RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00097
BRANCH OF SERVICE:  Army 	
DATE PLACED ON TDRL:  20051104	
DATE REMOVED FROM TDRL:  20070220

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E6, Cannon Crewmember, medically separated from the Temporary Disability Retired List (TDRL) for “pulmonary sarcoidosis,” with a disability rating of 10%.  

CI CONTENTION:  The CI contends that the Physical Evaluation Board (PEB) incorrectly separated him for chronic bronchitis instead of pulmonary sarcoidosis which would have resulted in a higher rating.  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 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 – 20050805/20070205	VARD - 20051207	
Condition	Code	Rating	Condition	Code	Rating
Proximate	
		TDRL
Placement	TDRL Removal			TDRL
Placement	TDRL
Removal	
Pulmonary Sarcoidosis	*6846	30%	*10%	Sarcoidosis	6846	30%	30%	
COMBINED RATING:  30% → 10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	
* The PEB TDRL removal modified the rating code to 6846-6600 (bronchitis, chronic) per the VASRD.

ANALYSIS SUMMARY:  

Pulmonary Sarcoidosis.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s condition began in November 2003 when the CI reported symptoms of dyspnea (shortness of breath) on exertion.  He was formally diagnosed with pulmonary sarcoidosis in February 2004.  Treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “sarcoidosis” for PEB adjudication.  According to the medical boards clinic evaluation on 29 April 2005 (6 months prior to placement on TDRL) the examiner noted that the CI had been on Prednisone 60mg tablets daily.  On the day of his examination the CI reported little improvement in his shortness of breath with exertion.  Steroid medication taper (slow decrease in dosage) was initiated in May 2005.   At the 14 June 2005MEB examination (recorded on DD Forms 2807 and 2808), 5 months prior to separation, the CI reported shortness of breath with wheezing and the use of an inhaler.  Physical examination was normal at rest without wheezing.  The 30 September 2005 VA Compensation and Pension (C&P) evaluation, performed 1 month before separation, showed a normal examination, but no documented pulmonary function test (PFT) results.  At that time the CI was not on oral steroids.  At the TDRL re-evaluation on 4 October 2006, the CI reported persistent dyspnea to the point that he could not significantly exert himself and that he became dyspneic (short of breath) climbing stairs.  He denied fevers, sweats, chills, weight loss, abdominal pain, chest pain, bony pain or other systemic symptoms.  The cardiovascular, lung and neck examinations were normal.  The examiner referenced the CI’s PFT as noted in the chart below.  The pulmonary examinations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.  

Pulmonary Exam	Pulmonary ~17 Mo. Pre-Sep (TDRL Entry)	Pulmonary Consult ~6 Mo. Pre-Sep (TDRL Entry)	VA C&P ~1 Mo.
Pre-Sep (TDRL Entry)	Pulmonary ~4 Mo. Pre-TDRL Removal	
FEV1 (% Predicted)	49	75	N/A	77	
FEV1/FVC	74	104	N/A	77	
DLCO (SB)	43	49	N/A	54	
Meds	Advair 250/50	Prednisone taper	No Meds		
§4.97 Rating	30%(6684)/60% (6600)	60%		60%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB at TDRL placement rated the pulmonary sarcoidosis 30% coded 6846 (sarcoidosis) citing that the condition required chronic maintenance corticosteroids and was not sufficiently stable for final adjudication.  The VA rated the pulmonary sarcoidosis 30% coded 6846 (sarcoidosis), based on the VA C&P examination 1 month before separation, citing pulmonary involvement with persistent symptoms requiring chronic low dose (maintenance) or intermittent corticosteroids.  The Board first considered its rating recommendation at the time of placement on TDRL.  A 30% rating for active sarcoidosis stipulates “pulmonary involvement with persistent symptoms requiring chronic low dose (maintenance) or intermittent corticosteroids.”  At the time of the NARSUM the CI was completing a steroid taper that had started at 30mg per day.  A 60% rating stipulates, “Pulmonary involvement requiring systemic high dose (therapeutic) corticosteroids for control.”  The board also considered rating based on the CI’s PFT results per the VASRD option to rate active disease or residuals as chronic bronchitis (coded 6600).  His 22 February 2005 PFT results noted above were significant for a Diffusion Capacity of the Lung for Carbon Monoxide (DLCO) by the Single Breath (SB) Method of 49.  This was slightly better than during his initial PFT in February 2004.  The FEV-1 of 75% met criteria for a 10% rating; the DLCO (SB) of 49% met criteria for a 60% rating.  IAW VASRD 4.7 (higher of two evaluations) the Board can assign the higher rating “if the disability picture more nearly approximates the criteria required for that rating.  Board members determined that the VASRD §4.97 threshold for a 60% rating was reasonably satisfied in this case on the basis of a DLCO (SB) of 49% and the associated functional disability.  A 100% rating was not justified in the absence of FEV-1 less than 40% of predicted value, or; the ratio of FEV-1/FVC less than 40%, or; DLCO (SB) less than 40% predicted, or; maximum exercise capacity less than 15 ml/kg/min oxygen consumption (with cardiac or respiratory limitation), or; right heart failure, or; right ventricular hypertrophy, or; pulmonary hypertension (shown by echo or cardiac catheterization), or; episode(s) of acute respiratory failure, or; requiring outpatient oxygen therapy.  

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 60% for the sarcoidosis condition at the time of TDRL placement.  

The Board next considered its recommendation for permanent disability rating at the time of removal from the TDRL.  The PEB at TDRL removal rated the pulmonary sarcoidosis 10% coded 6600 (bronchitis, chronic) as required by the VASRD for residual lung disease, citing the chest was clear on examination, PFTs recorded FEV-1 77% of predicted, and the CI did not require medications, ER visits, or hospitalizations.  The VA continued the pulmonary sarcoidosis rating at 30% coded 6846 (sarcoidosis) following TDRL removal, based on the original VA C&P examination 1 month before separation (30 September 2005).  The VASRD rates sarcoidosis as an active disease or for residuals as chronic bronchitis (coded 6600).  The Board noted that at the time of TDRL removal the CI no longer had an active disease; therefore, a rating based on residuals under code 6600 (chronic bronchitis) was appropriate.  Although the FEV-1 of 77% met criteria for a 10% rating; the DLCO (SB) of 54% met criteria for a 60% rating.  IAW VASRD 4.7 the Board can assign the higher rating “if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned.”  The Board noted that the CI had stabilized during the TDRL period and was no longer needing maintenance medications; however, he never returned to his pre-illness breathing capacity as shown in the PFT chart above. The TDRL re-evaluation noted reports of persistent shortness of breath on exertion and with stairs.  Board members determined that the VASRD §4.97 threshold for a 60% rating was reasonably satisfied in this case on the basis of a DLCO (SB) of 54% and the associated function disability.  A 100% rating was not justified in the absence of FEV-1 less than 40% of predicted value, or; the ratio of FEV-1/FVC less than 40%, or; DLCO (SB) less than 40% predicted, or; maximum exercise capacity less than 15 ml/kg/min oxygen consumption (with cardiac or respiratory limitation), or; right heart failure, or; right ventricular hypertrophy, or; pulmonary hypertension (shown by echo or cardiac catheterization), or; episode(s) of acute respiratory failure, or; requiring outpatient oxygen therapy.  

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 60% for the sarcoidosis condition at the time of TDRL removal.  

BOARD FINDINGS:  In the matter of the sarcoidosis condition, the Board unanimously recommends a disability rating of 60% at the time of placement on the TDRL and a rating of 60% at the time of removal from TDRL and permanent disability disposition, coded 6846-6600 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	RATING	
		TDRL	PERMANENT	
Pulmonary Sarcoidosis	8646-6600	60%	60%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160226, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB														

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
XXXXXXXXXXXXXXXXXX, AR20160016562 (PD201600097)

1.  Under the authority of Title 10, United States Code, section 1554(a), I approve the enclosed recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) pertaining to the individual named in the subject line above to  constructively place the individual on the Temporary Disability Retired List (TDRL) at 60% rather than 30% disability rating for the period 4 November 2005 to 19 February 2007 and then following this period recharacterize the individual’s separation as a permanent disability retirement with the combined disability rating of 60%.

2.  I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum:

	a.  Providing a correction to the individual’s separation document showing that the individual was separated by reason of temporary disability effective the date of the original medical separation for disability with severance pay.

	b.  Providing orders showing that the individual was retired with permanent disability effective the day following the TDRL period.

	c.  Adjusting pay and allowances accordingly.  Pay and allowance adjustment will account for recoupment of severance pay, provide 60% retired pay for the constructive temporary disability retired period effective the date of the individual’s original medical separation and then payment of permanent disability retired pay at 60% effective the day following the constructive TDRL period.  

	d.  Affording the individual the opportunity to elect Survivor Benefit Plan (SBP) and medical TRICARE retiree options.

3.  I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

BY ORDER OF THE SECRETARY OF THE ARMY:

CF: 
(  ) DoD PDBR
(  ) DVA