RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02259
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20020927

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Wheeled Vehicle Mechanic, medically separated from the Temporary Disability Retired List (TDRL) for “history of pancreatitis, now in remission,” with a disability rating of 0%.  

CI CONTENTION:  The CI contends his condition continues to worsen and negatively impacts daily activities.  The complete submission, with attachments, 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 - 20020725	VARD - 20010419	
Condition	Code	Rating	Condition	Code	Rating	Exam	
History of Pancreatitis, Now in Remission	7399-7347	0%	Chronic Pancreatitis with Anemia	7347	60%	20010207	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Recurrent Idiopathic Pancreatitis/History of Pancreatitis Now in Remission.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s pancreatitis began in April 2000 after complaining of abdominal pain, bloating and cramping.  The CI had multiple hospitalizations, but specialty studies including upper and lower endoscopy and Meckel scan were normal.  The CI had elevated blood markers (amylase and lipase levels) during recurrent attacks, with multiple hospitalizations and no clinical etiology found for the pancreatitis despite extensive testing.  The CI was clinically diagnosed with recurrent idiopathic pancreatitis.  Narcotic medications and pancreatic enzymes did not control symptoms sufficiently to allow full duty and the CI was placed on TDRL in March 2001 at 30%.  

The 6 May 2002 TDRL removal MEB gastroenterologist NARSUM examination, 5 months prior to separation, noted complaints of 2-3 episodes per month of epigastric abdominal pain with associated nausea, bloating and anorexia, and 24-hours of low-grade fevers.  The CI self-treated with rest and oral analgesia including narcotic pain medication.  The last attack took place 2 weeks prior to the 2 April 2002 TDRL removal examination.  The CI had no hospitalization while on TDRL and between episodes he had no dietary restrictions, diarrhea, or weight loss.  The frequency of attacks of abdominal pain had not changed since his initial evaluation though the CI indicated that severity of the attacks may be slightly less.  Physical examination showed a normal chest and abdominal findings.  The lipase was elevated at 76 (normal 21-51), with a normal blood count (no anemia), and normal liver enzymes.  Diagnostic imaging (CT, nuclear medicine, and ultrasound) was normal.  The gastroenterologist diagnosed chronic idiopathic pancreatitis and stated “the natural history of idiopathic pancreatitis describes intermittent episodes of abdominal pain of varying severity which follows no specific clinical course.”  There was no VA Compensation and Pension (C&P) evaluation performed proximate to TDRL removal (the 7 February 2001 C&P evaluation was performed prior to TDRL placement).  

The panel directed attention to its rating recommendation based on the above evidence.  The Informal PEB rated the pancreatitis condition 30% at TDRL removal, coded 7347 (pancreatitis), citing “2-3 episodes of epigastric pain, nausea, bloating and anorexia per month; episodes last for 24 hours followed by several days of abdominal distension, anorexia, bloating and low grade fever.”  However, the US Army Physical Disability Agency (USAPDA) modified the PEB findings, rating, and disposition (via DA Form 18) to a rating of 0%, coded 7399-7347, citing “history of pancreatitis, now in remission.  Soldier has subjective complaints of episodic abdominal discomfort.  Laboratory and radiographic studies are unremarkable.”  The USAPDA modification memo cited VASRD note 1 (under code 7347) “requires that abdominal pain must be confirmed as resulting from pancreatitis by appropriate laboratory and clinical studies.  Laboratory studies do not correctly support pancreatitis as directly causing the soldier's discomfort.”  The VA rated the pancreatitis condition 60% coded 7347, based on the VA C&P examination prior to TDRL entry, and there were no additional VARDs in evidence.  

The NARSUM gastroenterologist made a clear clinical diagnosis of chronic idiopathic pancreatitis, the lipase was elevated (abnormal laboratory study for normal values at that time) on examination, and there was an episode reported by the CI within two weeks of the examination with at least monthly episodes (2-3x/month) noted in the history.  Although there was no medical entry or diagnosis that the CI’s idiopathic pancreatitis was in remission, the USAPDA changed the nomenclature of the unfitting condition from pancreatitis to “history of pancreatitis, now in remission” based on a discussion with a gastroenterologist at Walter Reed Army Medical Center. 

The panel deliberated on the frequency and severity of episodes and whether each attack of abdominal pain had to be confirmed by clinical and laboratory evidence [7347 – Note 1] with a specialist-diagnosed condition of idiopathic pancreatitis.  Given the continued use of prescription narcotic pain medication providing symptom decrease after a 24-hour acute symptom period, the panel majority considered the scarcity of the TDRL clinical notes as not unreasonable.  

There was additional evidence of continuing post-separation significant abdominal symptoms including abdominal surgery (appendectomy and cholecystectomy) approximately 2 years after TDRL removal as well as evidence that his episodes of abdominal pain where not typical for chronic or acute pancreatitis.  His treating physician in July 2008, 6 years after TDRL removal, stated “I doubt that he has any pancreatic problem at all.”
 
The panel majority adjudged that there was sufficient evidence that the CI’s abdominal pain was adequately confirmed as resulting from pancreatitis by appropriate laboratory and clinical studies, along with the specialist’s diagnosis.  The CI’s disability picture at separation was closest to the 30% criteria of “moderately severe; with at least 4-7 typical attacks of abdominal pain per year with good remission between attacks.”  There was no evidence of malabsorption, diarrhea, severe malnutrition, loss of normal body weight, or other findings showing continuing pancreatic insufficiency between acute attacks for any rating higher than 30%.  

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 recurrent idiopathic pancreatitis condition, coded 7347.  

BOARD FINDINGS:  In the matter of the recurrent idiopathic pancreatitis condition, the panel majority recommends a disability rating of 30%, coded 7347 IAW VASRD §4.114.  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	
Recurrent Idiopathic Pancreatitis	7347	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150820, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

	

Minority Opinion:  The 30% moderately severe rating under VASRD diagnostic code 7347 (pancreatitis), proposed by the majority, requires at least 4-7 typical attacks of abdominal pain per year with good remission between attacks.  Note 1 under the 7347 code indicates that “abdominal pain in this condition must be confirmed as resulting from pancreatitis by appropriate laboratory and clinical studies.”  

During the 1 year period (1 March 2000 – 28 February 2001) prior to TDRL placement, the STR contains evidence of at least five emergency room visits for severe abdominal pain (27 March 2000, 27 April 2000, 6 July 2000, 13 July 2000, and 27 July 2000) and three laboratory studies that showed high lipase levels (27 March 2000, 4 April 2000, and 6 July 2000) as well as multiple other primary care clinic and gastroenterology clinic visits for abdominal pain.  Therefore, the rating of 30% at TDRL placement was well supported by the objective evidence in the STR.  However, at the time of TDRL removal, the NARSUM, dated 6 May 2002, indicated that the CI had “no recent hospitalizations and no anatomic complications from his recurrent bouts of pancreatitis.”  The CI stated in his contention to the Board that “while on TDRL [he] did not go to a doctor when [he] got sick and being that it was very frequent [he] did not have supporting documentation (labs, tests, Rxs, and treatments).”  There was evidence of only 1 emergency room visit (30 August 2002) for pancreatitis and this occurred after the NARSUM was dictated.  The CI told the NARSUM examiner that he was having “two to three episodes of epigastric abdominal pain with associated nausea, bloating and anorexia per month,” but evidently these were not significant enough to require emergent care and didn’t rise to the level required by the VASRD for a 30% rating.  Therefore, after considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt) the minority finds that the CI’s disability picture at TDRL removal was consistent with a 10% rating under diagnostic code 7347 “with at least one recurring attack of typical severe abdominal pain in the past year.”  

The rating for pancreatitis should be modified to 10% for satisfactory evidence of at least one recurring attack of pancreatitis in the past year as evidenced by the emergency room visit on 30 August 2002 proximate to TDRL removal.  

The minority recommends that the CI’s prior determination be modified as follows, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Pancreatitis	7347	10%	

AR20170012863, XXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and recommended that your percent of disability be increased to 30%.  I have reviewed the Board’s record of proceedings, majority recommendation, and minority opinion (copy enclosed).  I regret to inform you that I reject the Board’s majority recommendation and accept the Board’s minority opinion that your disability rating should be modified to 10% but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability.  There is insufficient justification to support the Board’s recommendation in accordance with Army and Department of Defense regulations.  

	This decision is final.  Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction.

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

Sincerely,

						      					
Enclosure