RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-04790
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20060911

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, M1 Armor Crewman, medically separated for “tender scar over the forehead” and “post concussive syndrome,” rated 10% each, with a combined disability rating of 20%.

CI CONTENTION:  Review requested of head injury and post traumatic stress disorder (PTSD) as well as additional conditions 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’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 - 20060605	VARD - 20070302	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Tender Scar over the Forehead	7804	10%	Tender Scar, Forehead	7804	10%	20070109	
Post Concussive Syndrome	8045-9304	10%	Post Concussive Syndrome with associated Headaches, Dizziness, and Insomnia	8045-9304	10%	20070109	
Generalized Anxiety Disorder with Elements of PTSD	Not Unfitting	Acquired Psychiatric Disorder to include PTSD with Anxiety Disorder Not Otherwise Specified	9411	30%	20070125	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:

Tender Forehead Scar.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI underwent frontal sinus fracture repair surgery in March 2005 due to a motor vehicle accident (MVA).  He developed a scar condition after a metal plate was placed in the bone underneath the skin.  A CT scan of the sinuses in February 2006 revealed frontal bone post-surgical changes without significant paranasal sinus disease.  

The 6 March 2006 MEB examination (recorded on DD Forms 2807-1 and 2808), 6 months prior to separation, revealed right frontal area plating and normal physical findings.  At the MEB NARSUM examination, on the same day, the CI reported the inability to wear a Kevlar helmet or apply direct pressure to the injury site due to the painful forehead scar.  Physical examination focused on the head which showed a subcutaneous palpable plate over the left forehead.  No other examination findings were cited.

At the 9 January 2007 VA Compensation and Pension (C&P) examination, 4 months after separation, the CI reported suffering from migraines, acne, forehead scar pain and post- concussion syndrome since the MVA in March 2005.  The review of systems documented general fatigue, insomnia and memory loss since returning from Iraq.  Physical examination of the head was unremarkable except for the forehead scar which was flat and minimally tender.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the scar condition 10%, coded 7804 (scars, unstable or pain), citing the inability to wear a helmet due to direct pressure on the injury site.  The VA also rated the scar condition 10%, coded 7804, based on the C&P examination, citing a superficial scar that was painful on examination.  Members agreed that a rating higher than 10% was not warranted without evidence of an unstable (frequent loss of skin covering over the scar) scar.  After due deliberation, considering all of 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 forehead scar.

Post Concussive Syndrome.  According to the STR and MEB NARSUM, the CI’s post concussive syndrome began after the MVA mentioned above.  The MEB NARSUM examination noted complaints of frequent headaches, difficulty with concentration and short-term memory, and marked frustration with the inability to multi-task.  He had headaches every 2-3 days, which lasted the entire day, and reported being released from work 2-3 times in the previous year.  Headache medication provided mild improvement, and dizziness and fatigue were not addressed.  The provider noted a normal gait and a maximum score on the mini-mental status examination which indicated normal cognitive functioning.  

At the neuropsychological examination on 24 April 2006, 5 months prior to separation, the CI reported being “knocked out for a few minutes” after the MVA and suffering memory problems, which included forgetting numbers and verbal instructions, and resulted in constant mistakes on the job.  He also described a personality change with decreased motivation and energy, and increased irritability.  Testing showed an average to above average IQ, average attention, and a high average working memory.  The psychologist concluded that the  test results showed no deterioration or impairment in the CI’s overall intellectual and neurocognitive functioning, and opined that he may have been experiencing very mild memory, processing speed, and complex attentional process inefficiencies due to either the head injury or anxiety.

The VA Compensation and Pension (C&P) examination noted complaints of migraine headaches, hearing loss, anxiety and post concussive syndrome to include fatigue, insomnia, and memory loss since the accident.  The CI was a full-time college student (less than 1 year), and while he missed school due to his symptoms, he had been able to pass his classes.  He also reported memory loss which required him to write things down more than in the past.  He no longer took prescribed headache medication, as requested by this primary care physician, but still took over-the-counter pain medication.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the post concussive syndrome 10%, analogously coded 8045-9304 (brain disease due to trauma-dementia due to trauma), citing headaches occurring every 2-3 days lasting the entire day with 7/10 pain intensity, no overall neuro-cognitive functioning deterioration, and a normal neurological examination.  The VA also rated the post concussive syndrome 10%, coded 8045-9304, based on the C&P examination, citing purely subjective complaints such as headaches, dizziness, and insomnia recognized as brain trauma symptoms. 

The 2002 VARSD in effect at the time of separation captured brain injuries under the generic category of brain disease due to trauma with two different scenarios for rating under code 8045.  First, purely neurological disabilities following brain trauma, such as hemiplegia, epileptiform seizures, facial nerve paralysis, etc., will be rated under the diagnostic codes specifically dealing with such disabilities, with citation of a hyphenated diagnostic code (e.g., 8045–8207).  Second, purely subjective complaints, such as headache, dizziness, insomnia, etc., recognized as symptomatic of brain trauma, will be rated 10%, and no more, under diagnostic code 9304, and will not be combined with any other rating for a disability due to brain trauma.  Ratings in excess of 10% for brain disease due to trauma under diagnostic code 9304 are not assignable in the absence of a diagnosis of multi-infarct dementia [multi-small localized dead tissue areas due to blood supply failure] associated with brain trauma.

The panel concluded that the CI’s post concussive syndrome was purely subjective and noted the STR and VA evidence did not render a multi-infarct dementia diagnosis.  Consequently, the maximum rating under code 8045-9304 is 10%.  A rating IAW VASRD §4.130 (schedule for rating-mental disorders) under code 9304 was not justified as the post concussive syndrome symptoms manifested as headaches and memory loss.  There were no other applicable VASRD codes for rating consideration.  After due deliberation, considering all of 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 post concussive syndrome.

Contended PEB Condition:  Generalized Anxiety Disorder (with elements of PTSD).  The panel’s main charge is to assess the fairness of the PEB determination that the contended condition was not unfitting.  The contended condition was not profiled or implicated in the commander’s statement, and did not fail retention standards.  There was no performance-based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition, so no additional disability rating is recommended.

BOARD FINDINGS:  In the matter of the scar condition and IAW VASRD §4.118, the panel recommends no change in the PEB adjudication.  In the matter of the post concussive syndrome and IAW VASRD §4.124a, the panel recommends no change in the PEB adjudication.  In the matter of the contended generalized anxiety disorder, the panel agrees it cannot recommend it for additional disability rating.  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:

[AR NUMBER], XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX

	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.

Enclosure