RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-00014
BRANCH OF SERVICE:  AIR FORCE 	SEPARATION DATE:  20041217

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Active Loadmaster Apprentice, for “diabetes mellitus” with a disability rating of 20%.  

CI CONTENTION:  “Review all conditions.”  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 Medical Evaluation Board (MEB), but determined by the PEB 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.  The panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections when appropriate.  The panel’s assessment of the PEB rating determination is based on review of medical records and all available evidence relevant to application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards for 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, which operates 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 disability at the time of separation.  

RATING COMPARISON:  

SERVICE PEB -20040907	VARD - 20050615	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Diabetes Mellitus Type I	7913	20%	Diabetes Mellitus, Type 2	7913	20%	20020223	

ANALYSIS SUMMARY:  

Diabetes Mellitus.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI was first diagnosed with diabetes mellitus in June 2004 (7 months before separation).  He was in mild ketoacidosis on presentation and was stabilized in the emergency department without admission.  He was promptly started on insulin and prescribed a diabetic diet.  Subsequent outpatient notes from the STR documented an uncomplicated course without further hospital admissions, ketoacidosis, hypoglycemic episodes, systemic diabetic complications, or requirement for frequent provider visits.  There were no STR entries that indicated any limitation of activities or a recommendation to that effect, and an endocrinology note of 16 August 2004 documented “patient states that he exercises regularly every morning between breakfast and lunch.”
The 20 July 2004 MEB NARSUM examination, 5 months prior to separation, relied heavily on an endocrinology consult a month earlier (22 June, only 3 days after the diagnosis).  At the time of that consult the CI was just starting insulin and there was no probative evidence for limitation of diet or regulation of activity, although diabetic teaching and dietary management was initiated shortly afterwards.  The NARSUM documented an insulin regimen of three daily doses with good control.  It did not document any limitation of activities. The physical examination was normal, without evidence of neuropathy or other diabetic complications.  

The profile was T4 (prohibiting deployment, reassignment, etc., during MEB proceedings) without any physical limitations, and it permitted fitness testing.  The commander’s performance statement documented that the CI’s condition “affects his ability to satisfy duty requirements only because he was taken off flying status…has no duty profile limitations” and recommended retention.

The 23 February 2005 VA Compensation and Pension (C&P) examination, 2 months after separation, documented that the CI was working full-time and “not currently under regular routine diabetic care” but was still on a daily split-dosing insulin regimen.  The examiner noted that he is “not on a restricted diet but he has to watch what his intake is…[and]…is a very active person and playing hockey frequently and he has to be careful juggling his caloric intake with activity and insulin.”  The physical examination was normal, without evidence of neuropathy or other diabetic complications.

The CI appealed his VA rating (as charted above) and obtained a memorandum (dated 15 July 2005, a month following the rating decision) from a provider at his prior military facility.  The memorandum specified dietary restrictions and stated “limits his physical activity around meals to ensure a steady blood glucose level without suffering from hyper or hypoglycemia.”  The VA did not change the rating on appeal, and the decision acknowledged the above memorandum in addition to referencing the C&P evidence.

The panel directed attention to its rating recommendation based on the above evidence.  Both the PEB and the VA conferred a 20% rating under the applicable code 7913 (diabetes mellitus).  The VA decision referenced the above quoted comments from the C&P examination.  The VASRD §4.119 criteria for a 20% rating under 7913 are “requiring insulin and restricted diet, or; oral hypoglycemic agent and restricted diet.”  The criteria for 40% are “requiring insulin, restricted diet, and regulation of activities.”  All higher ratings require all of the 40% criteria in addition to other criteria that were not supported (as above).  It was therefore clear that the only pathway to rating higher than the PEB’s 20% would be a 40% rating conceding the regulation of activities criterion.  The panel considered whether the latter could be supported by the evidence.  Panel members concluded that the only logical argument in support of the regulation of activities criterion was to concede that the need to balance exercise with the timing of meals and insulin administration was enough to constitute regulation of activities.  Panel members agreed that this was better characterized as a routine precaution applicable to diabetic management in general than as a ratable restriction on activity.  The regulation of activities criterion was therefore not reasonably justified.  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 condition.  

BOARD FINDINGS:  In the matter of the diabetes mellitus and IAW VASRD §4.119, the panel recommends no change in the PEB adjudication.  There were 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 20161201, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD  20762

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

		Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2017-00014.

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.

						Sincerely,

								XXXXXXXXXXXXXXXXXX
								Director
								Air Force Review Boards Agency

Attachment:
Record of Proceedings