RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-04264
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20051109

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Counter Intelligence Agent, medically separated for “endometriosis” with a disability rating of 10%.  

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 - 20050804	VARD - 20060515	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Endometriosis	7629	10%	Endometriosis with Chronic Pelvic Pain	7629	10%	20060111	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Endometriosis (Pelvic Pain).  According to the service treatment record and MEB narrative summary (NARSUM), the CI underwent laparoscopic surgical fulguration (cutting/lysing/removal) of endometriosis (along with removal of a cervical fibroid, endometrioma [cyst], and a normal appendix) on 21 August 2003.  The CI continued to have duty-limiting pelvic and abdominal pain.  
At the 18 April 2005 MEB NARSUM examination, 7 months prior to separation, the CI complained of persistent pelvic pain that was unresponsive to surgery, medication changes or evaluations by psychiatry, urology, the pain clinic or physical therapy.  Physical examination showed normal abdominal sounds with diffuse tenderness.  Pelvic examination showed right greater than left tenderness without masses or cervical tenderness, and a no abnormalities of the uterus.  On 16 June 2005 the CI underwent laparotomy with myomectomy (large fibroid removal) and fulguration of endometriosis.  

The 20 June 2005 NARSUM addendum, 5 months prior to separation, revealed that surgery disclosed recurrence of endometriosis with implants over the uterosacral and on the small bowel, and recurrent right broad ligament fibroid.  The CI was placed on medications and did well postoperative.  She was tolerating a regular diet, ambulating and urinating spontaneously.  The assessment was chronic pelvic pain with recurrence of endometriosis and recurrent right broad ligament fibroid, with a plan for 6 months of Lupron.  During the 14 July 2005 gynecology evaluation, the CI complained of continued mild lower abdominal pain on medications.  There was no abdominal tenderness or masses.  No pelvic examination was reported.  An ultrasound on 12 September 2005 revealed at least three fibroids.  

At the 11 January 2006 VA Compensation and Pension (C&P) examination, 2 months after separation, the CI reported return of pelvic and abdominal pain and that definitive surgery of hysterectomy was not desired due to the future possibility of pregnancy.  Physical examination from the 23 February 2006 C&P examination showed a soft, non-tender abdomen, but no pelvic examination was recorded.  The 10 April 2006 gynecology evaluation, 5 months after separation, noted complaints of 6/10 pelvic and abdominal pain “with exacerbation[s] that are severe and debilitating.”  Pelvic examination revealed right-sided pain to palpation of the ovary with no adnexal masses.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the endometriosis 10%, coded 7629 (endometriosis), citing no anemia.  The VA initially rated the endometriosis 10%, coded 7629, based on the C&P examination, citing pelvic pain or heavy or irregular bleeding requiring continuous treatment, and based on appeal and VA treatment records increased the rating to 30%, citing pelvic pain or heavy or irregular bleeding not controlled by treatment.  

Endometriosis was definitively substantiated by laparoscopy and pathology and rating under code 7629 was most appropriate.  The panel deliberated if the CI met the next higher 30% rating under code 7629 for “pelvic pain or heavy or irregular bleeding not controlled by treatment,” or the 10% criteria for “pelvic pain or heavy or irregular bleeding requiring continuous treatment for control.”  The CI underwent surgery following the initial NARSUM that the PEB noted for medication use, and the medication profiles do not typically include those medications supplied while hospitalized.  The medication profile included narcotic pain medication and muscle relaxants in January and March 2005, as well as multiple hormonally active medications which are the principal therapy for endometriosis.  

The record documented post-surgical worsening and the panel deliberated if the worsening was prior to separation, or only post-separation.  Given the entirety of the record with the CI seeking alternative treatments and reasonably refusing offered hysterectomy, the panel adjudged that the disability picture at separation most nearly approximated the 30% criteria for pelvic pain not controlled by treatment.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 30% for the endometriosis, coded 7629.  

BOARD FINDINGS:  In the matter of the endometriosis, the panel recommends a disability rating of 30%, coded 7629 IAW VASRD §4.116.  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	
Endometriosis	7629	30%	

The following documentary evidence was considered:

AR20190006882, 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 30% 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.  Inquiries 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.