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

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Dear Applicant:

		Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2017-00104.

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 not appropriate under the guidelines of the Veterans Affairs Schedule for Rating Disabilities.  Accordingly, the Board recommended your separation be re-characterized to reflect disability retirement, rather than separation with severance pay

I have carefully reviewed the evidence of record and the recommendation of the Board.    I concur with that finding, accept their recommendation and determined that your records should be corrected accordingly.  The office responsible for making the correction will inform you when your records have been changed.

As a result of the aforementioned correction, you are entitled by law to elect coverage under the Survivor Benefit Plan (SBP).  Upon receipt of this letter, you must contact the Air Force Personnel Center at (210) 565-2273 to make arrangements to obtain an SBP briefing prior to rendering an election.  If a valid election is not received within 30 days from the date of this letter, you will not be enrolled in the SBP program unless at the time of your separation, you were married or had an eligible dependent child, in such a case, failure to render an election will result in automatic enrollment.

Attachment:
Record of Proceedings 

RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX.  	CASE:  PD-2017-00104
BRANCH OF SERVICE:  Air Force	SEPARATION DATE:  20060510

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Communications Computer Systems Operator, medically separated for “left shoulder pain” and “major depression associated with undifferentiated somatoform disorder, panic disorder without agoraphobia and existed prior to service (EPTS) generalized anxiety disorder,” rated 10% each, with a combined disability rating of 20%.

CI CONTENTION:  The left shoulder, mental health and possibly other conditions were at least 30% disabling. 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 - 20060328	VARD - 20061220	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Shoulder Pain	5399-5304	10%	Degenerative Joint Disease, Left Shoulder…	5010-5201	20%	20060919	
Major Depression associated with Undifferentiated Somatoform DO, Panic DO without Agoraphobia and EPTS Generalized Anxiety DO	9434	10%	Major Depressive DO, Recurrent; Panic DO without Agoraphobia	9412-9434	30%	20060915	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:

Left Shoulder Pain.  According to the service treatment record (STR) and Medical Evaluation Board (MEB) narrative summary (NARSUM), the left-hand dominant CI underwent a left shoulder open Bankart surgery in 1992 and a second surgery in September 2005.  The 2 February 2006 MEB NARSUM examination, 3 months prior to separation, noted continued left shoulder pain with subluxations and dislocations.  He reported his lifting restriction was nothing heavier than a coffee cup.  He was unable to continue working as a computer operator due to his current rehabilitation program.  An orthopedic consultation was consistent with the CI’s report.  The orthopedic surgeon advised the patient would never have full use of the arms again with no anticipated return of function beyond 50% of range of motion (ROM).  Physical examination showed the CI was splinting his left arm when removing his top.  Shoulder strength was not assessed due to postoperative concerns.  Grip strength was 5/5 bilaterally.  

The 28 February commander’s statement noted the CI was working outside his primary assignment due to the 50 percent loss of ROM in his left arm.  He missed about 1-2 days of work per week due to medical appointments or treatment.  The MEB NARSUM addendum, a month before separation, reported no change in his left shoulder pain.

At the 19 September 2006 VA Compensation and Pension (C&P) evaluation, 4 months after separation, the CI reported daily aching left shoulder pain and loss of ROM aggravated by overhead use or laying on it.  Physical examination showed no deformity, crepitus, effusion or impingement; muscle strength was 5/5.  ROM was flexion to 90 degrees (normal 180) and abduction 90 degrees (normal 180) with pain in all planes.  There was an estimated 50 degrees loss of ROM with repetition due to pain.  X-rays showed internal rotation was limiting evaluation but there were possible mild degenerative changes at the glenohumeral joint.  The examiner noted severe loss of ROM with severe functional loss.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left shoulder condition 10%, analogously coded 5399-5304 (stabilization of the shoulder), citing moderate pain.  The VA rated the left shoulder condition 20%, coded 5010-5201, (degenerative arthritis-arm limitation of motion), based on the C&P examination, citing limitation of arm motion.

The panel noted the MEB NARSUM and the C&P examinations were nearly equidistant to the date of separation.  The MEB NARSUM cited the CI would never have full use of the arm with no anticipated return of function beyond 50% ROM.  Physical examination did not document ROM or other aspects of left shoulder function.  Members agreed the C&P examination was more complete and detailed and therefore of greater probative value.  Physical examination documented flexion and abduction of 90 degrees respectively.  Panel members concluded the findings under 5201 were consistent with a 20% disability.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 20% for the left shoulder pain condition, coded 5010-5201.

Major Depression associated with Undifferentiated Somatoform DO, Panic DO without Agoraphobia and EPTS Generalized Anxiety DO.  According to the STR and MEB NARSUM, the CI’s condition began in 2001 after a southwest Asia deployment.  He developed frequent and recurrent panic attacks as well as a depressed mood.  He was treated with Zoloft (anti-depression) and had complete remission; medication was eventually discontinued.  He had only mild, intermittent symptoms until April 2004 when symptoms escalated to decreased sleep, less interest, recurrent panic attacks, and increased irritability, guilt, and tension.  Zoloft was restarted with marked improvement.  He discontinued Zoloft in February 2005 since he was feeling so well due to remission of all depression and anxiety symptoms.  In April 2005 he began having dizzy spells and an episode of staring.  Neurological evaluations, to include MRI and EEG, were negative.  The neurologist noted the episodes were not seizures and diagnosed anxiety.
The 27 January 2006 MEB NARSUM examination, 4 months prior to separation, noted complaints of one mild episode of anxiety which woke him from sleep.  It was manageable with controlled breathing and relaxation.  There were continued problems with low energy during the day and awakening at night.  The CI reported quick resolution of staring episodes and headache with Clonazepam (anti-anxiety).  Medication also included Celexa (anti-depression).  Personality tests showed somatoform and anxiety symptoms.  

Mental status examination (MSE) showed an apathetic mood, some obsessiveness, and a poor level of insight.  Diagnoses of major depression in partial remission, moderate severity; panic disorder without agoraphobia, generalized anxiety disorder, EPTS; and undifferentiated somatoform disorder were rendered with a Global Assessment of Functioning (GAF) score of 60 (moderate symptoms, impairment).

At the 15 September 2006 C&P evaluation, 4 months after separation, the CI reported symptoms were moderate and duration had been continuous and chronic.  He reported significant remission using his current medications of Cymbalta (anti-depression) and Clonazepam.  He was working full-time in computer information technology.  He denied missing time from work due to a mental disorder, although some days he would leave early because of feeling overwhelmed by stress.  He reported a strong and supportive relationship with his pregnant wife.  He maintained some friendships and was able to participate in a normal range of social activities and leisure pursuits.  He was able to meet family responsibilities as well as work demands and responsibilities.  The MSE showed dysphoric behavior and he reported significant sleep impairment.  He interacted appropriately with others.  Diagnoses of major depressive disorder (MDD) and panic disorder without agoraphobia were rendered with a GAF score of 65 (mild symptoms, impairment).

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the “MDD associated with undifferentiated somatoform disorder and panic disorder without agoraphobia and EPTS generalized anxiety disorder” condition 10%, coded 9434 (MDD), citing the CI worked full shifts and performed at the highest EPR “5” level.  The VA rated the MDD with panic disorder without agoraphobia condition 30%, coded 9412-9434, (panic disorder without agoraphobia-MDD), based on the C&P examination, citing occasional occupational and social impairment.  The panel noted that because total psychiatric impairment (regardless of co-existing MH diagnoses) is subsumed under a single rating, the presence of multiple mental health diagnoses is irrelevant to rating.  Application of VASRD §4.129 is considered by the panel for all MH cases resulting in separation.  All members agreed that the ‘highly stressful event’ requisite for §4.129 was not satisfied in this case.  

The panel then considered the rating at the time of separation.  The §4.130 criteria for a 10% rating is “symptoms controlled by continuous medication,” and for a 30% rating it is “occupational and social impairment with occasional decrease in work efficiency and intermittent inability to perform occupational tasks.”  The MEB NARSUM and C&P examinations are equidistant and equally probative.  The MEB NARSUM documented marked improvement in symptoms and the C&P documented significant remission with medications.  The CI was working full time, had a good relationship with his wife and others and enjoyed leisure activities.  The panel agreed the symptoms were mostly controlled with medication.  The PEB noted the CI received the highest possible rating on his performance evaluation.  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 MDD condition.

BOARD FINDINGS:  In the matter of the left shoulder condition, the panel recommends a disability rating of 20%, coded 5010-5201 IAW VASRD §4.71a.  In the matter of the mental health condition and IAW VASRD §4.130, the panel recommends no change in the PEB adjudication.  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 the date of medical separation:

CONDITION	VASRD CODE	PERMANENT RATING	
Left Shoulder Pain	5010-5201	20%	
Major Depression associated with Undifferentiated Somatoform DO, Panic DO without Agoraphobia and EPTS Generalized Anxiety DO	9434	10%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170104, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record