RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01716
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040330

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Petroleum Supply Specialist, medically separated for “Behcet’s syndrome” with a disability rating of 0%.   

CI CONTENTION:  The CI made no specific 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 progression or complications of service-connected conditions after separation.  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 - 20040120	VARD - 20041117	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Behcet’s Syndrome	5099-5002	0%	Behcet’s Syndrome	6399-6354	10%	20040804	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Behcet’s Syndrome.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI first began developing symptoms in 2002 that ultimately led to a diagnosis of Behcet’s syndrome.  This is a systemic disease that is generally regarded as an autoimmune or rheumatologic disorder (precise etiology unclear) and has various manifestations, most notably: mucosal ulcers of the mouth and genitalia, rashes, eye involvement, vascular inflammation, joint inflammation, muscle pain, gastrointestinal involvement, and nervous system involvement.  The CI’s initial symptoms were rash and muscle pain.  She subsequently developed intermittent oral and genital ulcers and episodic pain localized to various specific bones and joints.  Examples of the latter in this case were bilateral feet and ankles, bilateral tibias, right hip, right knee, right rib cage, right wrist, and bilateral elbows.  There was no eye involvement (confirmed by serial ophthalmology consults), and there was no STR documentation of gastrointestinal, vascular, or nervous system complications.  Rheumatoid arthritis and systemic lupus erythematosus (SLE) were initial diagnostic considerations, but a rheumatologist made the diagnosis of Behcet’s syndrome in February 2003.  Follow-up rheumatology entries documented a favorable response to treatment with Imuran, an immune suppressant (with possibly serious adverse effects, but none were documented in this case).  

With regard to the functional disability and VASRD-ratable features attributable to the various manifestations of the disease (as linked to various coding options in the rating discussion which follows), there was evidence for the following.  Although there was joint pain as above, there was STR confirmation of the absence of synovitis or other physical signs of joint inflammation, and there was ample documentation of grossly normal range of motion (ROM) of all joints.  There was periodic documentation of limping, although this was not a constant finding.  There was intermittent difficulty with running, but not with walking or general mobility.  The oral ulcers, when present, interfered with eating and imposed a soft diet.  The rheumatologist noted a twice monthly frequency of mouth ulcers before treatment with Imuran.  Later notes documented improvement, but it was clear that occasional flares persisted.  There was one STR mention of fatigue, but this was not corroborated elsewhere, and there was no mention of cognitive impairment.  The commander’s performance statement (4 months before separation) characterized the CI as “hard working” and still able to complete a 2½ mile walk on the physical fitness test.  Although the disease course followed a waxing and waning course with episodic symptoms, the only distinct documentation of an exacerbation was described as “Behcet’s syndrome with a flare-up right now” in a rheumatology note of 2 September 2003 (7 months before separation and a month after starting Imuran).  This consisted of concurrent oral ulcers and specific joint pains, but did not result in a change in treatment and was characterized by the rheumatologist as an expected development before a positive response to Imuran could be expected.  There was no STR documentation of any flares or exacerbations that rendered the CI incapacitated (quarters assignment, unable to work, etc.).

In the 5 November 2003 NARSUM examination, 5 months prior to separation, the only active symptoms documented were “intermittent” oral and vaginal ulcers, rash, and joint pain (“especially in her right knee” at that time).  The physical examination recorded the absence of any current skin or mucosal lesions; noted tenderness of the right wrist, bilateral elbows and bilateral tibias without other positive findings; and, documented “full [ROM] of all joints” with no note of a limp.  

The 4 August 2004 VA Compensation and Pension (C&P) evaluation, 4 months after separation, documented that the CI was a full time student and was followed by a rheumatologist (no details if treatment remained the same). The examiner made note of oral and vaginal ulcers, rash, and joint pain similar to the NARSUM.  Severity and frequency were not elaborated other than a confusing stated frequency of the mouth ulcers “about three times per month…last for several weeks” (more logically meant every 3 months).  The physical examination recorded a normal gait, the absence of any current skin or mucosal lesions, and provided very detailed joint examinations.  There was no tenderness or swelling of any joint and measured ROM was normal in all planes “without difficulty.”

The panel directed attention to its rating recommendation based on the above evidence.  The PEB’s 0% rating was under code 5099-5002 (analogous to rheumatoid arthritis).  The PEB’s DA Form 199 did not cite a rationale, but presumably intended that the minimum rating criteria were not satisfied.  Code 5002 offers a minimum rating of 20% for “one or two exacerbations a year in a well-established diagnosis.”  The next higher 40% rating requires “…incapacitating exacerbations occurring three or more times a year.”  Code 5002 does not specify a symptom complex on which the rating is based, in contrast to alternate coding choices as elaborated below.  The VA’s 10% rating, derived from the C&P evidence, was under code 6399-6354 (analogous to chronic fatigue syndrome) and cited the applicable criterion “symptoms controlled by continuous medication.”  The next higher 20% rating requires nearly constant symptoms or prolonged periods of incapacitation; and, it should be noted that the earmarked symptoms of code 6354 are “debilitating fatigue, cognitive impairments (such as inability to concentrate, forgetfulness, confusion), or a combination of other signs and symptoms.”

There is no specific VASRD code for Behcet’s syndrome, thus analogous rating is obligatory.  The PEB’s analogous choice of rheumatoid arthritis was not unreasonable, although its 0% rating implied that the flare per the September 2003 rheumatology note (admittedly not captured in the NARSUM) did not constitute an exacerbation.  The VA’s analogous code for chronic fatigue syndrome is difficult to defend based on the absence of significant fatigue or cognitive impairment in evidence, with no match to the rated symptoms as quoted above.  An analogous choice with a clinically closer match would be code 5025 (fibromyalgia).  The “widespread musculoskeletal pain” referenced in 5025 is a reasonable fit with at least the joint pain, and it is reasonably concluded that joint pain made the dominant contribution to the disability in this case.  None of the numerous other rating elements specified by 5025, however, were in evidence.  The 10% criterion of code 5025 is identical to that for 6354, i.e., symptoms that “require continuous medication for control.”  The next higher 20% rating is for symptoms that “are episodic … but that are present more than one-third of the time.”  The 40% rating requires near constant symptoms that are refractory to therapy.  The final analogous match subject to consideration in this case is code 6250 for SLE.  Code 6250 does not specify a symptom complex, and many of the early features of SLE overlap with Behcet’s syndrome.  It should be noted however, that SLE is a significantly worse diagnosis in terms of complications and prognosis.  Code 6250 offers a 10% rating for “exacerbations once or twice a year or symptomatic during the past 2 years.”  The next higher 60% rating is for “exacerbations lasting a week or more, 2 or 3 times per year.”  The panel concluded that the only reasonably applicable analogous coding options for this case were 5002, 5025, and 6350.  Members agreed that the specified rating elements for code 6354 were not in evidence; and, it was further noted that its 10% criteria were identical to the more clinically justified code 5025, and that its higher rating criteria were not supported.  

Panel members agreed that a 0% rating under code 5002, as conferred by the PEB, could not be supported without violation of VASRD §4.7 (higher of two evaluations).  At least a 10% rating under code 5025 (continuous medication for control) or code 6250 (symptomatic during the past 2 years) was supported; and, there was not a sufficient rationale for defending 5002 as a better analogous choice over either the other coding options.  The panel considered whether the minimum 20% rating criteria under code 5002 (one or two exacerbations a year in a well-established diagnosis) were supported.  If even the one well-documented flare was conceded as constituting an exacerbation, and the “well-established diagnosis” was considered not applicable for analogous rating, then the criteria were satisfied.  Members ultimately agreed that reasonable doubt favored concession of the 20% criteria for rating under code 5002.  Members additionally agreed that no alternate code was more clinically applicable IAW VASRD §4.20 (analogous ratings), such that it would overcome the imperative of VASRD §4.7.  All members agreed as well that there was no evidence for any “incapacitating exacerbations” in support of higher rating under 5002.

The panel considered whether a higher rating could be supported under codes 5025 or 6250.  Members agreed that although the 20% criteria of code 5025 (symptoms present more than one-third of the time) were possibly satisfied, this was not established with any clarity; and, the overall range of symptoms specified for rating under 5025 (e.g., multiple symptoms in addition to musculoskeletal pain) rendered the code less applicable than 5002 for the equivalent 20% rating.  All members agreed that the constant refractory symptoms requisite for a 40% rating under 5025 were clearly not present given the favorable response to treatment in this case.  Finally, members agreed that the next higher 60% rating under code 6350 could not be justified given that the clinical severity of SLE would not analogously compare with the severity of Behcet’s syndrome at ratings higher than 10%, even if the literal criteria were conceded.  After due deliberation, considering all of the evidence and conceding VASRD §4.3 (reasonable doubt), the panel recommends a 20% rating for Behcet’s syndrome under code 5099-5002.  

BOARD FINDINGS:  In the matter of the Behcet’s syndrome, the panel unanimously recommends a disability rating of 20%, coded 5099-5002 IAW VASRD §4.71a.  There are no other conditions within the panel’s scope of review for consideration.  

The panel recommends that the CI’s prior determination be modified as follows, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Behcet’s Syndrome	5099-5002	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20161101, w/attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

AR20170019800, XXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found that your disability rating should be modified but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed) and I accept its recommendation.  This will not result in any change to your separation document or the amount of severance pay.  A copy of this decision will be filed with your Physical Evaluation Board records.  I regret that the facts of the case did not provide you with the outcome you may have desired.
  
	This decision is final.  Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction. 

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

Sincerely,	
Enclosure