RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01358
BRANCH OF SERVICE:  navy	SEPARATION DATE:  20090831

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Pharmacy Technician, medically separated for “diabetes mellitus” with a disability rating of 20%.  

CI CONTENTION:  The CI makes no contention.  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 (VA), 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 - 20090408	VARD - 20100120	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Diabetes Mellitus	7913	20%	Diabetes Mellitus Type II…	7913	20%	20090721	
Fatty Liver	Cat II	Liver Condition	7399-7345	NSC		
Essential Hypertension		Hypertension	7101	0%		
Sleep Apnea		OSA	6604-6847	50%		
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  80%	

ANALYSIS SUMMARY:  

Diabetes.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI developed type II diabetes mellitus in 2003 which ultimately required treatment with dietary restriction and oral hypoglycemic medication, which was later supplemented with insulin.  At the 5 December 2008 MEB NARSUM examination, 9 months prior to separation, the examiner noted the CI was taking 5 different oral hypoglycemic medications.  The examiner did not indicate that avoidance of strenuous occupational and recreational activities was medically necessary.  

According to the 16 December 2008 MEB examination (recorded on DD Forms 2807-1 and 2808), the examiner noted the CI was on those same oral hypoglycemic medications and did not indicate that avoidance of strenuous occupational and recreational activities was medically necessary.  The 6 March 2009 internal medicine appointment, 6 months prior to separation, noted the hypoglycemic medications being used at the time would be augmented by a prescription for insulin.  

At the 21 July 2009 VA Compensation and Pension examination, 1 month before separation, the examiner reported that the CI was taking two oral hypoglycemic medications (Actos and metformin) as well as two types of insulin (Humalog and Lantus).  At the mental health appointment on 27 July 2009, 1 month prior to separation, the examiner noted the CI was taking hypoglycemic medication along with long- and short-acting insulin.  The STR showed no episodes of ketoacidosis or hypoglycemia requiring hospitalizations or frequent visits to a diabetic care provider (twice a month or more frequently).  The duty limitations (LIMDU) restricted deployments and change of station and did not restrict activities.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the diabetes condition 20%, coded 7913.  The VA also rated the diabetes condition 20%, coded 7913, citing a requirement for insulin and a restricted diet.  The panel agreed the requirement for an oral hypoglycemic agent and restricted diet justified a 20% rating.  Treatment with insulin provided another avenue for the 20% rating.  Because there was no evidence of medically-prescribed regulation of activities, the next higher 40% rating was not justified.  Furthermore, following initiation of treatment at the time of diagnosis, the STR showed no episodes of ketoacidosis or hypoglycemia requiring hospitalizations or frequent visits to a diabetic care provider (twice a month or more frequently), or complications that could support higher ratings.  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 diabetes mellitus condition.  

The PEB listed the fatty liver, essential hypertension, and sleep apnea as Category II conditions (conditions related to the primary unfitting condition and which contribute to the primary unfitting condition).  The panel’s first charge for this these PEB Category II conditions is to assess whether any of them can be reasonably justified as separately unfitting for rating consideration.  While the MEB listed all of these conditions, the NARSUM indicated the CI was started on continuous positive airway pressure (C-PAP) with good relief of symptoms and stated:  “Ultimately he will likely require insulin to control his diabetes and is not considered deployable.  He is currently otherwise able to perform military duties as reflected by himself and by his supervisors.”  The LIMDU did not implicate sleep apnea.  The commander’s non-medical assessment (NMA) implicated only the diabetes condition as limiting performance of duties.  The panel therefore concluded that a preponderance of evidence indicated the Category II fatty liver, essential hypertension, and sleep apnea conditions were not justified as separately unfitting.  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 fatty liver, essential hypertension, and sleep apnea conditions as Category II conditions, so no additional rating is recommended.  

BOARD FINDINGS:  In the matter of the diabetes mellitus and IAW VASRD §4.119, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the contended fatty liver, essential hypertension, and sleep apnea 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.  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 20161001, 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 USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN