RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02495
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20070330

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Visual Equipment Operator, medically separated for “pulmonary amyloidosis” with a disability rating of 0%.

CI CONTENTION:  Additional unfitting conditions were not considered.  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 - 20070209	VARD - 20080922	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Pulmonary Amyloidosis	6899-6827	0%	Pulmonary Amyloidosis with Obstructive Pulmonary Disease	6827-6604	30%	20080422	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:

Pulmonary Amyloidosis.  According to service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s respiratory condition was diagnosed in October 2006 based on a CT scan and pathology studies.  The CI reported shortness of breath and a history of recurring upper respiratory infection since 2003, treated with antibiotics.  His shortness of breath was treated with bronchodilator medication.  The CI’s condition did not improve enough to allow for continued duty performance, therefore he was referred to the MEB.
The MEB forwarded “pulmonary amyloidosis” for PEB adjudication.

The 29 December 2006 MEB NARSUM examination, 3 months prior to separation, noted complaints of “blebs on lungs.”  The CI reported exertional dyspnea and difficulty passing the 2-mile run and that he barely made standards for passing the Army Physical Fitness Test.  He reported a history of bronchitis/sinusitis 3 times a year and absence of asthma history.  At the time of the NARSUM, he was not taking any medications.  Physical examination was unremarkable with the exception of a narrow oral cavity (often found in sleep apnea).  The examiner documented pulmonary function test (PFT) results from 22 May 2006 that recorded FVC of 84% predicted value, FEV1 of 64%, FEV1/FVC=67%, and DLCO (carbon monoxide diffusion capacity) of 81 ml/mm/Hg/min., improved to 101% when corrected for alveolar volume.  The examiner diagnosed primary pulmonary amyloidosis with a moderate degree of obstructive damage and an unclear prognosis.

At the 22 April 2008 VA Compensation and Pension (C&P) evaluation, performed 13 months after separation, the CI reported constant sinus problems that were incapacitating as often as 2 times a year.  He also had cough with sputum, pain or discomfort over the chest area on exertion and mild coughing up of blood that had not required hospitalization.  Physical examination was unremarkable.  The pulmonary function test recorded on the same day showed FEV1 of 64% of predicted value, FVC of 78% and FEV1/FVC of 70%.  The examiner stated, “A DLCO was not done as the PFT results were sufficient to evaluate the pulmonary status of the claimant.”  The examiner recorded the diagnosis as “amyloidosis pulmonary with post-biopsy scar, incidental finding of obstructive pulmonary disease by PFT evaluation.”

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the pulmonary amyloidosis condition 0%, analogously coded 6899-6827 (pulmonary alveolar proteinosis), citing the results of the May 2006 PFT results including DLCO.  The VA rated the respiratory condition 30%, analogously coded 6827-6604 (pulmonary alveolar proteinosis-chronic obstructive pulmonary disease), based on the VA C&P examination 13 months after separation and PFT results (22 May 2006), citing the CI was not receiving antibiotics, steroids or require out-patient oxygen for his condition; and the FEV-1 was 65% (sic) 64% to support a 30% disability evaluation.

The rating for chronic obstructive pulmonary disease (6604) is based on FEV1, or FVC or DLCO values; however, interstitial lung disease codes are based on FVC or DLCO values, and not FEV1.  The panel member’s consensus was that although there may have been some element of obstructive disease, the use of the 6827 code was most reflective of the CI’s respiratory condition since there was radiographic and pathological studies indicating the presence of a primary interstitial disease process.  

The higher rating of 10% under the 6827 and 6604 codes require FVC values between 75-80% predicted value or DLCO between 66-80% predicted value.  The panel agreed, the 10% rating was not justified based on the evidence most proximate to separation with FVC of 84% and DLCO of 81%, improved to 101% when corrected for alveolar volume; values not meeting the 10% threshold.

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 pulmonary amyloidosis condition.  

BOARD FINDINGS:  In the matter of the pulmonary amyloidosis condition and IAW VASRD §4.97, 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 re-characterization of the CI’s disability and separation determination.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20151026, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

	

MINORITY OPINION:  The minority voter recommends a 30% rating for the CI’s pulmonary amyloidosis complicated with chronic obstructive pulmonary disease condition (COPD).

Pure pulmonary alveolar proteinosis (code 6827) is a rare lung disorder of unknown etiology, and although pulmonary amyloidosis is usually best analogized to code 6827, pulmonary amyloidosis can be associated with different types of pulmonary lesions other than alveolar deposits (documented in this case).  The STR and VA records showed the CI had different types of pulmonary presentations with diagnostic imaging findings of bilateral cystic lung disease and PFT’s documenting an obstructive pattern of COPD.

According to VASRD §4.96 paragraph (a) pulmonary disability should be rated under “only one respiratory condition that is the most predominate disability.”  Given scant laboratory evidence disability from the interstitial disease process (code 6827), and the CI’s disabling and significant shortness of breath with laboratory evidence of an obstructive lung process, the minority voter’s opinion is that predominant disability should be analogously coded 6604 (COPD).  Restricting the coding and rating option to code 6827 is not consistent with the objective findings in this case and VASRD §4.97 (schedule of ratings–respiratory system).

The CI’s pulmonary symptoms and laboratory evidence of mixed interstitial disease and obstructive disease, with both the MEB pulmonary examination and the C&P examination most proximate to separation showed FEV-1 predicted of 64% which supports a 30% rating for “FEV-1 of 56- to 70-percent predicted” IAW code 6604.

IAW VASRD §4.96 and §4.7 (higher of two evaluations) and the preponderance of consistent-objective pulmonary findings, the minority voter recommends a disability rating of 30% for the CI’s pulmonary disease condition, analogously coded 6827-6604, IAW VASRD §4.97.

Consistent with the DoDI 6040.44 standard that Physical Disability Board of Review recommendations are fair and equitable to both the Service and the CI, the Secretary is respectfully requested to consider the minority recommendation that the CI’s disability separation be re-characterized to reflect permanent disability retirement, effective as of the date of the prior medical separation:

CONDITION	VASRD CODE	PERMANENT RATING	
Pulmonary Amyloidosis with Chronic Obstructive Pulmonary Disease	6827-6604	30%	

AR20170013266, XXXXXXXXXXXXXXXXXXX 

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found your separation disability rating and your separation from the Army for disability with severance pay to be accurate.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed), and I accept its recommendation.  I regret to inform you that your application to the DoD PDBR is denied.  

	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 been provided to the counsel you listed on your application, XXXXXXXXXXXXXXXXXXX.

Sincerely,					      
						      					
Enclosure