RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX 	CASE:  PD-2017-04380
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060609

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was a Reserve E6, Cargo Specialist, medically separated for “coronary artery disease [CAD] status post (S/P) angioplasty and stent placement” and “low back pain,” rated 10% each, with a combined disability rating of 20%.  

CI CONTENTION:  Review requested of coronary artery disease (CAD) and low back pain.  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 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 - 20060511	VARD - 20061121	
Condition	Code	Rating	Condition	Code	Rating	Exam	
CAD, S/P Angioplasty and Stent Placement	7005	10%	CAD, S/P Angioplasty and Stent Placements; High Blood Pressure	7005	10%	20060929	
Chronic Back Pain	5299-5242	10%	L4-L5 Bulging Disc ...	5243	20%	20061108	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

CAD.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI suffered an onset of chest pain in May 2005 while deployed to Afghanistan.  This was immediately diagnosed as a myocardial infarction and he was evacuated for timely intervention (angioplasty and stenting of a single lesion, proximal LAD).  He was stabilized on medication, and provider entries in the STR documented an uncomplicated course with no further infarctions, heart failure, syncope, unstable angina, or other VASRD-ratable manifestations.  An exercise stress test demonstrated a normal workload tolerance of 12.0 METS (metabolic equivalent units applicable to VASRD rating).  There was no cardiac hypertrophy or dilatation by electrocardiogram or imaging.  

The 9 February 2006 MEB NARSUM examination, 4 months prior to separation, corroborated the above evidence and did not document any active symptoms on standard medications.  All cardiovascular findings were normal by physical examination.  The 29 September 2006 VA Compensation and Pension (C&P) general examination, 4 months after separation, documented stable angina (~4 episodes a month promptly relieved by 1 nitroglycerin pill).  All cardiovascular findings were normal by physical examination except for bilateral leg edema.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the CAD 10%, coded 7005 (arteriosclerotic heart disease), citing the applicable VASRD §4.104 criteria (see below).  The VA conferred the same rating under the same code, based on the C&P examination and citing the same applicable criteria.  

Code 7005 is quite specific for CAD, and no alternative code is applicable or justifiable even for analogous rating.  The 10% criteria of 7005 are “workload of greater than 7 METs but not greater than 10 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; continuous medication or a pacemaker required.”  The 20% criteria are “workload of greater than 5 METs but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray.”  There was no evidence in support of any of the 20% criteria.  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 CAD condition.  

Low Back Pain.  The CI had a history of chronic low back pain dating to 1991 that was aggravated by the above deployment.  A 1 August 2005 MRI demonstrated degenerative disc disease (L4/5 and L5/S1 without neural compromise).  Neurological examinations were normal and surgery was not recommended.  Provider entries in the STR documented nonspecifically limited range of motion (ROM), with none indicating any severe limitation.  There was documentation of a normal spinal contour, although there was a mention of gait disturbance (albeit not correlated with spasm or guarding).  There was no STR documentation of incapacitating episodes.  

The NARSUM documented persistent low back pain rated “slight/intermittent” that was “exacerbated by prolonged walking, sitting, and standing positions.”  The physical examination recorded a normal gait without note of abnormal spinal contour, tenderness without note of spasm, and normal neurological findings.  The NARSUM cited thoracolumbar ROM measurements performed by physical therapy (PT) on 21 December 2005, 6 months before separation.  The PT examiner charted flexion to 80 degrees (normal 90) and combined ROM of 200 degrees (normal 240), specifying painful motion.  There was no STR documentation of any injury or other exacerbation of the lumbar condition in the interim between the preceding ROM measurements and separation.  

At the 8 November 2006 VA Compensation and Pension (C&P) spine examination, 5 months after separation, the CI reported daily pain rated “moderate” and that he was only able to walk a quarter mile.  Functional limitations were not further elaborated, although the examiner documented full-time employment as a maintenance worker and the absence of any incapacitating episodes.  There was no documentation of any interim injury or exacerbation.  The physical examination recorded a normal gait and spinal contour, tenderness, no spasm or guarding, and normal neurological findings.  Measured ROM was flexion to 30 degrees and combined 140 degrees, specifying painful motion but no ROM degradation with repetition.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the lumbar spine condition 10%, coded 5299-5242 (analogous to degenerative arthritis of the spine), citing the PT ROM evidence.  The VA rated the lumbar spine condition 20%, coded 5243 (intervertebral disc syndrome), based on the C&P examination and quoting the applicable VASRD §4.71a spine rating criteria.  The VA decision did not cite the evidence applied, and the panel noted that the C&P flexion to 30 degrees satisfied the 40% spine criterion for flexion “30 degrees or less.”  
The panel considered the disparate ROM evidence, with the significantly worse ROM measurements between the service PT and VA C&P examiners.  Ultimately panel members agreed that the service ROM evidence should be assigned the determinant probative value.  The temporal distance from separation and quality of the examinations were essentially equivalent.  There was no clinical explanation for such a severe deterioration in ROM of a chronic condition in the interim between separation and the VA examination, and the service ROM was more consistent with the pathology (mild, non-surgical disc disease).  Additionally, the VA ROM measurements were not correlated with other examination findings such as spasm, guarding, or altered spinal contour that would be clinically compatible with such severe limitation of motion.  

The panel 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/or combined ROM (greater than 120 degrees but not greater than 235 degrees), as reported on the service PT examination.  There was no evidence for abnormal gait or spinal contour associated with spasm and guarding, thus the next higher 20% rating was not justified on this basis.  There was no documentation of 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 lumbar spine condition.  

BOARD FINDINGS:  In the matter of the coronary artery disease and IAW VASRD §4.104, the panel recommends no change in the PEB adjudication.  In the matter of the lumbar spine condition and IAW VASRD §4.71a, 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 that there be no modification or re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:  

AR20200002316, 

Dear XXXXXXXXXXXXXXXX:

	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.

A copy of this decision has been provided to the counsel you listed on your application.