RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-02926
BRANCH OF SERVICE:  ARMY 	SEPARATION DATE:  20080308

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Air Defense C41 Tactical Operations Center Enhanced Operator/Maintainer, medically separated for “recurrent pre-syncopal attacks manifested by dizziness…without full syncope” with a disability rating of 10%.  

CI CONTENTION:  She was evaluated as having pre-syncopal episodes, but before the determination was made, she began having full syncopal episodes which are documented in her medical records.  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 - 20080116	VARD - 20080331	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Recurrent Pre-Syncopal Attacks	8299-8210	10%	Syncopal Episodes, Episodic	6299-6204	10%	20080207	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Recurrent Pre-Syncopal Attacks.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI first experienced exertional pre-syncopal symptoms in early training which escalated in late 2005.  The STR did not verify any loss of consciousness (syncope) with these episodes, and there was no record of any emergency department visits or hospital admissions.  The episodes were characterized as brief and self-limited, and usually, but not always, exertional (confined to sit-ups at onset).  There were no vestibular symptoms (vertigo, disequilibrium, ataxia, etc.), seizure features or any other acute associated symptoms, except for an occasional note of nausea and vomiting.  After multiple evaluation, there were no positive neurologic, vestibular or cardiovascular findings, and a thorough work-up (cardiac imaging, stress test, Holter monitor, etc.) was negative except for a positive tilt table test.  The suspected etiology was neurocardiogenic dysfunction and there was no improvement with various medication trial.  An STR clinical entry in June 2007 documented the frequency of these episodes as “weekly,” but a cardiology note 10 weeks later described them as “nearly daily.” 

The 14 December 2007 MEB NARSUM examination, 3 months prior to separation, characterized the episodes as “lightheadedness, faintness, associated with nausea and vomiting … initiated by physical exertion … worsened over time, occurring more frequently and with less exertion … last for less than 1 minute usually and can be brought on by light activity.”  A comprehensive physical examination was normal and the examiner diagnosed “pre-syncope (vasovagal, cardioinhibitory type).”  There was no evidence in the available STR from the interval between the NARSUM and separation with no corroboration of CI’s contention.  

At the 7 February 2008 VA Compensation and Pension (C&P) evaluation, 1 month before separation, the CI reported “syncopal” episodes, one of which resulted in her passing out while running and being transported by ambulance to an emergency room (timing not clarified).  The examiner stated, “Every time that she does strenuous activity she develops syncopal episodes” (frequency not specified).  While orthostatic vital signs were documented, there was no evidence of pre-syncopal or syncopal episodes during the examination, and neurologic findings were normal (no ataxia, nystagmus, etc.).  A provocative test (Barany) elicited “mild dizziness without vertigo, and the diagnosis was “syncopal episodes, episodic.”

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the recurrent pre-syncopal condition 10%, analogously coded 8299-8210 (incomplete paralysis of vagus nerve) citing the applicable “moderate” VASRD criterion.  The VA rated the syncopal episodes 10%, analogously coded 6299-6204 (peripheral vestibular disorders), based on the C&P evaluation, and citing occasional dizziness.  Panel members first weighed the probative value of the STR versus C&P evidence (and CI contention) regarding whether the rated episodes were transient pre-syncope or full syncope, and agreed that the preponderance of the evidence and clinical data suggested that pre-syncope was the dominant presentation, although occasional transient full syncope could not be excluded.  The panel further agreed that the distinction did not pose a significant influence on rating, given the brief and self-limited nature of the episodes and VASRD coding limitations.  

The VASRD does not offer a code specific for syncope or pre-syncope.  Although the etiology of the CI’s episodes was not definite, it was most consistent with vagus-mediated neurocardiogenic dysfunction, making code 8210 a reasonable choice for analogous rating.  Members agreed the disability in evidence was more reasonably characterized as moderate (10%) rather than severe (30%).  While code 6204 offers a 30% rating for “dizziness and occasional staggering,” it also requires objective findings related to the diagnosis of vestibular disequilibrium, which was not supported by the STR or C&P evidence.  The panel considered analogously coding to 8108 (narcolepsy) or 8911 (petit mal epilepsy), but these default to the VASRD §4.124a general seizure formula and would entail rating the pre-syncopal (or brief self-limited syncopal) episodes as equivalent to minor seizures.  Members ultimately agreed, however, that analogous rating as seizures in pursuit of a higher rating was not sufficiently justified by either VASRD §4.7 (higher of two evaluations) or §4.20 (analogous ratings).  The clinical features were well aligned with the PEB code, and the disability was not functionally analogous to that which would be suffered with minor seizures of the same frequency.  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 recurrent pre-syncopal attacks.

BOARD FINDINGS:  In the matter of the recurrent pre-syncopal attacks and IAW VASRD §4.124a, 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 20170424, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20180006150, 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