RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01556
BRANCH OF SERVICE:  Air Force 	DATE REMOVED FROM TDRL:  20020917

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Education and Training Journeyman, medically separated from the Temporary Disability Retired List (TDRL) for “microadenoma of pituitary associated with anterior falx meningioma and left parietal angioma” with a disability rating of 10%.

CI CONTENTION:  The CI made no specific contention.  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 - 20020729	VARD - 20020228	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Microadenoma of Pituitary associated with Anterior Falx Meningioma and Left Parietal Angioma	8003	10%	Microadenoma of Pituitary associated with Left Parietal
Angioma and Anterior Falx Meningioma	7915	0%	20011203	
Convergence Problems associated with Headaches	6021-6099	Cat II	Eye Convergence, Loss of Vision	6079	NSC	20011203	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20% 	

ANALYSIS SUMMARY:  

Pituitary Microadenoma, Anterior Falx Meningioma, and Left Parietal Angioma Condition.  The PEB combined the pituitary microadenoma, anterior falx meningioma, and left parietal angioma conditions as a single unfitting condition coded analogously to 8003 (brain, new growth of: benign) and rated 10%.  The 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 or implied adjudication that each condition was separately unfitting.  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 Disability Evaluation System 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 evidence for the pituitary microadenoma, anterior falx meningioma, and left parietal angioma conditions are presented together with attendant recommendations regarding separate unfitness and rating are presented in the rating discussion.

According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), in 1994 the CI was evaluated for galactorrhea (breast milk production not associated with childbirth or nursing that is inappropriate) and amenorrhea (absence of menstrual periods) and was discovered to have elevated prolactin (pituitary hormone that stimulates milk production and suppresses gonadotropin hormone release) levels.  

On 6 October 2000 the CI was separated from active duty, and on 7 October 2000 she was placed on the TDRL.  At the 1 December 2000 endocrinology follow-up, the CI indicated she had stopped the Bromocriptine in September due to nausea.  Since stopping she had not menstruated, had noted breast enlargement, and a small amount of milky discharge from her left breast.  The examiner indicated no change since prior year exam stating “normal energy level, no cold intolerance, and no skin or bowel changes”.  The neurological examination was normal.

The 3 December 2001 VA Compensation and Pension (C&P) Radiology addendum, 14 months after separation, the examiner stated the condition of anterior fascia per surgical meningioma was “unable to make a diagnosis because there is no pathology.”  In the 3 December 2001 VA C&P examination, 14 months after separation, the CI had no complaints referable to the meningioma.  The CI stated “the neurosurgeon told her that the disease is very benign and that it is not growing.”  A pituitary microadenoma was identified by magnetic resonance imaging (MRI)  to evaluate galactorrhea.  The CI did not tolerate the medications (Parlodel and Pergolide) to treat hyperprolactinemia and was not on any medications for the management of the galactorrhea.  A left parietal angioma was incidentally found by MRI and the CI had no complaints referable to the angioma.  The diagnoses listed meningioma, pituitary microadenoma, and left parietal angioma based upon history and MRI findings.  In the 3 December 2001 eye VA C&P examination by ophthalmology, 14 months after separation, the CI reported a 2-month history of visual blurring in 2000, for which a cause was undetermined.  “She believes that she had convergence problems.”  The CI had no ocular complaints at the time of evaluation.  The eye examination was unremarkable except for myopia (near sightedness).  The diagnosis listed myopia in both eyes and no other ocular findings.  

A 10 December 2001 brain computed tomography (CT) was normal.  The 3 July 2002 TDRL evaluation, 21 months after separation, recounted the history, studies, and interventions.  The CI reported a remote history of recurrent headaches with blurred vision, difficulty with memory, lack of concentration, and galactorrhea.  The neurologist documented “She was temporarily treated with Bromocriptine, at this time she reports no recurrence of galactorrhea.  During the work-up she had a brain MRI which showed an incidental finding of partial empty sella, venous angioma of the left temporal area, and an asymptomatic 2 cm parasagittal meningioma which was also asymptomatic. … she is working full-time as a day care provider.  For the last two years her symptoms are intermittent mainly with headaches.  She does not take any medications.”  The physical, mental status, and neurological examinations were unremarkable.  A brain MRI revealed a right anterior falcine meningioma (2 X 2 cm), an empty sella with a heterogeneous enhancing posterior right pituitary adenoma (8 mm), and a left parietal lobe venous anomaly.  The diagnoses listed asymptomatic anterior falx meningioma, right pituitary adenoma, incidentally found left parietal venous angioma, and history of headaches (resolved).  

The panel directed attention to its rating recommendation based on the above evidence.  As previously elaborated, the panel must first consider whether the incidentally found pituitary microadenoma, anterior falx meningioma, and left parietal angioma conditions remain separately unfitting, having been de-coupled from a combined PEB adjudication.  The PEB assigned a 10% rating for the Category I condition under the 8003 code (brain, new growth of: benign) citing microadenoma of pituitary associated with anterior falx meningioma and left parietal angioma.  Under 8003 the minimum rating under residuals is 10%.  The PEB did not assign a rating for the Category II condition under the 6021-6099 codes (entropion) citing the convergence problems associated with headaches, resolved was not currently compensable or ratable.  The VA assigned a 0% rating under the 7915 code (neoplasm, benign, any specified part of the endocrine system) based on the VA C&P examination 14 months after separation, citing a noncompensable evaluation is assigned unless there is disabling interference with endocrine functions.  There is no evidence to show that this condition is disabling, only that it exists and is benign.  While the CI had a pituitary microadenoma, presumably causing hyperprolactinemia, she was asymptomatic (no mass effect, amenorrhea, or galactorrhea) and taking no medications.    While the CI had an incidentally found meningioma, it was stable over serial MRIs, she was asymptomatic, and declined elective surgical intervention.  While the CI had an incidentally found congenital angioma, it was stable over serial MRIs, and she was asymptomatic.  The panel concluded that the evidence did not provide sufficient grounds for recommending separate disability ratings in this case, and that the combined rating of 10%, coded 8003, is a good analogy to both the pathology and disability.  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 pituitary microadenoma, anterior falx meningioma, and left parietal angioma condition.  

PANEL FINDINGS:  In the matter of the pituitary microadenoma, anterior falx meningioma, and left parietal angioma condition and IAW VASRD §4.71a, 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 re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150622, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD  20762

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2015-01556.

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 appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.

Sincerely,

XXXXXXXXXXXXXXXXXXX
Director
Air Force Review Boards Agency

Attachment:
Record of Proceedings