RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01155
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20041202

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Fire Protection Craftsman, medically separated for “hypercoagulopathy secondary to protein-S deficiency” with a disability rating of 10%.  

CI CONTENTION:  He needs to stay on anti-coagulant medicine for the rest of his life; he has weakness/nerve damage in his right upper leg.  Conditions not identified by the Medical Evaluation Board (MEB) and Physical Evaluation Board (PEB) were requested for review.  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 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 - 20040722	VARD - 20050809	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Hypercoagulopathy Secondary to Protein-S Deficiency	7704-7799	10%	Deep Vein Thrombosis with Protein-S Deficiency, Right Lower Leg	7199-7121	10%	20050125	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Hypercoagulopathy Secondary to Protein-S Deficiency.  According to the service treatment record and MEB narrative summary (NARSUM), the CI’s hypercoagulopathy (increased tendency to form blood clots) condition was identified in August 2003, status post appendectomy, when he developed pain in the right ankle and was subsequently admitted to the hospital with a deep vein thrombosis (DVT) in the right popliteal fossa.  He was treated initially with heparin (an anticoagulant) and then with Coumadin (warfarin, an anticoagulant).  Coincidentally, the CI had undergone right knee arthroscopy and lateral release on 6 February 2003.  The CI continued to have pain in the right leg and was unable to support any weight on the leg at the end of September 2003.  At a hematology clinic visit on 5 February 2004, the hematologist noted an initial workup at the time of the DVT included homocysteine, anticardiolipins, factor V Leiden, and prothrombin II complex mutation.  However, the anticoagulable workup could not be completed since the CI had been on heparin and Coumadin. Right lower limb weakness was evaluated by neurosurgery.  EMG abnormalities were suggestive of lumbosacral plexopathy due to a West Nile Virus infection.    

After 6 months the Coumadin was discontinued and studies for lupus anticoagulants, anticardiolipins, protein C, protein S, and antithrombin 3 were ordered.  On 19 February 2004, protein S activity was 28 (normal 61-110).  Protein C activity, antithrombin, and Russell viper venom (lupus anticoagulant), and cardiolipin antibody studies were normal.  On 6 March 2004 free protein S antigen was 24 (normal 55-155).  Further neurologic evaluation indicated the CI had both a peroneal and tibial neuropathy of the right lower extremity.  Clinically his peroneal innervated muscles exhibited some weakness with no definite weakness in tibial innervated muscles.  Homocysteine was normal on 11 March 2004.  At a hematology appointment on 7 April 2004, the result of a repeat protein S free antigen was reported to be 22 (normal 64-136), which was considered real evidence of protein S deficiency.  Based on the risks of delaying versus resuming the Coumadin, the CI and hematologist agreed to resume anticoagulation initially with Lovenox (enoxaparin, an anticoagulant) and then transition to Coumadin for life.  

The 8 June 2004 MEB NARSUM examination, 6 months prior to separation, noted complaints of protein S deficiency requiring long-term anticoagulation.  Physical examination showed normal heart rhythm and breathing.  The abdomen was benign as were the legs, and neurologic status was intact.  The examiner noted that since he required long term anticoagulation with Coumadin the CI was unable to continue firefighting where the risk of injury and bleeding was too great.

At the 25 January 2005 VA Compensation and Pension (C&P) evaluation, 2 months after separation, the CI reported continued use of Coumadin.  Physical examination revealed the CI’s gait was normal.  There was mild atrophy of the right quadriceps (62 cm on the right versus 64 cm on the left).  The right lower leg showed no atrophy.  The right popliteal fossa was normal with no residual DVT.  The right leg was definitely weaker than the left with some mild right peroneal weakness.  With toe or heel-walking, the CI did limp slightly on the right leg.  Deep tendon reflexes were normal.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the hypercoagulopathy condition 10%, coded 7704-7499 (polycythemia vera).  The VA rated the hypercoagulopathy condition 10%, coded 7199-7121 (post-phlebitic syndrome of any etiology), based on the C&P examination 2 months after separation, citing continued weakened lower leg with apparent atrophy of the right quadriceps noted on examination.  

Members noted the CI required lifetime Coumadin therapy for the protein S deficiency.  The PEB used an analogous code for polycythemia vera, which is an increase in red blood cells.  In the absence of requiring a phlebotomy, a 40% rating is not achievable using code 7704.  The note for code 7704 states “rate complications such as hypertension, gout, stroke or thrombotic disease separately.”  Other than pulmonary thromboembolism, only thrombosis related to sickle cell disease, brain vessels, or hemorrhoids are ratable, but none of them apply.  The VA rated based on an analogous post-phlebitic syndrome; however, there was no “persistent edema, incompletely relieved by elevation of extremity, with or without beginning stasis pigmentation or eczema” to warrant a 20% rating.  The VASRD does mention anticoagulant therapy in regard to code 6917 (pulmonary vascular disease), but requires “chronic pulmonary thromboembolism requiring anticoagulant therapy, or following inferior vena cava surgery without evidence of pulmonary hypertension or right ventricular dysfunction.”  The CI had one episode of a DVT, but no chronic pulmonary thromboembolism.  Therefore, a 60% rating under that code is not a viable rating option.  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 for the hypercoagulopathy condition.  

BOARD FINDINGS:  In the matter of the hypercoagulopathy condition and IAW VASRD §4.117, 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 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 20160928, 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-2016-01155.

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 appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.

Sincerely,

XXXXXXXXXXXXXXXXXX
Director
Air Force Review Boards Agency

Attachment:
Record of Proceedings