RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02269
BRANCH OF SERVICE:  NAVY 	SEPARATION DATE:  20090729

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Strike Planning Applications, medically separated for “type 1 diabetes on insulin pump therapy”, with a disability rating of 20%.   

CI CONTENTION:  The CI requested a review of all conditions.  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 - 20090604	VARD - 20100121 	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Type 1 Diabetes on Insulin Pump Therapy	7913	20%	Type 1 Diabetes	7913	20%	20100107	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  Primary source medical records prior to referral to the Medical Evaluation Board (MEB) were not available in evidence before the panel.  A further attempt at obtaining the missing documents would likely be unsuccessful and introduce additional delay in processing the case.  It was judged by the members of the panel that the missing evidence would not materially alter the panel’s recommendations.

Type 1 Diabetes on Insulin Pump Therapy.  According to the service treatment record (STR) and the MEB narrative summary (NARSUM), the CI’s diabetes type I condition began in October 2008 after presenting with symptoms of weight loss, polyuria (frequent urination), and polydipsia (drinking large amounts of fluids) along with hyperglycemia (elevated blood sugar) that was not responsive to metformin (an oral medication to treat diabetes) and which ultimately required treatment with insulin.  Because of episodes of hypoglycemia (low blood sugar) with heavy activity and exercising, the CI was given a mini-med paradigm insulin pump to prevent hypo-and hyperglycemia.  However, even after insulin pump basal setting adjustments, the CI still developed symptoms of weakness and lightheadedness if his blood sugar dropped below 50 mg/dL.  Limited duty (LIMDU) placement on 4 November 2008 noted no (PRT) physical readiness training and restricted exposure to extreme temperatures and prolonged activity.

The 8 May 2009 MEB narrative summary (NARSUM) examination, 3 months prior to separation, noted complaints of symptoms of weakness and lightheadedness and that the CI was taking insulin.  Physical examination showed essentially normal findings.  Neurologic findings were non- focal; the skin was without a rash, lesions, or ulcers of the feet; and monofilament testing to determine peripheral sensation was intact.  Due to extreme insulin sensitivity, the CI had a complicated insulin regimen to include carbohydrate counting.  The examiner stated that the CI was “not restricted from activity but must check his blood sugar prior to activity and must have access to 15g carbohydrate serving to take pre-exercise if his blood sugar is less than 100. It is also recommended that he be placed in a work environment that it does not expose him to extremes of temperature which increases risk of hypoglycemia.”  Nevertheless, it was determined that it was unsafe to be onboard ship or perform the requirements that his rating required and he would have to remain on insulin therapy life-long and was at risk for microvascular disease (retinopathy, neuropathy, and nephropathy) as well as increased risk of cardiovascular and macrovascular disease (cerebral and peripheral vascular).  

During the 19 May 2009 MEB examination (recorded on DD Forms 2807-1 and 2808), 2 months prior to separation, the CI reported he was taking insulin and had tingling and numbness in legs and headaches prior to using insulin.  The examiner did note the CI had type I diabetes mellitus and had an insulin pump in place, but did not explicitly or implicitly indicate that avoidance of strenuous occupational and recreational activities was medically necessary.   Following initiation of treatment at the time of diagnosis, the STR showed no episodes of ketoacidosis or hypoglycemia requiring hospitalizations or frequent visits to a diabetic care provider (twice a month or more frequently).  There was no evidence of diabetic complications prior to separation.

At the 7 January 2010 VA Compensation and Pension (C&P) evaluation, 5 months after separation, the CI reported he was using an insulin pump and liked it much better than previous insulin treatments (1 injection every 3 days instead of previous 4 times/day).  The examiner stated that the CI must be sure to adhere to strict diet and insulin use.  The physical examination including neurologic evaluation was normal.  The HgA1C was 10.5% (normal 4.4-6.4) on 28 October 2009, 3 months post-separation, thereby requiring modifications of the insulin dose and insulin pump settings. 

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the type 1 diabetes condition 20%, coded 7913 (diabetes mellitus, citing insulin pump therapy.  The VA also rated the type 1 diabetes condition 20%, coded 7913 (diabetes mellitus), based on the C&P examination 5 months after separation, citing a requirement for insulin and restricted diet.  
The panel agreed that the requirement for treatment with insulin and restricted diet justified a 20% rating.  Because there was no evidence of medically-prescribed regulation of activities, the next higher 40% rating was not justified according to the majority of panel members.  Furthermore, following initiation of treatment at the time of diagnosis, the STR showed no episodes of ketoacidosis or hypoglycemia requiring hospitalizations or frequent visits to a diabetic care provider (twice a month or more frequently), or complications that could support higher ratings.   After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel majority concluded that there was insufficient cause to recommend a change in the PEB adjudication for the type 1 diabetes condition.  

BOARD FINDINGS:  In the matter of the type 1 diabetes condition and IAW VASRD §4.119, the panel majority recommends no change in the PEB adjudication.  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, 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 20150824, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

Minority Opinion.  The panel agreed that the requirement for treatment with insulin and restricted diet justified a 20% rating.  However, despite the NARSUM examiner indicating the CI was “not restricted from activity;” nevertheless, it “was recommended the he be placed in a work environment that does not expose him to extremes of temperature which increases risk of hypoglycemia.”  His job at that time did increase his risk of such exposure.  A 40% rating requires insulin, a restricted diet, and regulation of activities.  The CI was on insulin and had a restricted diet where he was counting carbohydrates to determine his insulin dose and insulin pump settings.  However, the NARSUM examiner wrote of two antithetical statements:  The CI was “not restricted from activity,” while on the other and the CI should be “placed in a work environment that does not expose him to extremes of temperature which increases risk of hypoglycemia.”  Clearly the latter statement is a restriction of activity, the end result of which is hypoglycemia as is any other physical restriction of activities.  Furthermore, the phrase “not restricted from activity” is vague and overbroad, and therefore provides minimal to no guidance to either the CI or those who are required to determine what he could or could not do and under what circumstances.  The panel majority felt that the placement of the CI in a work environment that doses not expose him to extremes of temperature was only a recommendation.  However, whether it was a recommendation or an order in the form of a prescription; nevertheless, put the CI on clear notice that he was to avoid extremes of temperature.  In fact the LIMDU document dated 4 November 2008 noted no (PRT) physical readiness training and restricted exposure to extreme temperatures and prolonged activity.  Those two limitations unequivocally qualify as regulations of activities.  Furthermore, since the VASRD is the source of the PDBR’s rating determination IAW 38 CFR §4.119 (schedule of ratings-endocrine system), attention is directed to the U. S. Court of Appeals for Veterans Claims case Camacho v. Nicholson, which addressed the “regulation of activities” to mean “avoidance of strenuous occupational and recreational activities” in accordance with the VA interpretation, the case of which is posted at (http://www.knowva.ebenefits.va.gov/system/templates/selfservice/va_ss/#!portal/554400000001018/article/554400000014801/Camacho%20v.%20Nicholson,%20Jul%206,%202007,%2021%20Vet.App.%20360).  Note that nowhere in the wording for code 7913 require a prescription 
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 USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USN

		
		XXXXXXXXXXXXXXXXXX

as does code 5243 (intervertebral disc syndrome), for which Note (1) states:  “For purposes of evaluations under diagnostic code 5243, an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician.”  Therefore, a recommendation to the CI is clearly is “words to the wise,” and the failure to take heed in occupational and/or recreational activities, bears the risk of hypoglycemia and the symptoms (sweating, shakiness, tachycardia, anxiety, a sensation of hunger, weakness, tiredness, or dizziness, inappropriate behavior, difficulty with concentration, confusion, and blurred vision) and consequences in extreme cases (coma and death) related thereto. (http://emedicine.medscape.com/article/122122-overview)  Furthermore, despite using an insulin pump proximate to separation, the CI was still adjusting insulin doses and settings.  

Therefore, medical recommendation that the CI not be exposed to extremes of temperature which increases risk of hypoglycemia and his restriction from physical readiness training and exposure to extreme temperatures and prolonged activity further support unequivocal examples of regulation of activities.  Therefore, the next higher 40% rating is justified and recommended by the minority voter.  Furthermore, following initiation of treatment at the time of diagnosis, the STR showed no episodes of ketoacidosis or hypoglycemia requiring hospitalizations or frequent visits to a diabetic care provider (twice a month or more frequently), or complications that could support a higher rating than 40%.  

The minority voter recommends the ROP be modified to read as follows:

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 40% for the diabetes type 1 on insulin pump therapy condition, coded 7913.  

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	
Diabetes Type I on Insulin Pump Therapy	7913	40%