RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX.	CASE:  PD-2016-00124
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070920

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Motor Transport Operator, medically separated for atypical chest pain, with a disability rating of 0%.  

CI CONTENTION:  The CI made no specific contention.  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 - 20070516	VARD - 20080417	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Anterior Atypical Chest Pain	5099- 5003	0%	Heart Murmur/Ruptured Valve	7099-7000	NSC	20080327	
Tricuspid Regurgitation	Not Unfitting					
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  NSC	

ANALYSIS SUMMARY:  

Left Anterior Chest Atypical Chest Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI experienced an onset of chest pain in July 2004 with physical fitness testing.  The complaint persisted, consisting of localized chest pain (left parasternal) that was not exertional pattern or associated with other cardiovascular symptoms.  He underwent a comprehensive evaluation that included cardiology, pulmonary, and gastroenterology consultations.  Serial echocardiograms identified tricuspid regurgitation (a leaky valve) of mild to moderate severity.  There was no cardiac hypertrophy, no arrhythmias on Holter monitoring, and no abnormalities with other ancillary testing that included pulmonary function studies.  A stress test demonstrated normal exercise tolerance to 15 METs (metabolic equivalent units applicable to VASRD rating).  
Cardiology opined that valvular insufficiency was likely not the cause of the chest pain, proposing a possible musculoskeletal etiology; and, firmly asserted that surgery (valve replacement) was not indicated.  The latter opinion was corroborated by two other service cardiologists, since it was a matter of dispute with the CI who asserted that surgery was advised by a civilian cardiologist (no source evidence).  Reports of the frequency and duration of chest pain episodes varied in STR clinical entries, but was multiple times daily.  No medication was prescribed for treatment of the condition.  An episode of syncope was referenced in the NARSUM, but an associated entry was not found in the available STR.  

The 30 March 2007 NARSUM examination, 6 months prior to separation, documented non-exertional “pain in the anterior chest wall ... 3-4 times a week ... between 30 minutes and 1 hour on each episode” that was rated 8/10 by the CI.  With regard to functional limitations, the examiner specified general soldiering profile limitations and a 30-pound lifting restriction, but noted a 3-mile walking tolerance.  The physical examination was remarkable only for a minor (1/6 systolic) heart murmur. 

A 27 March 2008 VA Compensation and Pension (C&P) examination, 6 months after separation, documented that the CI was employed as a warehouse worker.  The VA examiner characterized the chest pains as “retrosternal” that were occurring “repeatedly during athletic activities.”  There was no further elaboration of the pain or functional limitations.  The VA physical examination yielded no pertinent findings.  An echocardiogram by the VA identified mitral valve prolapse (MVP) without insufficiency (leaking), but the tricuspid was normal (no regurgitation) and there was no hypertrophy or dilatation.  A VA stress test reported a tolerance to 7.7 METs without documentation of the limiting factor.  The VA examiner opined that the MVP did not account for the chest pain and did not ascribe it to any other etiology.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB’s 0% rating under code 5099-5003 (analogous to degenerative arthritis) cited the “minimal and intermittent” criterion of the US Army Physical Disability Agency pain policy.  The VA coded the condition 7099-7000 (analogous to valvular heart disease) and did not service connect it, citing the rationale that there were “no pathological findings” and that the MVP was congenital.  

The PEB’s code might be rationalized for analogous rating based on the chest wall component, although the VASRD §4.71a criteria for code 5003 (range of motion limitation, painful motion) are not readily applicable to either the clinical features or functional disability in this case.  The VA code 7000 is a good fit with the identified valve diagnosis, but there is a dubious link of the latter with either the etiology or the disability.  Code 7000 (and all VASRD §4.104 cardiovascular codes that might be applicable) is rated on criteria of METs tolerance, associated symptoms, cardiac hypertrophy or dilatation, and medication use; and, the criteria for the minimum 10% rating were not satisfied by the evidence.  

The only alternate code applicable for consideration in this case is 5399-5321 (analogous to thoracic [Group XXI] muscle disability).  This captures the chest wall component more compatibly than code 5003, and is a common analogous choice for atypical chest pain.  Code 5321 offers ratings of 0% for “slight,” 10% for “moderate,” and the maximum 20% for “severe or moderately severe” muscle disability.  

Member consensus was, however, that the functional disability in evidence (3-mile walking tolerance in the NARSUM and the occupational functioning per the C&P) did not support the above 20% criteria, and was better aligned with the slight (0%) than with the moderate (10%) criterion.  Rating under the muscle code was therefore not advantageous to the PEB’s coding choice; and, even if the moderate criterion were conceded, would be of no practical benefit.

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), panel consensus was that there was insufficient cause to recommend a change in the PEB adjudication of the atypical chest pain.

Contended PEB Condition:  Tricuspid Regurgitation.  The NARSUM examiner acknowledged the conflict between the service and (reported) civilian opinions with regard to the severity and surgical indications for the tricuspid regurgitation, and opined that it met retention standards.  The post-separation VA evidence corroborated the service evidence for concluding that it was a relatively benign condition.  The diagnosis was not referenced in the profile or in the commander’s performance statement.

The panel’s main charge was an assessment of the fairness of the PEB’s determination that the tricuspid regurgitation was not independently unfitting, although the issue was essentially moot in that the diagnosis was intrinsic to rating considerations for the unfitting chest pain.  It would therefore either be subsumed under the same rating; or, even if conceded as separately unfitting, would not achieve a minimum 10% rating.  This notwithstanding, members agreed that there was no performance-based evidence that indicated the valve diagnosis itself interfered with duty requirements to an extent that would have prohibited further military service.  

After due deliberation in consideration of the preponderance of the evidence, the panel concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the tricuspid regurgitation, thus it was not eligible for service rating.

BOARD FINDINGS:  In the matter of the atypical chest pain and IAW VASRD §4.71a, the panel by a majority vote recommends no change in the PEB adjudication.   The single voter for dissent recommends a rating modification to 10% and does not elect to submit a minority opinion.  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 20160316, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

	
AR20170014056 , XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

	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.

Sincerely,					      
						      					
Enclosure