RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00831
BRANCH OF SERVICE:  Air Force	SEPARATION DATE:  20041101

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Integrated Avionics Journeyman, medically separated for “left middle cerebral artery thrombosis secondary to lupus anticoagulant syndrome with residual fatigue and mild expressive aphasia, on coumadin” with a disability rating of 20%.  

CI CONTENTION:  “Review all conditions.”  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 Medical Evaluation Board (MEB), but determined by the PEB 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.  The panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections when appropriate.  The panel’s assessment of the PEB rating determination is based on review of medical records and all available evidence relevant to application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards for 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, which operates 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 disability at the time of separation.   

RATING COMPARISON:  

SERVICE PEB - 20040907	VARD - 20060131	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Middle Cerebral Artery Thrombosis Secondary to Lupus, Anticoagulant Syndrome with Residual Fatigue and Mild Expressive Aphasia, on Coumadin	8008-6354	20%	Residuals…CVA, RUE…	8009-8512	20%	20050415	
			Residuals…CVA, RLE	8009-8520	20%		
			Migraine Headaches	8009-8100	10%		
			S/T Memory Loss…CVA…	8009-9305	10%		
			CVA…due to Lupus	8009	0%		
			Aphasia…CVA	8009-8210	NSC		
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Left Middle Cerebral Artery Thrombosis.  According to the service treatment record and MEB narrative summary (NARSUM), the right-handed CI had a cerebrovascular accident (CVA/stroke) on 22 January 2004, with initial right-sided paralysis, weakness, and expressive aphasia; CAT and MRI scans showed a left basil ganglia infarct.  Initial symptoms improved following rehabilitation, however duty-limiting residuals remained.  
During the 16 June 2004 neurology examination, 5 months prior to separation, the CI reported right-sided arm and leg weakness, fatigue, tiredness, insomnia, and intermittent forgetfulness.  Medical history included meningitis in 2003, and an extensive work-up following the stroke showed a positive lupus anticoagulant test with very high titers and a diagnosis of lupus anticoagulant syndrome leading into stroke.  The CI had been placed on an anti-coagulant (Coumadin), and the specialist indicated a 92% improvement of his expressive aphasia.  He had recovered motor function “pretty much close to normal,” did not have any residual weakness in his right arm or right leg, and ambulated without difficulty.  The neurologist noted the CI no longer had any motor deficits but “some residual expressive aphasia problems only.”  He recommended continuing a 4-hour workday and gradually increasing to 6 hours as tolerated.  

The 23 July 2004 MEB NARSUM examination, 4 months before separation, noted CI complaints of residuals from his stroke to include insomnia, decreased strength and endurance, and intermittent forgetfulness; he remained on light duty 6 hours per day.  Physical examination on 28 June 2004 showed the CI was well developed, in no acute distress, and was ambulatory and conversant.  He had no obvious aphasia or word finding efforts, and was fully alert and oriented with no noted asymmetry.  Cranial nerves, sensory and motor evaluations were normal with no obvious deficits.  The examiner assessed the CI to be conversant at 90-92% of his expressive function, and while he was not yet able to return to full duties or physical training due to fatigue, he was capable of 6 hours of light duty each day.  The prognosis noted steady improvement with an expected 98% recovery over the next 12 months.  

At the 15 April 2005 VA Compensation and Pension (C&P) evaluation, 5 months after separation, the CI reported right-sided arm and leg weakness (dragging his foot when fatigued), memory loss, problems spelling, and new onset of migraine headaches (requiring going to a dark room and laying down once every couple weeks) since his stroke.  Physical examination showed normal posture and gait, but that he walked and sat with his right arm held in a protective manner.  While writing a paragraph, the examiner observed that the CI’s “hand got weak and his writing decreased in quality.”  Motor function was 4/5 on the entire right side, especially in the upper extremity compared to the left.  There was no change in range of motion after repetitive movement, but there was “noticeable fatiguing of the muscles on the right as you compared the smooth movement on the left.”  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left middle cerebral artery thrombosis condition 20%, coded 8008-6354 (thrombosis of brain vessels–chronic fatigue syndrome).  The VA rated CVA due to lupus at 0%, coded 8009 (hemorrhage from brain vessels), while separately rating the multiple CVA residuals:  right upper extremity…at 20%, coded 8009-8512 (hemorrhage from brain vessels–paralysis of lower cervical radicular group); right lower extremity… at 20%, coded 8009-8520 (paralysis of sciatic nerve); short term memory loss…at 10% coded 8009-9305 (vascular dementia); and found aphasia not service-connected as it had resolved.  All of these ratings were based on the C&P evaluation 5 months after separation.  

Panel members noted that rating analogously under code 6354 is for “debilitating fatigue, cognitive impairments (such as inability to concentrate, forgetfulness, confusion), or a combination of other signs and symptoms,” and that the CI’s symptoms were nearly constant with no periods of incapacitation.  A 40% rating requires symptoms “which restrict routine daily activities to 50 to 75 percent of the pre-illness level” and the 20% criteria indicates symptoms “which restrict routine daily activities by less than 25 percent of the pre-illness level.”  The NARSUM evaluation stated the CI was only capable of “light duty, 6 hour days” and was unable to do PT due to early fatigue, and thus members agreed the 40% criteria under code 6354 was most closely approximated.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 40% for the left cerebral artery thrombosis condition, coded 8008-6354.  
BOARD FINDINGS:  In the matter of the left cerebral artery thrombosis condition, the panel recommends a disability rating of 40%, coded 8008-6354 IAW VASRD §4.124a and §4.88b.  There are no other conditions within the panel’s scope of review for consideration.  

The panel recommends 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	PERMANENT RATING	
Left Middle Cerebral Artery Thrombosis Secondary to Lupus Anticoagulant Syndrome with Residual Fatigue and Mild Expressive Aphasia, on Coumadin	8008-6354	40%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160916, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record

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

XXXXXXXXXXXXXXXXXX

Dear Applicant:

		Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2016-00831.

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 your separation be re-characterized to reflect disability retirement, rather than 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 determined that your records should be corrected accordingly.  The office responsible for making the correction will inform you when your records have been changed.

As a result of the aforementioned correction, you are entitled by law to elect coverage under the Survivor Benefit Plan (SBP).  Upon receipt of this letter, you must contact the Air Force Personnel Center at XXXXXXXXXXXXXXXXXX to make arrangements to obtain an SBP briefing prior to rendering an election.  If a valid election is not received within 30 days from the date of this letter, you will not be enrolled in the SBP program unless at the time of your separation, you were married or had an eligible dependent child, in such a case, failure to render an election will result in automatic enrollment.

						Sincerely,

Attachment:
Record of Proceedings