RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01357
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20041029

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Automated Logistics Specialist, medically separated for “endometriosis” with a disability rating of 10%.  

CI CONTENTION:  Review all conditions.  The 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 - 20040915	VARD - 20050113	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Endometriosis 	7629	10%	Endometriosis	7629	10%	20041007	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Endometriosis.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s endometriosis condition began in 2001 when she started getting pain in her abdomen and lower back.  The CI underwent laparoscopic surgery in November 2003 with findings of endometriosis lesions.  Symptoms of abdominal pain returned and there was no further surgical indication.  The CI declined therapy with Lupron (preferred medication for treatment), which was adjudged as reasonable by the Service.  The MEB forwarded “chronic pelvic pain secondary to endometriosis” and “mood disorder due to general medical condition” for PEB adjudication.  

At the 20 May 2004 gynecology MEB outpatient evaluation for pelvic pain, the CI reported good results with the use of medication (Depo-Provera) but noted signs and symptoms of endometriosis including spotting, back pain, dysmenorrhea (menstrual cramps), and increased pain with activity.  Examination was normal.  The gynecologist stated “pain issues do not agree with objective datum,” and “endometriosis is not an apparent cause of (the CI’s) symptoms.”  

The 27 May 2004 psychiatric consult indicated the CI became depressed due to the unsuccessful treatment of her endometriosis and had been started on Celexa (antidepressant) and Ambien (for sleep) by her physician, in addition to pain medication.  The diagnosis was mood disorder due to a general medical condition with a Global Assessment of Functioning and social and industrial impairment of moderate.  The psychiatrist increased the Celexa dosage and referred pain management back to the gynecologist.  

The 25 June 2004 MEB NARSUM, 4 months prior to separation, noted complaints of endometriosis with constant abdominal pain exacerbated with activity or stress/anxiety.  The NARSUM physician summarized the 20 May 2004 gynecology evaluation (5 months pre-separation) as having a normal examination, noting some complaints not consistent with endometriosis and recommending Lupron for treatment of her gynecological condition, which the CI declined.  Physical examination (from 13 May 2004) showed mild tenderness in the left lower quadrant of the abdomen without guarding, rigidity, or rebound.  There was a negative pelvic shake, and bowel sounds were normal.  

The commander’s statement from April 2004 implicated only endometriosis and pain and indicated the CI was “an excellent soldier but simply not capable of doing all that all soldier[s] need to do.”  

At the 7 October 2004 VA Compensation and Pension (C&P) evaluation, 2 weeks before separation, the CI reported irregular menstrual cycles, heavy bleeding, pelvic pain, back pain, anemia, blood clots, urinary incontinence not requiring pads, and blood in the stool for the past 4 years.  Physical examination showed normal abdomen, pelvic and rectal findings.  There was no VA general psychiatric examination proximate to separation.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB combined the MEB diagnoses of “chronic pelvic pain secondary to endometriosis” and “mood disorder due to general medical condition” as a single unfitting condition of endometriosis coded 7629 (endometriosis), and rated 10%, citing a completely normal physical examination.  This approach by the PEB not uncommonly reflected its judgment that the constellation of conditions was unfitting, and there was no need for separate fitness adjudications.  The panel’s initial charge in this case was therefore directed at determining if the PEB’s approach of combining conditions under a single rating was justified in lieu of separate ratings.  When considering a separate rating for each condition, the panel considers each bundled condition to be reasonably justified as separately unfitting unless a preponderance of evidence indicates the condition would not cause the member to be referred into the DES or be found unfit because of physical disability.  When the panel recommends separate fitness recommendations in this circumstance, its recommendations may not produce a lower combined rating than that of the PEB.  

The VA rated the endometriosis condition 10%, coded 7629, based on the C&P examination 2 weeks before separation, citing pelvic pain or heavy or irregular bleeding requiring continuous treatment; and rated the claimed mood disorder at 0% citing the CI failed to show for an examination and having “no indication as to what implications this mental condition has on your current life.”  

The panel agreed that the endometriosis (pelvic pain) was separately unfitting and that the MEB diagnosis of mood disorder due to endometriosis was intrinsic to the rated endometriosis condition, and a separate rating cannot be supported without pyramiding (VASRD §4.14); thus, it is appropriately subsumed in the same rating.  Rating the endometriosis takes the mood disorder condition into consideration, and there was insufficient evidence that the mood disorder would be separately unfitting.  Endometriosis was substantiated by laparoscopy.  There was insufficient evidence of pelvic pain or heavy or irregular bleeding not controlled by treatment for any rating higher than the 10% awarded by the PEB and VA.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded there was insufficient cause to recommend a change in the PEB adjudication for the endometriosis condition (with mood disorder due to medical condition).  

BOARD FINDINGS:  In the matter of the endometriosis (with mood disorder due to a medical condition) condition and IAW VASRD §4.116, the panel unanimously recommends no change in the PEB adjudication.  There are no other conditions within the panel’s scope of review for consideration.  The panel, therefore, recommends 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 20150616, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170010040, XXXXXXXXXXXXXXXXXX 

XXXXXXXXXXXXXXXXXX

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,