RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD1201310
BRANCH OF SERVICE:  Army	BOARD DATE:  20140327
SEPARATION DATE:  20030820

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (14S10/Avenger Crewmember) medically separated for an allergic rhinitis condition.  The CI incurred a long history of severe refractory allergies despite treatment with multiple courses of topical and systemic allergy medications, steroids and immunotherapy.  His condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty or satisfy physical fitness standards.  He was issued a permanent P3 profile and referred for a Medical Evaluation Board (MEB).  Severe allergies, upper airway resistant syndrome and refractory allergic rhinitis were forwarded to the Physical Evaluation Board (PEB) as not meeting medical standards IAW AR 40-501.  No other conditions were submitted by the MEB.  The Informal PEB adjudicated “allergic rhinitis, without polyps or obstruction” as unfitting, rated 0%, with application of the VA Schedule for Rating Disabilities (VASRD).  The CI made no appeals and was medically separated.

CI CONTENTION:  “I am requesting the board review of the rating I was awarded when I separated from the USA and consider me for military disability retirement for the following reasons:  I feel the Medical Evaluation Board should have also evaluated the degree of my disability from my bilateral knee strain with arthritis and sleep apnea.  From the time the Medical Evaluation Board conducted their exam on 4/8/2003 to the time they rendered their decision on 6/16/2003 there were additional medical conditions identified on a physical exam on 5/22/203 that were no [sic] considered.  I am submitting copies of all the examinations and reports for your review.”

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 the unfitting allergic rhinitis (severe allergies, upper airway resistant syndrome and refractory allergic) condition are addressed below.  The knee condition, as per the contention, was not identified by the MEB or PEB; and, thus are not within the DoDI 6040.44 defined purview of the Board.  This and any other condition or contention not requested in this application, remain eligible for future consideration by the Board for Correction of Military Records.

RATING COMPARISON:

Service IPEB – Dated 20030617 | VA* (11.7 Mo. Post-Separation)
Condition | Code | Rating | Condition | Code | Rating | Exam

Allergic Rhinitis, with Polyps or Obstruction
(Includes:  Severe Allergies, Upper Airway Resistant Syndrome and Refractory Allergic Rhinitis)

6522

0%

Chronic Rhinitis Upper Airway Resistant Syndrome

6599-6522

0%

20040804

No Additional MEB/PEB Entries | Other x 4 | 20040804
Combined:  0% | Combined:  20%
*Derived from VA Rating Decision (VARD) dated 20040929 (most proximate to date of separation (DOS))

ANALYSIS SUMMARY:  The Board acknowledges the CI’s contention that suggests ratings should have been conferred for other conditions documented at the time of separation.  The Board wishes to clarify that it is subject to the same laws for service disability entitlements as those under which the Disability Evaluation System (DES) operates.  While the DES considers all of the member's medical conditions, compensation can only be offered for those medical conditions that cut short a member’s career and then only to the degree of severity present at the time of final disposition.  However, the Department of Veterans Affairs, operating under a different set of laws (Title 38, United States Code), is empowered to compensate all service-connected conditions and to periodically reevaluate said conditions for the purpose of adjusting the Veteran’s disability rating should the degree of impairment vary over time.

The PEB bundled the three conditions from the MEB and rated as a single entity. The Board agreed that the allergic rhinitis condition and the severe allergy conditions are part and parcel and will be discussed together.  The Board agreed that the upper airway resistant syndrome (UARS), a sleep breathing disorder closely related to obstructive sleep apnea, was an unrelated condition and will be discussed separately.  The Board’s initial charge in this case is directed at determining if the PEB’s approach of combining conditions under a single rating was justified in lieu of separate ratings.  The Board must apply separate codes and ratings in its recommendations if compensable ratings for each condition are achieved IAW applicable VASRD sections.  If the Board judges that separate ratings are warranted in such cases, it must satisfy the reasonable requirement that each ‘unbundled’ condition was unfitting in and of itself or at least an indispensable element of a combined effect rating.

Allergic Rhinitis, without Polyps or Obstruction.  The CI had a long history of allergies to environmental antigens which were difficult to control with varying combinations of antihistamine, nasal and oral steroids medications.  Symptoms included watery eyes, nasal congestion, dry cough and sneezing and infrequent episodes of facial swelling.  Included in treatments was surgical removal of tissue in the nose to improve breathing.  Apparent good relief was ultimately obtained with “immunotherapy” (desensitizing allergy shots) given daily or weekly by the allergy clinic.  The CI was doing well on this regimen and was deployed in 2003.  In theater the CI was unable to receive the allergy shots and developed increasing episodes of severe allergic reactions, manifest by neck and facial swelling with tongue itching requiring emergent treatment with anti-anaphylactic medication (Epinephrine and Benadryl).  He was returned from theater and his condition stabilized with resumption of immunotherapy without recorded subsequent reactions.  At the MEB narrative summary (NARSUM) exam on 28 April 2003, approximately 4 months before separation, the CI was breathing comfortably without swelling and in no apparent distress.  Exam of the oral pharynx revealed evidence of chronic reaction without masses.  Nasal mucosa had diffuse edema and erythema, but was patent (without polyp presence or obstruction).  The CI was continuing the immunosuppressive treatments at this time.  The recorded medication at that time was Allegra, Flonase and Singular.
At the VA Compensation and Pension (C&P) respiratory exam on 8 August 2004, approximately 12 months after separation, the CI reported that he had no dyspnea on rest or exertion.  He noted being on no medical treatment and offered that he “didn’t have time to stay home and see a doctor as he had to work.”  On physical examination, minimal nasal obstruction of 10% to 20% was present especially on the left.  Sinusitis and evidence of infection were not present.  Pulmonary exam was unremarkable.  Pulmonary function tests (PFTs) obtained at this time were normal.

The Board directs attention to its rating recommendation based on the above evidence.  Both the PEB and VA rated the allergy condition, allergic rhinitis, code 6522, 0%, IAW §4.97 and §4.31.  A higher rating of 10% under this code requires a greater than 50% reduction of nasal passage on both sides or complete obstruction on one.  The highest rating of 30% requires the presence of nasal polyps.  None of these is supported by the record in evidence.  The Board agreed that, at the time of separation the allergy condition was stabilized on treatment with normal PFT and found no other appropriate codes for consideration.  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 allergic rhinitis, without polyps or obstruction condition.

Upper Airway Resistance Syndrome (UARS).  According to the NARSUM, the CI was diagnosed with mild sleep apnea in July 2002, subsequently identified as UARS.  The CI apparently underwent treatment with continuous positive airway pressure (CPAP) although the details are not in the record.  Subsequently, the CI underwent uvulopalatopharyngoplasty, an oral procedure reserved for symptoms of sleep apnea.  As noted above, the CI was subsequently deemed fit for deployment.  The Board was unable to determine if the CI required CPAP at this time or whether CPAP was deployed with the CI to theater.  As noted above the CI had significant allergic reactions in theater, not related to any sleep condition, and was returned CONUS.  The diagnosis of UARS is presented in the NARSUM notes without discussion of the condition.  At the C&P evaluation, 4 years after separation, the CI noted some daily hyper-somnolence, but was receiving no medical care.  Pulmonary exam was normal.  Sleep studies obtained on 22 May 2005 revealed mild sleep apnea with improvement with addition of small amounts of CPAP.

The Board undertook to determine the fitting status of the sleep condition.  This condition was not profiled; was not implicated in the commander’s statement.  It was mentioned only by diagnosis in the service treatment record and DES.  There is no evidence of any emergency room or unscheduled clinic visits or hospitalizations for the sleep condition.  It was reviewed by the action officer and considered by the Board.  There was no indication from the record that this condition significantly interfered with satisfactory duty performance including deployment.  After due deliberation in consideration of the preponderance of the evidence, the Board unanimously concluded that the sleep condition, when unbundled, was not unfitting, and thus, no additional disability rating can be recommended.

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 allergic rhinitis, without polyps or obstruction condition, and IAW VASRD §4.97, 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 re-characterization of the CI’s disability and separation determination.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20120602, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

				
XXXXXXXXXXXXXXXXXX
President
Physical Disability Board of Review

SAMR-RB									

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXX, AR20140018973 (PD201201310)

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						    XXXXXXXXXXXXXXXXXX
						     Deputy Assistant Secretary of the Army
						          (Review Boards)
						         
CF: 
(  ) DoD PDBR
(  ) DVA