SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD 20762

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Dear XXXXXXXXXX:

		Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2017-03603.

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.

							

	RECORD OF PROCEEDINGS
	PHYSICAL DISABILITY BOARD OF REVIEW
NAME:  XXXXXXXXXX	CASE: PD-2017-03603
BRANCH OF SERVICE: AIR FORCE	SEPARATION DATE: 20070625

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Communications Signals Intelligence Craftsman, medically separated for “idiopathic anaphylaxis with a history of four episodes” with a disability rating of 10%.

CI CONTENTION:  “Please 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 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 – 20070504	VARD - NA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Idiopathic Anaphylaxis	7199-7118	10%	

No VA Examination Proximate to Separation in Evidence	
Asthma	Cat II		
Allergic Rhinitis	Cat II		
Migraine Headaches	Cat II		
Hymenoptera Allergy	Cat III		
Food Allergies	Cat III		
COMBINED RATING: 10%	COMBINED RATING OF ALL VA CONDITIONS: NA	

ANALYSIS SUMMARY:

Idiopathic  Anaphylaxis  (serious,  life-threatening allergic reaction).	According  to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI reported being allergic to

Brazil nuts and shell fish both of which required emergency room (ER) visits. The CI also reported requiring ER treatment with epinephrine shots and nebulizer therapy after being stung by a yellow jacket on the left wrist.  The dates of these ER visits were not documented.

The CI was seen by an allergy clinic on 2 November 2006 due to a possible allergic component to her asthma (see below). She experienced an anaphylactic reaction immediately after a skin prick test and intradermal allergen placement (diluted allergen is injected into the skin) for evaluation of allergic rhinitis. During allergy testing on 29 November 2006, the CI experienced a second anaphylatic reaction immediately following the final honeybee allergen extract was placed in the evaluation for hypersensitive hymenoptera (systemic allergic reaction to insect stings/venom). The CI responded to epinephrine administration (treatment for a life-threatening allergic reaction) on both aforementioned occasions. A presumptive diagnosis was made of mastocytosis (mast cells accumulate in the skin that can cause discoloration, blisters, hypotension (drop in blood pressure) or anaphylaxis). However, during a dermatology examination on 21 December 2006 no evidence was found of cutaneous (affecting the skin) mastocytosis. She was subsequently evaluated for systemic mastocytosis (mast cells accumulate in internal tissue or organs that can cause skin spots, hives, shortness of breath, or anaphylaxis). A diagnosis was not rendered because the CI did not have the required criteria, and had no further episodes of anaphylaxis; she was taught how to use an epinephrine pen for self-administration.

The 22 March 2007 MEB NARSUM examination, 3 months prior to separation, noted the complaint of a history of anaphylaxis. Physical examination showed stable vital signs and was otherwise unremarkable. The examiner noted the CI did not meet the criteria for systemic mastocytosis; however, she continued to be highly atopic with documented episodes of anaphylaxis secondary to food (Brazil nut), hymenoptera (insect venom allergy), and allergen skin testing. The CI’s elevated tryptase level (substance released by mast cells) was recommended to be followed yearly, to monitor possible early mastocytosis or other disorders to include myeloproliferative diseases (production of too many of one or more blood cell types). She was asymptomatic while on antihistamine medication and leukotriene receptor blockers (inhaled anti-inflammatory asthma medication) and had at least two epinephrine pens in case of anaphylaxis. She was also advised to avoid known triggers. There was no VA examination proximate to separation in evidence.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the idiopathic anaphylaxis condition 10%, analogously coded 7199-7118 (angioneurotic edema). Though another section of the PEB form listed a 20% rating, in February 2019 the Air Force PEB verified and confirmed the 10% rating. A 10% rating for 7118 requires “attacks without laryngeal involvement lasting 1 to 7 days and occurring two to four times a year.” Whereas, a 20% rating requires “attacks without laryngeal involvement lasting 1 to 7 days and occurring five to eight times a year, or, attacks with laryngeal involvement of any duration occurring once or twice a year.”

The panel noted that neither of the two anaphylactic episodes which occurred during allergy testing were associated with laryngeal involvement (sensation of throat closing). However, the three ER visits for anaphylaxis reported by the CI (Brazil nut, shellfish and yellow jacket sting) were associated with laryngeal involvement. However, in the absence of the ER records, the panel could not determine the ER visit dates and what treatment was rendered beyond epinephrine. Additionally, STR evidence did not record the CI’s requirement for intubation or hospitalization for laryngeal edema, spasm, or closure. Therefore, in the absence of supporting documentation, it would be speculative to assign a 20% rating using code 7199-7118. After due deliberation, considering all 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 idiopathic anaphylaxis condition.

Contended Category II Conditions: Asthma, Allergic Rhinitis, and Migraine Headaches. The panel’s main charge is to assess the fairness of the PEB determination that the contended Category II conditions (can be unfitting but are not currently compensable or ratable) were not unfitting.

Asthma. A temporary revised P4 profile was issued on 29 April 2004, 3 years prior to separation. Although it was unclear which condition was involved, asthma and Chiari malformation were specifically listed in the Individual Defect/Restrictions section. Therefore, asthma was a condition which contributed or may have contributed to make the CI unqualified for worldwide duty. In the 14 September 2006 MEB addendum, 10 months before separation, the CI was diagnosed with “asthma: severe persistent” per Army regulation. The examiner opined, “Symptoms are currently stable but could be exacerbated at any given time by environmental or physical triggers.” “The conclusion was the CI failed to meet retention criteria in accordance with Army Regulation 40- 501 paragraph 3-27a. That day, the CI was issued a permanent Army P3 profile for “asthma which is not currently under adequate control.”

On 26 October 2006, 8 months prior to separation, the CI was issued a temporary P4 profile with no specific medical conditions cited but with notes about the inability to move at least 2 miles with a fighting load due to inadequately controlled asthma. Restrictions included no 2-mile run and no walking, biking, or swimming. The examiner felt that given the failure to completely control symptoms over the past year, “the best course of action is to provide her with [a] permanent profile.” The 22 March 2007 MEB NARSUM stated, “The patient is currently controlled with inhaled corticosteroids, long-acting beta agonist [inhaled anti-inflammatory asthma medication] and as need[ed] short-acting beta-agonist therapy [inhaled bronchodilator therapy].” The examiner opined that the CI was asymptomatic and was using antihistamines. Her only functional limitation was a need to be near a medical facility in case of anaphylaxis because given her history, further anaphylactic episodes were unpredictable. The CI was given specific instructions on proper indications and use of the Epipens and avoidance of known triggers. The commander’s statement signed 2 April 2007, 3 months before separation, did not implicate a medical condition, but noted, “For what appears to be a variety and combination of medical factors, the [CI] has not met Air Force physical fitness standards for several years. I do not consider her world-wide deployable. My assessment of her current medical condition leads me to conclude that she will likely never be able to meet Air Force physical fitness standards and will never be medically or physically fit to serve as a fully functioning Airmen or to deploy.”

A 27 March 2007 MEB Report listed asthma, allergic rhinitis, food allergy, hymenoptera allergy, idiopathic anaphylaxis, and migraine headaches, but did not state which condition(s) failed to meet retention standards. The panel majority determined that there was not a preponderance of performance-based evidence to conclude that the asthma condition was unfitting. The last profile, issued by the Air Force, was designated a temporary profile. Air Force profiles do not list the medical condition(s) being profiled. The MEB NARSUM, issued by the Air Force, stated the CI was only limited in that she would need to be near a medical facility in case of anaphylaxis. The commander’s statement did not explicitly implicate which medical condition(s) caused the CI to fail Air Force physical standards and noted an inability for the CI to deploy. After extensive deliberation, the panel majority concluded there was insufficient cause to recommend a change in the PEB fitness determination for the contended asthma condition, so no additional disability ratings are recommended.

Allergic Rhinitis. On 2 November 2006 the CI complained of rhinitis symptoms (nasal congestion, itchy, watery eyes, postnasal drip, rhinorrhea, and cough) primarily from March to May and then from September to December. She tried Benadryl and Flonase (a nasal steroid spray) with minimal relief. She had a dog and two ferrets at home, but denied any symptoms around animals. She did note symptom exacerbation with fragrances and weather changes. Allergic rhinitis was confirmed by skin testing, which revealed hypersensitivities to oak tree, grasses, dust mites, and

cockroaches. She also tested positive for cat and dog antigens and had a mild anaphylactic reaction (see above). Because of her history of moderate to severe asthma, the CI was not a good candidate for aero-allergen immunotherapy. Treatment consisted of Allegra (an antihistamine), Singulair (an oral indirect-acting bronchodilator), Flonase, and saline rinses. Symptoms were much improved after initiation of the medications. There was no performance- based evidence from the record that allergic rhinitis condition significantly interfered with satisfactory duty performance at separation. After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determination for the contended allergic rhinitis condition, so no additional disability rating is recommended.

Migraine Headaches. There was no performance-based evidence from the record that the contended migraine headaches condition significantly interfered with satisfactory duty performance at separation. After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determination for the allergic rhinitis condition, so no additional disability rating is recommended.

Contended Category III Conditions: Hymenoptera Allergy and Food Allergies. The panel’s main charge is to assess the fairness of the PEB determination that the contended conditions (not separately unfitting and not compensable or ratable) were not unfitting. The panel noted that the hymenoptera allergy and food allergies were not separately unfitting, but contributed to the unfitting idiopathic anaphylaxis and to at least one episode of asthma. Once the CI avoided the allergens and received Epipens for immediate treatment, no additional episodes of anaphylaxis were reported. There was no performance-based evidence from the record that the hymenoptera allergy and food allergies significantly interfered with satisfactory duty performance at separation. After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determination for either of the contended conditions, so no additional disability ratings are recommended.

BOARD FINDINGS: In the matter of the idiopathic anaphylaxis condition, the panel recommends a disability rating of 10%, coded 7199-7118 IAW VASRD §4.104. In the matter of the contended asthma condition, the panel majority recommends no change from the PEB determinations as not unfitting. The single voter for dissent submitted the appended minority opinion. In the matter of the contended allergic rhinitis, migraine headaches, hymenoptera allergy, and food allergy conditions, the panel recommends no change from the PEB determinations as not unfitting. There are no other conditions within the panel’s scope of review for consideration. Therefore, the panel majority recommends no modification or re-characterization of the CI’s disability and separation determination.

Minority Opinion. Asthma is an unfitting condition and warrants a 30% rating. The panel majority felt the preponderance of evidence was insufficient to support an unfitting condition. However, the preponderance of evidence does not mean a greater mass of evidence; rather, preponderance means a superiority of evidence—the quality, not the quantity. (DoDI 1332.38 E2.1.26.) A factual finding that a service member is unfit because of physical disability depends on the evidence that is available to support that finding (DoDI 1332.38 E3.P3.6.). If a preponderance (that is, more than 50 percent) of the evidence indicates unfitness, a finding to that effect will be made. If, on the other hand, a preponderance of the evidence indicates fitness, the service member may not be separated or retired by reason of physical disability (DoDI 1332.38 E3.P3.6.2.).

The facts related to asthma are unequivocal. The CI was diagnosed with asthma and was prescribed Advair and then albuterol. Prior to a pulmonary clinic visit on 9 August 2006 she reported three ER visits for shortness of breath and wheezing. She felt that even a burst of steroids did not help the asthma. An MEB Addendum performed 14 September 2006, 9 months prior to separation, in the pulmonary clinic, noted complaints of shortness of breath, wheezing, and a cough with exercise. The examiner’s diagnosis was severe, persistent asthma and he felt she was functionally limited by being unable to pass a physical fitness test or participate in routine physical training. The examiner noted the CI “should not be assigned to a duty station without the availability of appropriate level of medical care – general internal medicine or family practice physicians available, emergency room and intensive care capabilities” and concluded the CI “fails to meet retention criteria in accordance with Army Regulation 40-501 paragraph 3-27a.” The minority voter is well aware that the CI was an enlisted member in the Air Force and that Army retention standards are not decisive in determination of fitness for Air Force personnel.   The   22 March 2007 NARSUM examination noted the CI’s asthma was controlled with inhaled corticosteroids (e.g. Advair (fluticasone component), a long-acting beta-agonist (e.g. Advair (salmeterol component), and as needed short-acting beta-agonist therapy (e.g. albuterol).

A temporary revised Air Force profile P4 was issued on 29 April 2004, although it was unclear which condition was involved, but asthma was specifically listed along with another condition. Asthma was a condition which contributed or may have contributed to make the qualifications of the individual for worldwide duty questionable; however in the MEB Addendum it was noted that the asthma failed the retention criteria of the Army and a permanent P3 profile was issued on 14 March 2006. Therefore, the minority voter notes the disparity between Army and Air Force examiners when it comes to her profile. However, the major problem the panel faced is the vague and silent position in the commander’s statement with regard to the CI being able to work in her Air Force specialty. On 30 October 2006 the commander wrote:  “For what appears to be a variety and combination of medical factors [she] has not met Air Force physical fitness standards for several years. As such, I do not consider her world-wide deployable. My assessment of her current medical condition leads me to believe she will never be able to meet Air Force physical fitness standards and will never be medically or physically fit to deploy.” An Informal PEB dated 11 December 2006 did in fact find the CI unfit for asthma and assigned a 10% rating. On 2 April 2007, the commander reiterated his statement and concluded she “will never be medically or physically fit to serve as a fully functioning Airman or to deploy.”

The issue in determination of this CI’s unfitness is directly related to the lack of specific reference to asthma in the commander’s statements. Clearly the medical record supports asthma as an unfitting condition, and more importantly, she was found to be unfit for the asthma by the first IPEB. The CI was taking a steroid/long-acting beta agonist medication and had not taken a physical fitness test for a long time nor was she training on a regular or consistent basis. While the exact details of her military specialty were not spelled out in the record, the commander’s reference that she “will never be medically or physically fit to serve as a fully functioning Airman or to deploy” implicitly, but clearly, points to the fact that she wasn’t and would not be doing the full spectrum of her military specialty duties.

Furthermore, the MEB Addendum examiner indicated her asthma did not meet Army retention standards, albeit those standards are not the same as Air Force standards, but the evidence for the unfitting nature of her asthma is strong and supported directly by quality medical documentation and medication usage as well as the implicit commander’s statement, which is the best evidence available to support her unfitting condition. Therefore, the underlying question is why the second IPEB dated 4 May 2007 removed asthma as an unfitting condition in view of document after document supporting the commander’s contention that the CI “will never be medically and physically fit to serve as a fully functioning Airman or deploy.”

The minority voter notes the panel’s main charge is to assess the fairness of the PEB’s determination that asthma was not unfitting. The panel’s threshold for countering fitness determinations requires a preponderance of evidence, but remains adherent to the DoDI 6040.44 “fair and equitable” standard. The minority voter contends without equivocation that based on the preponderance of evidence the threshold that the CI was unfit for asthma has been met; the “fair and equitable” standard has been achieved; and the benefit of the doubt goes to the CI IAW VASRD §4.3 (resolution of reasonable doubt) contrary to DoDI 1332.38 E3.P3.6.1 (Benefit of unresolved doubt shall be resolved in favor of the fitness of the service member under the rebuttable presumption that the member desires to be found fit for duty). The commander’s statements, along with the medical evidence, rebuts any notion that the CI desired to be found fit for duty. Furthermore, the fact that the initial IPEB found the CI unfit for asthma, while the second did not, speaks clearly and loudly that justice is warranted to make amends for the administrative imbroglio, where no justification for the 180 degree-turnaround was offered as the second IPEB’s focus shifted to the unfitting anaphylaxis. With asthma as a clear separately unfitting condition, the minority voter recommends a 30% rating.
The minority voter recommends the ROP be modified as follows:

After due deliberation, the panel agreed the preponderance of the evidence with regard to the functional impairment of asthma favors its recommendation as an additionally unfitting condition for disability rating. It is appropriately coded 6602 and meets the VASRD §4.97 criteria for a 30% rating, which stipulates “FEV-1 of 56- to 70-percent predicted, or; FEV-1/FVC of 56  to
70 percent, or; daily inhalational or oral bronchodilator therapy, or; inhalational anti- inflammatory medication.”

BOARD FINDINGS: In the matter of the idiopathic anaphylaxis condition and IAW VASRD §4.104, the panel recommends no change in the PEB adjudication. In the matter of the contended asthma condition, the panel agrees it was unfitting and recommends a disability rating of 30%, coded 6602 IAW VASRD §4.97. In the matter of the contended allergic rhinitis, migraine headaches, hymenoptera allergy and food allergies conditions, the panel recommends no change from the PEB determinations as not unfitting. 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	
Idiopathic Anaphylaxis	7199-7118	10%	
Asthma	6602	30%	
	COMBINED	40%