RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-03525
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20090227

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Carpentry/Masonry Specialist, medically separated for “recurrent episodes of syncope and near syncope” with a disability rating of 20%.

CI CONTENTION:  “Review all conditions.”  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 conditions 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 - 20081117	VARD - 20100629	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Recurrent Episodes of Syncope 	8999-8911	20%	Idiopathic Syncope	6299-6204	30%	20100602	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Recurrent Syncope.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), this condition first manifested as an episode of non-specific dizziness followed by transient syncope while running during physical training in 2007.  Similar episodes continued to occur.  A thorough evaluation (including neuroimaging, cardiac imaging, heart monitoring and exercise stress test) excluded any specific cardiovascular, neurological or other etiology.  None of the ancillary studies identified a ratable criterion under any of the various codes in VASRD §4.104 (cardiovascular system).  

Clinical entries in the STR documented initial episodes triggered by exertion, but later occurred at rest.  Some involved transient syncope of a few seconds duration, while others were characterized as subjective near-syncope.  Some were witnessed and none were associated with seizure activity or stigmata.  The frequency was not precisely documented other than in cardiology notes about 6 months after onset that recorded “5-10 episodes” since onset.  The majority of STR entries (including all of the cardiology notes) characterized the episodes as non-specific transient syncope or near-syncope without any vestibular or neurologic features.  A few later entries, however, documented a request for a cane “to help maintain balance” with conflicting evidence for occasional falls and no mention of staggering.  One of these mentioned a specific complaint of vertigo, “feels like the room is spinning” without nausea, which occurred daily but lasted only “a few minutes.”  There were multiple neurologic examinations in evidence that corroborated the absence of any objective abnormal vestibular findings (no nystagmus [jerky eye movements from vestibular dysfunction], normal balance and gait, and normal coordination).  There was no STR evidence for any positive vestibular findings.  

The 28 August 2008 MEB NARSUM examination, 6 months prior to separation, documented dizziness described as loss of balance and darkening of vision rather than true vertigo.  Episodes occurred three to four times a week at rest.  Sometimes he had dizziness without loss of consciousness, but with some episodes he lost consciousness.  However, he returned promptly to a normal state of consciousness within a few seconds.  The physical examination was normal, specifically recording the absence of nystagmus, a normal gait, a negative Romberg (normal balance challenged with eyes closed), and normal heel-to-toe walking (very sensitive for vestibular function).  The NARSUM diagnosis was “recurrent episodes of syncope and near syncope of undetermined origin.”  Clinical STR entries in the interval between the NARSUM and separation documented normal gait and other normal neurologic findings, without note of any vestibular symptoms or falls.

The earliest VA Compensation and Pension (C&P) evaluation was conducted 2 June 2010, 16 months after separation, and was thus of limited probative value temporally.  It documented that the CI continued to use a cane for balance (although not with him at examination), but specified that the falls had resolved and did not record a history or observation of staggering.  The examiner noted a non-specific complaint of “dizziness 1-2 times a day” and opined that the condition had stabilized without any current treatment or flares.  The physical examination recorded normal eye movements, normal tandem gait, good motor control and a negative Romberg.  The C&P diagnosis was “idiopathic syncope.”

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the syncope/near-syncope condition 20%, coded 8999-8911 (analogous to petit mal epilepsy).  The 20% criterion for minor seizures under code 8911 is “at least 2 minor seizures in the last 6 months,” and the 40% criterion is “averaging at least 5 to 8 minor seizures weekly.”  The PEB referenced the NARSUM frequency (3-4 per week), noted that not all the events were associated with loss of consciousness and stated, “Rated as having less than 5 syncopal episodes daily.”  The VA rated the condition 30%, coded 6299-6204 (analogous to peripheral vestibular disorders), referencing the C&P evidence and citing the applicable criterion of “dizziness with occasional staggering,” which is the highest rating offered by code 6204, which confers 10% for “occasional dizziness.”

The VASRD does not offer a code specific to syncope or near-syncope, and analogous coding based on the predominant impairment is required.  A specific etiology for the CI’s episodes was not ascertained.  The evidence established that they were very transient, sometimes resulting in LOC and sometimes not.  There was less consistent evidence for an overlay of vestibular symptoms involving balance, and only a single mention of symptomatic vertigo (also of very brief duration).  The PEB’s analogous code was aligned with the more conclusive evidence that was equivalent to transient episodes of syncope or near-syncope, and that was consistent with both the NARSUM and C&P diagnoses.  The VA’s analogous code was dependent on the vestibular overlay gleaned from the evidence.  The panel nevertheless conceded that the latitude offered under VASRD §4.20 (analogous ratings) would justify the VA coding choice.  The only other analogous coding options that might be considered in this case were 8199-8108 (analogous to narcolepsy), moot to the panel’s recommendation since it defaults to the same criteria as code 8911; and,  8299-8210 (analogous to incomplete paralysis of vagus nerve), rating as equivalent to vasovagal syncope (10% for “moderate” and 30% for “severe” disability).  Members agreed that the latter was neither aligned with the clinical evidence, nor favorable, since severe disability was not justified by the functional impairment in evidence.  As noted above, no favorable rating under any of the VASRD cardiovascular codes was achievable, nor were any justified as a clinical diagnosis.

The panel thus deliberated whether the PEB code (8999-8911) or the VA code (6299-6204) was the more applicable and fair option in this case.  Panel members noted that a significant barrier to opting for code 6204 was its qualifying note, “objective findings supporting the diagnosis of vestibular disequilibrium are required before a compensable evaluation can be assigned under this code.”  There was no evidence for such objective findings and there was ample evidence refuting the presence of such findings.  Furthermore, even if it were conceded that the note stipulation could be bypassed under the latitude of analogous rating, members agreed that the 30% criterion of “staggering” was not in evidence.  Although the CI used a cane for balance based on subjective disequilibrium, there was ample evidence that his gait was steady; there was no objective evidence for, or stated history of, staggering; and, the inconsistent history of falls was not an active complaint at the time of separation.  Conversely, members agreed that code 8911 was an easily rationalized analogous choice for transient syncope akin to the disability due to transient petit mal seizures.

Having agreed that the most applicable and defensible coding option was 8999-8911, members deliberated whether the 40% rating (as per above criteria) could be supported.  The PEB’s decision made it clear that loss of consciousness (LOC) was its analogous marker for a ratable event, but if all events were considered ratable it could be argued that the frequency was closer to (although still not meeting) the minimum criteria for a 40% rating than to those for 20%.  Members agreed, however, that, given the very transient nature of the episodes and the significant concession required to equate any of them with a seizure event, it was quite reasonable to require at least LOC for determining the frequency of ratable events.  The PEB’s 20% determination was thus fair IAW the VASRD coding options and criteria.  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 of the recurrent syncope or near-syncope.

BOARD FINDINGS:  In the matter of the recurrent syncope, 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 20170404, w/atchs
Exhibit B.  Service Treatment Records
Exhibit C.  Department of Veterans Affairs Record

AR20180009128, 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