RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-00135
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20050204

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty O3, Chaplain, medically separated for “Crohn’s disease” with a disability rating of 10%.  

CI CONTENTION:  His condition was rated for occasional attacks, but should have been rated for more frequent attacks.  He noted there was a partial resection of the small intestine and post-separation small bowel obstruction with additional surgical resection.  He also requested review of additional conditions not identified by the Medical Evaluation Board (MEB) and Physical Evaluation Board (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 PEB to be unfitting for continued military service, and when specifically requested by the CI, those conditions identified by the 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 - 20040826	VARD - 20060531	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Crohn’s Disease 	7399-7323	10%	Crohn’s Disease with GERD	7346-7323	30%	20060510	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Crohn’s Disease.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s Crohn’s disease began in June 2002 after experiencing episodes of nausea and vomiting, eructation, cramping abdominal pain, non-bloody diarrhea and anorexia.  CT scan of the abdomen in August 2002 revealed small bowel wall thickening of the ileum and infiltrates which suggested Crohn's disease.  Upper and lower endoscopies found a hiatal hernia, duodenitis, terminal ileum biopsies notable for focal ileitis, and small bowel follow through revealed enterocolonic fistulas in the small bowel.  Despite treatment with systemic steroids, mercaptopurine, and infliximab (Remicade – injection; immunobiologic).  A small bowel follow through in March 2004 confirmed two areas of stricture in the small bowel (ileum).  The CI had surgery of segmental small bowel resection on 7 June 2004.  

During the 30 July 2004 MEB NARSUM examination, 6 months prior to separation, the CI reported intermittent episodes of nausea and eructation despite medical and surgical management.  However, these symptoms lessened after surgery.  The CI tolerated small frequent meals of solid food without associated abdominal pain.  

The 15 October 2004 gastroenterology addendum, 4 months prior to separation indicated that although the CI had initial symptom improvement following surgery, his symptoms became more frequent and were occurring constantly on a daily basis.  Symptoms included reflux twice a day with belching, daily nausea after meals or with activity and diarrhea every other day which was associated with urgency.  Statements in September and October 2004 from the command chaplain and coworkers noted frequent episodes of urgent bathroom breaks and early work release due to post-surgical intestinal symptoms.  Laboratory evidence in December 2004 documented normal hemoglobin and hematocrit.  

At the 10 May 2006 VA Compensation and Pension (C&P) evaluation, 15 months after separation, the CI reported continued heartburn and belching all day with cramps in the mid-abdomen every day and regular diarrhea.  He was no longer taking injected medications.  Physical examination showed a well-developed CI with mid-abdominal tenderness and a well-healed non-tender abdominal scar.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the Crohn's disease 10%, analogously coded 7399-7323 (ulcerative colitis), citing intermittent episodes of nausea and eructation; lessened symptoms following surgery; toleration of small meals of solid food without abdominal pain; and hemoglobin of 12.9 (normal 13.2-16.8) and hematocrit of 38 (normal 40.2-52.3).  The VA rated the Crohn's disease 30%, analogously coded 7346-7323 (hernia hiatal – ulcerative colitis), based on the STR and C&P examinations, citing consideration of the entire picture of digestive problems to include daily, prolonged heartburn; daily belching; abdominal cramping; chronic bouts of diarrhea and occasional urgency to defecate which showed a moderately severe condition with persistent abdominal distress.  

The panel considered the guidance under VASRD  §4.114 (schedule of ratings—digestive system) that ratings under diagnostic codes 7301 to 7329, inclusive, 7331, 7342, and 7345 to 7348 inclusive will not be combined with each other.  A single evaluation will be assigned under the diagnostic code which reflects the predominant disability picture, with elevation to the next higher evaluation where the severity of the overall disability warrants such elevation.  The criteria from codes 7323, 7328 (intestine, small, resection of) and 7346 (hernia hiatal) were discussed and the panel adjudged the analogous 7323 coding was predominant.  The panel deliberated if the CI’s symptoms more nearly approximated the 30% criteria (moderately severe; with frequent exacerbations) or the 10% criteria (moderate; with infrequent exacerbations).  Given the gastroenterology addendum indicating increased symptoms following a likely “honeymoon” period after surgery, as well as the CI’s additional non-Crohn’s-type digestive system symptoms, the panel adjudged that the CI’s disability picture more nearly approximated the 30% disability picture.  

The evidence did not support a finding of severe impairment of health due to interference with absorption and nutrition, objectively supported by definitive weight loss, to support a rating higher than 30%.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 30% for the Crohn's disease, coded 7399-7323.  

BOARD FINDINGS:  In the matter of the Crohn's disease, the panel recommends a disability rating of 30%, coded 7399-7323 IAW VASRD §4.114.  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	
Crohn's Disease	7399-7323	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20161130, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20180012734, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX

I accept the recommendation of the Department of Defense Physical Disability Board of
Review (DoD PDBR) to re-characterize your separation as a disability retirement with the
combined disability rating of 30% effective the date of your medical separation for disability with
severance pay. Enclosed is a copy of the Board’s recommendation and record of proceedings
for your information.
The re-characterization of your separation as a disability retirement will result in an
adjustment to your pay providing retirement pay from the date of your original medical
separation minus the amount of severance pay you were previously paid at separation.
The accepted DoD PDBR recommendation has been forwarded to the Army Physical
Disability Agency for required correction of records and then to the U.S. Defense Finance and
Accounting Service to make the necessary adjustment to your pay and allowances. These
agencies will provide you with official notification by mail as soon as the directed corrections
have been made and will provide information on your retirement benefits. Due to the large
number of cases in process, please be advised that it may be several months before you
receive notification that the corrections are completed and pay adjusted. Inquiry concerning
your correction of records should be addressed to the U.S. Army Physical Disability Agency,
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557.
A copy of this decision has also been provided to the Department of Veterans Affairs.

Sincerely,

Enclosure