RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX 	CASE:  PD-2016-01282
BRANCH OF SERVICE:  Air Force	SEPARATION DATE:  20040927

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E6, Financial Manager, medically separated for “pain disorder associated with psychological factors…and chronic, benign abdominal pain” with a disability rating of 10%.  

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 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 - 20040708	VARD - 20050506	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Pain Disorder Associated with Psychological Factors…Chronic, Benign Abdominal Pain	9422	10%	Mood Disorder with Major Depressive Episode…	9400-9435	30%	20050122	
			Severe Pelvic Adhesive Disease, Cholecystectomy	7318-7301	50%	20050129	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  80%	

ANALYSIS SUMMARY:

Pain Disorder Associated with Psychological Factors and Chronic Benign Abdominal Pain.  The PEB combined the pain disorder and chronic abdominal pain conditions under a single disability rating, coded 9422 (pain disorder) and rated at 10%.  This approach by the PEB not uncommonly reflected its judgment that the constellation of conditions was unfitting, and there was no need for separate fitness adjudications.  The panel’s initial charge in this case was therefore directed at determining if combining conditions under a single rating was justified in lieu of separate ratings.  When considering a separate rating for each condition, the panel considers each bundled condition to be reasonably justified as separately unfitting unless a preponderance of evidence indicates the condition would not cause the member to be referred into the DES or be found unfit because of physical disability.  When the panel recommends separate fitness recommendations in this circumstance, its recommendations may not produce a lower combined rating than that of the PEB.  The evidence for the pain disorder and chronic abdominal pain conditions are presented separately, with attendant recommendations regarding separate unfitness, and separate rating if indicated.

According to the service treatment record (STR) and Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI initially saw a mental health (MH) counselor in 1989 for marital difficulties.  She subsequently saw a therapist again after her then ex-husband committed suicide.  In 1999 she was cleared for a Top Secret clearance, and in 2001, she was placed on medications for major depression and noted to have a history of alcohol abuse; she had a partial response to treatment.  The STR fell silent from 12 October 2001 until 6 March 2003 when the CI was evaluated for right upper quadrant abdominal pain which had been intermittently present for years.  Ultrasound, X-ray and nuclear medicine studies were normal but a CT scan showed a cyst in the lower left quadrant.  Exploratory surgery on 17 September 2003 found significant adhesions which were surgically excised.  She continued to have pain in the right upper and lower quadrants, and on 14 January 2004, underwent surgery for adhesion and gall bladder removal.  The CI’s pain continued and was treated with medications and time off from work as needed.  At a primary follow-up visit on 27 April 2004, she cried easily when discussing her medical history and was prescribed an anti-depressant.  A P4/S1 profile was issued and an MEB initiated for the chronic abdominal pain.  She was also referred to MH and scheduled for psychological testing. 

At the 10 August 2004 MEB NARSUM MH addendum examination, 2 months prior to separation, the CI reported impairment at work and home due to pain.  She worked half days when not in the hospital or on convalescent leave.  She cared for her 6-year old son as a single parent, and most of her symptoms were attributed to the underlying abdominal pain.  She also experienced a decrease in social/recreational activities, and increased frustration over not being able to do things she once enjoyed.  She had a current anti-depressant prescription.  The mental status examination (MSE) was unremarkable and psychological testing showed mild depressive and moderate anxiety symptoms. The Axis I diagnosis was “pain disorder associated with psychological factors and a general medical condition.”  A Global Assessment of Functioning (GAF) score was not given.  During a 13 October 2004 MH follow-up visit, 2 weeks after separation, the CI reported reduced pain symptoms with relaxation techniques and biofeedback (control body functions).  She reported feeling stressed with her impending move but no pain behaviors were evident.  Neither the commander’s performance statement nor MEB NARSUM examination were available and attempts to obtain these documents were unsuccessful.

At the 22 January 2005 VA Compensation and Pension (C&P) MH evaluation, 4 months after separation, the CI reported continued depression and anxiety symptoms with crying spells, hypersomnia (excessive sleep), and decreased energy; she was currently taking anti-depressant medication.  After a recent move, she spent her time caring for her son and unpacking, and was not yet working nor seeking employment.  The MSE was unremarkable and an Axis I diagnosis of “mood disorder due to chronic abdominal pain, with major depressive-like episode” and GAF of 70 (mild symptoms) were rendered.  The C&P general and gynecological examinations were accomplished on 29 January 2005, and both noted the CI suffered from chronic abdominal pain.  Physical examination revealed right lower quadrant tenderness with minimal rebound tenderness and no guarding.  Her gait and posture were normal.  Expected surgical changes were present and the right ovary/tube area was painful to palpation.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bundled pain disorder and abdominal pain conditions 10%, coded 9422 (pain disorder), citing psychological factors and multiple surgeries.  The VA rated the mental health condition 30%, analogously coded 9400-9435 (generalized anxiety disorder-mood disorder not otherwise specified), based on the C&P examinations 4 months after separation, citing occupational and social impairment at the 30% level with a GAF of 70.  The VA also rated pelvic adhesive disease at 50%, coded 7318-7301 (removal of the gall bladder-adhesions of the peritoneum), citing severe pelvic adhesive disease, cholecystectomy and diverticulitis.

The panel first considered whether the pain disorder, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The panel members concluded that the available preponderance of evidence did not overcome the presumption that the pain disorder condition would have caused the CI to be referred into the DES or to be found unfit.  The PEB determined the pain disorder condition unfitting and specifically coded 9422.  The CI worked half days; was assigned to a new base without a social support network; had a decrease in social, recreational and pleasure activities; and was prescribed anti-depressant medication.

The panel also determined that the preponderance of evidence did not overcome the presumption that the abdominal pain disorder condition would have caused the CI to be referred into the DES or to be found unfit.  The CI entered the MEB process because of the abdominal pain and was issued a P4 profile prohibiting self-paced running, walking, pushups or crunches.

The panel considered the pain disorder rating recommendation.  The CI was a single mother who cared for a 6-year old son at separation.  She was able to work part-time, but the record showed no evidence of significant MH impairment; however, she was prescribed psychotropic medication which supports a 10% rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the pain disorder condition.

The panel next considered the chronic benign abdominal pain condition rating recommendation.  As detailed above, the CI had an extensive evaluation and treatment course for her abdominal adhesions.  The evidence indicates she was limited to working partial days primarily due to her abdominal pain.  The panel agreed that the abdominal pain impairment is appropriately coded 7301 (adhesions of the peritoneum) and meets the VASRD §4.114 criteria for a 10% rating.  An obstruction was not present to support a higher rating.  Members also considered diagnostic code 7318, but the STR did not show a change in the abdominal pain before or after the CI’s gallbladder removal.  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 chronic benign abdominal pain condition, coded 7301.

BOARD FINDINGS:  In the matter of the pain disorder condition and IAW VASRD §4.130, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the chronic benign abdominal pain condition, the panel unanimously recommends a disability rating of 10%, coded 7301 IAW VASRD §4.114.  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, effective as of the date of the prior medical separation:

CONDITION	VASRD CODE	PERMANENT RATING	
Pain Disorder	9422	10%	
Chronic Benign Abdominal Pain	7301	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160930, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

SAF/MRB

XXXXXXXXXXXXXXXXXX

Dear Applicant:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2016-01282.

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.

Sincerely,

Attachment:
1.  Directive 
2.  Record of Proceedings 

cc:
SAF/MRBR