXXXXX
	(i) PDBR ltr dtd 20 Sep 17 ICO XXXXXXXXXXXXXXXXXXX 

1.  Pursuant to reference (a), the recommendations of the Physical Disability Board of Review set forth in references (b) through (i) are approved.  The official records of the following individuals are to be corrected as follows:

     a. XXXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge. 

     b. XXXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 10 percent) effective date of discharge.

     c. XXXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 20 percent) effective date of discharge.

     d. XXXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 10 percent) effective date of discharge.

     e. XXXXXXXXXXXXXXXXXXX, former USN: Placement on Temporary Disability Retired List with a 60 percent disability rating for six months at time of separation followed by a permanent disability rating of 20 percent.

     f. XXXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 0 percent) effective date of discharge.

     g. XXXXXXXXXXXXXXXXXXX, former USMC: Placement on Temporary Disability Retired List with a 50 percent disability rating for six months at time of separation followed by a permanent disability rating of 10 percent.

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS

     h. XXXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge. 
     
3.  Please take action to implement these decisions and provide notification to the above individuals once those actions are complete.

                                  XXXXXXXXXXXXXXXXXXX
                                  Principal Deputy, Assistant Secretary
                                  Of the Navy (Manpower and Reserve Affairs)	
                                  Performing the Duties of Assistant 
                                  Secretary of the Navy 
                                  (Manpower and Reserve Affairs)