RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01919
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20071029

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Security Forces Journeyman, medically separated for “major depressive disorder associated with cognitive disorder,” with a disability rating of 10%.

CI CONTENTION:  The CI states he is undergoing care and treatment from the VA for service connected issues and has been rated at 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 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 - 20070716	VARD - 20080519	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Major Depressive Disorder Associated with Cognitive Disorder	9434	10%	Cognitive Disorder…with Adjustment Disorder…	9304-9440	30%	20080221	
Obstructive Sleep Apnea (OSA)	Cat II	Sleep Apnea	6847	50%	20080305	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  90%	

ANALYSIS SUMMARY:  

Major Depressive Disorder (MDD) Associated with Cognitive Disorder.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI was in his usual state of health until a motor vehicle accident o/a 19 November 2003 while stationed overseas.  He was taken to a local emergency room (ER) and treated for hip and neck pain.  These records were not available for review.  He was released and then transported by security police (his squadron) to the local US military ER.  He reported right hip and neck pain, but denied headache (HA), nausea, vomiting, visual changes, chest pain, or shortness of breath.  Neither head trauma nor loss of consciousness (LOC) were documented.  On examination, he was tender over the right pelvis near the hip, but not other signs of trauma were documented.  X-rays of the right hip and a CT of the neck were normal.  He was placed on 72 hours quarters for the right hip injury.  He was seen the next day in orthopedics and reported right hip and left knee pain.  He was thought to have a bruise (contusion).  The CI also reported headaches with bright light and was again evaluated in the ER on 21 November for this.  He reported a 2-day history of headaches and that he hit the back of his head in the MVA; LOC was not recorded.  On examination, the neurological and mental status evaluations were normal.  Slight swelling and tenderness were noted over the posterior scalp.  A CT of the head was normal.  The CI declined intravenous medications (for the headache) and was discharged to home (he had one day of quarters remaining for the right hip).  He reported continued symptoms of dizziness and light sensitivity at an orthodontic appointment on 24 November 2003 and was referred to the ER.  There, he also reported rib pain.  On examination, the head was normal as was the neurological examination.  The ribs and right hip were mildly tender; a chest X-ray was normal.  He continued to have headaches as well as difficulty sleeping, decreased concentration, and increased stress.  His examination remained unremarkable.  He was referred to neurology for a post-concussive syndrome.  The CI was also seen in mental health on 21 January 2004 for his symptoms.  He was thought to have a cognitive disorder and referred for neuropsychological testing.  He was placed on medications for mood irritability and mood lability.  He maintained an S1 profile though.  The neurology evaluation was on 20 February 2004, 3 months after the MVA.  He reported persistent headaches and cognitive complaints, both of which were improving.  The cognitive complaints included impaired short term memory and slow processing of information.  The CI reported that he had 5-6 seconds of LOC.  The neurologist wrote that the CI “…is not certain how he came up with that estimate as there was no passenger/immediate witness.”  The panel observed that this was the first the LOC was found recorded in the evidence.  The examination was normal including a mini-mental status examination (MMSE, which was completely normal at 30/30 correct).  He was thought to have a post-concussive syndrome with somatic and affective symptoms.  His prognosis was good with continued improvement/full resolution expected over the next few months.  The examiner concurred with neuropsychological (NP) testing.  This was accomplished on 4 March 2004, 2 weeks later.  The CI reported a LOC of less than 1 minute.  He noted both perceptual disturbances and cognitive difficulties which were improving.  It was noted the he took 2 hours to complete the clinic paperwork which normally is finished in less than 30 minutes and that he scored 27/30 on the MMS (it was 30/30 2 weeks earlier).  His testing showed some deficits, but it was thought that this could be from an underlying adjustment disorder following the MVA as well as his pre-morbid personality.  He was thought to have a possible mild traumatic brain injury (TBI).  Improvement was anticipated and repeat testing in 6 months was recommended.  A family practice note dated 5 August 2004 noted that the CI had returned to full duty, but that his commander was concerned about the CI’s tardiness.  On examination, the CI showed slowed speech and response as well as confusion.  A brain MRI on 2 September 2004 was normal.  Repeat NP testing was performed on 9 November 2004.  The CI reported improvement in his symptoms.  It was noted that his performance was generally similar to the previous testing, but with greater variability in the level of performance.  Again, a combination of pre-morbid personality structure, possible head trauma, and a mood disorder were thought to be the cause of the deficits observed, but the mood disorder was thought to have the greatest impact.  Continued improvement was anticipated.  The CI continued to be seen over the next several years in mental health for the cognitive disorder and mood disorder.  The S1 profile was maintained.  He reported to the ER on 31 May 2006, 17 months prior to separation, for an “emergency life skills problem.”  He reported stress from his supervisor, out-processing (for a military move), and a relationship.  Neither suicidal nor homicidal ideation was recorded.  He had not been able to make an appointment in life skills and therefore presented to the ER.  He was released to duty and a follow up appointment was made in life skills 2 days later.  Over the next few months his medications were adjusted due to side effects.  His mental health symptoms persisted, but were mild.  On 12 January 2007, 9 months prior to separation, the CI was noted to have had a major depression, single episode, in remission.  He remained on medications and without side effects.  
The MEB NARSUM examination on 17 April 2007, 6 months prior to separation, noted the onset of depressive symptoms since the MVA (in November 2003) and a cognitive disorder.  He was in remission, but was presented for an MEB due to the need for ongoing treatment (with Prozac).  He reported a LOR for being late for a formation and another LOR for failure to show.  The mental health examination was normal.  He was diagnosed with a major depressive disorder, single episode in full remission, and a cognitive disorder.  The latter did not impair military duty.  The examiner specifically noted that the CI was being referred to a PEB for the ongoing need for a psychotropic medication (Prozac) and that he did not have a cognitive deficit incompatible with military service.  The final mental health clinical note in the record prior to separation was dated 18 June 2007 and also noted that he remained in remission.  An update to the NARSUM was dated 19 June 2007.  It noted that the CI was restricted from weapons due to the policy of the local security police squadron and not from a medical recommendation.  It also noted that his mental health examination was sable from the NARSUM above.  The commander’s letter was dated 21 June 2007.  It noted that the CI was not able to meet duty requirements due to his mental and physical conditions.  He was working as a pass and registration clerk.  He had not missed any work in the past 90 days.  It also noted that while he was capable of performing office duties, he did not display any enthusiasm and contributed minimally to the mission.  

At the VA Compensation and Pension (C&P) evaluation performed on 21 February 2008, 4 months after separation, the CI reported that he had been in Special Forces.  He reported that he had been harassed by various supervisors.  He also addressed the MVA stating that he lost consciousness and was evaluated in a hospital for a day.  He reported ongoing problems with depression and sleep disturbances (discussed below; the CI reported resolution of his symptoms with treatment for the OSA).  He noted ongoing anxiety as well associated with searching for a job since separation.  He also endorsed increased alcohol use.  He reported inappropriate behavior including vandalism.  He reported being on “watch” for suicidal ideation in 2007 (not supported by the records in evidence).  On examination, he appeared depressed, slowed, and forgetful.  A cognitive function test was impaired with a score of 23 (normal is 27-30; values of 21-26 show mild neurocognitive disorder for a high school graduate, which he was).  He was thought to have a cognitive disorder, and adjustment disorder, and alcohol dependence.  It was thought that he retained the ability to perform simple work.  The CI was interviewed by telephone for mental health on 23 April 2008, 6 months after separation.  He reported trouble with anger and panic attacks when stressed out.  He stated that he was not currently in treatment.  A mental health note dated 4 August 2008 noted that he was able to work and to carry a firearm.  The CI was evaluated in mental health on 13 August 2008, 10 months after separation.  He reported that he had gotten mad at a supervisor at work and needed a letter to return.  He reported that he had a concussion and bleeding in his head (this is not supported by the evidence) and was off duty for 6 months (he was profiled, but not off work).  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the MDD associated with cognitive disorder condition at 10%, coded 9434 (major depressive disorder).  The VA rated the cognitive disorder due to brain trauma with adjustment disorder and alcohol dependence condition 30% coded 9304-9440 (dementia due to head trauma – chronic adjustment disorder), based on the C&P examination 4 months after separation, citing occasional decrease in work efficiency or intermittent periods of inability to perform occupational tasks while under stress.  The CI was clearly improved over the latter months of his active service and this was stable on the final entry prior to separation.  The commander noted that the CI had not missed any duty the prior 90 days.  The level of impairment described in the C&P examination was more than observed the final months of active service and is greater than expected given the length of time from the initial injury (over 4 years previously) and level of performance documented on the mental health clinical notes.  The medical officer noted that the typical course of cognitive impairment from a TBI is improvement with time, especially for a mild head injury such as was recorded in this case.  In fact, initially, there was not a record of any head trauma.  The depression was in remission prior to separation.  The CI reported symptoms at the C&P examination, but a few months later was cleared both for work as a security guard and to carry a weapon.  A review of the records did not show that the CI had been hospitalized for a mental health condition nor that he had been to the ER other than 1 visit 17 months prior to separation.  The ER visit was due to the fact that he had not been able to make an outpatient appointment.  The panel did not find evidence that there were periods the CI was unable to perform his job proximate to separation; accordingly, a higher 30% rating is not supported.  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 MDD associated with cognitive disorder condition.  

Contended PEB Conditions:  OSA.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended condition was not unfitting.  The contended condition was not profiled or specifically implicated in the commander’s statement.  It was judged to fail retention standards, but the NARSUM addendum dated 17 April 2007 recorded that the CI was asymptomatic on treatment.  There was no performance-based evidence from the record that the condition 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 the contended condition and so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the MDD associated with cognitive disorder condition and IAW VASRD §4.130, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the contended OSA condition, the panel unanimously recommends no change from the PEB determination as a Category II condition, one that can be unfitting, but was not currently compensable or ratable.  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 20150624, w/atchs
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-2015-01919.

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