RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW NAME: XXXXXXXXXXXXXXXX CASE: PD1200427 BRANCH OF SERVICE: ARMY BOARD DATE: 20130418 SEPARATION DATE: 20060126 SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an activated National Guard SSG/E-6 (31B30/Military Police [MP]) medically separated for a heart condition. He has a history of symptomatic bradycardia and in October 2004 underwent an uncomplicated placement of a permanent pacemaker. The condition could not be adequately rehabilitated to meet the deployable requirements of his Military Occupational Specialty (MOS). He was issued a permanent P2 profile and referred for a Medical Evaluation Board (MEB). The heart condition, characterized as “AV Block 2nd degree, stable with pacemaker” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501 and no other conditions were submitted by the MEB. The Informal PEB (IPEB) adjudicated the heart condition as unfitting, rated 10% with application of the Veteran’s Administration Schedule for Rating Disabilities (VASRD). The CI made no appeals, and was medically separated with a 10% disability rating. CI CONTENTION: The CI makes no contentions. SCOPE OF REVIEW: The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e.(2). It is limited to those conditions determined by the PEB to be unfitting for continued military service and those conditions identified but not determined to be unfitting by the PEB when specifically requested by the CI. The rating for the unfitting heart condition is addressed below; and, no additional conditions are within the DoDI 6040.44 defined purview of the Board. Any conditions or contention not requested in this application, or otherwise outside the Board’s defined scope of review, remain eligible for future consideration by the Board for Correction of Military Records. RATING COMPARISON: Service IPEB – Dated 20051209 VA - (6 Mos. Pre -Separation) Condition Code Rating Condition Code Rating Exam AV Block, 2nd Degree Pacemaker 7015 10% Mobits Type II Heart Block S/P Pacemaker Placement 7015 60% 20050727 No Additional MEB/PEB Entries Other x 4 20050727 Combined: 10% Combined: 70% Derived from VA Rating Decision (VARD) dated 20061222 (most proximate to date of separation [DOS]). ANALYSIS SUMMARY: Heart Condition. The narrative summary (NARSUM) notes that following placement of the pacemaker in October 2004, the CI did well both postoperatively and for the remainder of the year leading up to the MEB. He was without complaints or problems during that period and was considered to have been doing well at routine follow up exams. His condition was considered stable and it was not expected to interfere with his ability to function in general and specifically with his ability to run, perform push-ups or sit-ups. It was recommended that he not be deployed to OCONUS because of the potential need for timely maintenance of the pacemaker. The commander’s statement citing the stresses of his job as a squad leader in an MP platoon, felt that he was not medically fit to perform the duties required of his MOS. At the MEB cardiology exam about a month prior to separation, the CI reported no cardiac complaints. Treadmill stress test revealed a maximum workload of 12.8 metabolic equivalent of tasks (METS) and was discontinued because of fatigue. Electrocardiogram (ECG) was non-diagnostic. X-ray study done as part of the MEB physical demonstrated optimal appearance and positioning of the pacemaker leads and tips. At the VA Compensation and Pension (C&P) exam performed 6 months prior to separation, the CI reported that pacemaker placement had improved his symptoms and that he could perform functions that would not make him very tired. His METS level was determined to be “about four to five” as reported on 27 July 2005. However, it is noted that a treadmill test dated 28 July 2005 by a civilian consultant revealed a measured maximum workload of 10 METS. Although left ventricular hypertrophy (LVH) was noted in stress testing in this exam, that finding was not replicated in the cardiology addendum to the MEB or in subsequent exams. Echocardiogram (ECHO) performed 3 months after separation showed no LVH and an ejection fraction of 55-60. The CI was seen for chest pain 12 months after separation and underwent cardiac catheterization (normal coronary arteries). Additionally, a myocardial perfusion scan performed 12 months after separation demonstrated a large, mildly severe, septal wall defect and ejection fraction was calculated at 47% with normal left ventricle size. The CI was diagnosed with “atypical chest pain and cardiomyopathy now symptom free ...” An ECHO performed 14 months after separation documented no LVH, normal wall motion and a normal ejection fraction of 60%. Subsequent VA exams were noted and subsequent VA ratings of 60% were based on decreased ejection fraction “of 30 to 50 percent.” The Board directs attention to its rating recommendation based on the above evidence. The only applicable code is VASRD 7015 (atrioventricular block) assigned by both the PEB and VA. The Board first considered the PEB’s rating of the disability at 10%. In doing so, the PEB cited the cardiologist’s note, a month prior to separation, wherein it was stated that the CI was asymptomatic and that he was able to achieve 12.8 METS on exercise testing. The PEB determined that the condition merited a 10% rating because of the requirement of the pacemaker. The VA, however, based its initial rating on a C&P exam done in July 2005, about 5 months prior to separation, in which the CI’s METS level was stated as “about four to five.” It awarded a 60% rating under 7015 for which the condition would qualify with a METS score of between 3 and 5. It is obvious that there is a clear disparity between these examinations, with very significant implications regarding the Board's rating recommendation. The Board thus carefully deliberated its probative value assignment to these conflicting evaluations, and carefully reviewed the service file for corroborating evidence in the 12-month period prior to separation. Subsequent VA ratings of 60% were based on decreased ejection fraction, which was not present at the time of separation. The decline in ejection fraction noted at a year post- separation was adjudged post-separation worsening. The Board concluded that the evaluation done by the cardiologist as part of the MEB exam, a month prior to separation, was the most probative both because it was a specialist examination using measurements obtained through treadmill stress testing and also because it was the exam most proximate to the date of separation. In addition, further support is given to the PEB rating by the results of the civilian consultant mentioned above whose METS determination of 10 was more closely aligned with that of the cardiologist done a few months later. There did not appear to be any objective data in evidence proximate to the date of separation which indicated functioning at a lower level or evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray that would justify a higher 30% rating; or an ejection fraction of 30 to 50 percent for a higher 60% rating under 7015. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the second degree atrioventricular block condition/pacemaker condition. The Board concluded therefore that this condition could not be recommended for additional disability rating. BOARD FINDINGS: IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication. The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised. In the matter of the second degree AV Block condition and IAW VASRD §4.104, the Board unanimously recommends no change in the PEB adjudication. There were no other conditions within the Board’s scope of review for consideration. RECOMMENDATION: The Board, therefore, recommends that there be no recharacterization of the CI’s disability and separation determination, as follows: UNFITTING CONDITION VASRD CODE RATING AV Block, 2nd Degree Pacemaker 7015 10% COMBINED 10% The following documentary evidence was considered: Exhibit A. DD Form 294, dated 20120530, w/atchs Exhibit B. Service Treatment Record Exhibit C. Department of Veterans’ Affairs Treatment Record xxxxxxxxxxxxxxxxxxxxxxx, DAF Director of Operations Physical Disability Board of Review SFMR-RB MEMORANDUM FOR Commander, US Army Physical Disability Agency (TAPD-ZB / xxxxxxxxxxxx), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557 SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for xxxxxxxxxxxxxxxxxxxxxxxxxx, AR20130009624 (PD201200427) I have reviewed the enclosed Department of Defense Physical Disability Board of Review (DoD PDBR) recommendation and record of proceedings pertaining to the subject individual. Under the authority of Title 10, United States Code, section 1554a, I accept the Board’s recommendation and hereby deny the individual’s application. This decision is final. The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail. BY ORDER OF THE SECRETARY OF THE ARMY: Encl xxxxxxxxxxxxxxxxxxx Deputy Assistant Secretary (Army Review Boards)