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Dear XXXXXXXXXX:

The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found that your disability rating should be modified but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed) and I accept its recommendation.  This will not result in any change to your separation document or the amount of severance pay.  A copy of this decision will be filed with your Physical Evaluation Board records.  I regret that the facts of the case did not provide you with the outcome you may have desired.
  
	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. 

	A copy of this decision has also been provided to the Department of Veterans Affairs and to the counsel you listed on your application, XXXXXXXXXX, 1700 Clairmont Road, Suite 1-305, Decatur, GA 30033.

RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXX	CASE:  PD-2017-03944
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20061022

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was a National Guard E4, Health Care Specialist, medically separated for “irritable bowel syndrome” with a disability rating of 10%.  “Migraine headaches” were determined to have existed prior to service (EPTS) and were not rated.  

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 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 - 20060928	VARD - 20070412	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Irritable Bowel Syndrome 	7319	10%	Irritable Bowel Syndrome	7319	10%	20070111	
Migraine Headaches	8100	EPTS	Migraine Headaches	8100	30%	20070111	
Chronic Pain, Left Wrist	Not Unfitting	Left Wrist Pain	5215	10%	20070111	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Irritable Bowel Syndrome (IBS).  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s IBS began in June 2005.  She was initially thought to have food poisoning, but her symptoms persisted despite treatment and dietary modifications.  An extensive evaluation including colonoscopy, radiographic studies and laboratory testing was negative.  She was then diagnosed with IBS.  At a gastroenterology evaluation on 16 March 2006, the CI reported 2-4 soft to diarrhea like bowel movements a day.  She denied systemic symptoms, such as fever or chills, and had a normal appetite.  

During the 18 July 2006 MEB examination (recorded on DD Forms 2807-1 and 2808), 3 months prior to separation, the CI reported abdominal pain.  The examination of the abdomen was unremarkable.  The 64 inch CI weighed 190 pounds, down 20 pounds from 210 the previous December and May.  Unintentional weight loss was not recorded and the CI was noted to be obese.  The 8 August 2006 MEB NARSUM examination, 2 months prior to separation, noted complaints of ongoing abdominal pain of variable intensity.  No physical examination was recorded.  

At the 11 January 2007 VA Compensation and Pension (C&P) examination, 3 months after separation, the CI reported cramping and diarrhea 3-4 times a day.  She noted benefit from medications and dietary modifications.  Neither systemic signs nor weight loss were addressed.  The abdominal examination was normal, weight was not recorded and there was no objective evidence of pain.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the IBS 10%, coded 7319 (irritable colon syndrome), citing moderate impairment.  The VA also rated the IBS 10%, coded 7319, based on the C&P examination, citing frequent episodes of bowel disturbance with abdominal distress.  The panel noted that a higher (30%) rating requires evidence of severe symptoms with more or less constant abdominal distress.  This level of impairment was not supported by the records in evidence.  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 IBS.

Migraine Headaches.  According to the STR and MEB NARSUM, the CI’s migraine headaches began in 1994 or earlier.  She was placed on medications with some benefit.  A review of the records did not demonstrate the presence of incapacitating headaches.  There was one issuance of quarters in evidence.  It followed an ER visit 5 days before separation.  The complaint though was of head trauma (she had been kicked accidentally by a child and then struck her head on furniture).  During the MEB examination, 3 months prior to separation, the CI reported constant headaches.  Physical examination was unremarkable.  The MEB NARSUM examination, 2 months prior to separation, noted poor symptom control with medications, but did not document incapacitation.  

At the C&P examination the CI reported that her headaches began in 1974 (at which time she was one year old) and became more frequent in 2004.  She noted that they occurred two or three times a week and were relieved with medications.  They persisted for 2-4 hours.  She occasionally had nausea or visual disturbances, but denied dizziness or incoordination.  It was noted that there was no incapacitation.  The physical examination was non-contributory.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB determined the migraine headaches, coded 8100 (migraine headaches) EPTS, citing DODI 1332.39, paragraph E.2.A1.4.1.4, noting no permanent service aggravation beyond natural progression.  The VA rated the migraine headaches 30%, coded 8100, based on the C&P examination, citing characteristic prostrating attacks averaging at least once a month.  The panel noted that the examiner actually stated there was no incapacitation.  

The panel first considered the EPTS adjudication by the PEB.  The panel determined there was no evidence to refute the MEB NARSUM’s history of the CI’s migraine headaches prior to service.  The panel next considered if the CI’s migraine headaches were permanently service aggravated.  The panel determined that presumption of service aggravation was not overcome by a preponderance of competent medical evidence and accepted medical principles that the natural progression of a pre-existing condition was clearly unaltered by any consequence of the CI’s military service.  Therefore, the panel agreed the migraine headaches were permanently service aggravated.  The panel then considered the rating for the unfitting migraine headaches.

The panel noted there was no STR performance based evidence that the CI was unable to satisfactorily perform her military duties due to prostrating migraine headaches.  The evidence showed the CI was placed on quarters on only one occasion and that was after head trauma resulting in a migraine headache.  There were no other prostrating events documented.  Therefore, the panel recommends a 0% rating for “less frequent attacks.”  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 0% for the migraine headaches, coded 8100.

Contended PEB Condition:  Left Wrist Pain.  The panel’s main charge is to assess the fairness of the PEB determination that the contended condition was not unfitting.  The panel majority determined that the commander’s statement implicated the left wrist condition.  The condition was also profiled (P3) and noted to fail retention standards by the MEB.  The panel majority agreed based on the preponderance of evidence, the CI’s left wrist condition was separately unfitting.  The panel then considered the rating for the unfitting left wrist condition.

The panel agreed there was no limitation of motion which supported a rating under the diagnostic codes for wrist limitation (5214, 5215).  However, there was evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45), as recorded on the MEB NARSUM and VA examinations.  After due deliberation, the panel majority agreed the preponderance of the evidence with regard to the functional impairment of the left wrist condition favors its recommendation as an additionally unfitting condition for disability rating.  It is appropriately coded 5299-5215 and meets the VASRD §4.71a criteria for a 10% rating.  

BOARD FINDINGS:  In the matter of the IBS and IAW VASRD §4.114, the panel recommends no change in the PEB adjudication.  In the matter of the contended EPTS migraine headaches, the panel recommends a disability rating of 0%, coded 8100 IAW VASRD §4.124a. In the matter of the contended left wrist condition, the panel agrees it was unfitting, and recommends a disability rating of 10%, coded 5299-5215 IAW VASRD §4.71a.  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, effective the date of medical separation:

CONDITION	VASRD CODE	PERMANENT RATING	
Irritable Bowel Syndrome 	7319	10%	
Migraine Headaches	8100	0%	
Chronic Pain, Left Wrist	5299-5215	10%	
COMBINED	20%