RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2017-05360
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050922

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was a Reserve E6, Unit Supply Specialist, medically separated for “chronic abdominal pain” with a disability rating of 0%.

CI CONTENTION:  Given a higher rating by the VA for the unfitting abdominal condition and not unfitting foot condition.   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 – 20050615	VARD - 20060616	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Abdominal Pain	5099-5003	0%	Chronic Pelvic Pain Status Post Hysterectomy with Bilateral Salpingo-oophorectomy (Claimed as Endometriosis Muscle Damage and Chronic Abdominal Pain	7699-7617	50%	20060504	
Foot Surgery 	Not Unfitting	Hallux Abductovalgus of the Left Foot with Bunionectomy and Pin Fixation	5280	10%	20060504	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  80%	

ANALYSIS SUMMARY:  

Chronic Abdominal Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI began experiencing chronic pelvic pain in June 2000, which persisted as a result of/or despite multiple gynecologic surgical procedures.  In September 2000, she had a laparoscopic myomectomy for symptomatic uterine fibroids, and adhesions from the left adnexa to the left side wall were noted.  A year later, she underwent laparoscopy with fulguration of endometriosis and lysis of adhesions, and in June 2003, she had a laparoscopic assisted vaginal hysterectomy with bilateral salpingo-oophorectomy (removal of the uterus, tubes, and ovaries), at which time there was no obvious evidence of endometriosis in the right ovary or right pelvic wall.  Postoperatively, lower abdominal pain persisted, but a pelvic CT scan showed no abdominal or pelvic lymphadenopathy or free fluid.  The gall bladder was not visualized, and the other abdominal organs were normal.  Cystoscopy and colonoscopy results were normal.  

During a primary care visit in November 2004, the provider noted the CI had two opinions that the pelvic pain was secondary to adhesions and a rheumatology work-up was negative. Imaging studies showed a small, inconsequential disc bulge at L4-L5 with no nerve root or canal involvement, but an orthopedic consult indicated that the CI’s symptoms were not orthopedic in nature and no treatment was warranted.  At a gynecology appointment in December 2004, the CI complained of suprapubic, moderate, aching pain aggravated by activity.  Examination of the abdomen was normal, but there was tenderness of the vulva and vagina.   The provider’s assessment was chronic pelvic pain and vulvar vestibulitis (increased sensitivity to pain).  A barium enema in February 2005 showed no significant evidence of pathology, and the CI’s primary care provider opined that the chronic pelvic pain was most likely from adhesions.  

The 11 May 2005 MEB NARSUM examination, 4 months prior to separation, noted complaints of chronic lower abdominal pain of a nonspecific origin which did not resolve with a hysterectomy or bilateral salpingo-oophorectomy.  The examiner documented the ability to bend forward to 110 degrees (normal 90); however, no abdominal or gynecologic findings were recorded.  The CI underwent a laparoscopic cholecystectomy (gallbladder removal) on 6 April 2006, less than 7 months after separation, due to increasing upper abdominal pain.

At the 4 May 2006 VA Compensation and Pension (C&P) examination, 7 months after separation, the CI reported chronic pelvic pain and frequent urinary tract infections with bowel issues to  include constipation and/or diarrhea, but no vaginal bleeding.  Physical examination revealed no abdominal tenderness, but the laparoscopic scars were mildly tender.  Upon palpation, there was some pain in the suprapubic and sub-umbilical regions bilaterally and mild discomfort about the liver.  The spleen was not palpable and there was no costovertebral or spinal tenderness.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated abdominal pain 0%, analogously coded 5099-5003, citing application of the US Army Physical Disability Agency pain policy.  The VA rated chronic pelvic pain 50%, analogously coded 7699-7617 (uterus and both ovaries, removal of, complete), based on the C&P examination, citing complete loss of the uterus and both ovaries following a period of postsurgical convalescence.  Panel members noted that the CI had chronic pelvic pain for years prior to separation and had undergone several gynecologic surgical procedures, that at one time or another, showed fibroids, endometriosis and adhesions.  She underwent a hysterectomy and bilateral salpingo-oophorectomy, but the pain persisted and did so even after a post-separation gallbladder removal.   The panel majority favored the view that the chronic pelvic pain was due to adhesions and noted that code 7301 (peritoneum, adhesions of) offers a 10% rating  for moderate adhesions with “pulling pain on attempting work or aggravated by movements of the body.”  Although endometriosis was found by laparoscopy in June 2003, subsequent surgeries showed no evidence of the condition.  Thus, the panel majority adjudged that use of code 7629 (endometriosis) was not applicable, and that removal of the uterus, tubes, and ovaries (code 7617) was not the cause of the CI’s unfitness and was likewise not applicable.   After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel the panel recommends a disability rating of 10% for the abdominal condition, coded 7301.

Contended PEB Condition:  Foot Surgery.  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 abdominal (pelvic) condition, the panel majority recommends a disability rating of 10%, coded 7301 IAW VASRD §4.114.  The single voter for dissent submitted the appended minority opinion.  In the matter of the contended foot condition, the panel recommends no change from the PEB determination as not unfitting.  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	
Chronic Abdominal (Pelvic) Pain	7301	10%	

The following documentary evidence was considered:

Minority Opinion.  The minority voter recommends a 30% rating using code 7629 (endometriosis), which was clearly and unequivocally documented in the STR.  While at the time of the subsequent laparoscopic hysterectomy and bilateral salpingo-oophorectomy, performed in an attempt to alleviate the pelvic pain, no obvious endometriosis was noted on the right ovary or right pelvic wall.  However, there was a limited laparoscopic examination of the remainder of the pelvis and abdomen to see whether other foci of endometriosis were present as compared to an open laparotomy where of all organs of the pelvis and abdomen are examined under direct vision.  Furthermore, there was no pathology report in the STR which could indicate the presence of microscopic foci of endometriosis, if there were any present.  A 30% rating requires the diagnosis of endometriosis be substantiated by laparoscopy, which it was, and the individual should have “pelvic pain or irregular bleeding requiring continuous treatment for control.”  The CI unquestionably had pelvic pain rather than abdominal pain, and underwent aggressive surgery consisting of the hysterectomy and bilateral salpingo-oophorectomy in an attempt to relieve the pain.  She also underwent multiple studies to find the etiology for the pelvic pain including colonoscopy, barium enema, and cystoscopy, all of which were normal.  Nevertheless, the pelvic pain continued unabated even after a post-separation cholecystectomy.  While there is no doubt the CI had pelvic adhesions from her many pelvic surgical procedures as well as recurrent urinary tract infections and occasional bowel problems, the pelvic pain persisted in the presence of a history of endometriosis.  Furthermore, there was a lack of a definitive statement rather than the observation that there was no obvious endometriosis of the right ovary.  Additionally, the absence of a pathology report in the STR cannot answer the question of whether there were microscopic foci in right ovary or in or on any other structure that was removed at the time of surgery.   Not only is use of code 7629 at 30% reasonable for the persistent pelvic pain, but its use is supported by VASRD §4.7 (higher of two evaluations) which states:  “Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned.”  Therefore, since the CI had continued pelvic pain even after the hysterectomy and bilateral salpingo-oophorectomy, the disability picture more closely favors a 30% rating, which is more accurate than the 10% afforded by code 7301 for peritoneal adhesions, which was not proved definitively by a follow-up laparoscopy, but was speculated as a possible etiology of the pelvic pain, which could have many causes.  Therefore, the definitive history of endometriosis coding fits better in this case since it clearly addresses pelvic pain rather than the peritoneal adhesions that refer to abdominal pain related to colic, nausea, constipation, or abdominal distension. Therefore, the minority voter recommends the ROP be modified as follows:

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 chronic abdominal (pelvic) pain condition, coded 7629.  

BOARD FINDINGS:  In the matter of the abdominal (pelvic) condition, the panel recommends a disability rating of 30%, coded 7629 IAW VASRD §4.116.  In the matter of the contended foot condition, the panel recommends no change from the PEB determination as not unfitting.  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	
Chronic Abdominal (Pelvic) Pain	7629	30%	

AR20200003858

Dear XXXXXXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and by majority vote, recommended your disability rating should be modified to 10% but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement.  I have reviewed the Board’s record of proceedings, majority recommendation, and minority opinion.  I reject the Board’s recommendation and I accept the Board’s minority opinion to recharacterize your separation as a permanent 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, minority opinion and record of proceedings for your information.

	The recharacterization of your separation as a permanent 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.  Inquiry concerning your correction of records should be addressed to the U.S. Army Physical Disability Agency

	A copy of this decision has also been provided to the Department of Veterans Affairs.