RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW NAME: XXXXXXXXXXXXXXXXXXXX BRANCH OF SERVICE: ARMY CASE NUMBER: PD1201375 SEPARATION DATE: 20030805 BOARD DATE: 20130122 SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SGT/E-5 (13B20/Cannon Crew Member), medically separated for narcolepsy. The CI had multiple medical problems and was on profile for various aliments for a significant portion of his career. He was evaluated by a neurologist on 17 August 2001 for headaches and leg pain. Among others, a diagnosis of “questionable sleep apnea” was made and nocturnal polysomnography (PSG-sleep study) recommended. While sleep apnea was not ruled out by the sleep study, the CI underwent another nocturnal polysomnography with continuous positive airway pressure breathing device (CPAP) and multiple sleep latency testing on 27 January 2002 was interpreted as diagnostic of narcolepsy. The CI did not meet retention standards for military duty in accordance with AR 40-501, or DoD Instructions. He was issued a permanent P3 profile and referred for a Medical Evaluation Board (MEB). The MEB also identified and forwarded three other conditions, identified in the rating chart below, as being medically acceptable. The Physical Evaluation Board (PEB) adjudicated the narcolepsy condition as unfitting, rated 20%, with cited application of Department of Defense Instruction (DoDI) 1332.39, and the Veteran’s Affairs Schedule for Rating Disabilities (VASRD). The remaining conditions were determined to be not unfitting and not ratable. The CI initially appealed but subsequently withdrew his request. He was then medically separated. CI CONTENTION: “I have received a 50% rating from the VA for the same condition.” 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 ratings for unfitting conditions will be reviewed in all cases. The unfitting narcolepsy condition, as requested for consideration meets the criteria prescribed in DoDI 6040.44 for Board purview and is addressed below. The condition of OSA with CPAP, considered part of the CI’s contended VA 50% rating proximate to separation, and any other 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 respective service Board for the Correction of Military Records. RATING COMPARISON: Service IPEB – Dated 20030303 VA (At Separation) – All Effective Date 20030806 Condition Code Rating Condition Code Rating Exam Narcolepsy 8108 20% Obstructive Sleep Apnea w/ Narcolepsy 8108-6847 50% 20030828 Maxillary Sinus Disease Not Unfitting Maxillary Sinus Disease, Post-Op Nasal Cysts 6513 0% 20030828 Chronic Testicular Pain Not Unfitting Post-Op Rt Testicle Scar 7805 0% 20030828 Post-Op Rt Testicle Scar 7805 0% 20030828 Chronic Lower Extremity Pain Not Unfitting Fibromyalgia w/ Lower Extremity (& Other) Pain 5025 10% 20030828 .No Additional MEB/PEB Entries. Heart Condition Mitral Valve Prolapse 5025 30% 20030828 Tinnitus 6260 10% 20030828 Asthma 6602 10% 20030828 Headaches 8100 10% 20030828 0% X 5 (Includes Above) / Not Service-Connected x 3 20030828 Combined: 20% Combined: 80% ANALYSIS SUMMARY: Narcolepsy Condition. Initial onset of symptoms was not detailed; however, in October 2001 the CI presented to the pulmonary outpatient office on referral from the primary care clinic for evaluation of possible sleep apnea. The pulmonologist determined a need for a sleep study with multiple sleep latency (MSLT) tests; study findings were consistent with idiopathic hypersomnia (excessive sleepiness), and “possibly an occult OSA syndrome.” The CI was given a trial of CPAP and reported feeling better with CPAP. The physician stated, “It is difficult to know whether he has true idiopathic hypersomnia or simply mild sleep apnea not sufficiently treated with CPAP therapy and for this reason, nocturnal PSG with CPAP and MSLT were arranged.” Narcolepsy was diagnosed based on the MSLT results. Between the January 2002 sleep study and follow up visit with the sleep center, 11 months later, the CI was started on Modafinil and reportedly was doing extremely well with the medication. The narrative summary (NARSUM) dictated 10 months prior to separation acknowledged the result of the sleep study and it’s finding of narcolepsy and stated “No significant obstructive sleep apneas were identified,” and noted the CI no longer used CPAP. It was concluded the diagnosis of narcolepsy was incompatible with continued military service. A NARSUM addendum was conducted approximately 2 weeks after the initial NARSUM. It recorded the CI’s complaint of falling asleep easily and episodes of sudden paralysis which had occurred after events such as sneezing. The CI attributed a motor vehicle accident (MVA) to one of his sleep attacks, where he fell asleep and hit a truck. The CI subsequently lost his driver’s license. The examiner stated “His condition greatly effects his job in that he cannot accomplish tasks as a section chief because he falls asleep easily.” The CI’s diagnosis was narcolepsy with evidence of cataplexy (loss of muscle tone in response to emotional stimuli). Degree of military impairment was stated as “moderate,” with social and industrial impairment as “definite.” The commander’s performance statement (9 months prior to separation) stated, “The soldier does not have the ability to operate a motor vehicle or a weapon due to his narcolepsy.” He was working in his unit as a repair and upkeep NCO. The CI had had a profile that restricted his use of driving and power tools. A letter from a pulmonologist to an Army Administrative Law Attorney about 5 months prior to separation referenced the CI’s diagnosis of narcolepsy without cataplexy and indicated there was no contraindication to the operation of a motor vehicle or the operation of power equipment. The examiner stated: “(The CI’s) level of excessive somnolence is well controlled with Modafinil 400mg daily. There is no history of classic cataplexy.” At the VA Compensation and Pension (C&P) exam, approximately 3 weeks after separation, the examiner noted that the CI was being medically separated from the Army for narcolepsy evident by attacks of sleep that had occurred for at least 3 months. “He is on CPAP and he is getting medically boarded out for the same. Symptoms of classic narcolepsy are described. … This does him a moderate amount of physical impairment.” The Board directs its attention to its rating recommendation based on the above evidence. The PEB assigned a 20% rating (based on “at least 2 minor seizures in the last 6 months”). The VA rated the CI’s narcolepsy combined with obstructive sleep apnea (OSA) at 50%, coded 8101- 6847. The VA rating decision specified use of the 6847 OSA criteria for their rating, and did not specify frequency of narcolepsy events. The PEB specified application of DoDI 1332.39 (now rescinded) for their rating. Although sleep attacks were reported, there was no quantification of the frequency or timing of the episodes, and the CI did not experience episodes of cataplexy. The CI had a confirmed diagnosis of narcolepsy. VASRD rating criteria for narcolepsy uses the criteria of petit mal epilepsy, under the general rating formula for minor seizures. These criteria are based on the number of episodes over specified time periods; “5 to 8 minor seizures weekly” are rated at 40% and “at least 2 minor seizures in the last 6 months” are rated at 20%. The Board noted that there was no quantification of episodes of inappropriate falling asleep, other loss of awareness symptoms equivalent to a minor seizure aside from the single report of an MVA related to falling asleep, or cataplexy episodes. The pulmonary specialist indicated no episodes of cataplexy, and that excessive somnolence was controlled on medication. Rating strictly on the number and frequency of episodes specified in the record did not support rating above the 20% criteria. 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’s 20% adjudication for the narcolepsy condition. 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. As discussed above, PEB reliance on DoDI 1332.39 for rating narcolepsy was operant in this case and the condition was adjudicated independently of that instruction by the Board. In the matter of the narcolepsy condition and IAW VASRD §4.124a, 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 Narcolepsy 8108 20% COMBINED 20% The following documentary evidence was considered: Exhibit A. DD Form 294, dated 20120904, w/atchs Exhibit B. Service Treatment Record Exhibit C. Department of Veterans’ Affairs Treatment Record XXXXXXXXXXXXXXXXXXXXX, DAF Acting Director Physical Disability Board of Review SFMR-RB MEMORANDUM FOR Commander, US Army Physical Disability Agency (TAPD-ZB / XXXXX), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557 SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXX, AR20130003935 (PD201201375) 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 XXXXXXXXXXXXXXXXX Deputy Assistant Secretary (Army Review Boards)