RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00035
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20051113

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve E6, Military Police, medically separated for “chronic pelvic pain” with a disability rating of 10%.

CI CONTENTION:  The CI submitted a lengthy contention which included her unfit chronic pelvic condition as well a depression condition.  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 at the time of separation.  The panel has neither the role nor the authority to compensate for progression or complications of service-connected conditions after separation.  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 - 20050804	VARD - 20060221	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pelvic Pain Associated with Major Depressive Disorder	7699-7629	10%	Hysterectomy and Bilateral Oophorectomy	7617	50%	20051227	
			Depressive Disorder, Not Otherwise Specified (NOS)	9434	10%	20051230	
Migraine Headaches	Not Unfitting	Chronic Headaches/Migraines	8100	NSC	20051212	
History of Carpal Tunnel Syndrome		Right Carpal Tunnel Syndrome	8515	10%		
		Left Carpal Tunnel Syndrome	8515	10%		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY:  The PEB combined the chronic pelvic pain and major depressive disorder (MDD) conditions as a single unfitting condition coded 7699-7629 noting that the depression was secondary to the pelvic pain condition and not separately ratable.  The panel’s initial charge in this case was therefore directed at determining if the PEB’s approach of combining conditions under a single rating was justified in lieu of separate ratings.  When considering a separate rating for each condition, the panel considers each bundled condition to be reasonably justified as separately unfitting unless a preponderance of evidence indicates the condition would not cause the member to be referred into the DES or be found unfit because of physical disability.  When the panel recommends separate fitness recommendations in this circumstance, its recommendations may not produce a lower combined rating than that of the PEB.  The evidence for the chronic pelvic pain and MDD are presented separately, with attendant recommendations regarding separate unfitness, and separate rating if indicated.  

Chronic Pelvic Pain Associated with Major Depressive Disorder (MDD).  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s chronic pelvic pain began after a bilateral tubal ligation in June 2001.  Medical management was unsuccessful and the CI underwent an endometrial ablation as well as cauterization of endometrial implants (endometriosis) on 11 October 2002.  

She continued to have pain and then had a laparoscopic assisted vaginal hysterectomy (LAVH) and bilateral removal of the tubes and ovaries (BSO) on 28 March 2003.  No remaining endometriosis was noted at the second surgery.  

The MEB NARSUM examination on 25 March 2005, 8 months prior to separation, noted that while there had been some improvement in her pain following the LAVH BSO, the CI remained unable to participate in physical training and comfortably wear her military uniform.  On examination, the abdomen was soft and without tenderness.  The pelvic examination showed diffuse tenderness, but was otherwise an unremarkable post-operative examination.  She was thought to have persistent chronic pelvic pain without a specific etiology cited.  The final profile, dated 8 April 2005, listed both the chronic pelvic pain and depression, coded P3S3.  The commander only cited the physical limitations in his assessment dated 22 April 2005 and noted that the CI maintained her daily administrative duties.  

At the 19 May 2005 MEB examination (recorded on DD Forms 2807 and 2808), 6 months prior to separation, the CI reported her prior history without comment on current symptoms.  Her lower abdomen was noted to be tender to palpation, but without signs of an acute abdomen (rebound, guarding).  

At the 27 December 2005 VA Compensation and Pension (C&P) gynecological evaluation, 2 months after separation, the CI reported persistent lower abdominal pain which was partially treated with medications.  The examination was unremarkable other than surgically removed uterus, tubes, and ovaries.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic pelvic pain at 10%, coded 7699-7629 (analogous to endometriosis), citing “constant and moderate pain.”  The PEB cited the MDD as not separately ratable because it was secondary to the CI’s chronic pelvic pain.  The MDD is discussed further below.  The VA rated the chronic pelvic pain 50%, coded 7617 (uterus and both ovaries, removal of, complete), citing complete loss of the uterus and both ovaries following a period of post-surgical convalescence.  

The panel observed that the unfitting condition was the pelvic pain.  The surgical absence of the uterus, tubes, and both ovaries is not unfitting.  The CI was noted to have findings of endometriosis on the initial surgery and evidence of scarring from endometriosis at the second surgery.  The panel considered the evidence, but found no better clinical description for the etiology of the pelvic pain.  She was on continuous medications for pain control which supported the 10% rating adjudicated by the PEB.  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 chronic pelvic pain condition.  

Major Depressive Disorder.  The PEB determined that the MDD condition was not separately ratable as it was due to the unfitting pelvic pain condition.  It was not noted to be a “not unfitting” condition though.  The panel noted that it was found medically unacceptable by the MEB and profiled S3, although not cited by the commander as impairing duty.  Accordingly, the panel determined that it was separately unfitting and considered the rating at separation.  No separate mental health records from prior to separation were in evidence for review.  The final NCO report in the record closed out in early 2004.  She was noted to have superior administrative and interpersonal skills and rated among the very best with 1/1 senior ratings for performance and potential, the highest ratings available.  

The mental health addendum to the NARSUM was dated 27 January 2005.  It noted long standing treatment, but that by the end of October 2004, she was reporting a generally good mood except when dealing with stressful situations.  Her mental status examination was unremarkable and her prognosis thought to be fair in a low stress civilian occupation.  The commander, in the assessment dated 22 April 2005, noted that the CI maintained her administrative duties.  A review of the record showed no evidence of hospitalizations or emergency room visits for a mental health condition.  

At the 30 December 2005 VA C&P specialty evaluations for mental disorders, 2 months after separation, the CI reported that she was working in real estate, but looking for a job with the Federal Government.  She reported that she had lost a month of work due to mental health issues, but the panel found no evidence to support this in the records available for review.  Thought processes and communications were not impaired.  A VA examination remote from separation, dated 20 March 2014, recorded that the CI had been working as a contractor for the US Army since 2005.  

The VA rated the MDD 10% coded 9434 (major depressive disorder), based on the VA C&P examination 2 months after separation, citing mild or transient symptoms.  The panel considered the evidence.  The CI was taking daily medications which supported a 10% rating as adjudicated by the VA.  There was no evidence that the CI was intermittently unable to perform her occupational requirements to support a higher (30%) rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel majority recommends a disability rating of 10% for the major depressive disorder condition, coded 9434.  

Contended PEB Conditions:  Migraine Headaches and History of Carpal Tunnel Syndrome.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  Neither of the conditions was profiled nor implicated in the commander’s statement.  Both were judged to meet retention standards.  There was no performance-based evidence from the record that either of the conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded that there was insufficient cause to recommend a change in the PEB fitness determination for either of the contended conditions and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the chronic pelvic pain condition and IAW VASRD §4.116, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the major depressive disorder condition, the panel majority recommends a disability rating of 10%, coded 9434 IAW VASRD §4.130.  In the matter of the contended migraine headache and carpal tunnel syndrome conditions, the panel unanimously recommends no change from the PEB determinations as not unfitting.  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, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Pelvic Pain	7699-7629	10%	
Major Depressive Disorder	9434	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160112, w/attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170013195, XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found that your disability rating should be modified but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed) and I accept its recommendation.  This will not result in any change to your separation document or the amount of severance pay.  A copy of this decision will be filed with your Physical Evaluation Board records.  I regret that the facts of the case did not provide you with the outcome you may have desired.
  
	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