RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-00926
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20050224

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Maintenance Management Analysis Journeyman, medically separated for “diabetes mellitus type I” 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 - 20050107	VARD - 20050822	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Diabetes Mellitus Type I	7913	20%	Diabetes Mellitus Type I	7913	20%	20050804	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  20% 	

ANALYSIS SUMMARY:  

Diabetes Mellitus Type I.  According to the service treatment record and MEB narrative summary (NARSUM), the CI’s type I diabetes condition began in June 2004 after experiencing symptoms of dizziness, polyuria, polydipsia, lower extremity paresthesias, fatigue, and unintentional weight loss.  Laboratory studies on 4 June 2004 revealed a glucose of 170 mg/dL (normal 75-110), 3+ glucose in the urine, and Hgb A1C 9.4% (normal <6%).  The CI was started on Glucovance tablets (glyburide and metformin) to treat the diabetes pending further laboratory studies, and was educated on monitoring his blood sugars.  A note dated 14 June 2004 indicated the CI’s blood sugar was 417 mg/dL in the emergency room the prior evening.  In the clinic his blood sugar was 284 mg/dL.  Because he was not improving with oral therapy, he was started on Lantus (insulin glargine) subcutaneously and a sliding scale of Humulin (insulin) Regular as well as a 2200 calorie antidiabetic diet.  Based on additional test results (C-peptide less than 0.5 ng/ml (normal 1.1-5.0) and an insulin level of 1.7 mIU/ml (normal 2.6-24.9)), the CI was determined to have diabetes mellitus type 1.  The Lantus dose was increased and effective use of insulin to prevent hypoglycemic episodes was reviewed.  Ophthalmologic evaluation on 23 June 2004 revealed no evidence of diabetic retinopathy.  The CI underwent diabetes education on 26 July 2004, which included the proper and timely use of insulin as well as diet.  NovoLog (insulin aspart) replaced the Humulin.  In August 2004 his Hgb A1C was 7.1%.  On 1 September 2004 the CI reported his blood sugars were averaging 70-150 mg/dL.  A P4 profile dated 17 September 2004 listed restrictions of no permanent change of station, TDY (temporary duty), or deployment.  A note dated 12 November 2004 indicated the CI was to receive an insulin pump and needed training.  On 22 November 2004 the CI reported his average blood sugars were between 200 and 300 mg/dL and blood glucose was 223 mg/dL on 1 December 2004.  

The 1 December 2004 MEB NARSUM examination, 3 months prior to separation, noted the complaint of diabetes mellitus type 1.  Physical examination was unremarkable with his sensation intact and no skin breakdown noted in the feet.  The examiner noted the CI had done very well adjusting to the diagnosis and lifestyle changes associated with his diabetes.  He was able to perform fully with his duty AFSC and missed no days of work due to illness or complications from his diabetes.  The examiner recommended the CI be retained on active duty with the appropriate assignment limitations.  The commander’s statement dated 13 December 2004 indicated the CI’s “medical profile does not have any impact on his productivity or his daily duties.  He is able to perform primary tasks in his assigned AFSC and grade.”  

At the 4 August 2005 VA Compensation and Pension (C&P) examination, 5 months after separation, the CI reported diabetes mellitus type 1 and hypoglycemia approximately once a week when he was too active or used too much insulin.  Physical examination showed a blood pressure of 110/65 and pulse 65 beats per minute.  The remainder of the examination was unremarkable.  There was no decreased sensation and no ulcers of the feet.  Pulses were symmetrical bilaterally. At a VA clinic visit on 20 October 2005 the CI reported he was receiving the NovoLog by pump, and on examination the skin of both feet was intact as were his pulses and sensation.  Glucose was 135 mg/dL and the Hgb A1C was 8.4% on 20 October 2005.  At an endocrinology evaluation on 20 October 2005 the CI reported his fasting glucose was between 100-140 mg/dL.  He had no polyuria or polydipsia and no complaints of blurriness or diplopia (double vision).  He denied lower extremity ulcerations or lesions.  Physical examination was unremarkable. 

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the type I diabetes condition 20%, coded 7913 (diabetes mellitus type I), citing the CI’s “medical condition is not compatible with the rigors of military service as evidenced by the long-term impact the condition’s limitation will have on the member’s career progression and the inequities created in deployment/remote assignment obligations” and general DoD and VASRD guidelines.  The VA also rated the type I diabetes condition 20%, coded 7913, based on the C&P examination, citing a documented requirement for insulin and restricted diet or oral hypoglycemic agent and restricted diet.  

The panel agreed that the requirement for treatment with insulin and restricted diet justified a 20% rating.  Because there was no evidence of medically prescribed regulation of activities, the next higher 40% rating was not justified.  Furthermore, he did not require frequent visits to a diabetic care provider other than for educational purposes and renewal of medications, nor were there episodes of ketoacidosis, hypoglycemic reactions requiring hospitalizations, or diabetic complications that could support higher ratings.  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 diabetes type I condition.  
BOARD FINDINGS:  In the matter of the type I diabetes mellitus condition and IAW VASRD §4.119, the panel recommends no change in the PEB adjudication.  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 20170218, 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-2017-00926.

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