RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01855
BRANCH OF SERVICE:  Army 	SEPARATION DATE: 20040316
DATE PLACED ON TDRL:  20000828	
DATE REMOVED FROM TDRL:  20040316

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Medical Specialist, medically separated from the Temporary Disability Retired List (TDRL) for “asthma” with a disability rating of 0%.  

CI CONTENTION:  The CI contends that not all the medical documents were considered in her disability rating, that the pharmacy record was incorrect, and that she obtained and was using medication from out of the country.  The CI’s complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The Board’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 Board’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 Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’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 Board 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 Board 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 – 20000522/20040130	VARD - 20020123	
Condition	Code	Rating	Condition	Code	Rating
Proximate	
		TDRL
Placement	TDRL Removal			TDRL
Placement	TDRL
Removal	
Asthma	6602	30%	0%	Asthma	6602	30%	30%	
COMBINED RATING:  30% → 0%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Asthma Diagnosis.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI was evaluated in September 1997 for developing shortness of breath with exertion.  A diagnosis of asthma was made based on pulmonary function testing (PFT) and clinical presentation.  Over the next 2 years, the CI required treatment with oral (systemic) prednisone, emergency room visits, IV steroids, and intermittent inhaled bronchodilators.  Despite treatment, the asthma condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for an MEB.  The MEB forwarded “severe persistent asthma” for PEB adjudication.  

According to the allergy clinic evaluation on 23 March 2000 (5 months prior to TDRL placement) the examiner noted that the CI had exacerbations of viral congestion, chest tightness, and wheezing requiring 17 days of systemic steroid treatment in January 2000 and 21 days of systemic steroid treatment in February 2000.  The CI was prescribed Flovent (inhalation steroid) twice daily, Serevent (inhalation bronchodilator) twice daily, and Albuterol (inhalation bronchodilator) as needed.  The examiner noted despite daily medications the CI symptomatology persisted.  

During the MEB NARSUM examination on 21 April 2000, 4 months prior to TDRL entry, the CI was tested in the allergy clinic and found to be allergic to animal dander.  Medications included Theo-Dur (oral bronchodilator) daily, montelukast (receptor antagonist) daily, Serevent twice daily, and Proventil (inhalation bronchodilator) as needed 4-5 times per day.  Radiographic studies of the chest were normal.  

There was no VA Compensation and Pension (C&P) examination in the evidence of record.  

At the time of the TDRL re-evaluation examination on 19 November 2001 (15 months after TDRL placement; 23 months before TDRL removal), the CI reported continued symptoms despite maximal medical therapy.  The CI incurred two emergency department visits while traveling abroad, but no hospital admission.  Symptoms reported included shortness of breath/dyspnea on exertion, wheezing, worst in the morning and at night with no identified triggers.  The last systemic prednisone was August/October 2000.  Medications included Flovent (inhalational steroid) inhaler twice daily, and Albuterol inhaler 4-5 times per day.  Physical examination revealed diffuse expiratory wheezing with oxygen saturation at 97% (normal).  PFTs were reported as FEV1 74% of predicted and FEV1/FVC of 59%, and the physician started a systemic steroid burst and changed the inhaled anti-inflammatory medication from Flovent to Advair, a combination inhaler.  

At the time of the final TRDL re-evaluation examination on 9 October 2003, 5 months prior to TDRL removal, the CI noted a temporary improvement in her symptoms during a recent pregnancy, but continued to have daily symptoms of shortness of breath, wheezing, and dry cough.  Singulair and an anti-reflux medication were stopped during pregnancy and not restarted.  Medications included Flovent (inhalational steroid) inhaler twice daily, and an Albuterol inhaler up to four times per day (as needed).  PFTs were reported as FEV1 65% of predicted and FEV1/FVC of 60%.  The diagnosis was “asthma, severe persistent with daily symptoms, requiring daily medication use to provide moderate control of disease.”  

The PFTs in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below:  

Pulmonary Examination	MEB ~5 Mo. Pre-TDRL	TDRL Re-Eval ~15 Mo. Post-TDRL 	Final TDRL Re-Eval ~ 5 Mo. Pre-Removal	
FEV1 (% Predicted)	66%	74%	65%	
FEV1/FVC	81%	60%	60%	
Meds	Daily bronchodilator / inhaled anti-inflammatory	Daily bronchodilator / inhaled anti-inflammatory	Daily bronchodilator / inhaled anti-inflammatory	
§4.97 Rating	30%	30%	30%	

The Board directed attention to its rating recommendation based on the above evidence.  The Board first considered its rating recommendation at the time of placement on TDRL.  The PEB rated the asthma condition 30%, coded 6602 (asthma) citing use of daily medications.  The VA also rated the asthma condition 30%, coded 6602 effective August 2000 based on the STRs prior to separation (TDRL placement), based on the STRs prior to separation, citing the 30% rating criteria, and FEV-1 predicted value of 58% (in March 2000).  

All evidence proximate to TDRL placement supported the 30% rating awarded by the PEB for medication use or PFTs.  A 60% rating was not justified by PFTs or in the absence of at least monthly visits to a physician for required care of exacerbations, or intermittent (at least 3 per year) courses of systemic corticosteroids.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication of 30% for the asthma condition at TDRL placement.  

The Board next considered its rating recommendation at the time of TDRL removal.  The Formal PEB (FPEB) rated the asthma condition 0%, coded 6602, stating “pharmacy record showing extreme gaps in the use of medication which would not account for any discontinuance during the soldier's pregnancy.  Physical examination notes occasional end expiratory wheeze.  Rated 0% as soldier is non-compliant with medical management.”  A 30% rating stipulates “FEV-1 of 56- to 70-percent predicted, or; FEV-1/FVC of 56 to 70 percent, or; daily inhalational or oral bronchodilator therapy, or; inhalational anti-inflammatory medication;” additionally the “inhalational anti-inflammatory medication” clause of the 30% language does not specify “daily.”  

In its deliberations, the members considered the issue of whether the requirement for daily bronchodilator and/or routine anti-inflammatory therapy was met in this case, as that is the pivotal criteria between a 0%, 10% or 30% rating IAW VASRD §4.97.  The Board considered the military medication profile as one item of evidence for medication use frequency and weighed the probative value with other evidence in the treatment notes and the CI’s statement of medication use.  Potential sources of medication (ER, inpatient, troop clinics, providers’ samples, pulmonary testing labs, civilian or VA pharmacies, etc.) were not routinely captured in the medication profile proximate to the CI’s date of separation.  Additionally, the FEV-1/FVC closest to TDRL exit was 56 to 70 percent, also meeting the 30% criteria.  

Board members agreed that the VASRD §4.97 threshold for a 30% rating was reasonably satisfied in this case at TDRL removal on the basis of inhalational anti-inflammatory medication use.  A 60% rating was not justified by PFTs or in the absence of at least monthly visits to a physician for required care of exacerbations, or intermittent (at least 3 per year) courses of systemic corticosteroids.  

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 30% for the asthma condition coded 6602, at TDRL removal.  

BOARD FINDINGS:  In the matter of the asthma condition, the Board unanimously recommends no change (a disability rating of 30%) at the time of placement on the TDRL, and a rating of 30% at the time of removal from TDRL and permanent disability disposition, coded 6602, IAW VASRD §4.97.  There were no other conditions within the Board’s scope of review for consideration.  

The Board 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	RATING	
		TDRL	PERMANENT	
Asthma	6620	30%	30%	
RATING	30%	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150707, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB																		

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
XXXXXXXXXXXXXXXXXX, AR20170000697 (PD201501855)

1.  Under the authority of Title 10, United States Code, section 1554(a), I approve the enclosed recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) pertaining to the individual named in the subject line above to re-characterize the individual’s separation as a permanent disability retirement with the combined disability rating of 30% effective the date of the individual’s original medical separation for disability with severance pay.  

2.  I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum:

	a.  Providing a correction to the individual’s separation document showing that the individual was separated by reason of permanent disability retirement effective the date of the original medical separation for disability with severance pay.

	b.  Providing orders showing that the individual was retired with permanent disability effective the date of the original medical separation for disability with severance pay.

	c.  Adjusting pay and allowances accordingly.  Pay and allowance adjustment will account for recoupment of severance pay, and payment of permanent retired pay at 30% effective the date of the original medical separation for disability with severance pay.

	d.  Affording the individual the opportunity to elect Survivor Benefit Plan (SBP) and medical TRICARE retiree options.

3.  I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

BY ORDER OF THE SECRETARY OF THE ARMY:

Enclosure
CF: 
(  ) DoD PDBR
(  ) DVA