RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01608
BRANCH OF SERVICE:  ARMY	SEPARATION DATE:  20040830

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a National Guard E5, Motor Transport Operator, medically separated for “massive lymphedema, left leg” with a disability rating of 20%.

CI CONTENTION:  Evidence supports a higher rating.  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 - 20040412	VARD - 20041006	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Massive Lymphedema, Left Leg	7199-7121	20%	Chronic Lymphedema of the Left Lower Extremity	7121	60%	20040917	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:

Massive Lymphedema, Left Leg.  According to the service treatment record and Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s left leg lymphedema condition began in June 1991 after a cactus thorn prick during a field exercise, and resulted in a 2-week hospitalization.  A Doppler study revealed superficial and deep femoral vessel clots, and he was treated with anticoagulant medications for a year.  The CI again presented with left leg swelling in July 1992 and a Doppler study was negative for recurrent deep vein thrombosis.  In July 1994 the CI was diagnosed with chronic left leg lymphedema (swelling to the left leg due to poor lymphatic drainage).

The 26 March 2004 MEB NARSUM examination, 5 months prior to separation, noted complaints of chronic, severe left leg swelling.  The CI reported throbbing left leg pain when on his feet more than an hour.  Physical examination showed “massive non pitting edema from the upper thigh down to the foot.”  There was no evidence of ulceration or skin discoloration (brawny).  The upper thigh (8 inches below the anterior superior iliac spine) measured right 24 in/left 28.5 in; the lower thigh (4 inches above the superior border of the patella) was right 19.3 in/left 27.3 in; and the calf (4 inches above the malleolus) was right 10 in/left 24 in.  The examiner noted left foot skin changes (thickened and calloused calcaneus), consistent with the increased leg mass.
	
At a 1 June 2004 primary care visit, 2 months before separation, the examiner noted the CI had “virtually no lymph system to his left lower extremity [LLE]“ and venous insufficiency that could not be treated surgically.  He was receiving gradual compression treatments in physical therapy, but physical examination showed “a massively swollen left leg.”   

At the 17 September 2004 VA Compensation and Pension (C&P) joint evaluation, 1 month after separation, the CI reported persistent LLE swelling with difficulty putting on clothes.  He had tingling in the outer left thigh, but no LLE pain.  Physical examination showed a slight limp, firm swelling throughout the LLE, and no tenderness.  The comparative lower extremity measurements, in inches, were: right foot 9-5/8, left 10-1/4; right calf 15-3/4, left 24-1/2; and mid-right thigh 20-1/2, left 26-3/4.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left leg lymphedema condition 20%, analogously coded 7199-7121 (post-phlebitic syndrome of any etiology), citing phlebitic syndrome.  The VA rated the left leg lymphedema condition 60%, also coded 7121), based on the C&P examination 1 month after separation, citing persistent edema, stasis pigmentation, and persistent ulceration.  The panel noted that the 20% rating adjudicated by the PEB required “some relief with elevation of the extremity with or without skin changes.”  Multiple treatment entries and the NARSUM documented complete lymph blockage and persistent edema not relieved by compression stockings and elevation.  The commander stated that the CI was unable to wear regulation clothing or stand for any length of time due to leg swelling; and the NARSUM examiner documented foot skin changes due to increased LLE mass.  Panel members agreed that the CI’s functional impairment more closely approximated a 40% rating for “persistent edema and stasis pigmentation.”  However, there was no evidence of “persistent ulceration” for a 60% rating.  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 leg lymphedema condition, coded 7121.

BOARD FINDINGS:  In the matter of the left leg lymphedema condition, the panel unanimously recommends a disability rating of 40%, coded 7121 IAW VASRD §4.104.  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	
Massive Lymphedema, Left Leg	7121	40%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20161025, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20180002553, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

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 40% effective the date of your medical separation for disability with Reserve retirement.  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. 

	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, (AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557.

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

Sincerely,					      
Enclosure