RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01868
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060609

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Traffic Management Coordinator, medically separated for “asthma,” with a disability rating of 0%.

CI CONTENTION:  “Review all conditions.”  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 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 - 20060212	VARD - 20061212	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Asthma	6602	0%	Asthma	6602	0%	STR	
Allergic rhinitis	Not Unfitting	No VA Placement	
Hyperlipidemia	Not Unfitting 		
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Asthma.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s asthma condition began in October 2001 due to sick call visits for shortness of breath, sneezing and coughing.  The diagnosis was late confirmed with pulmonary function testing (PFT).  The CI had a long history of asthma, with multiple asthma attacks while deployed and continued asthma attacks upon return.  Between 30 September 2003 and May 2004, she was in the ER multiple times and prescribed steroids.  On a 10 February 2005 from the CI’s pulmonologist he stated that the CI had had steroid dependent asthma for three years.  On 2 March 2005 the CI filled a 600 day supply of prednisone (150 20mg tabs; take ½ every other day).  At the pulmonary clinic evaluation on 22 March 2005 (15 months prior to separation) the examiner noted that the CI was on prednisone, Advair, albuterol, Singular and Allegra.  The CI was still having breakthrough symptoms requiring albuterol treatments 4 times per week.  The best of multiple Pulmonary Function Tests (PFT) in the STR showed moderate restrictive ventilator defect with an FEV-1 of 51% of predicted and an FEV-1/FVC of 111%.  The CI appeared to improve until another attack (as related at a 22 May 2005 pulmonary clinic appointment, 12 months prior to separation).  At that time, the treatment record showed the CI was taking prednisone, Advair, albuterol, and Singular.  The CI was given a nebulizer treatment and sent home with current meds and began to taper her off her steroids.  According to the pulmonary clinic evaluation on 2 August 2005 (10 months prior to separation) the examiner noted that the CI was on Advair, albuterol and Singular.  The CI stated she used albuterol 4 times weekly and complained of trouble with her voice and wheezing.  The examiner diagnosed asthma of unclear severity with history of steroid dependency possibly contributing to the possible vocal cord dysfunction; and stating the CI might be a candidate for Xolair and not allergen immunotherapy (AIT).  The examiner also stated that daily medications were required for asthma control, and instructed the CI to continue use of Claritin, Singular and Advair.  The better of 2 PFTs performed that day showed an FEV-1 of 50% of predicted and an FEV-1/FVC of 110%.  The examiner opined that the PFT showed poor effort making the results unreliable.  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 “Asthma, extrinsic” for PEB adjudication.  At the MEB examination (recorded on DD Forms 2807 and 2808) dated December 2005, 6 months prior to separation, the CI had indicated issues with asthma, shortness of breath, wheezing, and sinusitis.  Physical exam showed lungs as normal.  The MEB NARSUM examination on 7 December 2005, 6 months prior to separation, noted tapering of the steroids, with good success on Advair, Singular and Flonase; with reduced complaints of issues down to twice weekly.  She was still using albuterol as needed twice per week.  The CI had not had significant shortness of breath.  Physical examination showed an 8-month pregnant female with normal respiratory rhythm and depth, clear to auscultation, with no wheezing or rhonchi heard.  There was no VA Compensation and Pension examination proximate to separation in evidence.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the “asthma” condition 0%, coded 6602 (Asthma, bronchial), noting the last receipt of asthma medication was over 4 months prior to the PEB; and that physical examination reported lungs clear to examination.  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.”  The panel majority agreed that inhaled anti-inflammatories medication (Advair) was “regularly taken by the CI” as documented by the MEB NARSUM examiner 6 months before separation and documented as a current medication.  The panel noted the 30% asthma rating for “inhalational anti-inflammatory medication” does not require daily use.  The panel next considered if a higher rating was warranted.  A 60% rating stipulates “FEV-1 of 40- to 55-percent predicted, or; FEV-1/FVC of 40 to 55 percent, or; at least monthly visits to a physician for required care of exacerbations, or; intermittent (at least three per year) courses of systemic (oral or parenteral) corticosteroids.  A 60% rating was not deemed justified by the panel majority in this case by FEV-1 of 50-percent predicted as noted by the 2 August 2005 pulmonary examination.  The test result was considered due to a poor effort on the CI’s part and not indicative of the CI’s actual condition.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel majority recommends a disability rating of 30% for the asthma, bronchial condition, coded 6602.  

Contended PEB Conditions:  Allergic Rhinitis, Hyperlipidemia.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  None of the conditions were profiled or implicated in the commander’s statement or judged to fail retention standards.  There was no performance-based evidence from the record that any 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 asthma, bronchial condition, the panel majority recommends a disability rating of 30%, coded 6602 IAW VASRD §4.100.  In the matter of the contended allergic rhinitis and hyperlipidemia conditions, the panel unanimously recommends no change from the PEB determinations as not unfitting.  The single voter for dissent submitted the appended minority opinion.  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; 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	
Asthma	6602	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150602, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

		

MINORITY OPINION:  The minority dissent with the majority recommendation is based on the totality of the evidence from the STR as accurately portrayed in the above proceedings.  Based on a preponderance of this evidence, the minority member opines that the CI met the criteria for a 60% rating.  The majority vote favored a 30% rating for the asthma condition, however, the minority member opines that the CI met the criteria for 60%.  Said criteria are: 1) FEV-1 of 40- to 50-percent predicted, or; 2) FEV-1/FVC of 40 to 55 percent, or; 3) at least monthly visits to a physician for required care of exacerbations, or; 4) intermittent (at least three per [emphasis added] year) courses of systemic (oral or parental) corticosteroids.  The CI clearly met the first criteria.  The FEV-1 measurements from multiple PFTs in evidence, as per the proceedings, did satisfy the 60% criteria.  The panel majority discounted the most recent PFT (2 August 2005) primarily due to it being labeled “a poor effort-results unreliable.”  However, it is not at all uncommon for individuals with poor lung function to perform poorly on PFTs.  The cited PFT was the better of 2 that day and almost identical to the best of 4 PFTs 5 months earlier (22 March 2005) when the CI was still steroid dependent and having frequent breakthrough symptoms.  In the opinion of the minority member, the fourth criterion was also met.  In May 2005 the CI was still steroid dependent for the control of her asthma and had been on oral steroids almost continuously for the previous there years.  She was able to be tapered off corticosteroids during the summer of 2005 and had not had an exacerbation severe enough to require them prior to the PEB.  The minority differs with the majority’s interpretation of the above VASRD §4.97 language, in that the latter noted that the CI had not been on any corticosteroids within 12 months of her discharge date.  While this is debatable, had the CI been discharged within 90 days of her PEB, she would have clearly been within 12 months of having been steroid dependent for 3 years.  The exact date she stopped taking steroids is unclear but given her long dependence on steroids and normal tapers, it was likely well into June or early July of 2005.  That would have been within 12 months of the 9 June 2006 discharge date.  In the opinion of the minority member, this over 3 year continuous dependence on steroids overlapping the discharge date by less than 12 months equated to the “at least three per year courses of systemic corticosteroids” requirement for corticosteroids to the same acuity as a patient requiring that treatment “per year” as clearly specified in the language.  The CI had a long history of severe steroid dependent asthma with consistently poor PFTs.  Though she was able to come off the steroids in the months prior to her PEB, she had no measurable improvement in her PFTs.  It is the minority member’s opinion that the CI met two of the four criteria for a rating of 60%.  The minority member offers no dissent with the panel conclusion that the §4.97 threshold for a minimum 30% rating was reasonably satisfied in this case; since, there was evidence from multiple providers that inhaled anti-inflammatories, which are not specified as a daily requirement under the 30% rating provision, were prescribed.  Consistent with the DoDI 6040.44 standard of recommendations that are fair and equitable to both the Service and the CI, the Secretary is respectfully requested to consider the minority recommendation that the CI’s discharge with severance pay be re-characterized to reflect a permanent 60% disability retirement. 

CONDITION	VASRD CODE	PERMANENT RATING	
Asthma	6602	60%	

AR20170009226, 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, (AHRC-DO), XXXXXXXXXXXXXXXXXXX.

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

Sincerely,					      
Enclosure