RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01822
BRANCH OF SERVICE:  Navy 	SEPARATION DATE:  20090716

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E7, Automatic Combustion Control (General Regulator) Maintenanceman, medically separated from the Temporary Disability Retired List (TDRL) for “post ablation hypothyroidism” with a disability rating of 10%.  

CI CONTENTION:  “Judgment of PEB was wrongly based solely on (2) conditions sited as dis-chargeable.  Post separation VA rating is 100%.”  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 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.  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 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 - 20090512	VARD - 20100112	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Post Ablation Hypothyroidism	7903	10%	Mild Proptosis Secondary to Grave's Disease (Claimed as Graves Ophthalmopathy and Hypothyroidism Post Oblative)	6019-7800	0%	20090914	
Graves	Cat II					
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  90%	

ANALYSIS SUMMARY:  

Post-Ablation Hypothyroidism (Graves’ Disease).  According to the service treatment record (STR) and the MEB narrative summary (NARSUM), the CI complained of heat intolerance, heart palpitations, tremor, proptosis/exophthalmos (forward displacement of eyeballs), and a 40 pound weight loss over 2 months in July 2005.  The 15 July 2005 thyroid function tests (TFTs) revealed elevated thyroxine (T4) and triiodothyronine (T3) levels (thyroid hormones which control metabolism, energy utilization, growth, and protein synthesis) and a suppressed/undetectable thyroid stimulating hormone (TSH) level (pituitary hormone that stimulates thyroid hormone production and thyroid growth) consistent with hyperthyroidism.  Based upon the 2 August 2005 nuclear medicine thyroid scan/uptake, TFTs, and physical examination, the CI was diagnosed with Graves' disease (autoimmune disease that can affect thyroid, orbits, and skin).  He failed a trial of anti-thyroid medication (Methimazole) and Graves’ hyperthyroidism (autoimmune disease caused by TSH receptor antibodies stimulating thyroid hormone production and thyroid growth) recurred.  The 16 August 2005 ophthalmology assessment listed mild Graves’ orbitopathy (autoimmune disease increasing retroorbital tissues volume displacing eyeballs forward).  The 18 April 2006 ophthalmology assessment listed hyperthyroidism.  The ophthalmologist documented “no graves opthalmopathy [orbitopathy] that requires intervention at this point.”  In July 2006 the CI was treated with radioactive iodine to ablate his thyroid gland and render him hypothyroid (low T4/T3 and high TSH levels).  By 13 September 2006, he was biochemically and clinically severely hypothyroid with low/undetectable T4/T3 levels and an extremely elevated TSH level.  The CI was started on body weight based synthetic thyroid hormone (Synthroid) replacement.  The 16 October 2006 ophthalmology evaluation listed the diagnosis of Graves' ophthalmopathy and the ophthalmologist documented “There is no current exophthalmos, clear cornea, no diplopia [double vision] and healthy nerve, pt needs undilated refraction, annual follow-up.”  The 1 November 2008 TFTs revealed the CI was biochemically euthyroid (normal T4/T3 and normal TSH levels) on thyroid hormone (Synthroid) replacement.  The 9 October 2007 VA Compensation and Pension (C&P) examination diagnosis listed mild proptosis secondary to Graves' disease.  It documented “This patient has a minimal proptosis in each eye and he states that he occasionally ends up with dry eyes for which he instills Artificial Tears.”  

The 30 January 2009 report of TDRL periodic physical by endocrinology, 6 months before TDRL removal, recounted the history and interventions.  The CI’s Graves’ hyperthyroidism was treated with radioactive iodine, he developed post ablation hypothyroidism, and was taking 175 mcg of thyroid hormone (Synthroid) replacement.  “He is not exercising, … but denies headache, tremor, palpitations, or heat and cold intolerance.  He does report some increasing fatigue.  He was seen in Ophthalmology in the past for left eye proptosis, which does not require intervention.”  The physical examination documented “Extraocular muscles were intact with mild proptosis of the left eye, but better.  The sclerae were clear, and there was no lid lag or stare.  Neck was supple, thyroid without enlargement, nodules, and was non-tender.”  The examiner recounted the 6 January 2009 TFTs which were consistent with subclinical hypothyroidism (normal T4/T3 and high TSH levels).  The diagnoses listed hypothyroidism, Graves' ophthalmopathy, and Graves' hyperthyroidism, resolved.  The endocrinologist documented “He is clinically and biochemically hypothyroid with obesity and fatigue, and given mild elevation in TSH, it is recommended that he follow-up with the VA to resume his higher dose of Synthroid that he was previously on.  I put in a prescription for the 200 micrograms so he can start taking it, but he should then follow-up with the VA to inform them of this change.  The goal TSH is 0.5 to 2, if tolerating without hyperthyroid symptoms.  His goiter [thyroid enlargement and/or nodularity] is resolved, and the left eye proptosis is stable.”  

The 14 September 2009 VA C&P examination for eye by optometry, 2 months after TDRL removal, listed the diagnosis of myopia (nearsightedness).  The optometrist documented “There is no Grave's disease cause for visual impairment or disability.  Corrected vision was 20/20 OU [both eyes].  Myopia noted OU.  No evidence or any residual evidence of Grave's disease affecting the eyes.  No diplopia noted OU.  No obvious proptosis noted OU.”  The 5 February 2010 TFTs were consistent with subclinical hypothyroidism and the 26 March 2010 TFTs were consistent with euthyroidism. 

The panel directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under the 7903 code (hypothyroidism) citing post ablation hypothyroidism.  The Category II condition (Graves) was considered to contribute to the unfitting hypothyroidism condition.  The VA assigned a 0% rating under the 6019-7800 codes (ptosis, unilateral or bilateral-burn scar; scar, or other disfigurement of the head, face, or neck) based on the C&P examination 2 months after separation, citing mild proptosis related to past history of Grave's disease, (claimed as Graves' ophthalmopathy and hypothyroidism post ablative), no Grave's disease cause for visual impairment or disability by examination, no evidence or any residual evidence of Grave's disease affecting the eye by examination, and a noncompensable evaluation is assigned unless there is significant disfigurement or the pupil is obscured by one-half or more.  While the CI had been rendered hypothyroid by radioactive iodine thyroid gland ablation, he was treated to goal with synthetic thyroid hormone (Synthroid).  Regarding Graves’ ophthalmopathy, there was no visual impairment or obvious proptosis.  There was no visual impairment or disfigurement for consideration under 6019 (ptosis, unilateral or bilateral).  The panel agreed that findings were consistent with the 10% rating under 7903 (fatigability, or; continuous medication required for control).  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 Graves’ disease.  

BOARD FINDINGS:  In the matter of the post-ablation hypothyroidism (Graves’ disease) 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 modification or re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150701, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR DIRECTOR, SECRETARY OF THE NAVY COUNCIL OF REVIEW
               BOARDS 

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS
 
Ref:   (a) DoDI 6040.44

      In accordance with reference (a), I have reviewed the cases listed below and approve the recommendations of the PDBR that the following individual’s records not be corrected to reflect a change in either characterization of separation or in the disability rating previously assigned by the Department of the Navy’s Physical Evaluation Board:

		- XXXXXXXXXXXXXXXXXX, former USMC
		-XXXXXXXXXXXXXXXXXX, former USMC
		-XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN

	
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	     				  Acting