RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2021-00057
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20090510

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Power Generator Equipment Repair Specialist, medically separated for “residuals of traumatic brain injury [TBI]” with a disability rating of 10%. 

CI CONTENTION:  Review requested of chronic headaches and neck/shoulder spasms.  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 - 20081217	VARD - NA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Residuals of TBI	8045	10%	No VA Examination in Evidence	
Left Suprascapular	Not Unfitting		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:  

TBI Residuals.  According to the service treatment record and MEB narrative summary (NARSUM), in August 2007, the CI was exposed to a grenade blast without loss of consciousness.  At the 22 September 2008 MEB examination (recorded on DD Forms 2807-1 and 2808), 8 months before separation, he reported nervous trouble, memory loss, frequent trouble sleeping, and depression.  

The 15 October 2008 neuropsychological evaluation showed no cognitive impairments and that the CI was well within expectations on measures of executive functioning, attention, concentration, cognitive processing speed, and visuospatial and constructional abilities.  Neurobehavioral and mood symptoms were absent.  The MEB NARSUM examination, on the same day, recorded complaints of hearing loss and headaches, but an unremarkable CT head scan (with the exception of asymmetric ventricles believed to be congenital) and brain MRI.  The examiner noted that neuropsychological testing did “not provide any evidence of impaired cognitive function.”  The CI was followed by neurology for medication to treat his headaches and sleep problems, both of which had improved but persisted at a lower level.  He reported daily headaches that were “mostly tolerable” but got “bad 4 or 5 times a week.”  They usually resolved within 15-20 minutes at which time he was able to resume activity.  He denied having seizures, dizziness, vertigo, fatigue, bowel or bladder problems, changes in taste or smell, or sound or light sensitivity.  Memory impairment was not noted, and physical examination was unremarkable. There was no VA examination proximate to separation in evidence.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the TBI residuals 10%, coded 8045 (residuals of TBI), citing “soldier does not meet the requirements for a 10% rating because he only has one subjective symptom that mildly interferes with work.  However, IAW VASRD 4.7, higher of two evaluations, Soldier is rated at 10% because the overall disability picture is closer to [the] 10% rating based on mild impairment.”  Evaluation of TBI residuals in the VASRD are based upon the highest level of severity for any facet of cognitive impairment and other residuals identified as associated with the condition.  The next higher rating of 40% requires demonstration of impairment corresponding to level 2, but this was not supported by the evidence.  The record documented no objective findings of memory loss, impaired judgment, inappropriate social interactions, or orientation, communication, or behavior issues that interfered with workplace interactions.  The commander did not mention any impairment in memory, learning, or judgment, or difficulties with language comprehension.  The treatment records only substantiated headaches as a clinically significant impairment at the time of separation.  The CI complained of memory impairment, daily mild to moderate headaches, and frequent insomnia, which supports a rating of “1” (10%) for level of impairment.  There was no mention of prostrating headaches to rate the condition under the migraine headache code (8100).  Additionally, there was no objective evidence of memory deficits found on the neuropsychological evaluation.  Therefore, panel members agreed that a rating higher than the 10% adjudicated by the PEB was not justified for the TBI residuals under code 8045.  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 TBI residuals.  

Contended PEB Condition:  Left Suprascapular.  The panel’s main charge is to assess the fairness of the PEB determination that the contended condition was not unfitting.  The condition was not profiled and did not fail retention standards; and 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 TBI residuals and IAW VASRD §4.124a, the panel recommends no change in the PEB adjudication.  In the matter of the contended Left suprascapular 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.  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 20210411, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20210017114, XXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXX:

	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.

Sincerely,