RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-00044
BRANCH OF SERVICE:  Air Force	SEPARATION DATE:  20080707

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an Air National Guard E5, Security Forces Journeyman, medically separated for “mood disorder associated with mild cognitive defects” and “acute disseminated encephalomyelitis (ADEM),” rated 10% each, with a combined disability rating of 20%.  

CI CONTENTION:  The VA gave him higher ratings for his 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 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 - 20080529	VARD - 20080306	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Mood Disorder Associated with Mild Cognitive Defects	9435	10%	Major Depression and Cognitive Disorder… 	8045-9434	10%	20080116	
ADEM	8010	10%	ADEM	8045-8000	10%	20080123	
Bilateral Shoulder and Knee Arthropathy	Not Unfitting	Left Shoulder Arthralgia… 	5299-5203	10%	20080123	
		Right (Dominant) Shoulder Arthralgia …	5299-5203	10%	20080123	
		Right Knee Arthralgia…	5299-5260	10%	20080123	
		Generalized Myalgia as a Result of Anthrax Vaccine Reaction	5299-5025	10%	20080204	
Interstitial Nephritis	Not Unfitting	History of Mild Renal Insufficiency	7599-7535	0%	20080123	
Recurrent Scleritis /Uveitis	Not Unfitting	Iritis, History of Recurrent Acute Anterior Uveitis OU with Posterior Synechia OS	6000-6003	0%	20080116	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Mood Disorder and ADEM.  According to the service treatment record and Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s mental health condition began in late summer of 2004 and was temporally related to receiving a third anthrax vaccination.  He originally presented with multiple conditions and symptoms including arthralgias, fatigue, fever of unknown origin, elevated liver enzymes, interstitial nephritis, and recurrent scleritis.  He was evaluated by rheumatology, neurology, psychiatry, ophthalmology, infectious disease, and the Vaccine Healthcare Center with eventual improvement in symptoms, but no specific reason for the recovery.  In 2006, the CI’s health again declined after Hepatitis B and influenza vaccinations, and magnetic resonance imaging (MRI) demonstrated acute disseminated encephalomyelitis (rare autoimmune disease marked by a sudden widespread attack of inflammation in the brain and spinal cord).  

An 18 July 2006 psychiatrist’s summary noted the CI was treated for a severe depressive episode and a history of manic episodes.  He was diagnosed with a mood disorder (bipolar type) secondary to a general medical condition, with an MRI revealing white matter lesions.  At an 8 August 2006 neuropsychiatric evaluation, the mental status evaluation (MSE) was normal. The examiner’s clinical impression indicated the CI met criteria for depression, but had cognitive problems not accounted for by depression; and his performance was "typical of individuals with complex cognitive deficiencies."  

At a September 2006 VA Compensation and Pension (C&P) evaluation, 22 months prior to separation, the psychiatrist diagnosed major depressive disorder (MDD) secondary to general medical condition and cognitive disorder, not otherwise specified (NOS), moderate to severe.  The assigned Global Assessment of Functioning (GAF) score was 50 (serious symptoms).  

On 19 December 2006, the CI was hospitalized for an expedited neurologic evaluation.  The examiner noted a 6 December 2006 MRI which revealed moderate diffuse confluent cerebral leukoencephalopathy (vanishing white matter that mainly affects the brain and spinal cord), but that there was no radiographic or clinical progression of the condition in the previous 6 months. 
 
An 8 September 2007 flight medicine summary by the state Air National Guard surgeon, 10 months prior to separation, indicated multiple diagnoses from a panel of neurologists:  mood disorder; bipolar; functionally impaired by depression; severe central nervous system demyelinating disease; and confluent cerebral encephalopathy.  The surgeon noted the CI was functioning well enough on a daily basis to be able to perform light duty for drill purposes.  He had also returned to many of his civilian duties and was working as a physical education teacher.

The 25 October 2007 MEB NARSUM examination, 9 months prior to separation, noted CI complaints of multiple persistent disabling conditions temporally related to required vaccinations.  Physical examinations were noted to be those from previously referenced specialists.  The final recommendations indicated he would never be able to return to full duty without restrictions, and would never be able to be deployed due to immunization restrictions.  

At the 16 January 2008 mental disorders C&P evaluation, 6 months before separation, the CI reported his psychiatric symptoms had steadily improved since the fall of 2006.  He was taking psychiatric medication and had returned to full-time work.  The MSE revealed a happy mood and affect within normal limits.  There were no signs of major psychopathology such as delusions, hallucinations or preoccupations and symptoms suggestive of psychosis, speech disturbance, objective cognitive impairment, or other abnormality.  The GAF score was 80, reflecting minimal or transient symptoms with no more than slight impairment in social and occupational functioning.  

At the 23 January 2008 neurological disorders C&P evaluation, the CI complained of headaches, cognitive changes, Bell’s palsy, and disequilibrium/dizziness associated with ADEM.  He had occasional memory problems and word finding difficulty that did not interfere with his work or daily life.  He stated he was working full-time and the “depression was gone.”  Physical examination documented that a mini-MSE and neurologic evaluations were essentially normal.  The examiner stated the “headaches, fatigue, depression, balance problems, paresthesias and visual symptoms have all resolved.”  

A 14 February 2008 treating psychiatrist’s summary, 5 months before separation, indicated the CI had been fairly stable since late 2006.  In March 2007, he returned to work and most of his usual activities, and was on psychoactive medications.  The diagnosis was “mood disorder, bipolar type severe without psychotic features secondary to a general medical condition-central nervous system demyelination.”  The GAF was 75 (transient symptoms) and the psychiatrist indicated the CI was in remission, but would be at risk with significant future stressors.  

At the 15 July 2009 mental health C&P evaluation, 12 months after separation, the CI complained of increased cognitive problems in May 2009 with a need to take medical leave from his job.  He reported that his treating psychiatrist felt the condition was due to too many stimulants (creatine, “fat burner,” coffee, and Adderall).  He further indicated he was laid off from his job in May, along with other teachers, due to budget cuts.  The MSE was unremarkable, with the examiner clarifying that the CI did show concentration difficulties.  The diagnosis remained unchanged as in remission, and the GAF was 70 (mild symptoms).  

The panel directed attention to its rating recommendation based on the above evidence.   The PEB rated the mood disorder associated with mild cognitive defects condition 10%, coded 9435 (mood disorder, NOS), citing the CI’s return to work and to most usual activities, and a medical report that he did not have current activity restrictions.  The VA rated the major depression and cognitive disorder 10%, coded 8045-9434 (MDD caused by brain disease due to trauma), based on the C&P examination 6 months before separation, citing a requirement for psychiatric medication associated with mood disorder, improved cognitive functioning, remission of major depression, and a GAF of 80.  

Panel members first agreed the evidence did not support a traumatic stressor as the cause of the mental condition for which application of VASRD §4.129 would be appropriate.  The panel next considered the §4.130 rating at the time of separation.  A 30% rating requires evidence of “occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks” due to  such symptoms as:  depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events.”  At the C&P and treating civilian psychiatrist evaluations, 6 and 5 months before separation, the examiners indicated the CI was working full-time, taking medications and that symptoms were in remission.  Members agreed that occupational and social impairment as noted by the GAFs and descriptions was at most slight, and best supported by a 10% rating.  

The PEB rated the ADEM condition 10%, coded 8010 (myelitis), citing the CI’s nearly complete recovery; no recent documentation of nephritis or scleritis; resolution of headaches, fatigue, balance problems, paresthesias, and visual symptoms; and residual pain in the knees and shoulders that didn’t affect quality of life or occupation.  The VA rated the ADEM condition 10%, coded 8045-8000, (encephalitis caused by brain disease due to trauma), based on the C&P evaluation 6 months before separation, citing ascertainable residuals.  At the time of the NARSUM and C&P neurology and mental health evaluations, the examiners indicated there were only slight memory problems that did not interfere with his work or daily life, and other symptoms had resolved.  Panel members noted that 8010 code has a minimum rating of 10%, and there were no other ratable residuals for any higher rating.  There was no applicable alternative coding for any rating higher than that adjudicated by the PEB.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded there was insufficient cause to recommend a change in the PEB adjudication for the mood disorder and ADEM conditions.  

Contended PEB Conditions:  Bilateral Shoulder and Knee Arthropathy, Interstitial Nephritis, and Recurrent Scleritis/Uveitis.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  None of the conditions were profiled, implicated in the commander’s statement nor judged to fail retention standards.  There was no performance-based evidence from the record that any of the conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determination for any of the contended conditions and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the mood disorder and IAW VASRD §4.130, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the ADEM condition and IAW VASRD §4.124a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the contended bilateral shoulder and knee arthropathy, interstitial nephritis, and recurrent scleritis/uveitis 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 20161208, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment 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-2017-00044.

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