RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-03203
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050103

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, M1 Armor Crewman, medically separated for “atypical chest pain” and “sleep apnea,” rated 0% each, with a combined disability rating of 0%. 

CI CONTENTION:  Review requested for sleep apnea and an additional condition not identified by the Medical Evaluation Board (MEB) and Physical Evaluation Board (PEB).  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 PEB to be unfitting for continued military service, and when specifically requested by the CI, those conditions identified by the 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 - 20041102	VARD - 20050128	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Atypical Chest Pain	5099-5003	0%	Disability Manifested by Chest Pain	7099-7005	NSC	20050105	
Sleep Apnea	6847	0%	Sleep Apnea	6847	50%	20050105	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  60% 	

ANALYSIS SUMMARY:  

Atypical Chest Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI had a multi-year history of atypical chest pain, which involved the left chest and frequent evaluations.   A clinical dietetics note on 30 April 2003 also indicated a history of hypertension, GERD, and hyperlipidemia, for which he took medications; and obstructive sleep apnea (OSA), and obesity.  He used a continuous positive airway pressure (CPAP) device and was on a weight loss program.  
At an internal medicine appointment on 23 July 2003, the provider noted the CI was doing better with the medications and the non-cardiac chest pain was controlled with a nonsteroidal anti-inflammatory drug (Daypro).  On 21 January 2004, the CI reported a long history of intermittent sternal, substernal, and left anterior chest pain that was both exertional and non-exertional.  Daypro seemed to be irritating and was changed to Mobic.  An echocardiogram on 27 January 2004 revealed moderate pulmonic hypertension, mild mitral regurgitation, mild concentric left ventricular hypertrophy, and an estimated left ventricular ejection fraction of 50-55%; an increased dose of a hypertensive agent was added to the treatment protocol.  Chest X-rays on 28 April 2004 indicated no acute cardiopulmonary process. 

During the 28 April 2004 MEB examination (recorded on DD Forms 2807-1 and 2808), 8 months prior to separation, the CI reported having chest pain for the past 2 years.  Physical examination revealed no checks in the clinical evaluation, but chronic chest pain was listed in the summary of defects and diagnoses. A nuclear medicine stress test on 4 June 2004 showed minimal redistribution present within the high lateral wall, and no significant ischemia, although equivocal ischemia was seen on quantitative images.  The CI achieved a metabolic equivalent (MET) of 9.8 without significant EKG changes, but discontinued testing due to fatigue.  On 20 July 2004, a cardiologist indicated the stress test did not represent ischemia and weight loss was recommended.  

The 22 October 2004 MEB NARSUM examination, 2 months before separation, recorded CI complaints of sharp chest pain.  The provider noted he was alert and oriented times three and had a conjugate gaze (paired eye movement) as well as regular heart rate/rhythm and clear lungs.  The abdomen was soft and the cranial nerves were intact with no focal neurological signs. 

At the 5 January 2005 VA Compensation and Pension (C&P) examination, 2 days after separation, the CI was measured at 75 inches and 293 pounds.  There was no adenopathy of the neck and the thyroid was non-palpable.  The chest was clear to auscultation and the heart had a regular rate and rhythm with no murmurs or bruits; pulses were intact and there was no pedal edema.  The abdomen was soft and nontender without any organomegaly.  Hyperpigmented macules were in the center of the chest extending to below the nipple line.  The remainder of examination findings were normal and the provider did not address the chest pain in his impression.

Post-separation, the CI was seen in the VA emergency room on 4 August 2005, 7 months after separation, with worsened chest pain associated with shortness of breath, lightheadedness and dizziness.  A chest X-ray revealed an incidental finding of a right infrahilar abnormality, and a CT scan demonstrated a large, bulky, subcarinal and right hilar adenopathy.  Another CT scan on 17 September 2005 indicated a possible sarcoid, and a bronchoscopy on 29 November 2005 confirmed the diagnosis of sarcoidosis histologically marked by submucosal granulomatous inflammation of the right middle lobe and granulomatous inflammation of the right lower lobe; treatment, to include a steroid, was scheduled.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the chest pain 0%, analogously coded 5099-5003 (arthritis, degenerative), citing slight and occasional pain in accordance with the US Army Physical Disability Agency pain policy.   The VA did not service-connect “disability manifested by chest pain” based on the STR and C&P examination, citing no diagnosis.  Members noted the CI had non-cardiac chest pain for years with no diagnosis until the post-separation discovery of sarcoidosis.  Evaluation prior to separation did not identify any pulmonary findings, although the CI discontinued a stress test due to fatigue, but achieved 9.8 METs.  Thus, although the CI had a non-cardiac chest pain etiology including pulmonary hypertension while in service, a 10% rating using code 7099-7005, which calls for a “workload of greater than 7 METs but not greater than 10 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; continuous medication required,” is reasonable.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for non-cardiac chest pain, coded 7099-7005.  

Sleep Apnea.  According to the STR and MEB NARSUM, the CI’s sleep apnea began in early 2002.  A sleep study (polysomnogram) on 16 June 2002 showed OSA with a respiratory disturbance index of 8.4 events per hour.  A repeat sleep study showed the CPAP device required a minimum of 11 cm of water to adequately limit apneas and hypopneas.  Occasional episodes of insomnia were treated with an anti-depressant.  The 16 August 2004 commander’s statement indicated the CI was physically incapable of performing his duties as a tank crewman due to his sleep apnea and CPAP use which precluded him from field duty.  An STR entry on 27 April 2004 noted that the CI was unable to pass his physical fitness test and the examiner had doubts about CPAP used during deployment.  

At the MEB examination, the CI reported sleep apnea for the past 1½ years.  Physical examination showed the CI’s height to be 73 inches and his weight at 298 pounds, with blood pressure of 155/90.  Nothing was checked as abnormal on clinical evaluation; however, sleep apnea was listed as a significant or disqualifying defect.  A cardiology note on 20 July 2004 indicated that based on stress testing and an echocardiogram, pulmonary hypertension was found, which the examiner believed was a consequence of the sleep apnea.  

The 29 September 2004 MEB NARSUM examination, 2 months before separation, noted a diagnosis of sleep apnea and complaints of problems with sleeping during the day.  Physical examination showed the CI to be alert and oriented times three with a conjugate gaze.  No jugular venous distension was present, heart rhythm and rate were regular, the lungs were clear, and the abdomen was soft.  Cranial nerves were intact and the CI moved all of his extremities.  A P3 profile was issued in October 2004 for sleep apnea with required access to CPAP at all times.

At the C&P examination, the CI reported sleep apnea.  The provider noted dentition intact, clear oral mucosa, no neck adenopathy, and a normal thyroid.  The chest was clear to auscultation and the heart had a regular rate and rhythm without any murmur or bruits.  Peripheral pulses were intact and there was no pedal edema.  The remainder of the examination was within normal limits and the impression was OSA with CPAP use, secondary to obesity and likely to improve with weight loss.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the sleep apnea 0%, coded 6847 (sleep apnea syndromes), citing “requirements for maintenance and electric power prevent operation outside a garrison/home environment… rated IAW DoDI 1332.39 para E2.A1.2.21.”  The VA rated the sleep apnea 50%, also coded 6847, based on the C&P examination, citing required CPAP use.  The panel noted that the CI’s requirements for CPAP availability at all times with a source of electricity were unlikely to be met in the field or in combat conditions as a tank crew member.  Therefore, the panel agreed that that a 50% rating was warranted, but a higher rating was not indicated in the absence of “chronic respiratory failure with carbon dioxide retention or cor pulmonale, or…tracheostomy.”  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 50% for the sleep apnea, coded 6847.  

BOARD FINDINGS:  In the matter of the non-cardiac chest pain, the panel recommends a disability rating of 10%, coded 7099-7005 IAW VASRD §4.104.  In the matter of the sleep apnea condition, the panel recommends a disability rating of 50%, coded 6847 IAW VASRD §4.97.  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	
Non-Cardiac Chest Pain	7099-7005	10%	
Sleep Apnea	6847	50%	
COMBINED	60%	

The following documentary evidence was considered:

AR20180012271, 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 60% 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.

Enclosure