RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02343
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050215

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, M1 Armor Crewman, medically separated for “asthma” with a disability rating of 10%.  

CI CONTENTION:  The CI requested review of all conditions.  The CI’s complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The Board’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 Board’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 Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’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 Board 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 Board 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 - 20050114	VARD – 20050608	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Asthma	6602	10%	Bronchial Asthma	6602	0%	STR	
COMBINED RATING:  10%	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 experienced an asthma attack in February 2003 that sent him to the emergency room.  He was deployed to Iraq shortly thereafter and in in April 2004 he developed respiratory distress.  Recurrent respiratory distress led to evaluation for possible asthma.  Inhaled anti-inflammatory (Advair and Flovent) and bronchodilators (albuterol) were prescribed and systemic steroids (prednisone bursts) were started.  On 23 June 2004 (8 months prior to separation) while deployed, the pulmonary specialist evaluated the CI the day after an emergency department visit for acute wheezing.  The examiner stated that the CI’s history of asthma diagnosis was “unclear; states he told his recruiter that he had asthma, but was sent for a pulmonary evaluation and cleared for enlistment.”  [Note:  The CI’s entry physical (dated 3 June 2002) documented no use of asthma medications and no diagnosis of asthma.]  History included having been treated with prednisone (systemic corticosteroids) three times and visited the “TMC/ER” four times since deployment.  Pulmonary function testing (PFTs) on 30 June 2004 showed an FEV-1 of 108% of predicted and an FEV-1/FVC of 85% (normal), with normal PFTs on 22 July 2004.  Both anti-inflammatory and bronchodilator inhalers were continued and the CI was medically evacuated to home station for pulmonary evaluation.  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 MEB.  The MEB forwarded “asthma” for PEB adjudication.  

According to the internal medicine evaluation on 28 July 2004, the CI’s asthma history included asthma as a child with two emergency department visits prior to entering the Army; use of daily Advair beginning at age 16/17; and that when the CI “entered the Army, he was only on Flovent.  He did not need the albuterol hardly at all.”  Methacholine challenge was positive.  Examination showed decreased breath sounds bilaterally and the CI was started on a burst of systemic steroids (7 days).  According to the allergy clinic evaluation on 10 August 2004 (6 months prior to separation) the examiner noted that the CI had been prescribed albuterol, Advair (inhalational steroid/bronchodilator combination) alternate weeks, Flovent (inhalational steroid) twice a day, alternate weeks, and Singulair (oral indirect-acting bronchodilator).  PFTs showed an FEV-1 of 64% of predicted and an FEV-1/FVC of 94%, with pulmonologist comment that effort seemed blunted.  

During the MEB examination (recorded on DD Forms 2807 and 2808) in October 2004, 4 months prior to separation, the CI reported taking Flovent and Singulair.  The DD Form 2807 dated 8 October 2004 specified “prednisone off/on.  He took prednisone for 6 weeks in the last 2 months.”  

The MEB NARSUM examination on 8 December 2004, 2 months prior to separation, indicated a history of asthma since 12 years old with use of Flovent daily and albuterol prior to sports and two emergency department visits for asthma symptoms as a teenager.  “He reports that when he enlisted in the Fall of 2002, he used Flovent daily and only rarely required albuterol.”  The summary noted that the CI was begun on three courses of prednisone while deployed and was now taking an inhaled anti-inflammatory (Flovent) twice a day, inhaled bronchodilators (albuterol) as needed, and oral bronchodilators (Singulair) daily.  Review of the STR showed multiple separate clinical encounters in evidence documenting the use of an oral or parenteral steroid for asthma during the year prior to separation.  Intermittent courses of systemic (oral) corticosteroids were clearly documented on 19 June 2004 (5 days), 29 June 2004 (7days), and 28 July 2004 (7days) as well as a note in September 2004 indicating recent completion of a prednisone course, the October 2004 DD 2807 notation as above, and 5 November 2004 (unknown duration).  Review of the STR showed at least monthly visits to a physician for required care during the 6 months leading up to the time of separation.  VA treatment notes in March 2005, 1 month after separation, indicated that the CI had continued asthma symptoms of wheezing about 1-2 times per week in the night or early morning and had been on chronic (although not always daily – “2-3x/week for 6 months”) prednisone treatment for 6 months with significant weight gain, as well as daily use of Flovent and Singulair, with Albuterol as needed.  Systemic steroids were stopped and the inhaled steroid was changed to another compound.  There was no VA Compensation and Pension (C&P) evaluation proximate to separation.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the asthma condition 10%, coded 6602, citing FEV-1 after treatment 83%, not requiring daily inhalational treatment and permanent aggravation of a pre-existing (EPTS) condition without a deduction.  The VA rated the asthma condition as a final 0%, coded 6602, citing the CI did not report for his scheduled VA examination and evidence indicated the CI had asthma meeting the 30% criteria (daily inhalational therapy), but that prior to service the disability was also 30% for daily inhalational therapy and an EPTS deduction of 30% was therefore made.  The Board discussed the probative value of the evidence for options of a 60% rating for intermittent (at least three per year) courses of systemic (oral or parenteral) corticosteroids or a 30% rating for “inhalational anti-inflammatory medication” (which are not specified as a daily requirement under the 30% rating provision).  It was agreed that there was satisfactory evidence that in the year prior to separation the CI required at least three courses of intermittent systemic steroids use sufficiently to satisfy the requirement for the 60% rating.  It was unclear if the CI was on chronic or intermittent systemic oral steroids at separation, and the CI was never on immuno-suppressive medications, had respiratory failure, or had PFTs that warranted any rating higher than 60%.  

The Board deliberated on the issues of the CI’s EPTS history, potential medication use at entry noted in the STR and the NARSUM and indication from the PEB that there was no rating deduction for EPTS.  The service entry physical indicated that the CI was not taking asthma medication at service entry, however, there were multiple treatment notes and the NARSUM that indicated the CI had been using at least episodic inhaled anti-inflammatory medications prior to and proximate to entry.  Although the Board does not typically apply an EPTS deduction when the PEB did not, there was compelling evidence, with a virtual certainty, that despite the entry physical (no asthma history or medication use), that the CI had a history of asthma on entry and was using at least intermittent inhalational anti-inflammatory medication (Flovent) that met the 30% rating criteria on entry.  The Board unanimously agreed that a 30% EPTS deduction was warranted.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a final disability rating of 30% (60%-30%) for the asthma condition, coded 6602.  

BOARD FINDINGS:  In the matter of the asthma condition, the Board unanimously recommends a disability rating of 30%, coded 6602 IAW VASRD §4.97.  There were no other conditions within the Board’s scope of review for consideration.  

The Board 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 20150601, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170004246, XXXXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXXXX:

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), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557.

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

Sincerely,
Enclosure