RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00334
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20051101

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

CI CONTENTION:  “Please review all conditions for being unfit for duty and rated.”  The CI listed sleep apnea, narcolepsy, anxiety, ulcer/h-pylori, hypertension and headaches/migraines.  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 - 20050803	VARD - 20060925	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Narcolepsy	8108	0%	Narcolepsy	8108	10%	20060302	
Headaches	Cat II	Headaches 	8199-8100	10%	20060227	
Hypertension	Cat II	Hypertension	7101	0%	20060227	
Obstructive Sleep Apnea	Cat II 	Obstructive Sleep Apnea	 6847	50%	20060227	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  80%	

ANALYSIS SUMMARY:  

Narcolepsy.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI suffered from daytime somnolence in 2003 and subsequent to an extensive clinical work-up, the CI was definitively diagnosed with narcolepsy.  At the 08 July 2005 MEB NARSUM examination, 4 months prior to separation, the CI indicated that he had made great improvement in his illness, denying any periods of daytime sleepiness or "cloudy thoughts" or "blanking out" since April 2005.  He admitted to still getting "tired," but nothing like he had formerly.  Under “Review of Systems”, the CI reported no history of seizures or coordination problems.  His physical examination (PE) was detailed and normal.  His diagnoses were listed as narcolepsy and obstructive sleep apnea (OSA).  

At the 02 March 2006 VA Compensation and Pension (C&P) evaluation, 4 months after separation, the CI reported, “…doing pretty well with the [medication] and denies any sudden sleep attacks.”  His PE was unremarkable.  His diagnoses remained unchanged.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the narcolepsy condition 0%, coded 8108 (narcolepsy).  Utilizing the same VASRD code, the VA rated the narcolepsy condition 10%, based upon the C&P examination 4 months after separation, citing a confirmed diagnosis of epilepsy or if continuous medication is necessary.  As per VASRD guidance, narcolepsy is to be rated as for petit mal epileptic seizure activity which further directs a final rating under “minor epileptic seizures”.  Although the minimum VASRD rating under minor seizure activity includes having an actual “history of seizures”…this case would not support that criteria and thus would not rate above 0%; however, VASRD Note (1) under petit mal epilepsy states, “When continuous medication is shown necessary for the control of epilepsy, the minimum evaluation will be 10%.”  His continued use of narcoleptic medication near the time of service separation clearly supported the parameters of the above “Note (1)”.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the narcolepsy condition, coded 8108.  

Contended PEB Conditions:  Headaches, hypertension, and obstructive sleep apnea (OSA).  The panel’s main charge was to assess the fairness of the PEB’s determination that the contended conditions of were not unfitting.  The NARSUM noted headaches under past medical history stating the CI was seen one time on 09 October 2002 and was successfully treated.  The CI denied any trouble with migraines since that time.  Hypertension was also listed in the past medical history.  Records indicate his blood pressure was consistently elevated in the 130s/90s throughout his time in the military and was taking medication for its control.   There were two separate sleep studies performed on the CI.  The first was on 23 February 2004 (20 months prior to separation) which did not support criteria for the diagnosis of OSA, but did reveal evidence of snoring and “upper airway resistance”.  The primary working diagnosis centered on strong evidence of narcolepsy.  His second sleep study was performed on 03 March 2005 (8 months prior to separation) which revealed 82 total arousals; 78 spontaneous and four of which were associated with non-obstructive respiratory events.  Additionally, the sleep study demonstrated 0 obstructive events and 0 hypopneas (breathing that is shallower or slower than normal).  “Continuous positive airway pressure (CPAP) was started at 5 [cms] and increased to a level of 7 [cms].”  The examiner noted, “Respiratory events eliminated.”  Despite such clinical findings, the examiner listed the diagnosis as OSA syndrome.  At a sleep/neurology evaluation conducted on 19 April 2005 (6 months prior to separation), the examiner stated, “It would seem to me that with the recent institution of CPAP therapy [the CI] has felt somewhat better, but still has significant residual sleepiness, which is likely secondary to ongoing narcolepsy.”  At a Neurology clinic appointment on 15 August 2005 (2 months prior to separation) the CI reported “100% back to normal with regards to his daytime sleepiness and narcolepsy” and denied any problems with sleep paralysis.  The commander’s statement noted “his medical condition does not hamper his ability to perform his duties…but does impose duty restrictions of not driving heavy machinery or driving the flight line and was classed as non-deployable.  

Panel members first considered the contended Category II conditions of headaches and hypertension and agreed that there was no performance-based evidence from the record that either of these two conditions significantly interfered with satisfactory duty performance at or near separation and that there was insufficient cause to recommend a change in the PEB’s fitness determination and so no additional disability ratings were recommended.   
As for the condition of OSA, all panel members extensively deliberated as to determine if the condition was separately unfitting.  Throughout the STR, the evidence of a firm diagnosis amongst medical providers in this case appeared to vacillate between narcolepsy and or OSA.  Members reviewed the serial sleep studies performed at 20 and 8 months prior to separation and remained uncertain as to why the diagnosis of OSA was rendered when there was specific evidence of 0 obstructive respiratory events and 0 hypopnic events during the study.  Panel members were left to presume that the examining provider made such a diagnosis of OSA simply based upon the elimination of respiratory events; however, the 4 associated respiratory events seen on the study were non-obstructive events.  In addition, 6 months later (2 months prior to separation) the CI’s self-reporting of “100% back to normal with regards to [his] daytime sleepiness and narcolepsy” provided further consideration as to the known primary diagnosis in this case as being narcolepsy.  Therefore, after due deliberation, the panel concluded that there was insufficient cause to recommend a change in the PEB’s fitness determination for the stated OSA condition and so no additional disability rating was recommended.  

BOARD FINDINGS:  In the matter of the narcolepsy condition, the panel unanimously recommends a disability rating of 10%, coded 8108 IAW VASRD §4.124a.  In the matter of the contended headaches, hypertension and OSA 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	
Narcolepsy	8108	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160601, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD  20762

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2016-00334.

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was not appropriate under the guidelines of the Veterans Affairs Schedule for Rating Disabilities.  Accordingly, the Board recommended modification of your assigned disability rating without re-characterization of your separation with severance pay. 

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding, accept their recommendation and direct that your records be corrected as set forth in the attached copy of a Memorandum for the Chief of Staff, United States Air Force.  The office responsible for making the correction will inform you when your records have been changed.  This will not result in any change to your separation documents or the amount of severance pay you are entitled to.  Disability severance pay is computed the same regardless of a rating of 0, 10 or 20 percent.

Sincerely,

Attachment:
Record of Proceedings