RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-01799
BRANCH OF SERVICE:  army 	SEPARATION DATE:  20070115

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Land Combat Electronic Missile System Repairer, medically separated from the Temporary Disability Retired List (TDRL) for “right (dominant) upper extremity paresthesias and pain” with a disability rating of 0%.

CI CONTENTION:  The VA gave her a higher rating.  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 - 20070115	VARD - NA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right (Dominant) Upper Extremity Paresthesias and Pain	8599-8513	0%	No VA Examination Proximate to Separation in Evidence	
Chronic Hepatitis C	Not Unfitting		
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:  

Right Upper Extremity (RUE) Paresthesias and Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI underwent a first rib resection on the right for thoracic outlet syndrome marked by terrible pain down her arm, numbness of the hands and neck pain in August 1998.  The condition worsened and multiple trials of occupational and physical therapy were unsuccessful.  On 15 January 2002, she was placed on the TDRL and remained on it for 5 years.  Although the CI had symptoms bilaterally, only the right (dominant) upper extremity is in the scope of review.  On 1 August 2006, she reported she was able to sleep through the night and no longer had neck pain.  However, she had pain with overhead use of the arm, especially if prolonged, or if she carried a heavy backpack for a period of time.  Her hand fell asleep if she weeded her yard for more than 20 minutes and symptoms were worse with stress.  Her hand typically appeared swollen in the morning.

The 1 August 2006 TDLR removal NARSUM examination performed by physical medicine, 5 months prior to TDRL removal, noted complaints of a history of thoracic outlet syndrome with right first cervical rib resection and pain with overhead use.  Physical examination showed a well-healed surgical scar near the base of the right neck.  There was mild tenderness to palpation in the proximal shoulder musculature bilaterally.  Shoulder abduction was to 165 degrees (normal 180) on the right and 175 degrees on the left.  Range of motion (ROM) was within normal limits for elbow flexion and extension, wrist extension and flexion, finger abduction, adduction, extension and flexion.  Muscle strength was 4/5 for shoulder abduction bilaterally, limited in part by a small amount of pain, otherwise upper extremity groups were 5/5.  Sensation was intact to light touch and pinprick.  Deep tendon reflexes were +2 in the biceps, triceps, and brachioradialis as well as at the patellar and Achilles tendons.  There was no clonus and there were negative Babinski’s (to determine a brain stem or spinal cord problem), Hoffman’s (a measure of spinal reflex processing), Adson’s (a provocative test for thoracic outlet syndrome) and Allen’s (to assess blood flow in the hand) tests.  Magnetic resonance imaging in 2005 showed no anatomic compromise of vasculature.  

There was no VA examination in evidence proximate to TDRL removal.  The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the RUE condition 0%, coded 8599-8513 (incomplete paralysis of all radicular groups), citing “rated as neuralgia, IAW para B-15 of AR 635-40.”  

Panel members noted the CI had pain with overhead use of the arm, especially if prolonged, or if she carried a heavy backpack for a period of time.  When she had pain, she rested her arm and used medication.  Furthermore, her hand fell asleep if she weeded her yard for more than 20 minutes and symptoms were worse with stress.  Muscle strength was 4/5 for shoulder abduction bilaterally, limited in part by a small amount of pain.  Although her condition improved since TDRL placement, nevertheless, she still had mild symptoms with overhead use, pain, and numbness as well as decreased strength for abduction of the shoulder, although the remainder of the upper extremity group of muscles were normal.  Therefore, a 20% rating is reasonable, since a 0% rating would indicate there were no symptoms, which was not the case.  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 right upper extremity paresthesias and pain condition, coded 8599-8513.  

Contended PEB Condition:  Chronic Hepatitis C.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended condition was not unfitting.  The CI was evaluated on 14 August 2006 in the gastroenterology clinic where the CI indicated she did not have further tests for hepatitis C since an initial liver biopsy years earlier, which showed mild chronic active hepatitis C with minimal disruption of the delaminating plate and minimal piecemeal necrosis. She also had elevated liver enzymes and a positive hepatitis C PCR (polymerase chain reaction) test in the past and failed 48 weeks of treatment with Rebetron (interferon alfa-2b and ribavirin) prior to separation in 2001.  She admitted to “drinking again” with heavy alcohol use.  She did not want to undertake any therapy for the hepatitis C since she did not want to experience side effects while in school.  She had no jaundice, malaise, fatigue or abdominal pain.  Examination of the abdomen was normal on visual inspection and auscultation and palpation revealed no abnormalities.  The liver, spleen and gallbladder were normal to palpation.  Liver function tests were within normal limits except for ALT at 49 (normal 0-48).  Glucose was 116 mg/dL (normal 70-115) and chloride 109 (normal 98-107) were elevated and the complete blood count was normal.  In November 2002 ALT was 61, AST 40 (normal 14-36), and GGTP 116 (normal 8-78).  The examiner noted that based on his current assessment with the available information, he saw no evidence of progression of liver disease, although the only other way to make an accurate determination would be to have a liver biopsy.  The CI refused treatment of the hepatitis C due to school demands.  She was “otherwise functional and was completing a vigorous academic program.”  She drank alcohol and would not be treated while consuming it.  A liver biopsy was planned and laboratory studies for HCV RNA by PCR, hepatitis A, B, C panel, genotype of HCV, and protime; however, there were no results in the STR.

The CI still had hepatitis C, which was considered to have failed after treatment with Rebetron, although only the AST was elevated very slightly at TDRL removal compared to elevations of the AST and GGTP.  Therefore, members felt that the CI was still unfit, since she did not have a current liver biopsy, viral titers, genotyping of the hepatitis C or recent treatment.  After due deliberation, the panel agreed that the preponderance of evidence with regard to the functional impairment of the chronic hepatitis C condition favors its recommendation as an additionally unfitting condition for disability rating.  It is appropriately coded 7354 and meets the VASRD §4.114 criteria for a 0% rating since she was not symptomatic.  A rating of 10% or higher was not warranted in the absence of any reporting of “intermittent fatigue, malaise, and anorexia, or; incapacitating episodes (with symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain) having a total duration of at least one week, but less than two weeks, during the past 12-month period.”

BOARD FINDINGS:  In the matter of the RUE condition, the panel recommends a disability rating of 20%, coded 8599-8513 IAW VASRD §4.124a.  In the matter of the contended chronic hepatitis C condition, the panel agrees that it was unfitting and recommends a disability rating of 0%, coded 7354, 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, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Right (Dominant) Upper Extremity Paresthesias and Pain	8599-8513	20%	
Chronic Hepatitis C	7354	0%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170303, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record

AR20180008177, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found that your disability rating should be modified but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed) and I accept its recommendation.  This will not result in any change to your separation document or the amount of severance pay.  A copy of this decision will be filed with your Physical Evaluation Board records.  I regret that the facts of the case did not provide you with the outcome you may have desired.
  
	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. 

	A copy of this decision has also been provided to the Department of Veterans Affairs. 

Sincerely,					      
Enclosure