20RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW
NAME:  XXXXXXXXXXXXXXXXXX	CASE: PD-2017-04204
BRANCH OF SERVICE: ARMY	SEPARATION DATE: 20080206

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E6, Utility Equipment Repairman, medically separated from the Temporary Disability Retired List (TDRL) for “lumbar degenerative disc disease [DDD],” “coronary artery disease [CAD] following myocardial infarction,” and “antiphospholipid antibody syndrome [APS]” rated 10%, 10% and 0%, respectively, with a combined disability rating of 20%.

CI CONTENTION: Review requested of additional conditions (PTSD, sleep apnea, shoulder/knee pain) 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 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 - 20080411	VARD - 20090105	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Lumbar DDD	5299-5242	10%	Lumbar Spine DDD…	5243	10%	20080102	
CAD…	7005	10%	Status Post Myocardial Infarction, Atherosclerotic Cardiovascular Disease	7006	10%	20080102	
APS	7199-7120	0%	APS	7199-7121	10%	20080102	
COMBINED RATING: 20%	COMBINED RATING OF ALL VA CONDITIONS: 40%	

ANALYSIS SUMMARY:

Lumbar Degenerative Disc Disease (DDD). According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s lumbar DDD began in 2003 after a severe back strain. An MRI in March 2007 demonstrated mild degenerative changes in the L3-L4 and L4-L5 discs and mild osteoarthritic changes in the facet joints at those levels. Physical therapy (PT) range of motion (ROM) measurements on 17 October 2007 revealed flexion to 60 degrees (normal 90) and a combined ROM of 195 degrees (normal 240), with pain. A decreased lumbar lordosis was observed, but gait was normal and there was no localized tenderness, muscle spasm, or guarding. At the 25 October 2007 MEB NARSUM TDRL examination, 3 months prior to separation, the CI complained  of back pain,  and  the examiner noted  somewhat tender  paraspinal muscles   and

spasm, but no antalgic gait. At the 2 January 2008 VA Compensation and Pension (C&P) examination, 1 month before separation, the CI reported chronic low back that radiated to the left hip area with tingling in both thighs. Physical examination showed forward flexion to 90 degrees and a combined ROM of 240 degrees, without pain or loss of motion with repetition. There was no muscle spasm or guarding, and gait and spinal contour were normal.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the low back condition 10%, analogously coded 5299-5242 (degenerative arthritis of the spine), citing tenderness and spasm without abnormal gait. The VA also rated the low back condition 10%, but coded 5243 (intervertebral disc syndrome (IVDS)), based on the C&P examination, citing the 10% rating criteria. Panel members agreed that a 10% rating, but no higher, was justified for limitation of flexion (greater than 60 degrees but not greater than 85 degrees) and combined ROM (greater than 120 degrees but not greater than 235 degrees), as reported on the PT examination. There was no muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour, thus the next higher 20% rating was not justified on this basis. There was no documentation of IVDS with incapacitating episodes which would provide for a higher rating under that formula. 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 low back condition.

CAD. In November 2005, the CI awoke with chest pain, diagnosed with a myocardial infarction, and under underwent a percutaneous intervention with a bare-metal stent placement in the proximal left anterior descending artery. He had no recurrent angina (chest pain) since the MEB, and test results one year earlier showed good functional capacity with no inducible ischemia, a normal ejection fraction, and a large fixed defect in the apical region suggestive of prior scar tissue. He had no change in symptoms since working full-time as a supervisor and was compliant with all medications (atenolol, Zestril, aspirin, Coumadin, Zocor, and nitroglycerin); he specifically noted his functional capacity was limited by chronic back pain. Chest X-rays on 1 October 2007 showed the cardiac silhouette at the upper normal size, but probably accentuated by a fat pad. There were no definite signs of a cardiopulmonary process.

At the MEB NARSUM TDRL examination, the CI reported CAD and a history of an apical myocardial infarction. The examiner noted that carotid arteries, respiration, jugular venous pressure, and heart rate/rhythm were all normal. Heart sounds were also normal with no murmurs, and lungs were clear to auscultation. An EKG revealed a normal sinus rhythm with a right bundle branch block, and the examiner’s assessment was CAD without recurrent angina and a normal ejection fraction. From a cardiovascular status there was no return to duty limitation, but because a lifelong need anticoagulation medication (see below) and orthopedic issues, permanent discharge was considered appropriate. At the C&P examination, the CI had no cardiac complaints and walked an equivalent of one mile at work without any cardiovascular issues. Physical examination showed normal vital signs with regular heart sounds and size, and no bruits or edema. An exercise stress test on 17 December 2007 was normal and showed a 10 METs level of activity, normal functional capacity, and no arrhythmias or ST changes.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the CAD 10%, coded 7005 (arteriosclerotic heart disease (CAD)), citing “stable at this point, not requiring nitroglycerin, METs 10.1, requires medication.” The VA also rated the CAD 10%, but coded 7006 (myocardial infarction), based on the C&P examination, citing a workload greater than 7 METs but not greater than 10 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or continuous medication required. Panel members noted that under codes 7005 and 7006, a 30% rating requires a “workload of greater than 5 METs but not greater than 7 METs [that] results in dyspnea, fatigue, angina, dizziness, or syncope…” Because the CI had a workload of 10 METs, a rating higher than 10% is not warranted using either code. After due deliberation,

onsidering 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 CAD.

APS. In March and April 2006, blood tests after the CI’s myocardial infarction revealed APS with elevated titers for anticardiolipin antibodies IGM and IGG, APTT (activated partial thromboplastin time), lupus anticoagulant, and viper venom time. As a result, he required chronic systemic anticoagulation with warfarin, and subsequently could not be involved in contact sports, work at excessive heights, or use machinery with moving parts. After multiple internal medicine clinic visits from 31 July 2007 through 28 December 2007, the anticoagulation medication dosage was increased. During the MEB TDRL NARSUM examination, he denied any easy bleeding or bruising, and the examiner found general skin appearance to be normal. At the VA C&P examination, the CI reported that he had been on warfarin since being diagnosed with APS. Physical examination showed good peripheral pulses, and no edema or bruits.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the APS 0%, analogously coded 7199-7120 (varicose veins), citing no episodes of thrombophlebitis or pulmonary emboli in past year. The VA rated the APS 10%, analogously coded 7199-7121 (post-phlebitic syndrome of any etiology), based on the C&P examination, citing permanent anticoagulant treatment and subjective complaints of limitation with prolonged movement. Panel members noted that under codes 7120 and 7121, a 10% rating requires “intermittent edema of extremity or aching and fatigue in leg after prolonged standing or walking, with symptoms relieved by elevation of extremity or compression hosiery.” Because there was no evidence of edema, aching or fatigue, or use of compression hosiery for either of the CI’s legs, the panel agreed that a 0% rating, and no higher, was warranted under either code. While code 6817 (pulmonary vascular disease) addressed anticoagulant therapy with a 60% rating, there was no evidence of chronic pulmonary thromboembolism or inferior vena cava surgery with unresolved symptoms. 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 APS.

BOARD FINDINGS: In the matter of the low back condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication. In the matter of the heart condition and IAW VASRD §4.104, the panel recommends no change in the PEB adjudication. In the matter of the antiphospholipid antibody syndrome and IAW VASRD §4.104, 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:

DEPARTMENT OF THE ARMY
ARMY REVIEW BOARDS AGENCY
251 18TH STREET SOUTH, SUITE
385
ARLINGTON, VA 22202-3531

AR20200000156, XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXX
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.

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