RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01100
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050629

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Power Generator Equipment Repairman, medically separated for “insulin dependent diabetes mellitus,” with a disability rating of 20%.

CI CONTENTION:  “I would like for my rating to be updated to reflect the VASRD that was in effect in 2005.”  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 - 20050316	VARD - 20050720	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Insulin Dependent Diabetes Mellitus (Type 1)	7913	20%	Insulin Dependent Diabetes Mellitus Type I with Diabetic Nephropathy 	7913	20%	20050330	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Insulin Dependent Diabetes Mellitus.  According to service treatment records (STRs) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s diabetes mellitus condition marked by excessive thirst, urination, blurred vision, night sweats and some feet numbness, tingling and burning began in July 2003 which required treatment with dietary restriction and insulin.  Despite treatment his glucose levels continued to fluctuate and run in the higher range.  The CI was referred for diabetes education and nutrition therapy for dietary regulation in January 2004.  He was treated in the ER (Emergency Room) in March of 2004 for symptomatic hypoglycemia (low blood sugar) and his dose of insulin was lowered.  In June 2004 the CI was evaluated in the ER for an unexplained episode of sleeping versus syncope, which improved after eating a sandwich.  Despite taking Novolog (insulin aspart [rDNA origin]), Lantus (insulin glargine), and lisinopril (a medication to protect renal function) his weight increased and his diabetes was not well controlled.  By 12 January 2005 the Hgb A1C (a measure of long term diabetic control) was elevated at 11.1 (normal < 5.7) since the CI adjusted his insulin based on “how he feels” and he was unable to report exactly how much insulin he was taking. 

A permanent profile dated 1 March 2005 was issued for insulin dependent diabetes mellitus; however he was not restricted from physical activities, but was prevented from deployment, consumption of combat rations, or assignment where access to definitive medical care was not available. The commander’s statement dated 3 March 2005 indicated the CI was physically capable of performing his duties regardless of his illness of diabetes, although it noted that the CI could not take part in field exercises and deployments. 

According to the MEB examination (recorded on DD Forms 2807-1 and 2808) dated 3 March 2005, 3 months prior to separation, the CI reported tingling and foot pain associated with high sugar levels, frequent urination, and headaches.  When sugar levels were too low he blacked out.  The examiner noted that the CI had IDDM (insulin dependent diabetes mellitus) and did not have peripheral neuropathy or ulcerations or lesions of the feet.  There was no indication in the STRs that avoidance of strenuous occupational and recreational activities was medically necessary.  The MEB narrative summary (NARSUM) examination on 3 March 2005, 3 months prior to separation, noted that the CI was on Lantus and NovoLog (insulin).  The CI reported no issues with military duties specific within his MOS in garrison, but had difficulty in the field environment due to combat rations.  He was able to perform the basic activities of daily living without difficulty.  On examination there was no effusion, edema or muscle atrophy of the extremities.  Neurologic evaluation was unremarkable.  There were no ulcerations or lesions of the feet and the CI had a normal gait.  Although the examiner did not indicate that avoidance of strenuous occupational and recreational activities was medically necessary, duty restrictions included no assignment requiring continuous consumption of combat rations and no assignment where access to definitive medical care was not available.  The examiner additionally noted that the condition required ongoing medical care.

At the 30 March 2005 VA Compensation and Pension (C&P) evaluation, performed 3 months before separation the CI reported he was hospitalized in the prior year and visited the doctor six times per year for his diabetes.  He reported progressive loss of strength, tingling and numbness in the feet and hands, very frequent urination, blurry vision and dry skin.  On physical examination, the CI’s eyes, lungs, heart, kidneys, and neurological examination were normal.  Laboratory studies dated 31 March 2005 revealed a glucose of 320 mg/dL; urinalysis revealed 3+ glucose and ketones 2+ with a specific gravity greater than 1.035 (normal 1.005-1035), but the absence of protein.  There were negative casts, crystals, and bacteria and no white blood cells, red blood cells, or epithelial cells.  The Hgb A1C was 10.3.  The examiner’s diagnosis was insulin dependent diabetes mellitus type 1 and he noted the CI had diabetic nephropathy as a complication of the diabetes because his diabetes was poorly controlled.  He noted the diabetes did not cause any restriction of activities and the CI did not have a non-diabetic condition that was aggravated by the diabetes. 

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 20% rating for the insulin dependent diabetes mellitus condition under the code 7913 (Diabetes mellitus), citing “only one episode of hypoglycemia, but mostly having increased sugars.”  The VA assigned a 20% rating for “insulin dependent diabetes mellitus type II [actually type I] with diabetic nephropathy” using the 7913 code, based on the VA C&P examination 3 months before separation, citing a requirement for insulin and restricted diet, or oral hypoglycemic agent and restricted diet.    

The Board agreed that the requirement for treatment with insulin and restricted diet justified a 20% rating.  Because there was no evidence of medically prescribed regulation of activities, albeit the CI was restricted from duties in the field due to the use of combat rations, the next higher 40% rating is not justified.  Furthermore, the CI did not require frequent visits to a diabetic care provider nor were there episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or diabetic complications that could support higher ratings, although the CI had ER visits for hypoglycemia and sleeping versus syncope that did not result in a hospitalization either time.  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 diabetes mellitus condition

BOARD FINDINGS:  In the matter of the diabetes mellitus condition and IAW VASRD §4.119, 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 20150609, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170005806, XXXXXXXXXXXXXXXXXX. 

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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,