RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01149
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20021002

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Infantryman, medically separated for “right flank pain,” with a disability rating of 10%.

CI CONTENTION:  The CI’s condition continues to worsen and negatively impacts daily activities.  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 - 20020522	VARD - 20030125	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Flank Pain	5099-5003	10%	Medullary Sponge Kidney Hematuria Syndrome with Nephrolithiasis	7533	0%	STR	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Right Flank Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s right flank pain condition began in approximately January 2001.  The CI reported right flank pain that radiated to the right groin and hematuria (visible blood in his urine, and at times with nausea/vomiting.  The CI underwent a comprehensive evaluation.  Primary care notes in September 2001 indicated that possible kidney stones were noted on abdominal films in June 2001 and on ultrasound in July 200.  Magnetic resonance imaging and computed tomography (CT) of the abdomen and pelvis were normal.  An imaging study (intravenous pyelogram) in June 2006 diagnosed medullary sponge kidneys (birth defect of the kidneys associate with hematuria, kidney stones, and urinary tract infections; most cases do not appear to be inherited).  A pain management note dated 3 December 2001 indicated the CI was diagnosed with medullary sponge kidney and ureteral spasm.  A nephrology visit on 11 December 2001 noted that the pain of medullary sponge kidney disease was usually due to kidney stones, but there had been no documented stones in this case.  However, he noted an extensive evaluation found no other cause for the CI’s symptoms.  Diet changes were noted to see if they helped his symptoms.  At serial examinations in the STR the CI was noted to have blood pressures of 130/87, 111/58, 132/74, and 138/83 mmHg (millimeters of mercury) and hematuria without protein or white blood cells or evidence of infection.  

The MEB NARSUM examination on January 2002, 10 months prior to separation, noted complaints of right flank pain with episodes of hematuria following strenuous activity.  The NARSUM was completed at the time of discharge from a hospitalization for diagnostic studies.  The MEB NARSUM examiner noted that the CI had been treated with cryoablation (cold ablation) of the L1 nerve root with a moderate response.  A cystoscopy (evaluation of the bladder) was negative, evaluation of the ureters was normal and a renal scan showed normal renal flow and function of both kidneys.  Urinalysis showed microscopic hematuria but no urinary casts or sediment.  The CI was taking pain medication and an anti-spasmodic agent for right flank and groin pain.  Physical examination showed a normal abdominal exam and no swelling of the extremities.  

A pain management note on 28 March 2002, 6 months before separation, indicated the CI had been treated with pulsed radiofrequency (RF) treatment for his chronic flank and groin pain and that it had helped.  The CI reported that he now felt he was developing a renal stone and he was scheduled for another pulsed RF treatment on 9 April 2002.  A pain management note on 19 April 2002 indicated diagnoses of nephrolithiasis (kidney stones) along with medullary sponge kidney.  The CI underwent another L1 nerve block at that visit and another pulsed RF treatment for inguinal pain was recommended “after stones pass.”

At the MEB examination (recorded on DD Forms 2807 and 2808) dated April 2002, 7 months prior to separation, the CI’s blood pressure was 123/73 mmHg.  Urinalysis showed “TNTC” (too numerous to count) red blood cells without protein (albumin).  The CI was not anemic.  

The CI failed to report to the scheduled VA Compensation and Pension (C&P) evaluations on 9 and 21 January 2003.  At the original VA C&P examination, performed on 9 June 2003, 8 months after separation, the CI reported flank and groin pain daily and hematuria several times per week, increased by activity.  He reported approximately three periods of antibiotic treatment for urinary infection and “multiple” small stones.  The CI was taking medications for prevention of urinary infections (methenamine, ascorbic acid) and reported use of Methadone for renal colic pain three to four times per week and anti-nausea medication as needed.  Physical examination showed blood pressure of 102/62 mmHg.  There was right groin tenderness to palpation (TTP) and TTP of the right flank (in the area of the kidney – “CVA” tenderness.)  Examination was noted to be otherwise negative.  The VA examiner indicated that the blood work showed no anemia and kidney function was normal, but there was blood noted on the urinalysis.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right flank pain condition 10%, coded analogously to 5003 (degenerative arthritis), citing the US Army Physical Disability Agency (USAPDA) pain policy.  The VA rated the kidney condition 0% coded 7533 (cystic diseases of the kidneys (polycystic disease, uremic medullary cystic disease, medullary sponge kidney, and similar conditions)), citing the CI did not attend the scheduled VA C&P examination.  

The PEB assigned a 10% rating as noted above.  Therefore the panel reviewed to see if a higher rating was supported with any applicable code.  There was no evidence of protein in the urine (albumin), edema, or hypertension at least 10 percent disabling under diagnostic code 7101 (“diastolic pressure predominantly 100 or more, or; systolic pressure predominantly 160 or more, or; minimum evaluation for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control”) for a higher rating under 7533.  There was no evidence of chronic pyelonephritis that required “long term drug therapy, 1-2 hospitalizations per year and/or requiring intermittent intensive management” for urinary tract infections to support a rating under 7504 (pyelonephritis, chronic).  The panel considered if rating under nephrolithiasis was warranted based on the evidence in record.  No kidney stones were definitively documented during the CI’s evaluation and treatment, which included multiple imaging studies and evaluations of the kidneys and urinary tract system, including straining of the urine.  However, possible stones were noted on X-rays and ultrasound and the panel noted that medullary sponge kidney is often associated with recurrent kidney stones, usually small and passed without intervention.  At the pain management visit in March 2002 the CI reported that he thought he was developing a kidney stone and at the VA exam examination he reported passing multiple small stones.  In accordance with VASRD 4.3 (reasonable doubt), the panel resolved reasonable doubt that the CI was experiencing recurrent kidney stones in favor of the CI and considered a rating under 7508 (nephrolithiasis).  A trial of dietary changes was noted at the nephrology visit in December 2001.  However, there was no evidence that the CI remained on a restricted or special diet at examinations later in the record.  The CI was also not on regular drug therapy to prevent kidney stones, but ascorbic acid (Vitamin C) was noted at the VA examination, which may have been tried in part to reduce calcium stone formation, but the panel did not think this was sufficient evidence of “regular drug therapy” to support a 30% rating since Vitamin C is an over the counter supplement and routine component of healthy daily diets.  The CI did not undergo procedures for kidney stone removal or degradation to facilitate passing them more than two time per year proximate to separation to warrant a 30% rating.  Although the CI did have multiple episodes of renal colic, without infection, that did not require catheter drainage to support a 10% rating coded as 7509 (hydronephrosis), there was no evidence of required catheter drainage to warrant a 20% rating under 7509 and therefore this coding approach offered no ratings benefit to the CI and was abandoned.  There was therefore no higher rating than 10% available for the right flank pain under any applicable VASRD code.  The panel noted that the PEB’s reliance on the USAPDA pain policy was not detrimental to arriving at the highest rating and therefore no change to the PEB code is recommended.  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 right flank pain condition.  

BOARD FINDINGS:  In the matter of the right flank pain condition and IAW VASRD §4.115a and 4.115b the panel unanimously recommends no change in the PEB adjudication.  There were no other conditions within the panel’s scope of review for consideration.  The panel, therefore, recommends that there be no modification or re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150610, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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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,