RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXX	CASE:  PD-2021-00084
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040826

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Helicopter Repairer, medically separated for “narcolepsy without cataplexy and borderline mild sleep apnea syndrome” with a disability rating of 10%.    

CI CONTENTION:  “Spc. Hines was diagnosed by the Medical Examination Board (MEB) with borderline mild sleep apnea syndrome.  The MEB also diagnosed Spc. Hines with narcolepsy without cataplexy.  Although sleep apnea and narcolepsy are separate medical conditions with a combined disability rating of 40% under the Veterans Affairs Schedule for Rating Disabilities, the Physical Examination Board (PEB) assigned Mr. Hines a disability rating of only 10% for narcolepsy.  Our accompanying brief in support of this application establishes that Mr. Hines should have been disability retired with a permanent disability rating of 40% based on separate diagnoses of sleep apnea and narcolepsy.  Mr. Hines therefore respectfully requests that the Physical Disability Board of Review recommend to the Secretary of the Army that Mr. Hines’ permanent disability rating be increased to 40%, and his separation be re-characterized to disability retirement, instead of medical separation.”  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 - 20040607	VARD - 20040924	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Narcolepsy w/o Cataplexy, Borderline Mild Sleep Apnea Syndrome	8108	10%	Narcolepsy	8108	10%	20040520	
			Sleep Apnea Syndrome	6847	30%	20040520	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40% 	

ANALYSIS SUMMARY:  

Narcolepsy w/o Cataplexy, Borderline Mild Sleep Apnea Syndrome.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI had a long history of tiredness and sleepiness as well as loud snoring.  In the year prior to entry into the disability evaluation system (DES), the CI started noticing increased tiredness, particularly in the morning hours.  
During the 19 February 2004 MEB examination (recorded on DD Forms 2807-1 and 2808), 6 months before separation, the CI endorsed sleeping problems and noted “apnea and narcolepsy.”  Physical findings were unremarkable, but the provider noted the CI was taking a stimulant medication to treat the narcolepsy and had been removed from flight status due to the diagnosis.  The only two diagnoses listed by the examiner included narcolepsy and hyperlipidemia.

The 22 March 2004 MEB NARSUM examination, 5 months prior to separation, documented complaints of chronic tiredness and daytime sleepiness.  The CI reported two episodes of dozing off while acting as crew chief in an aircraft, despite having on average 7 hours of sleep on a regular basis.  There were no symptoms of cataplexy and medication improved his condition.  The examiner recommended a different alertness medication for treatment of the narcolepsy, and   determined the condition (Chapter 3-30 (h)) was medically unacceptable.  The examiner placed the CI on a permanent profile solely for narcolepsy and recommended referral to a PEB.

At the 20 May 2004 VA Compensation and Pension (C&P) examination, 3 months before separation, the CI reported a two-year history of narcolepsy with a total of three attacks averaging two each year; there was no report of an attack in the past 6 months.  The condition impaired his ability to safely operate machinery or military vehicles.  The CI noted he did not lose any time from work due to his narcolepsy.  Physical examination was unremarkable.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB bundled the narcolepsy and sleep apnea under a single 10% rating, coded 8108 (narcolepsy), citing treatment with stimulant medication, and mild social and industrial impairment.  The VA rated the narcolepsy 10%, also coded 8108, based on the C&P examination, citing a “confirmed diagnosis of epilepsy with a history of seizures,” or “if continuous medication is necessary for the control of epilepsy.”  The VA additionally rated the sleep apnea 30%, coded 6847 (sleep apnea syndrome), based on the C&P examination, citing persistent daytime hypersomnolence.

The panel first considered if the narcolepsy, having been de-coupled from the combined PEB adjudication, remained separately unfitting.  The condition was profiled, implicated in the commander’s statement, and failed retention standards IAW AR-40-501, Chapter 3-30 (h-narcolepsy).   The MEB neurologist opined the condition was treatable by implementing strategies to promote alertness during the day with medication.  However, the commander indicated the CI was unable to perform Blackhawk repairer duties because his condition rendered him unable to climb aircraft to perform routine maintenance, be present for duty at late night or early morning missions, or drive aircraft ground handling vehicles.  Thus, the panel agreed the evidence of functional limitations caused by the narcolepsy contributed to the CI’s inability to perform his military duties, and accordingly a separate disability rating is recommended.

The panel next proceeded with the rating recommendation based on the evidence at the time of separation.  A 10% rating under code 8108 (rated as for epilepsy, petit mal, using code 8911) applies when there is a confirmed diagnosis of epilepsy with a history of seizures; or when continuous medication is shown necessary for the control of epilepsy (cannot be combined with any other rating for epilepsy).  A higher 20% rating is warranted when there is “at least 1 major seizure in the last 2 years; or at least 2 minor seizures in the last 6 months.”  Panel members considered the evidence and agreed the STR did not demonstrate attacks of sleep, loss of muscle tone, or any or form of episode in the 6 months prior to separation.  The CI reported no episode of falling without loss of consciousness prior to the narcolepsy diagnosis in 2003.  While he did report two episodes of dozing off while on duty in an aircraft, there was no indication that any episode occurred in the 6 months prior to separation.  At the VA examination, the CI reported three attacks over the previous two years.  Panel members concluded the evidence does not support a rating higher than the 10% adjudicated by the PEB.  After due deliberation, considering all the evidence, the panel recommends a separately unfit determination with a disability rating of 10% for the narcolepsy.  

The panel next considered whether the sleep apnea was separately unfitting.  Panel members first noted the apnea was not profiled or implicated in the commander’s statement, and did not fail retention standards.  The MEB listed the condition as a diagnosis, but indicated the medically unacceptable condition was narcolepsy without cataplexy, “PARA 3-30h, AR 40-501.”  The NARSUM referenced October 2003 sleep study findings, which showed a mildly elevated apnea-hypopnea index.  However, the examiner opined that the study did not demonstrate the condition would significantly contribute to the  daytime symptoms.  The examiner noted the CI was at higher risk for developing significant sleep-disordered breathing; but there was no evidence of worsening sleep apnea in the 12 months after separation.  The STR did not indicate treatment related to sleep apnea.  Therefore, panel members concluded that the preponderance of evidence showed the mild sleep apnea would not reasonably have caused the CI to be referred into the DES or be found unfit.  After due deliberation, considering all the evidence, the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the bundled narcolepsy and sleep apnea condition.

BOARD FINDINGS:  In the matter of the narcolepsy without cataplexy, borderline mild sleep apnea syndrome 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 20210331, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20210017328, XXXXXXXXXXXXXX. 

Dear XXXXXXXXXXXXXXX:

	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.

	A copy of this decision has been provided to the counsel you listed on your application; XXXXXXXXXXXXXXXXX

Sincerely,