RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02305
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060407

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Administrative Specialist, medically separated from the Temporary Disability Retired List (TDRL) for “asthma” and “major depressive disorder,” rated 10% and 10%, respectively, with a combined disability rating of 20%.  

CI CONTENTION:  The CI contended for those conditions for which he was granted disability compensation by the Department of Defense (DOD).  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 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 - 20060221	VARD - 20060329	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Asthma	6602	10%	Asthma	6602	10%	20041012	
			Allergic Rhinitis	6522	10%	20041007	
Major Depressive Disorder, Recurrent Without Psychotic Features, In Partial Remission	9434	10%	Major Depressive D/O	9434	30%	20041007	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Asthma.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s asthma condition began in approximately January 2003 with exertional dyspnea and shortness of breath.  He required use of Albuterol (inhaled bronchodilator) daily and daily controller medication of Advair (inhaled anti-inflammatory) and Singulair (equivalent to oral bronchodilator).  The CI had had 1-2 emergency room (ER) visits per month and used systemic steroids for flares.  The CI was placed on TDRL at 30% for moderate persistent asthma (code 6602) on 11 June 2004.  

The 15 December 2005 TDRL re-evaluation for asthma examination, 4 months prior to separation from the TDRL, noted complaints of extreme dyspnea and wheezing with exercise, and night-time symptoms 2-3 times a week.  Medications included “a long acting beta agonist, inhaled steroids, a pill, and albuterol rescue inhaler.”  He related seeing his pulmonologist every 1-2 months over the past year, had had two courses of systemic steroids and was finishing up his third course at the time of the TDRL re-evaluation.  He had not been hospitalized for his asthma.  Physical examination showed normal heart and lungs with pulmonary function testing (PFT) interpreted as normal; with the examiner indicating that the CI was finishing a prednisone taper and had taken prednisone prior to the testing.  The forced expiratory volume in one second (FEV-1) was 86 percent of predicted and the ratio of FEV-1 to forced vital capacity (FVC) was 76%.  

The 2 January 2006 prescription profile documented inhaled anti-inflammatory medication (Asmanex Twisthaler and/or Advair Diskus) issued in February, March, September, and December 2005; oral and inhaled bronchodilators (albuterol, Foradil/aerolizer, and/or Singulair) issued in February, March, April, September, and December 2005; and oral steroids issued in March 2005.  

At the 2 May 2007 VA Compensation and Pension (C&P) respiratory evaluation, performed, 13 months after separation from TDRL, the CI reported fatigue, sensation of chest tightness, chest pain when coughing and constant wheezing.  He related approximately 8 episodes of exacerbation in the last year requiring ER treatment.  The CI indicated he took daily oral bronchodilators, inhaled bronchodilator (albuterol) at least 5 days per week, and oral steroids (prednisone) prescribed by his pulmonologist.  The examiner indicated “Asthmanet (one pill daily)” [there is no medication by that name, and it was unclear if this referred to Asmanex Twisthaler (inhaled anti-inflammatory) described above].  The CI had no recent hospitalization for asthma and chest X-ray was normal.  Physical exam showed normal lung findings, and PFTs that were not interpretable.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the asthma condition 10%, coded 6602 (asthma, bronchial), citing FEV-1 86% intermittent bronchodilator therapy and medication profile consistent with intermittent bronchodilator therapy.  The VA rated the asthma condition 10% coded 6602 (asthma, bronchial), based on the VA C&P examination 13 months after separation from TDRL, citing PFTs and use of bronchodilator medication.  

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.”  There was no PFT proximate to separation that would rate higher than 10%.  However, the record documented that the CI was taking daily inhaled anti-inflammatory medication, and the prescription profile supported issuance of inhalational anti-inflammatory medication for numerous months prior to separation from TDRL.  

Inhaled anti-inflammatories were also prescribed and used, as noted by the TDRL examiner and pharmacy profile.  Panel members agreed that the VASRD §4.97 threshold for a 30% rating was reasonably satisfied in this case on the basis of inhalational anti-inflammatory medication use.  The panel deliberated on the 60% rating criteria as the TDRL examiner indicated three courses of systemic corticosteroids in the year prior to the examination and frequent visits to a pulmonologist; however, the panel adjudged that there was not sufficient evidence of the prior courses of systemic steroids or at least monthly visits to a physician for required care of exacerbations, to warrant the higher 60% rating.  

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

Major Depressive Disorder, Recurrent without Psychotic Features, in Partial Remission.  According to the STR and the MEB NARSUM, the CI’s major depressive disorder condition began in December 2002 related to depression with family and work stressors.  The CI was hospitalized in September 2003 and continued taking two psychoactive medications.  The MEB forwarded “schizoaffective disorder, depressive type” and “major depressive disorder” for PEB adjudication, and the CI was placed on TDRL on 11 June 2004 (at a combined 40% with asthma above) with a 10% rating for “major depressive disorder, recurrent, with psychotic features, co-morbid with schizoaffective disorder,” coded 9434 (major depressive disorder).  

At the 5 October 2005 VA C&P mental disorder evaluation, 6 months prior to separation from TDRL, the CI reported symptoms of depression without psychotic or cognitive symptoms.  He was working full time and was living with his (divorced) wife.  On mental status examination his mood was depressed and the affect was constricted and appropriate.  There was no suicidal ideation, delusions, hallucinations or other symptoms suggestive of psychosis, speech disturbance, objective cognitive impairment, or other abnormality.  The examiner stated “the signs and symptoms described above are seriously interfering with the (CI’s) employment and social functioning.”  The diagnosis was major depressive disorder, recurrent, severe, without psychotic features.  The global assessment of function (GAF) was 50 (50 - 41 serious symptoms).  

The 17 January 2006 TDRL psychiatrist’s re-evaluation, 3 months prior to separation from TDRL, noted complaints of mood swings, including irritability and crying episodes.  He was “employed full-time as a GS-4 at the local MEPS station” and going to school in the evening for computer technology.  He was seeing a psychiatrist monthly for medication management only.  The CI indicated that this medication was largely ineffective and that he had been entered into a day hospital program on 7 to 12 June 2004 and 1 to 9 June 2005 for symptom exacerbation with therapy only on those occasions.  He had not required hospital admission for psychiatric symptoms.  The mental status examination was unremarkable.  The diagnosis was major depressive disorder, recurrent without psychotic features, in partial remission and the psychiatrist indicated the impairment for further military duty was mild and the impairment for social and industrial adaptability was also mild.   

The panel directed attention to its rating recommendation based on the above evidence.  At separation from TDRL, the PEB rated the “major depressive disorder, recurrent without psychotic features, in partial remission” condition 10%, coded 9434 (major depressive disorder), citing day hospital care, a requirement for psychotropic medication, full time employment and “rated as mild social and industrial impairment” (likely application of AR 635-40).  The VA rated the major depressive disorder condition 30% coded 9434, based on the C&P examination 18 months prior to separation from TDRL, citing the 30% criteria.  The C&P examination 6 months prior to separation from TDRL was considered in the 5 July 2007 Board of Veterans’ Appeal determination that supported the 30% rating, but not a requested higher rating.  

All panel members agreed that the evidence of the record did not support a traumatic stressor as the cause of the mental condition for which application of VASRD §4.129 would be appropriate.  The panel adjudged that the TDRL psychiatrist’s re-evaluation had the highest probative value for rating at separation from TDRL.  The CI was fully employed and the psychiatrist examiner indicated impairment as mild which best supports a 10% rating.  All panel members agreed the CI’s condition at the time of separation from TDRL did not support the higher 30% disability rating, and that his level of impairment was better described as occupational and social impairment due to mild or transient decrease in work efficiency and inability to perform occupational tasks only during periods of significant stress.  

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 major depressive disorder condition.  

BOARD FINDINGS:  In the matter of the asthma condition, the panel unanimously recommends a disability rating of 30%, coded 6602 IAW VASRD §4.97.  In the matter of the major depressive disorder condition and IAW VASRD §4.130, the panel unanimously recommends no change in the PEB adjudication.  There are 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%	
Major Depressive Disorder, Recurrent Without Psychotic Features, In Partial Remission	9434	10%	
COMBINED	40%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150902, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

	

AR20170012228, 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 40% 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 and to the counsel you listed on your application, XXXXXXXXXXXXXXXXXXX.

Sincerely,					      
Enclosure