RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00114
BRANCH OF SERVICE:  nAVY 	SEPARATION DATE:  20090810

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an Reserve E3, Aircraft Maintenance Technician, medically separated for “residual of TBI [traumatic brain injury]” with a disability rating of 10%.   

CI CONTENTION:  “Developed an anxiety and depression problem due to my separation diagnosis.”  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 - 20090429	VARD - 20100528	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Residual of TBI	8045	10%	No VA Placement	
Headache	Cat II	No VA Placement	
Fainting		No VA Placement	
Dizziness and Lightheadedness		Premature Ventricular Contractions 	7011	NSC	STR	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:  

Residual of TBI.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s TBI condition began in September 2007 after fainting while sitting in a chair, causing him to fall and hit his head on the floor.  The CI subsequently experienced persistent daily dizziness and vertigo.

The 5 March 2009 MEB NARSUM examination, 5 months prior to separation, noted the complaint of dizziness.  The CI reported daily brief episodes of lightheadedness and feeling dizzy even while sitting.  It worsened with head turning and sudden positional changes.  The CI reported at the time of the accident, he felt “lightheaded” and then he passed out for less than 1 minute, per witness account.  He had no convulsive movements, or tongue biting or loss of bowel/bladder.  The CI denied problems with gait, vision, or hearing impairment.  He had a normal ears, nose, and throat evaluation.  The CI also reported frequent brief left sided headaches with sharp pain behind the left eye and absence of nausea, photo or phonophobia.  He took medication for his symptoms and found no relief.  Physical examination was unremarkable.  His mental status examination demonstrated full orientation and normal cognitive function.  The cranial nerve functioning was intact.  The CI could tandem walk and heel and toe walk without difficulty.  His gait was normal and he had a negative Romberg.  Motor strength and sensation were intact.  The NARSUM also noted that Neuropsychological testing was conducted in October 2008 and the examiner opined that the results were “not consistent with the presence of a clinically significant, organically based, cognitive impairment.”  The examiner noted that any deficit found during the examination likely reflected the CI’s baseline cognitive functioning.   It was noted that the CI was not experiencing any acute emotional distress.  During the 16 March 2009 MEB examination (recorded on DD Forms 2807-1 and 2808), 5 months prior to separation, the CI reported he had dizziness and headaches every day since he hit his head on the floor.  Physical examination was unremarkable and the neurological examination was essentially normal.  There was no VA examination in evidence proximate to separation.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the residual of TBI condition 10%, coded 8045 (residuals of TBI).  The PEB also listed headache, fainting and dizziness and lightheadedness as related Category II conditions (conditions that contributed to the primary unfitting condition but were not separately ratable).  The panel agreed, the impairment from these conditions were properly subsumed under the overall rating for the TBI condition IAW §4.14 (avoidance of pyramiding; more than one rating based on the same impairment is prohibited).  

At the time of the PEB rating, code 8045 was modified as “residuals of TBI’ and facets were used for rating.  However, evidence that the PEB rated the CI’s condition under the modified VASRD is not clear.  The panel is required to evaluate cognitive disorder IAW VASRD.  The VA assigns an evaluation based upon the highest level of severity for any facet (there are 10 facets with “3” as highest level of severity) of cognitive impairment and other residuals identified as associated with the condition.  The higher rating of 40% requires demonstration of impairment level corresponding to level 2, was not supported by the evidence.  The record documented no objective findings of memory loss, impairment in judgment, inappropriate social interaction, issues with orientation, communication, or behaviors that interfered with workplace interactions. The clinical record did not substantiate clinically significant impairments at the time of separation. The Commander’s Performance Statement did not mention any impairment in memory, judgment, or difficulties with the comprehension of language, or identified any impairment in learning.  In fact, it was stated that the CI’s condition had not affected his ability to effectively perform his duties, and retention was recommended.  The panel agreed that a 10% rating, but no higher, was justified for the residual of TBI condition under the code 8045.

The panel also considered code 6205 (Meniere’s syndrome); however, hearing impairment was not a reported symptom, and therefore, a higher rating was not achievable under this code.   Code 6204 (peripheral vestibular disorders) was also considered, but a higher rating under code 6204 was not warranted since occasional staggering was not identified as part of his condition.

There were no additional applicable codes to consider for rating the condition.  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 residual of traumatic brain injury condition.  

BOARD FINDINGS:  In the matter of the residual of TBI condition and IAW VASRD §4.124a, the panel recommends no change in the PEB adjudication.  There are no other conditions within the panel’s scope of review for consideration.  The panel, therefore, recommends that there be no modification or re-characterization of the CI’s disability and separation determination. 

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150603, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment 

MEMORANDUM FOR DIRECTOR, SECRETARY OF THE NAVY COUNCIL OF REVIEW
               BOARDS 

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS
 
Ref:   (a) DoDI 6040.44

      In accordance with reference (a), I have reviewed the cases listed below and approve the recommendations of the PDBR that the following individual’s records not be corrected to reflect a change in either characterization of separation or in the disability rating previously assigned by the Department of the Navy’s Physical Evaluation Board:

		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USMC

		
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	     				  Acting