RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01405
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20080103

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Satellite Communication Systems Operator Maintainer, medically separated for “coronary artery disease,” with a disability rating of 0%.

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 - 20071009	VARD - 20081031	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Coronary Artery Disease	7005	0%	Coronary Disease	7005	30%	20080623	
Left Knee Pain 	Not Unfitting	Residuals of Partial Medial Menisectomy…Left Knee	5099-5003	10%		
Right Knee Pain		Residuals of Arthroscopic Surgery…Right Knee	5099-5003	10%		
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Coronary Artery Disease.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the first record in evidence for cardiac disease was an exercise stress test accomplished on 19 July 2005.  The CI was at high risk for cardiac disease as he was overweight, had a strong family history of early cardiac disease, and was being treated (with medications) for both increased lipids and an elevated blood pressure.  The CI achieved 10.1 METS (metabolic equivalents), but the test was non diagnostic (neither normal or definitely abnormal) due to an increased heart rate (tachycardia) and left arm numbness, both of which persisted longer than anticipated after the test was stopped.  The CI was continued on medical management.  His symptoms increased and the stress test then repeated on 10 August 2006.  It is not in evidence, but was cited as positive for ischemia (changes due to poor cardiac perfusion) on a cardiac catheterization report dated 14 August 2006.  The catheterization report also noted an ejection fraction of 67% (normal).  Multi-vessel disease was found and aggressive medical management recommended.  Despite this, his symptoms persisted and he underwent dilation of one coronary vessel (LAD) on 25 October 2006.  The stress test was repeated on 7 December 2006 and the CI went 9 minutes and 44 seconds (near 10.0 METS) without ischemic changes on the ECG (electro-cardiogram).  On 22 February 2007, the CI presented with chest pain at rest and underwent a diagnostic cardiac catheterization.  It showed that the previously dilated LAD remained patent and overall the examination was not markedly changed from his previous study in October.  Continued medical management was recommended.  In a cardiology follow up appointment on 26 March 2007, the CI reported ongoing angina at predictable levels of exercise although he was able to walk, bike, and use an elliptical trainer without angina (cardiac chest pain from ischemia).  His examination was unremarkable other than persistent obesity (70 inches and 236 pounds).  He had lost 10 pounds since his previous visit.  On 26 July 2007, 6 months prior to separation, the CI had another exercise stress test and achieved 13.4 METS, exercising for 11 minutes and 7 seconds.  His blood pressure rose from 119/74 at rest to 199/77 maximum with exercise.  The test was stopped due to fatigue.  The test was significant for left shoulder discomfort, but no changes were present on the ECG.  It was noted that his weight had increased to 250 pounds.  His overall prognosis was thought to be good and he remained asymptomatic with normal activities.  He was not thought to be worldwide deployable and was therefore entered into the MEB process.  The MEB NARSUM was accomplished that day based on the cardiac evaluation.  The NARSUM was updated on 14 September 2007 and noted a generally normal examination other than obesity and crepitus (a grinding sensation or sound on manipulation) of the knees.  

At the VA Compensation and Pension (C&P) evaluation, performed in a German Hospital on 26 June 2008, 5 months after separation, the CI reported chest pain if he walked too fast, but that he could climb stairs without problems.  His weight was noted to be 117 kg (an increase of about 8 pounds).  His blood pressure was elevated at rest at 148/86.  An echocardiogram (ultrasound of the heart) was limited by obesity, but showed a normal ejection fraction of 68% without evidence of hypertrophy (although on the borderline).  A stress test was done and stopped at 6.8 METS due to a hypertensive response with a blood pressure of 220/110 (the medical officer observed that 250 is considered the maximum before termination of the test by some authorities).  The examiner did note that there were no signs of ischemia and that the limited endurance was due to a lack of fitness rather than to an ischemic reaction.  His increased blood pressure was attributed to the obesity.  The panel noted that the examiner was apparently not a cardiologist, but an orthopedic surgeon.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the coronary artery disease condition 0%, coded 7005 [arteriosclerotic (atherosclerotic) heart disease (Coronary artery disease)], citing a non-compensable METS [metabolic equivalent] values.  The VA rated the coronary disease condition 30% coded 7005, based on the VA C&P examination 5 months after separation, citing METS limited to 6.8.  

The panel considered the evidence.  The METS recorded prior to separation exceeded 10 on the two for which it was recorded and were near 10 on the other.  The test closest to separation showed a METS value of over 13.  Eleven months later and 5 months after separation, the stress test was terminated at 6.8 METS due to a hypertensive response.  However, this was not at the maximal level accepted by American authorities and the CI was noted to have poor endurance due to a lack of fitness rather than to ischemia (a cardiac cause).  The hypertension was attributed to the obesity which was increased from when on active duty.  The probative value for this test is accordingly reduced and a higher probative value assigned to the pre-separation test which is almost as proximate to separation.  The panel noted that the criteria for a 30% rating, assigned by the VA, include either cardiac hypertrophy or dilation which were not present.  Also, 30% is supported if a workload between 5 and 7 METS results in shortness of breath, fatigue, angina, dizziness, or faintness.  These were not documented.  A 10% rating is supported by the use of continuous medications which the CI did report.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommended a disability rating of 10% for the CAD condition, coded 7005.  

Contended PEB Conditions:  Left and Right Knee 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 implicated in the commander’s statement.  Both were profiled L2, but judged to meet 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 either of the contended conditions and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the coronary artery disease condition, the panel unanimously recommends a disability rating of 10%, coded 7005 IAW VASRD §4.104.  In the matter of the contended left and right knee pain conditions, the panel unanimously recommends no change from the PEB determinations as not unfitting.  There were 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, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Coronary Artery Disease	7005	10%	
COMBINED	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150801, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170007472, XXXXXXXXXXXXXXXXXX.

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Dear XXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found that your disability rating should be modified but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed) and I accept its recommendation.  This will not result in any change to your separation document or the amount of severance pay.  A copy of this decision will be filed with your Physical Evaluation Board records.  I regret that the facts of the case did not provide you with the outcome you may have desired.
  
	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. 

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

Sincerely,