RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01322
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20060619

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Aircraft Armament Systems, medically separated for “asthma, mild persistent” with a disability rating of 10%.  

CI CONTENTION:  The CI requested a review of 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 - 20060301	VARD - 20070216	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Asthma, Mild Persistent	6602	10%	Asthma	6602	0%	 STR	
Chronic Urticaria and Angioedema	Cat II	Angioedema and Urticaria	7118	NSC	STR	
Seasonal Allergic Rhinitis	Cat II	Seasonal Allergic Rhinitis	6522	0%	STR	
Obesity	Cat III	No VA Placement	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:   

Asthma, Mild Persistent.  According to the STR and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI presented initially with sporadic urticaria (hives) and angioedema (allergic swelling) as below.  In September 2005 (9 months before separation) he was diagnosed with “mild persistent asthma” as well.  He was started on albuterol (inhalational bronchodilator) as needed and Advair (inhaled steroid with bronchodilator), with daily dosing prescribed.  Subsequent STR clinical entries corroborated intermittent use of albuterol and compliance with Advair.  An entry of 29 December 2005 (6 1/2 months before separation) documented a trial of discontinuing Advair.  There were, however, subsequent STR entries that included Advair in the medication list.  

There were three pulmonary function tests (PFT) in the STR over the period after treatment was begun.  Post-bronchodilator measurements of FEV1 ranged from 70% predicted to 85% predicted (most proximate to separation it was 73%), and FEV1/FVC ratios ranged from 89% to 99%.  There was no STR evidence for respiratory failure, hospital admissions, continuous requirement for systemic corticosteroids, or monthly exacerbations requiring physician visits (criteria for VASRD ratings higher than 30%).   Despite treatment, the asthma condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for an MEB.  The MEB forwarded ‘asthma” for PEB adjudication.

The NARSUM examination on 1 January 2006 (6 months before separation) documented “mild persistent ... clinically stable” asthma symptoms.  The medication list included Advair prescribed daily and albuterol prescribed as needed.  The physical examination recorded clear lungs (including with forced expiration).  

The CI failed to report for an initially scheduled VA Compensation and Pension (C&P) examination following separation.  A C&P examination of 23 March 2012 (more than 5 years after separation) documented the CI’s report that “he’s only used albuterol 1-2 times since 2006 and he hasn't been using any inhaled steroids since then.” 

The Board directed attention to its rating recommendation based on the above evidence.  VASRD §4.97 defines both PFT-derived criteria and clinical treatment criteria for rating under code 6602 (asthma).  The 6602 criteria for a rating higher than 30% were not in evidence as above.  The criteria for the ratings under consideration are: 30% - “FEV-1 of [56-70%] predicted, or; FEV-1/FVC of [56-70%], or; daily inhalational or oral bronchodilator therapy, or; inhalational anti-inflammatory medication;” and, 10% - “FEV-1 of [71-80%] predicted, or; FEV-1/FVC of [71-80%], or; intermittent inhalational or oral bronchodilator therapy.”  A 10% rating is supported by the PFT criteria in this case.  This was likely the basis of the PEB’s rating determination, although a rationale was not cited.  The VA’s 0% rating (based on STR evidence) cited only measured FVC in the rationale (not a specific 6602 criterion) and did not address medication criteria.

The Board deliberated whether the use of Advair should be conceded as satisfying the above medication criteria for a 30% rating.  The rating language does not specify a daily requirement for inhalational anti-inflammatory use, but members noted some confusion with regard to whether Advair was temporarily or permanently discontinued 6 months prior to separation.  Members ultimately agreed that, although it was possible that the CI had discontinued the use of Advair at the time separation, it was equally plausible that the trial was short term and that he had resumed his usual treatment.  The fact remained that all medication lists in the STR, including the NARSUM, continued to list Advair over the months from the time that the trial was initiated through to separation; and, members agreed that this evidence alone constituted sufficient reasonable doubt for conceding the criterion.  After due deliberation, considering all of the evidence and conceding VASRD §4.3 (reasonable doubt), the Board recommends a 30% rating for the asthma condition under code 6602.

Contended PEB Conditions: Chronic Urticaria and Angioedema, Seasonal Allergic Rhinitis and Obesity.  The Category III condition of obesity is not subject to service compensation IAW DoDI 1332.38 and the VASRD.  Although a diagnosis of seasonal allergic rhinitis was noted in the NARSUM and submitted to the PEB, it was not elaborated, and there were no outpatient STR clinical entries that indicated any acuity or directed treatment associated with the condition.  The CI had a history of recurrent urticaria dating to age 16.  The earliest entry in the available STR was for emergency department (ED) treatment for hives (no angioedema) in October 2004 (20 months before separation).  He was placed on a daily antihistamine, but continued to have break-through episodes, and was treated in the ED again in January 2005.  There was mild angioedema (objective perioral, subjective throat) in addition to urticaria at that time.  He was prescribed an epi-pen for rescue emergency treatment, the anti-histamine dosage was increased, and later a systemic anti-inflammatory (Singulair) was added.  Other than a single passing reference (most likely recounting the one ED episode), there was no STR evidence of recurrent angioedema associated with the urticaria, and several entries specifically denied it.  There was no STR evidence that the epi-pen was ever required or that there were any incidents of laryngeal or upper airway compromise.  Other than one more visit in May 2005 (11 months before separation) when the CI forgot to take his antihistamines, there was no other ED treatment for urticaria; and, follow-up notes indicated an improving stable course.  The NARSUM stated “still experiencing symptoms despite medical therapy” without elaborating the severity at that time.  The P4 profile did not specify conditions; and, the commander’s performance statement referenced only the running prohibition for physical fitness testing and inability to deploy, recommending retention in as an instructor.  The VA did not service connect the condition, opining that it existed prior to service and was not service-aggravated.  

The Board’s main charge was to assess the fairness of the PEB’s determinations that the above conditions were not unfitting.  There was no evidence implicating seasonal allergic rhinitis as more than a minor stable condition with no fitness implications.  Members agreed that the angioedema was fully controlled and that the urticaria was satisfactorily controlled at the time of separation.  Although subject to escalation and recalcitrant to permanent resolution, there was no performance-based evidence indicating that it interfered with duty requirements to an extent that would have resulted in MEB referral and termination of service at the time of separation.  

After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determinations for the chronic urticaria and angioedema and seasonal allergic rhinitis conditions; thus, they were not eligible for rating.  

BOARD FINDINGS:  In the matter of the asthma condition, the Board unanimously recommends a disability rating of 30%, coded 6602, IAW VASRD §4.97.  In the matter of the contended chronic urticaria and angioedema and seasonal allergic rhinitis conditions, the Board unanimously recommends no change from the PEB determinations 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; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of his prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Asthma	6602	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150611, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAF/MR

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2015-01322.

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 your separation be re-characterized to reflect disability retirement, rather than 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 determined that your records should be corrected accordingly.  The office responsible for making the correction will inform you when your records have been changed.

As a result of the aforementioned correction, you are entitled by law to elect coverage under the Survivor Benefit Plan (SBP).  Upon receipt of this letter, you must contact the Air Force Personnel Center at XXXXXXXXXXXXXXXXXXX to make arrangements to obtain an SBP briefing prior to rendering an election.  If a valid election is not received within 30 days from the date of this letter, you will not be enrolled in the SBP program unless at the time of your separation, you were married or had an eligible dependent child, in such a case, failure to render an election will result in automatic enrollment.

Sincerely,

Attachment:
Record of Proceedings 

cc:
SAF/MRBR