RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-04554
BRANCH OF SERVICE:  Air Force	SEPARATION DATE:  20080123

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty  E3, Security Forces Apprentice, medically separated for “narcolepsy” with a  disability rating of 10%.

CI CONTENTION:  “My disability is more debilitating than I originally assumed.  My grades in college suffer because I cannot always attend class.  It is hard to hold a job because I cannot be reliable to wake up.”  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 - 20071113	VARD - 20080922	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Narcolepsy	8108	10%	Narcolepsy	8108	20%	20080903	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Narcolepsy.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI was first seen clinically for his narcolepsy symptoms May 2007 with complaints of chronic difficulty awakening from sleep and falling asleep during the day.  Even though he slept for 11 hours, he could not wake up regularly.  The neurological evaluation on 14 May 2007 raised the possibility of idiopathic hypersomnolence or narcolepsy rather than sleep apnea based on clinical grounds.  A neurology note on 15 June 2007 indicated the polysomnogram performed to evaluate the CI’s sleep showed a few events in REM (rapid eye movement) sleep and some sleep fragmentation with good sleep efficiency at 93% (503 minutes).  The MSLT (mean sleep latency time) was 8 minutes with 280 REMs.  Provigil (modafinil for narcolepsy) was initiated.  The CI reported headaches and no benefit from the Provigil on 17 July 2007.  A trial of Ritalin SR (methylphenidate for narcolepsy and ADHD) was instituted for the narcolepsy.  

The 25 July 2007 MEB NARSUM examination, 6 months prior to separation, noted complaints of excessive daytime somnolence.  Physical examination showed vital signs of 97/56 blood pressure, heart rate 59 and respiratory rate 20.  The CI was a well-developed, well-nourished male in no distress, who did not appear sleepy.  Clinical findings including neurologic evaluation were essentially normal.  The examiner noted the CI’s prognosis was fair, but was largely dependent on his response to medications and whether or not he had any of the stimulating side effects that could interfere with his ability to bear arms.  Furthermore, the examiner indicated the CI should avoid working above ground or floor height, and avoid activities in which sudden incapacitation could be lethal.

On 9 August 2007 the CI reported he did better with the Ritalin, but also took Provigil with it on some days and had a headache if out in the sun.  The neurologist’ assessment was narcolepsy without cataplexy.  The Provigil was discontinued; Ritalin SR was continued and Xyrem (sodium oxybate 4-(hydroxybutanoic acid) for narcolepsy) was initiated.  On 23 October 2007, the CI reported after he stopped taking the Xyrem 3 weeks earlier, he had not had any trouble with awakening or over sleeping.  Since then he slept 9-10 hours at night, he felt refreshed and was able to stay up until a bedtime of 2200 and slept until 0600.  He was able to work 8 hour shifts 6 days a week.  The neurologist noted the CI was off medication and was doing well, but it raised the question of validity of the diagnosis of narcolepsy; however, the sleep studies were consistent with the diagnosis.  Further observation was planned.  A note dated 28 December 2007 indicated the CI was prescribed Ritalin to use as needed.

At the 3 September 2008 VA Compensation and Pension (C&P) narcolepsy examination, 7 months after separation, the CI reported 12 attacks in the prior year, averaging 1 each month, but did not provide details of an attack or maintain a log.  He stopped taking Ritalin in January 2008 and reported he did not experience any functional impairment from the condition.  Physical examination including neurologic evaluation was normal.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the narcolepsy condition 10%, coded 8101 (narcolepsy).  The VA rated the narcolepsy condition 20%, also coded 8108, based C&P Narcolepsy examination, citing the CI had 12 episodes during the previous year.

Panel members noted the CI had a diagnosis of narcolepsy marked by excessive daytime sleepiness, which with treatment improved such that the CI was able to work 8 hour shifts, 6 days a week prior to separation.  However, the rating for code 8108 is based on code 8911 (epilepsy, petit mal), which uses the general rating formula for minor seizures.  While the CI had episodes of hypersomnolence and a diagnosis of narcolepsy, he did not have any seizures.  A 10% rating requires a confirmed diagnosis, whereas a 20% rating requires at least two minor seizures (episodes) in the last 6 months.  However, the CI did not provide details of an attack or maintain a log of attacks, and the STR did not provide evidence of at least two episodes in the 6 months prior to separation.  Evidence of the 12 episodes reported on the VA C&P examination, 5 months after separation, was not indicated in the STR 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 narcolepsy condition.  

BOARD FINDINGS:  In the matter of the narcolepsy and IAW VASRD §4.124a, 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:

Exhibit A.  DD Form 294, dated 20170511, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD 20762

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX
		Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2017-04554.

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.

						Sincerely,

		

Attachment:
Record of Proceedings