RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01364
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20090822

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

CI CONTENTION:  The CI contended for his livedoid vasculopathy, left knee patellar tendonitis, mixed anxiety, depression, tinnitus and hearing loss  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 - 20090330	VARD - 20091217	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Livedoid Vasculopathy 	7899-7826	10%	Cutaneous Lividdoid (sic) Vasculitis	7899-7826	0%	20091020	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Livedoid Vasculopathy (LV).  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s LV condition began prior to enlistment, but was permanently service aggravated.  In late 2007 the CI developed painful red lesions on his legs with associated left knee pain, aggravated by running.  In 2008 the CI had a biopsy performed by dermatology and was diagnosed with LV-a vascular disease of the lower extremities associated with hypercoagulability and thrombosis/ulceration.  No underlying cause of the condition was identified.  At the 14 January 2009 at the Internal Medicine evaluation noted complaints of increased lesions with stress and fatigue as well as decreased cardiovascular fitness with difficulty breathing with running.  The examiner noted that recent tests for asthma, pulmonary embolism, and cardiac ischemia were normal.  The CI reported that the skin lesions were raised, hard, and painful.  The lesions were aggravated by physical activity, but never completely resolved and over the past year, the condition had worsened.  The physical examination showed multiple red lesions with central pallor on the extremities and the trunk, which were fading from a previous visit, as well as a new area of bruising and ulceration on the left thigh and livedo reticularis (lacy skin discoloration caused by swelling of veins due to small blood clots).  The CI was evaluated for any associated hypercoagulability disorder and was found to have an enzyme deficiency, which by itself was not considered a risk for significant hypercoagulability.  Evaluations for pulmonary embolism and cardiac ischemia were negative.  The examiner indicated that the CI continued to have painful eruptions, primarily of the lower extremities and that the dermatology consultant believed the condition was chronic.  The CI was not treated with immunosuppressive medications or any other medications for the condition.  At the 27 January 2009 MEB examination (recorded on DD Forms 2807-1 and 2808), 7 months prior to separation, physical exam showed several raised red lesions about the bilateral legs.  

At the 4 March 2009 MEB NARSUM examination, 6 months prior to separation, noted complaints of vasculitis and right shoulder pain associated with developing skin lesions in this area.  The CI was taking no medications.  Physical examination during the MEB DD Form 2808 examination was cited as showing full range of motion of the upper extremities without redness or bruising of the extremities.  There was no evidence of instability or shoulder impingement.  The MEB NARSUM examiner indicated that the CI’s present condition was one of ongoing development of painful lesions on both lower extremities which “seem to come out if he undergoes physical activity.  Thus, he can have some control over this vasculitis.”  The CI’s lesions were limited to at or below the knees in before 2007, but at the end of 2008 and into 2009 the lesions were developing above the knees and on both forearms as well.  The condition was noted to be aggravated by running, eating large meals, cold exposure, and poor sleep and alleviated by the avoidance of aggravating actors.  

At the 20 October 2009 VA Compensation and Pension (C&P) evaluation, performed 2 months after separation, the CI reported cutaneous vasculitis.  Physical examination showed multiple small red cutaneous nodules without description of their location.  The remainder of a comprehensive examination including the heart, lungs, abdomen, extremities, and joints was normal.  Screening blood work was all normal.  Chest X-ray and electrocardiogram were normal.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the LV condition 10%, coded 7899-7826 (analogous to primary cutaneous vasculitis) citing recurrent episodes, occurring one to three times during the past 12 month period.  The VA also coded the vasculopathy condition, but provided a 0% rating, based on the C&P examination 2 months after separation.  
  
The PEB rated the LV condition analogously to primary cutaneous vasculitis.  However, the panel noted that immunosuppressive medications are not recommended for treatment of LV, whereas they may be recommended for primary cutaneous vasculitis.  Therefore, the panel focused its deliberations on the frequency criteria of 7826, without regard to use of immunosuppressive medications.  The LV condition was rated 10% and the panel therefore reviewed to see if a higher rating was supported under 7826.  The 30% rating specifies “recurrent debilitating episodes occurring at least four times during the past 12-month period.”  Based on the evidence in record, proximate to separation, the CI had chronic ongoing development of painful lesions of both legs, trunk, and forearms which “never completely resolved” but would wax and wane with exacerbating factors of cold exposure, eating heavy meals, fatigue, and physical exertion, such as running.  The panel agreed the frequency criteria were satisfied, but discussed at length whether the recurrent episodes were “debilitating” which was a term included the 30% rating language, but not the 10% rating.  

The MEB NARSUM noted that by avoiding strenuous activity and other aggravating factors, the CI could “have some control” over the condition.  All members agreed the CI was not incapacitated by recurrent episodes.  However, he had reproducible recurrence of painful lesions with physical activity which limited him.  Additionally, other noted aggravating factors were quite common and taken together suggested that “control” through avoiding them was likely going to be a difficult to achieve goal that would require management of diet, cold exposure, fatigue, and physical activity levels.  The panel majority thought that based on this evidence the CI’s condition could reasonably be described as debilitating for the 30% rating.  A higher rating could not be recommended under 7826 because the discriminating factor for the next higher rating was only related to the frequency of immunosuppressive medication use (constant versus intermittent), which was not present in this case.  

The panel then turned its attention to other VASRD skin codes as a check on its analogous rating recommendation.  The rating criteria of other skin disorders such as 7806 (eczematous dermatitis), psoriasis (7816), or papulosquamous disorders, not listed elsewhere (7822), all include a quantitative assessment of areas of skin involvement as a basis for a higher rating independent of medications prescribed.  Under each of these codes a 30% rating is supported for “20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected,” which was satisfied in this case by the ongoing development of lesions of both lower extremities, trunk, both forearms, and possibly the right shoulder area.  This further supported the panel’s contention that a 30% rating recommendation was “fair and equitable” and consistent with the VASRD approach to rating of skin conditions.  There was insufficient evidence of affected skin area of more than 40 percent for a higher rating under any of these codes.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 30% for the livedoid vasculopathy condition, coded 7899-7826.  

Contended PEB Conditions:  Indigestion and Non-Cardiac Chest pain.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  Neither of the conditions was profiled or implicated in the commander’s statement or judged to fail retention standards.  There was no performance-based evidence from the record that either of the conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded that there was insufficient cause to recommend a change in the PEB fitness determination for any of the contended conditions and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the livedoid vasculopathy condition, the panel unanimously recommends a disability rating of 30%, coded 7899-7826 IAW VASRD §4.118.  In the matter of the contended indigestion and non-cardiac pain conditions, the panel unanimously recommends no change from the PEB determinations as not unfitting.  There are 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; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Livedoid Vasculopathy 	7899-7826	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150615, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170011801, XXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

	I accept the recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) to re-characterize your separation as a disability retirement with the combined disability rating of 30% effective the date of your medical separation for disability with severance pay.  Enclosed is a copy of the Board’s recommendation and record of proceedings for your information.

	The re-characterization of your separation as a disability retirement will result in an adjustment to your pay providing retirement pay from the date of your original medical separation minus the amount of severance pay you were previously paid at separation.
 
	The accepted DoD PDBR recommendation has been forwarded to the Army Physical Disability Agency for required correction of records and then to the U.S. Defense Finance and Accounting Service to make the necessary adjustment to your pay and allowances.  These agencies will provide you with official notification by mail as soon as the directed corrections have been made and will provide information on your retirement benefits.  Due to the large number of cases in process, please be advised that it may be several months before you receive notification that the corrections are completed and pay adjusted.  Inquiry concerning your correction of records should be addressed to the U.S. Army Physical Disability Agency.

	A copy of this decision has also been provided to the Department of Veterans Affairs.

Sincerely,					      
Enclosure