RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01753
BRANCH OF SERVICE:  navy 	SEPARATION DATE:  20040429

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Aviation Boatswain's Mate (Fuel Handler), medically separated for “hypersomnia” with a disability rating of 0%.   

CI CONTENTION:  The CI’s contention covers all conditions identified by the MEB and PEB.  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 - 20040112	VARD - 20040608	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Hypersomnia	6847	0%	Obstructive Sleep Apnea, Central Apnea, and Hypersomnia	6847	50%	20040330	
Obstructive Sleep Apnea on Continuous Positive Airway Pressure	Cat II					
Chiari I Malformation	Cat II	Status Post Spinal Canal De-compression, Excision of
Intervertebral Disc, and Pseudo-meningocele Repair for Chiari I Malformation Cluster Headaches	8024	30%	20040330	
Pseudomeningocele  	

Cat II					
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY:  

Hypersomnia.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s hypersomnia (excessive sleepiness) condition began in April 2002 after surgery for a Chiari I decompression and repair of the pseudomeningocele.  
On 29 April 2002 the CI reported a history of snoring, morning headaches, memory problems, dozing at the wheel, and being late to work, and his spouse noted him choking at night.  On examination he had a large and extended uvula.  Polysomnography (sleep study) dated 14 July 2002 revealed 27 hypopneas (abnormally slow or shallow breathing) with the mean apnea (no breathing) duration of 18.9 seconds and an apnea maximum of 32 seconds.  The examiner’s impression was severe obstructive sleep apnea, which required use of a CPAP (continuous positive airway pressure) machine titrated to 9.0 cm H20.  A sleep study on 4 May 2003 revealed the best CPAP titration was 12 cm H20, while a sleep study on 14 July 2003 indicated the best CPAP titration was 20 cm H20.  A pulmonary note dated 24 July 2003 indicated the hypersomnia was likely secondary to severe obstructive sleep apnea.  The examiner noted the CI was not deployable, should not stand watches, operate machinery, work at heights or around electrical sources, or operate motor vehicles or work “mids or nites.”  A trial of Provigil TM (modafinil, a stimulant) was instituted and CPAP was reduced to 16 cm H20.  

The 24 July 2003 MEB NARSUM examination, 9 months prior to separation, noted that the symptoms of obstructive sleep were incompletely relieved by the use of the CPAP machine.  As a result he had a minor motor vehicle accident where he dozed off at the wheel of the car.  He also fell asleep waiting for a medical appointment.  Physical examination showed the CI to be 5 feet 9 inches tall and he weighed 237 pounds.  Blood pressure was 131/78.  He had erythema of the throat with an elongated and low lying soft palate an enlarged uvula.  His neck demonstrated no adenopathy or thyromegaly (enlarged thyroid).  Extremities had no clubbing, cyanosis, or edema.  The author noted that despite multiple CPAP re-titrations and use of an auto-titrating CPAP machine, the CI still complained of significant excessive daytime sleepiness.  The opinion of the MEB Board was that the sleep apnea had been adequately treated and the excessive daytime sleeplessness was a real finding and was most likely related in part to the central nervous system malformation and was unlikely to resolve on its own or with continuous CPAP.  To maintain continued alertness the CI will require oral stimulant therapy and the sleeplessness precluded him from shipboard duty or driving an automobile. 

According to the 14 August 2003 MEB examination (recorded on DD Forms 2807-1 and 2808), 9 months prior to separation, the CI reported obstructive sleep apnea and hypersomnia.  The examiner likewise noted sleep apnea and hypersomnia.  An electroencephalogram, performed for daytime hypersomnia on 23 October 2003, was normal.  A pulmonary function study performed on 30 March 2004 revealed an FVC 119% predicted, FEV1 116% predicted, and an FEV1/FVC ratio of 97%, which was interpreted as a normal study.  The 23 December 2003 MEB NARSUM Addendum examination, 4 months prior to separation, noted that the CI had been given a period of observation on stimulant medications since the July 2003 including modafinil, methylphenidate and amphetamine (Adderall XLTM). The first two medications were not successful in increasing alertness.  The use of Adderall XL in the morning had improved excessive daytime sleepiness during the earlier part of the day, but at the end of the day the effect of the medication began wane and the CI felt sleepy.  He had difficulty with driving prolonged distances (from his home to work) because he became sleepy behind the wheel of the car.  The CI had not worked in his rate since placement on LIMDU (limited duty).  Overall the CI felt that there was slight improvement in his hypersomnolence, but it had not completely resolved.  The opinion of the Medical Board was that the CI’s hypersomnolence was multifactorial and noted “[c]learly patients with obstructive sleep apnea despite treatment with continuous positive airway pressure, can have residual sleepiness.”  The MEB Board found it intriguing that the complaints of hypersomnolence directly followed the repair of the Arnold-Chiari malformation, which is associated with obstructive sleep apnea as well as central sleep apnea.  The author hypothesized the repair may have been a culprit that contributed to the hypersomnia, although the literature did not have any reports to support the hypothesis.  However, the author did have another patient with a similar history.  Furthermore, it was the MEB Board opinion that the CI continued to be unable to perform his duties due to insufficient alertness to refuel aircraft and work on a flight deck situation underway onboard a ship.  
At the 30 March 2004 VA Compensation and Pension (C&P) evaluation, 1 month before separation, the CI reported falling asleep after breakfast, in a classroom, or in a waiting room.  Treatment was with a CPAP machine and Adderall; however, his functional response time was slowed and it took longer time to do tasks, but he did not lose time from work.  Physical examination showed the CI to be 69 inches tall and weigh 240 pounds.  Blood pressure ranged from 118/76 to 120/76.  He had an enlarged uvula.  Pulmonary function testing was normal.  A skull X-ray was within normal limits.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the hypersomnia condition 0%, coded 6847 (sleep apnea syndromes (obstructive, central, mixed)).  The Navy PEB also listed obstructive sleep apnea on continuous positive airway pressure as a related Category II condition (a condition that contributed to the primary unfitting condition but was not separately ratable).  The impairment from the obstructive sleep apnea on continuous positive airway pressure was properly subsumed under the overall rating for the hypersomnia IAW §4.14 (avoidance of pyramiding; more than one rating based on the same impairment is prohibited).  The VA rated the hypersomnia condition 50%, coded 6847, (sleep apnea syndromes), based on the C&P examination 1 month before separation, citing for the requirement of a breathing assistance device such as a continuous airway pressure (CPAP) machine.  

Panel members noted that the PEB used the code 6847 for the hypersomnia.  However, code 6847 includes obstructive sleep apnea treated with CPAP at a 50% rating, but also includes persistent daytime hypersomnolence at a 30% rating.  Since the hypersomnia etiology was determined to be multifactorial, the use of the analogous code 6899-6847 is felt to be more applicable than code 6847.  The obstructive sleep apnea Navy Category II condition, which contributed to the hypersomnia, was documented in the STR and the CI had duty limitations; and CPAP was identified by the NARSUM examiner as a required treatment.  VASRD §4.97 provides for a minimum rating of 50% for obstructive sleep apnea requiring a breathing assistance device, and the evidence establishes that the latter criterion was met in this case.  Therefore, a 30% rating is superseded by the CI’s use of the CPAP.  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 hypersomnia condition, coded 6899-6847.  

The PEB listed the Chiari I malformation and pseudomeningocele as Navy Category II conditions, conditions that are related to the primary unfitting condition and contributed to the primary unfitting condition.  The panel’s first charge for these Navy PEB Category II conditions is to assess whether either of the conditions could be reasonably justified as separately unfitting for rating consideration.

A neurosurgical note dated 29 October 2001 indicated the CI had a long history of severe headaches.  Magnetic resonance imaging (MRI) of the brain and cervical spine revealed a 6 mm extrusion of the cerebellar tonsils consistent with a Chiari I malformation.  The CI underwent a posterior fossa decompression and C1 laminectomy with a duraplasty (a dural patch) to relieve the cerebellar tonsils herniation compressing the brainstem on 10 January 2002.  On 28 January 2002 the CI was placed on LIMDU for 8 months.  A note dated 8 October 2002 indicated the CI did well postoperatively, but did form a pseudomeningocele (an abnormal collection of cerebrospinal fluid (CSF) that occurs due to leakage from the CSF-filled spaces surrounding the brain and spinal cord) noted in April 2002, but there was no need to address it since the CI was doing well.  On examination there was some softness at the site of the pseudomeningocele, but it was clearly under no pressure.  Nevertheless, because of intermittent chronic headaches and enlargement of the pseudomeningocele during an intense headache, surgery was recommended.  On 1 November 2002 the CI underwent repair of the suboccipital pseudomeningocele.  On 1 April 2003 the CI reported he no longer had problems with headaches, numbness, or tingling.  Neurological examination was unremarkable.  From a neurosurgical standpoint the CI was felt to be fit for full duty and was recommended to return to full duty.  Members concluded that a preponderance of evidence indicates the Category II Chiari I malformation and pseudomeningocele conditions were not justified as separately unfitting; given the fact that the neurosurgeon indicated the CI was fit for full duty and his headaches had diminished considerably, although at the VA examination, 1 month prior to separation, the CI did report reoccurring headaches, which were described as “pressure.”  He also noted dizziness, but was not receiving treatment for either condition, and there was no functional impairment nor was there any time lost from work. 

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 Chiari I malformation and pseudomeningocele conditions as a Category II conditions, and therefore no additional ratings are recommended.

BOARD FINDINGS:  In the matter of the hypersomnia condition, the panel unanimously recommends a disability rating of 50%, coded 6899-6847 IAW VASRD §4.97.  In the matter of the contended obstructive sleep apnea, Chiari I malformation, and pseudomeningocele conditions, the panel unanimously recommends no change from the PEB determinations as Navy Category II conditions.  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; 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	
Hypersomnia 	6899-6847	50%	

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 

MEMORANDUM FOR DEPUTY COMMANDANT (Manpower and Reserve Affairs)
		   COMMANDER, NAVY PERSONNEL COMMAND	
	                          
Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS          

Ref:  (a) DoDI 6040.44
	(b) PDBR ltr dtd 01 Mar 18 ICO XXXXXXXXXXXXXXXXXX 
	(c) PDBR ltr dtd 20 Feb 18 ICO XXXXXXXXXXXXXXXXXX
	(d) PDBR ltr dtd 27 Feb 18 ICO XXXXXXXXXXXXXXXXXX
	(e) PDBR ltr dtd 13 Feb 18 ICO XXXXXXXXXXXXXXXXXX
	(f) PDBR ltr dtd 02 Oct 17 ICO XXXXXXXXXXXXXXXXXX

1.  Pursuant to reference (a), the recommendations of the Physical Disability Board of Review set forth in references (b) through (f) are approved.  The official records of the following individuals are to be corrected as follows:

     a. XXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 10 percent) effective date of discharge. 

     b. XXXXXXXXXXXXXXXXXX, former USN: Placement on the Temporary Disability Retired List at time of discharge for six months with a disability rating of 50 percent followed by transfer to the Permanent Disability Retired List with a 30 percent rating (increased from 10 percent).

     c. XXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 50 percent rating (increased from 0 percent) effective date of discharge. 

     d. XXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.      

     e. XXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.   
     
2.  Please take action to implement these decisions and provide notification to the above individuals once those actions are complete.

                                 	XXXXXXXXXXXXXXXXXX
                                  	Acting