RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00420
BRANCH OF SERVICE:  MARINE CORPS 	SEPARATION DATE:  20051231

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Security Force Guard, medically separated for “neurocardiogenic syncope” with a disability rating of 10%.  

CI CONTENTION:  The condition continues to worsen.  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 - 20051024	VARD - NA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Neurocardiogenic Syncope	8299-8210	10%	No VA Examination Proximate to Separation in Evidence 	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS: NA	

ANALYSIS SUMMARY:  

Neurocardiogenic Syncope.  According to the service treatment record (STR) and Medical Evaluation Board (MEB) documents, the CI began to develop exertional near syncope in early 2003.  These episodes were characterized by nausea and a fainting sensation occurring with strenuous activity, typically running.  There was no documented loss of consciousness (LOC) with these events, and they were self-limited and of relatively brief duration.  There were no associated cardiac or neurologic symptoms and no stigmata of seizure activity.  An initial work-up (endocrine and metabolic screen, cardiac imaging, stress test and tilt table test) was negative.  A repeat tilt table test in August 2004 was positive with hypotension, bradycardia with a 12-second pause and brief LOC.  A diagnosis of neurocardiogenic (vasovagal) syncope was made.  Various medication trials (Atenolol, Florinef, Prozac) did not completely control the symptoms.  Later cardiology entries in the STR confirmed that the episodes remained near syncopal without LOC and occurred only with exertion.  

A 23 May 2005 cardiology MEB evaluation, 7 months prior to separation, documented that the CI had discontinued his medications.  He suffered “occasional episodes of lightheadedness, but was “symptom free without exertional exercise/activity.”  He had stopped running, but was “lifting weights [and could walk a] couple of miles.”  The physical examination recorded normal cardiovascular and neurological findings.  The diagnosis was “neurocardiogenic syncope,” although it was noted that the only documented syncope (as opposed to near syncope) occurred with the tilt table stress test.  The MEB physical examination, recorded on DD Form 2808, was 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’s 10% rating under code 8299-8210 (analogous to incomplete paralysis of vagus nerve).  The VASRD does not offer a code specific to syncope or near syncope.  Since the etiology of the CI’s episodes was vagus-mediated neurocardiogenic dysfunction, 8210 is a reasonable code on clinical grounds for analogous rating.  Members also agreed that, under criteria of code 8210, the disability in evidence was not reasonably characterized as severe in support of a higher 30% rating.  The only other codes that might be considered for analogous rating in this case are 8108 (narcolepsy) or 8911 (petit mal epilepsy).  Both of these default to the VASRD §4.124a general seizure formula and would entail rating the near syncopal episodes as equivalent to minor seizures.  Members agreed, however, that analogous rating as seizures for a higher rating was not sufficiently justified by either VASRD §4.7 (higher of two evaluations) or §4.20 (analogous ratings).  The clinical features were well aligned with the PEB code and the disability was not functionally analogous to that which would be suffered with minor seizures of the same frequency.  Furthermore, the episodes were confined to strenuous activity, a variable under the CI’s control.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded there was insufficient cause to recommend a change in the PEB adjudication of the neurocardiogenic syncope condition.

BOARD FINDINGS:  In the matter of the neurocardiogenic syncope condition and IAW VASRD §4.124a, the panel unanimously recommends no change in the PEB adjudication.  There are no other conditions within the panel’s scope of review for consideration.  Therefore, the panel recommends 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 20160625, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

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:

		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USN