RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01302
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040926

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an E6, Cannon Crewmember, medically separated for “obstructive sleep apnea” and “dermatomyositis,” each rated at 0%, with a combined disability rating of 0%.  

CI CONTENTION:  Requests review of hypertension, erectile dysfunction, PTSD, TBI, heart attack with bypass, insomnia, muscle weakness, generalized pain and tremors, chest pain and shortness of breath.  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 - 20040723	VARD - 20050419	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Obstructive Sleep Apnea Requiring CPAP	6847	0%	Obstructive Sleep Apnea	6847	50%	20050107	
Dermatomyositis	5099-5021	0%	Dermatomyositis	8199-8100	30%	20050107	
Major Depression	Not Unfitting	PTSD	9411	30%	20050103	
Erectile Dysfunction	Not Unfitting	Erectile Dysfunction	7599-7522	0%	20050107	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  80%	

ANALYSIS SUMMARY:  

Obstructive Sleep Apnea (OSA) Requiring CPAP (Continuous Positive Airway Pressure).  According to the service treatment record (STR) and Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI underwent a polysomnogram (sleep study) on 11 September 2002 and was diagnosed with OSA requiring CPAP. He had prior cardiac evaluation for chest pains and palpitations, as well as ear, nose and throat evaluations for poor sleep and headache.  The CI had a good clinical response to CPAP treatment and reported better sleep, increased daytime energy and resolution of headaches.  In April 2003, he deployed with his CPAP machine, but was unable to use it due to lack of electricity; when his chest pain and palpation symptoms recurred, he was administratively returned to CONUS on 18 September 2003.  On 8 October 2003, the CI was seen in the emergency room for complaints of headache, high blood pressure, and chest pain.  On 11 November 2003, a repeat polysomnogram showed a markedly abnormal study; his CPAP was re-titrated and symptoms subsequently resolved.  The 8 June 2004 MEB NARSUM examination, 3 months prior to separation, noted complaints of OSA requiring CPAP with symptoms recurring when the device was not used.  Physical examination was unremarkable.  

At the 3 January 2005 VA Compensation and Pension (C&P) evaluation, 4 months after separation, the CI reported OSA requiring CPAP and that he slept well with no symptoms when using the machine.  Physical examination was unremarkable.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the OSA 0%, coded 6847 (sleep apnea syndromes (obstructive, central, mixed)), citing that the CI was asymptomatic when able to use CPAP [likely application of DoDI 1332.39 rating guidance, which differed from VASRD rating criteria].  The VA rated the OSA condition 50%, coded 6847, based on the C&P examination 4 months after separation, citing requirement for a breathing assistance device.  The OSA condition was documented in the STR, and required CPAP treatment was identified by the NARSUM examiner, MEB, and PEB.  VASRD §4.97 provides for a minimum rating of 50% for OSA requiring a breathing assistance device, and the evidence establishes that the latter criterion was met in this case.  There was no evidence of chronic respiratory failure with carbon dioxide retention, cor pulmonale, or the requirement for a tracheostomy to support the next higher 100% rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 50% for the OSA condition, coded 6847.  

Dermatomyositis.  According to the STR and MEB NARSUM, the CI’s dermatomyositis condition began in April 2003 while deployed to Iraq with diffuse arthralgias (knees, shoulders) muscle “stiffness” soreness and weakness attributed to not using his CPAP.  He developed a skin rash on his face, trunk, and extremities.  On 8 October 2003, the CI was seen for headaches and chest pain and found to have an elevated creatine phosphokinase (CPK, an enzyme found mainly in the heart, brain and skeletal muscles used to show muscle damage) at 2570 (normal between 38-174).  However, cardiac disease was considered unlikely.  On 18 December 2003, he developed increasing myalgias, initially thought to be rheumatoid arthritis or sarcoidosis.  On 23 January 2004, CPK was again elevated and the CI was referred to a neuromuscular specialist.  Electromyogram (EMG) and nerve conduction studies were normal (aside from findings consistent with right carpal tunnel), and he was determined to have a mild case of dermatomyositis “not clinically active at this time,” and not requiring muscle biopsy.  A 22 April 2004 bronchoscopy with biopsies was negative for sarcoidosis.  

During the 20 January 2004 MEB examination (recorded on DD Forms 2807-1 and 2808), 8 months prior to separation, the CI reported joint pain with morning stiffness, and pain with cool weather.  Shortness of breath with stair climbing, foot and knee pain, and daily headache (not requiring treatment) were specifically noted.  Physical examination showed bilateral shoulder tenderness with no diffuse musculoskeletal tenderness and full range of motion.  

The 8 June 2004 MEB NARSUM documented the CI’s history of resolved skin rash, CPK elevations, muscle pains and neurology, pulmonary, and neuromuscular specialist evaluations to include a normal EMG and normal bronchoscopy.  Physical examination noted the above MEB findings as well as recent normal neurologic and motor examinations by specialists.  The diagnosis was dermatomyositis and the physician stated “his current status is that he has variable myalgias that are aggravated by physical exertion.”  The 22 June 2004 MEB NARSUM internal medicine addendum, 3 months prior to separation, recorded CI complaints of excessive muscle fatigue and pain with prolonged physical activity.  He had a burning sensation in his biceps and had to switch hands after holding the phone to his ear for 3 to 4 minutes; he also reported stopping golf practice after 20 swings because his back was "burning."  Physical examination showed normal strength (5/5) in upper and lower extremities with good ability to squat and heel-toe walk.  Gait, reflexes and lung examinations were normal and there were no gross focal neurological deficits.  The specialist indicated that laboratory studies supported a diagnosis of myositis (chronically elevated CK levels, elevated aldolase and a prior elevated C-reactive protein), but that serum antibodies often associated with dermatomyositis had been negative.  The diagnosis was “myositis, nonspecific, with dermatomyositis still a possibility.”  

At the 7 January 2005 VA C&P evaluation, 4 months after separation, the CI reported his skin condition had resolved, but he had chronic muscle pain (soreness and burning) with morning stiffness which took several hours to improve.  The CI had flare-ups with severe burning pain “with the most minimal activity, such as holding a phone to his ear or chewing food.”  Flares could last for several days but he could go a week or two without a flare-up.  He used a non-steroidal anti-inflammatory drug for flare-ups and there was no evidence of any regular medical treatment since release from service.  Physical examination showed a normal gait, muscle strength, and tone and bulk with no tenderness.  Reflexes and sensory testing were also normal.  Joint range of motion was full with some bilateral shoulder pain on repetition.  The only abnormal neurologic finding was a mildly positive Tinel’s sign (nerve irritation sign at the wrist) on the right.  The examiner diagnosed dermatomyositis.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the dermatomyositis condition 0%, analogously coded 5099-5021 (myositis), citing no treatment required with restricted activity and without loss of joint motion.  The VA rated the dermatomyositis condition 30%, analogously coded 8199-8100 (migraine), based on the C&P examination 4 months after separation, citing muscular stiffness and flares.  The panel adjudged that there was insufficient evidence of any single joint limitation or painful motion to warrant separate unfitness and rating of any specific joint or collection of minor joints higher than 0%; however, alternative analogous rating was considered, as the dermatomyositis was deemed an active condition.  Panel consensus was that the well-established diagnosis of dermatomyositis (or myositis) as an active systemic process was similar to an active rheumatoid process (5002), and supported a 20% rating analogously coded 5021-5002.  The CI had numerous flares, however, there were no objective evidence of incapacitating exacerbations or symptom combinations indicating definitive health impairment to support the next higher rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel majority recommends a disability rating of 20% for the dermatomyositis condition, coded 5021-5002.  

Contended PEB Conditions:  Major Depression and Erectile Dysfunction.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  Neither of the conditions were profiled, implicated in the commander’s statement or judged to fail retention standards.  There was no performance-based evidence from the record that either of the conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded that there was insufficient cause to recommend a change in the PEB fitness determination for either of the contended conditions and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the OSA condition, the panel unanimously recommends a disability rating of 50%, coded 6847 IAW VASRD §4.97.  In the matter of the dermatomyositis condition, the panel majority recommends a disability rating of 20%, coded 5021-5002 IAW VASRD §4.71a.  The single voter for dissent elected not to submit a minority opinion.  In the matter of the contended major depression and erectile dysfunction 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 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	
Obstructive Sleep Apnea Requiring CPAP	6847	50%	
Dermatomyositis	5021-5002	20%	
COMBINED	60%	

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 

AR20170019696, XXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

	I accept the recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) to re-characterize your separation as a disability retirement with the combined disability rating of 60% effective the date of your medical separation for disability with severance pay.  Enclosed is a copy of the Board’s recommendation and record of proceedings for your information.

	The re-characterization of your separation as a disability retirement will result in an adjustment to your pay providing retirement pay from the date of your original medical separation minus the amount of severance pay you were previously paid at separation.
 
	The accepted DoD PDBR recommendation has been forwarded to the Army Physical Disability Agency for required correction of records and then to the U.S. Defense Finance and Accounting Service to make the necessary adjustment to your pay and allowances.  These agencies will provide you with official notification by mail as soon as the directed corrections have been made and will provide information on your retirement benefits.  Due to the large number of cases in process, please be advised that it may be several months before you receive notification that the corrections are completed and pay adjusted.  Inquiry concerning your correction of records should be addressed to the U.S. Army Physical Disability Agency.

	A copy of this decision has also been provided to the Department of Veterans Affairs.

Sincerely,					      
Enclosure