RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-01229
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20060609

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Medical Laboratory Specialist, medically separated for “chronic bilateral flank pain and associated depression” with a disability rating of 20%.

CI CONTENTION:  Current condition supports a higher rating.  Additional unfitting conditions were not considered.  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 - 20060505	VARD - 20080422	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Flank Pain and Associated Depression	5099-5003	20%	Nephrolithiasis/Renal Papillary Necrosis with Flank Pain	7508	30%	20061218	
			Major Depressive Disorder	9434	30%	20061218	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  90%	

ANALYSIS SUMMARY:

Chronic Bilateral Flank Pain Attributed to Papillary Necrosis and Associated Depression.  The PEB combined the conditions of flank pain attributed to papillary necrosis and depression due to chronic pain under a single disability rating, coded analogously to 5003 and rated 20% with application of the US Army Physical Disability Agency (USAPDA) pain policy.  This approach by the PEB not uncommonly reflected its judgment that the constellation of conditions was unfitting, and there was no need for separate fitness adjudications.  The panel’s initial charge in this case was therefore directed at determining if combining conditions under a single rating was justified in lieu of separate ratings.  When considering a separate rating for each condition, the panel considers each bundled condition to be reasonably justified as separately unfitting unless a preponderance of evidence indicates the condition would not cause the member to be referred into the DES or be found unfit because of physical disability.  When the panel recommends separate fitness recommendations in this circumstance, its recommendations may not produce a lower combined rating than that of the PEB.  The evidence for the kidney and behavioral health conditions are presented separately, with attendant recommendations regarding separate unfitness and separate rating.  

Chronic Bilateral Flank Pain Attributed to Papillary Necrosis.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s flank pain condition began in December 2004.  Trauma or injury was not cited.  A 17 December 2004 primary care clinic note, 18 months prior to separation, noted the CI presented with left flank pain.  The examiner reported tenderness and medications included Percocet.  A urinalysis (UA) revealed 30 to 50 RBCs (red blood cells per high power field (HPF)).  Treatment included a Toradol shot, Phenergan, Demerol, IV saline, and hospital admission for pain control as noted below.  The diagnosis was “probable renal stone”.  Computerized tomography (CT) demonstrated a 4 millimeter (mm) stone in the left kidney and a 2 mm stone in the right kidney.  They were not in the ureter.  During admission the CI did not pass the kidney stones.  The 23 December 2004 discharge summary noted the CI had a five day history of flank pain.  The CI was given IV pain control and fluid until she could be managed on oral pain control and Fentanyl patches.  

During a 25 February 2005 radiologic intravenous pyelogram (IVP) procedure, the impression was the findings were consistent with papillary necrosis.  The left was greater than the right.  At the 31 March 2005 urology consultation, 15 months prior to separation, the CI reported the pain was almost continuous and she used a Fentanyl patch, which was supplemented by Oxycodone and Zofran.  The examiner reported moderate left costovertebral angle tenderness (CVAT) and the bladder was not palpable.  The UA report was:  golden, hazy, 3+ blood, microscopy:  50+ RBCs, 0-1 white blood cells (WBCs), and 5 to 10 epithelial cells per HPF.  The urologist noted chronic continuous left flank pain, which required significant analgesia, small single calculus in each kidney, and micro-hematuria with gross hematuria when fiving urinary specimen.  Also noted was possible papillary necrosis by IVP report, but the examiner was unable to comment on the IVP study as it was not available for review.  

At the 8 July 2005 emergency department physician’s report, 11 months prior to separation, the CI reported acute flank pain.  The examiner reported CVAT of the left.  The blood urea nitrogen was 9 (milligrams per deciliter (mg/dL)) and the creatinine was 0.8 (mg/dL).  The UA was positive for blood and nitrite negative.  The 26 October 2005 perfusion study was performed due to IVP report that stated the findings were consistent with papillary necrosis.  The radiotracer study showed normal perfusion, localization, and excretion from both kidneys.  There was equal differential function.  The 10 November 2005 emergency room (ER) examination, 7 months prior to separation, noted complaints of significant pain even after application of a Fentanyl patch and Percocet in the morning.  The examiner reported mild left CVAT and chemistry 7 panel test was within normal limits (WNL).  

At the 7 February 2006 ER examination, 4 months prior to separation, the CI reported flank pain.  The examiner reported the UA was normal with a specific gravity of 1.030.  Pain medication included Fentanyl.  The CI was encouraged to drink lots of fluids.  During the 20 March 2006, ER examination, 3 months prior to separation, the CI reported a flare-up of her longstanding back/flank pain without a specific trigger.  Review of systems cited no fever, dysuria, or gastrointestinal complaints.  The examiner reported the CI was ambulatory and there was no typical CVAT.  The CI received a Toradol shot.  The recommendation was to continue previously prescribed medication which included fentanyl, and rest.  

The 5 April 2006 MEB NARSUM examination, 2 months prior to separation, noted complaints of flank pain.  The examiner reported her vital signs were stable and she was afebrile, alert, oriented, and in no acute distress.  The CI did not show any pain and did not flinch as she walked in and sat down or during the entire examination.  Physical examination to include head, neck, heart, lungs, back, and abdomen was normal.  The CI’s back exhibited a full range of motion.  The area of the chronic flank pain showed no abnormalities, no edema, no ecchymosis, and was non-tender.  

At the 18 December 2006 VA Compensation and Pension (C&P) general examination, 6 months after separation, the CI reported a diagnosis of papillary necrosis secondary to kidney stones in Alaska in 2005 which was not currently a problem.  Physical examination showed:  normal gait, well-nourished female in no acute distress, and no CV tenderness.  Ultrasonography demonstrated a grossly normal appearance of the kidneys.  No definitive mass or hydronephrosis was noted.  The impression revealed small bilateral renal calcifications or stones.  The UA was normal.  Chemistry 18 panel test was WNL.  The complete blood count was WNL. 

The panel first considered if the chronic bilateral flank pain condition, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The chronic bilateral flank pain condition was considered to fail retention standards, was implicated by the NARSUM and the commander’s statement, and was profiled.  Panel members agreed the evidence reasonably justified that the functional limitations of the condition contributed to the CI’s inability to perform her military duties, and accordingly a separate disability rating is recommended.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic bilateral flank pain and associated depression conditions 20%, analogously coded 5099-5003 (degenerative arthritis), citing the depression could not be separately rated due to pyramiding and the USAPDA pain policy rated as moderate and constant.  The VA rated the flank condition 30%, coded 7508 (nephrolithiasis), based on the C&P examination, citing evidence of invasive or non-invasive procedures more than two times per year, diet therapy, or drug therapy.  The panel determined that VASRD diagnostic code 7508 (nephrolithiasis), which is rated as hydronephrosis, except for recurrent stone formation, most closely approximates the anatomic location and functional impairment associated with the bilateral flank pain condition.  There was no evidence of recurrent stone formation as the 2 stones of 2mm and 4mm were not eliminated.  This finding was supported by straining of all urine and post imaging demonstration of the 2 stones, 1 in each kidney pre and post imaging studies.  Also, the STR did not demonstrate invasive procedures (e.g., drainage with a stent, percutaneous nephrostomy), or non-invasive procedures such as lithotripsy, were utilized.  Conservative treatment consisting of pain management and increased fluids was utilized.  Evidence of infection was lacking due to STR reporting the CI was afebrile and her CBC was WNL (e.g., no elevation of WBC suggesting an infection). This most closely approximates a separate rating of 10% with criteria including no infection and not requiring catheterization.  

Depression Due to Chronic Pain.  According to the STR and MEB NARSUM, the CI’s mental health treatment began approximately in April 2005 associated with her constant pain.  On the 15 April 2005 mental health questionnaire, 14 months prior to separation, the CI reported that nearly every day she experienced anhedonia, insomnia, and lethargy.  These problems made it very difficult for her to perform work, take care of things at home, or get along with other people.  

At the 3 August 2005 psychology consult, 10 months prior to separation, the CI endorsed anhedonia, hopelessness, difficulty with concentration, and depression.  The psychologist stated the mood/affect was consistent with presentation and recommended consultation with a psychiatrist for a prescription of an anti-depressant.  She was diagnosed with adjustment disorder with depressed mood.  According to the 4 November 2005 mental health clinic note, 7 months prior to separation, the CI’s energy had increased since being on Elavil.  The psychologist reported the CI appeared alert, oriented, was in no apparent distress, and hygiene was normal.  These findings were congruent with the report given by the CI.  She was diagnosed with mood disorder due to a general medical condition.  

At the 13 December 2005 psychiatric clinic appointment, 6 months prior to separation, the CI reported improved mood, but she had gained 30 pounds with medication.  She was interested in switching to medication with less weight gain.  The examiner reported the CI’s symptoms were consistent with mood improvement as stated by the CI.  The examiner started a taper from Elavil while in the process switching to Cymbalta.  Her diagnoses included depression, chronic pain syndrome, and mood disorder due to a general medical condition.  A 9 January 2006 mental health clinic note, 5 months prior to separation, noted the CI had difficulties, which included getting going in the morning, hypersomnia, feelings of hopelessness, anhedonia, absence of motivation, decreased effectiveness or productivity, and dangerousness.  The examiner noted the CI experienced a relapse of her depression and pain symptoms due to being weaned off Elavil as a result of her significant weight gain of 30 pounds.  

An 18 January 2006 inpatient psychiatric note, 5 months prior to separation, noted that the CI reported a suicide attempt with medications the week prior to admission.  The physician reported she appeared profoundly depressed.  The CI’s speech was slow but coherent and tearful at times when discussing her suicide attempt.  The physician recommended starting back on Elavil, but on a lower dose that might benefit her sleep and help with pain control.  A 25 January 2006 psychiatric discharge summary reported the CI was psychiatrically hospitalized for 8 days due to suicidal ideation from 18 January 2006 through 25 January 2006 while stationed in Alaska.  The CI reported she presented to the community hospital mental health clinic due to depression, which had become worse with thoughts of harming herself, and she did not feel that it would be safe to return home.  She had been experiencing ongoing chronic pain and an increase in symptoms of depression due to medication changes.  Also, there was a significant family issue affecting the ability of the family to stay on post.  

The 29 March 2006 MEB NARSUM psychiatric addendum, 2 months prior to separation, noted complaints of pain, which was associated with both medical and psychological factors.  The examiner reported the CI exhibited appropriate grooming, psychomotor slowing, normal speech rate and rhythm, and logical thought processes, and was cooperative.  The thought content was devoid of suicidal ideation, homicidal ideation, or delusions.  The CI denied auditory or visual hallucination.  Judgment and impulse control were intact.  Insight was moderate.  Cognition was not formally assessed, but appeared grossly intact.  The CI’s affect was mood congruent, which appeared depressed.  Also, the CI exhibited insomnia and impaired concentration.  At the 18 December 2006 C&P mental disorders evaluation, the examiner reported a history of psychiatric hospitalization for 8 days for suicidal ideation from 18 January 2006 through 25 January 2006 while stationed in Alaska.  

The panel first considered if the depression due to chronic pain condition, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The condition was considered to fail retention standards, implicated by the NARSUM and the commander’s statement, and profiled. Panel members agreed the evidence reasonably justified that the functional limitations of the condition contributed to the CI’s inability to perform her military duties and was separately unfitting.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic bilateral flank pain and associated depression conditions 20%, analogously coded as 5003 (degenerative arthritis), citing the depression could not be separately rated due to pyramiding.  The VA rated the mental health condition 30%, code 9434 (major depressive disorder), based on the C&P examination, citing occupational and social impairment with occupational decrease in work efficiency and intermittent periods of inability to perform occupational tasks.  The panel noted that multiple treatment notes and the NARSUM and VA evaluations documented depression secondary to chronic pain.  Panel member agreed that IAW VASRD §4.126 (d) the chronic pain and depression conditions resulted in a single disability and that the dominant aspect of the condition was the chronic bilateral pain condition; therefore the depression cannot be rated separately due to pyramiding.  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 depression due to chronic pain condition.

BOARD FINDINGS:  In the matter of the chronic bilateral flank pain attributed to papillary necrosis and associated depression condition and IAW VASRD §4.71a, 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 that there be 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 20170222, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record

AR20180004938, XXXXXXXXXXXXXXXXXX 

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found your separation disability rating and your separation from the Army for disability with severance pay to be accurate.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed), and I accept its recommendation.  I regret to inform you that your application to the DoD PDBR is denied.  

	This decision is final.  Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction.

Sincerely,					      
Enclosure