RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-02889
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20070110

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E7, M1 Armor Crewman, medically separated from the Temporary Disability Retired List (TDRL) for “aplastic anemia” and “antiphospholipid syndrome” rated 20% and 0%, respectively, with a combined  disability rating of 20%.

CI CONTENTION:  The conditions continue to worsen.  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 - 20061205	VARD - NA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Aplastic Anemia	7716-5099-5002	20%	No VA Examination Proximate to TDRL Removal in Evidence	
Antiphospholipid Syndrome	7199-7120	0%		
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:

Aplastic Anemia.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI underwent treatment for his condition of aplastic anemia, which included a bone marrow transplant.  He developed graft versus host disease (GVHD) shortly after in August 2004.  The CI was placed on the TDRL on 1 August 2003.  

The 16 August 2005 interim TDRL hematology re-evaluation noted complaints of chronic mild fatigue and constant generalized pain.  There was no fever, chills, weight loss or weight gain.  On examination, the CI appeared healthy.  However, he had dry skin and the general look of fatigue.  Laboratory results demonstrated normal white blood cell (WBC), differential and platelet counts.  Hemoglobin was 12.8 grams per deciliter (g/dL).  The hematologist reported the CI was generally doing very well, with a minimum of GVHD (dry skin, but no eye, liver, GI issues at present).  There was a very mild anemia present.  

At the 26 September 2006 TDRL hematology re-evaluation, 4 months prior to TDRL removal, the CI complained of constant bothersome pain and feeling tired, but denied fever, chills or recent weight loss or gain.  Physical examination showed the CI was generally healthy appearing. However, he had dry skin and the general look of fatigue.  There was modest erythema with some ulcers in the mouth.  Laboratory results revealed normal WBC, differential and platelet counts.  The hematologist stated the CI’s condition of aplastic anemia was in remission with a very mild anemia.  He had chronic GVHD of the oral mucosa and to a lesser degree his skin.  He had chronic muscle aches and pain, which were not an uncommon finding after treatment for aplastic anemia.  The hematologist also noted the CI had recently received outpatient treatment for community acquired pneumonia (CAP) and completed a 10 day course of Avelox (moxifloxcin).  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the aplastic anemia 20%, dual coded 7716-5099-5002 (aplastic anemia-arthritis rheumatoid).  VASRD code 7700 (anemia) was also considered.  The panel noted the CI’s blood parameters were relatively stable over the past year without the need for hospitalizations or transfusions.  The TDRL hematologist noted the CI had recently completed a 10-day course of Avelox for CAP, which does meet the criteria for 30% IAW VASRD code 7716.   

The panel noted the PEB coded the CI’s disability as 7716-5099-5002 and the first line in the disability description stated, “GVHD following bone marrow transplant in treatment of aplastic anemia, with oral and cutaneous involvement, arthralgias.”  The panel majority noted the primary underlying disease process of aplastic anemia with the particularly interdependent nature of the treatment and residuals of the disease course of this complex case, as indicated by the PEB on the DA 199.  The coding should have been changed to 5099-5002-7716 to more accurately reflect the CI’s disease process.  

The panel majority noted the TDRL examiners report of infections associated with the CI’s disease process of aplastic anemia and with documentation of his most recent treatment, which is IAW with the criteria of VASRD code 7716 for a 30% rating, for infections occurring at least once per year but less than once every 3 months.  Briefly, his post-transplant course was complicated by CMV (cytomegalovirus) antigenemia, which was treated and resolved.  (Note:  He underwent bone marrow transplant in August 2004.)  He also had post-transplant lymphoproliferative disorder with a right tonsillar lesion resected in January 2005, EBV-positive, for which he was treated with rituxan times four weekly doses.  In June 2005, he was noted to have cavitating nodules on CT scan and was treated with voriconazole.  Since the last visit to the hematology clinic in 2005, he had an FUO (fever of unknown origin) admission (no source found by report) and recent outpatient treatment for CAP (avelox).  The panel also, considered additional evidence for insight into the severity of the CI’s disability.  During the TDRL psychiatric examination, dated 6 February 2006, the CI "stated that he continues to be very active both with his family and children, at work in the Post Office, and recreationally hunting and fishing.”  After due deliberation, considering the totality of the evidence and mindful of VASRD §4.3 (reasonable doubt) and VASRD 4.79 (the higher of two evaluations), the panel recommends a disability rating of 30% for infections occurring at least once per year but less than once every 3 months for the CI’s condition of aplastic anemia, coded 7716.  

Antiphospholipid Syndrome.  According to the STR and MEB NARSUM, the CI’s antiphospholipid syndrome (immune system attacks normal blood proteins) began in January 2005 after experiencing a severe pulmonary embolism.  Coumadin was prescribed following his pulmonary embolism.  

At the 15 July 2005 C&P examination, 18 months prior to TDRL removal, the CI reported shortness of breath with full exertion.  He reported no shortness of breath at rest nor a history of chest pain or symptoms of claudication.  The last blood transfusion was May 2005, where he received two units of packed red cells.  Physical examination showed no evidence of active bleeding to include the nose.  Sclera was white.  Pulmonary examination was normal.  Laboratory values reported a WBC count of 8,800 per microliter and 14.1 grams per deciliter, but there was no platelet count recorded.  (Note, the mean platelet volume was recorded, but no platelet count.)  WBC count and hemoglobin was within normal limits (WNL).  

During the 16 August 2005 interim TDRL hematology re-evaluation, the CI reported no pulmonary symptoms.  Physical examination revealed the sclera was normal without discoloration or injection.  There was no evidence of gum bleeding and the pulmonary and extremity examinations were WNL.  Skin was noted as dry, but no report of ecchymoses was noted.  Laboratory values reported a WBC count of 6,300 per microliter, 12.8 grams per deciliter and 205,000 platelets per microliter of blood.  The hematologist reported the CI’s WBC and platelet count was WNL.  He had a very mild anemia.  The hematologist noted the CI had a coumadin requirement.  No additional evidence of a thromboembolic event was cited by the hematologist while the CI was anticoagulated.  

At the 26 September 2006 TDRL hematology examination, 4 months prior to TDRL removal, the CI reported no pulmonary symptoms and reported no tendency for easy bleeding or bruising.  Physical examination revealed no evidence of bleeding, bruising or gingival hemorrhaging.  There was no localized joint swelling and no bone pain.  Skin demonstrated some diffuse, small ecchymoses that was defined as less than one centimeter.  Laboratory values reported a WBC of 6,300 per microliter, 12.8 grams per deciliter and 205,000 platelets per microliter of blood.  The hematologist noted that the CI had a serious clot and was therefore in need of lifelong anticoagulation, given lupus anticoagulant positivity.  There was no additional evidence of pulmonary embolism following treatment cited by the hematologist.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the antiphospholipid syndrome 0%, analogously coded 7199-7120 (varicose veins), citing chronic anticoagulation therapy required, with no embolic event in prior year.  The panel noted no evidence of thromboembolic events during anticoagulant therapy.  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 antiphospholipid syndrome.  

BOARD FINDINGS:  In the matter of the aplastic anemia, the panel majority recommends a disability rating of 30%, coded 7716 IAW VASRD §4.117.  The single voter for dissent submitted the appended minority opinion.  In the matter of the antiphospholipid syndrome, and IAW VASRD §4.104, 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	
Graft versus Host Disease following Bone Marrow Transplant in Treatment of Aplastic Anemia	7716	30%	
Antiphospholipid Syndrome	7199-7120	0%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170425, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record

Minority Opinion.  The aplastic anemia was in remission at the time of removal from the TDRL, and the hematologist indicated the condition that might render the CI unfit was the GVHD.  Basically, the CI was successfully treated for his anemia, but the treatment and results thereof caused him to still be unfit at the time of removal from the TDRL (not the anemia).  The PEB correctly adjudicated this once it was proposed (albeit somewhat unclearly) by the hematology TDRL examination.  This mindset and reality was reflected in the PEB report description of condition (“Graft Versus Host Disease Following Bone Marrow Transplant in Treatment of Aplastic Anemia, with Oral and Cutaneous Involvement, Arthralgias”).  It is also made clear by the coding choice of the PEB, 7716-5099-5002, which means that aplastic anemia (7716) was the source for the unfitting GVHD (analogized to 5002, rheumatoid arthritis).  Therefore, the unfitting condition was the side-effect (GVHD) of the successful treatment of the aplastic anemia.  Coding analogous to 5002 only supports a 20% rating, because there was no evidence of more than one or two exacerbations in a year of the unfitting GVHD (basically looking for evidence of exacerbations of pain and arthralgias).  The CI was gainfully employed and enjoying a reasonably active lifestyle, including recreation involving hunting and fishing.  While not indicative of the severity of the condition at the time of removal, the CI was still in remission for aplastic anemia at least six years after removal from TDRL.

The majority errs by turning that protocol on its head, and tries to say (by VASRD disability coding protocol) that the GVHD caused the aplastic anemia, which is clearly not the case.  In this case, the successful treatment of aplastic anemia led to GVHD, which caused the pain and arthralgias.  Furthermore, the majority makes an additional error, in that if the aplastic anemia is unfitting, then the GVHD must also be separately rated as an unfitting condition, because the main complaint was the pain from the GVHD.  For that matter, the infection listed by the majority to support the 30% rating was attributable to the treatment (immune suppression for the GVHD, the new bone marrow cells rejecting the cells of the body).  Any immune suppression for aplastic anemia had ceased prior to the bone marrow transplant. 

Aplastic anemia was in remission (essentially cured), and the major complaint at the time of removal from the TDRL was the GVHD (the effects of successful treatment for the anemia).  The minority recommends no change to the disability rating adjudicated by the PEB.

AR20180008792, 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