RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW
NAME:  XXXXXXXXXXXXXXXXXX	CASE: PD-2017-04398
BRANCH OF SERVICE: NAVY	SEPARATION DATE: 20070329

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Culinary Specialist, medically separated for “cardiomyopathy, symptomatic” and “Graves’ disease and hyperthyroidism,” each rated 10%, with a combined disability rating of 20%.

CI CONTENTION: “I believe I was not given an adequate and thorough evaluation by the medical staff at Groton Naval Hospital and Medical Board.” 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 – 20061218	VARD - 20071203	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Cardiomyopathy, Symptomatic	7020	10%	Cardiomyopathy	7020	NSC	20071030	
Graves’ Disease and Hyperthyroidism	7900	10%	Hyperthyroidism	7900	10%	20071030	
COMBINED RATING: 20%	COMBINED RATING OF ALL VA CONDITIONS: 30%	

ANALYSIS SUMMARY:

Symptomatic Cardiomyopathy. According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s cardiomyopathy began in April 2005 when he experienced chest pain with high intensity exercise. During a stress echocardiogram on 2 June 2005, he reached an exercise level of 15 METS (one MET (metabolic equivalent) is the energy cost of standing quietly at rest), and the test was terminated due to fatigue. The associated results showed global hypokinesis (decreased heart wall movement) with left ventricular ejection fraction (EF) between 40-45% (Mayo Clinic normal is 55% or greater). The CI was diagnosed with a dilated cardiomyopathy, and an electrocardiogram on 18 April 2006, indicated mild left ventricular hypertrophy. The condition was controlled with medications, but limited the CI’s ability to exercise.

The 17 November 2006 MEB NARSUM examination, 4 months prior to separation, noted that follow-up internal medicine visits showed symptoms of paroxysmal nocturnal dyspnea and

severe shortness of breath/coughing at night when supine, and that medications had been adjusted to maximize cardiac function. Physical examination showed blood pressure of 130/70 mmHg and normal cardiac findings with good control on current medications.

At the 30 October 2007 VA Compensation and Pension (C&P) examination, 7 months after separation, the CI reported that he worked as a cook after separation, but left the job because the stressful pace induced fatigue, shortness of breath and chest tightness. Physical examinations showed blood pressures of 120/80, 124/80 sitting and 130/90 standing. Regarding exercise capacity, he could walk or jog about a mile, but strenuous activity caused chest tightness and mild shortness of breath for 5-10 minutes. Physical examination of the heart was normal, but on a chest X-ray, the heart appeared enlarged and possible cardiomegaly was noted. Repeat X-rays were recommended due to technique. The VA examiner indicated that the CI’s service medical records were not available for review, but an echocardiogram revealed an EF of 55% and a stress test showed he was able to achieve an exercise level of 10.7 METS.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the cardiomyopathy 10%, coded 7020 (cardiomyopathy). The VA did not service connect the cardiomyopathy based on the C&P examination, citing no evidence of permanent residual or chronic disability. Panel members noted that the CI’s diagnosis of dilated cardiomyopathy is a condition characterized by cardiac chamber enlargement and dysfunction, and thus discussed VASRD §4.100 (application of evaluation criteria for diagnostic codes 7000- 7007, 7011, and 7015-7020), which notes that METS testing is required even if a 30% rating is supported by evidence of cardiac hypertrophy or dilatation. The issue in question was whether
§4.100 implies that a rating based on METS takes precedence over a rating base on cardiac enlargement for the 30% rating, and, after lengthy deliberation, panel agreed that the 30% rating criteria (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) as written provided for a rating based on either METS or evidence of cardiac enlargement. Panel members adjudged that a 30% rating was supported for cardiac hypertrophy or dilatation found on the April 2006 electrocardiogram and the VA chest X-ray post-separation. Although the initial echocardiogram showed an EF of 40 to 45%, the test results for the VA examination showed improvement with an EF of 55%, and the panel found the evidence insufficient to support a 60% rating (based on either METS or EF). 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 cardiomyopathy, coded 7020.

Graves’ Disease and Hyperthyroidism. According to the STR and MEB NARSUM, the CI’s hyperthyroid condition began in April 2004 when elevated blood sugar levels and high blood pressure were noted during a routine physical. He was admitted to the hospital and further testing showed hyperthyroidism which was eventually diagnosed as Grave’s disease. A past history of hypertension and hyperthyroidism was noted to possibly be the cause of the newly elevated blood sugar levels, and he was treated with medication to reduce thyroid hormone levels, with thyroid ablation planned after he was stable for several months on medication.

The MEB NARSUM examination noted the CI’s hyperthyroidism appeared to be under control, but he had not yet had the thyroid ablation. Blood pressure was well-controlled on medications, but blood sugar levels were poorly controlled on insulin. Physical examination showed a blood pressure of 130/70 mmHg with a heart rate of 90 and normal cardiac and eye examination (no proptosis/bulging eyes). A recent hemoglobin A1C (measures blood sugar levels over approximately 2-3 months) was 9.0% (normal less than 5.7%). The examiner noted thyroid enlargement and a goiter with no nodularity, but the remaining physical findings were normal.

At the C&P examination, the CI reported no weight loss, diarrhea, nervousness or shakiness. He was taking the thyroid medication, and blood sugar levels were better controlled. Physical

examination showed blood pressures as noted above, and no masses in the neck. Remaining physical findings, including an eye examination, were unremarkable. Measured thyroid stimulating hormone level was 0.44 milliunits per liter (normal .34 to 5.6).

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the hyperthyroid condition 10%, coded 7900 (hyperthyroidism). The VA also rated the hyperthyroid condition 10%, coded 7900, based on the C&P examination, citing tachycardia and tremor or a requirement for continuous medication. Panel members agreed that a 10% rating was supported under code 7900 for hyperthyroidism controlled with medication. There was no evidence of tachycardia, tremor, increased pulse pressure or blood pressure for a higher rating under that code, and no evidence of ophthalmopathy (6090) or atrial fibrillation (7008) for higher ratings under those codes. 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 hyperthyroid condition.

BOARD FINDINGS: In the matter of the cardiomyopathy, the panel recommends a disability rating of 30%, coded 7020 IAW VASRD §4.104. In the matter of the Graves’ disease and hyperthyroidism and IAW VASRD §4.119, the panel recommends no change in the PEB adjudication. 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	
Cardiomyopathy	7020	30%	
Graves’ disease and Hyperthyroidism	7900	10%	
	COMBINED	40%	

DEPARTMENT OF THE NAVY
SECRETARY OF TIIE NAVY COUNCIL  OF  REVIEW  BOARDS 72 0 KElmON STREET SE STE 3 0 9
WASHINGTON NAVY YARD, DC 20374-5023

IN REPLY REFER TO:
1850
CORB:003 12 Oct 20

From: To:

Subj:

Ref:

Director, Secretary of the Navy Council of Review Boards 
PHYSICAL DISABILITY BOARD OF REVIEW (PDBR)
(a) DoDI 6040.44
(b)	PDBR ltr of 29 Nov 19
(b)	

1.	Pursuant to reference (a), the PDBR reviewed your case and forwarded its recommendation (reference (b)) to the Department of the Navy for appropriate action.

2.	On 5 October 2020, the Assistant Secretary of the Navy took action in your case by accepting the correct recommendation of the PDBR.	Accordingly, your records will be corrected to reflect an increase in the disability rating awarded by the Physical Evaluation Board from 20 to 40 percent with assignment to the Permanent Disability Retired List.

3.	

The Assistant Secretary's determination, which represents final action in your case by the Department of the Navy, was sent to the Navy Personnel Command, for correction of your records as stated above.	You will be notified once those changes are complete.