RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXX	CASE:  PD-2013-02461
BRANCH OF SERVICE:  AIR FORCE 	BOARD DATE:  20140724
SEPARATION DATE:  20050914

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SrA/E-4 (2A753/Aircraft Structural Maintenance Journeyman) medically separated for a restrictive airway disease condition.  The condition could not be adequately rehabilitated to meet the physical requirements of his Air Force Specialty (AFS) or satisfy physical fitness standards.  He was issued a P4L4 profile and referred for a Medical Evaluation Board (MEB).  The restrictive airway disease condition was forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123.  No other conditions were submitted by the MEB.  The Informal PEB adjudicated “dyspnea on exertion and shortness of breath due to restrictive airway disease” as unfitting, rated 10%, citing criteria of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The PEB also adjudicated obesity as a Category III condition (not separately unfit & compensable/ratable). The CI made no appeals, and was medically separated.

CI CONTENTION:  “At the time of separation I had 7yrs, a line number for Staff Sgt., and was looking to serve my country as long as the Air Force would let me.  I was an aircraft Structural Maintenance Journeyman who came in the Air Force with no history of sarcoidosis (reactive airway disease).  I was medically disqualified from the service due to my disability, and even at the time I could not go to Airman Leadership School due to my disability so I could claim my line number (Sgt).  I had a lot going on around that time my son (born Sept 9, 2005), my wife was in the hospital, and I was still dealing with a foot injury that was mis-diagnosed.  I felt then that I should of at least been medically retired, but was told this is probably the best (10%).”

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 restrictive airway disease 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 20050802 | VA - (3 Mos. Post-Separation)
Condition | Code | Rating | Condition | Code | Rating | Exam

Restrictive Airway Disease

6602-6699

10%

Sarcoidosis, to Include Claim for Dyspnea and Reactive
Airway Disease

6846-6600

30%

20051201

Obesity | CAT III | No VA Entry
No Other MEB/PEB Entries | Other x 8 | 20051201
Combined:  10% | Combined:  70%
Derived from VA Rating Decision (VARD) dated 20060413 (most proximate to date of separation).

ANALYSIS SUMMARY: 
Reactive Airway Disease Condition.  The narrative summary (NARSUM) notes the CI developed shortness of breath (SOB) and dyspnea on exertion (DOE) in April 2003.  Initial chest X-ray suggested enlargement of the heart.  Full cardiac evaluation revealed no etiology for the symptoms.  Pulmonary function tests (PFT) performed on 14 May 2002, revealed moderately severe restrictive airway disease.  At his clinical evaluation on 8 July 2008, the CI reported intermittent SOB and asthma medications were empirically initiated.  At this time the CI was moderately severely obese with a body mass index (BMI) of 30; (BMI: 18.5–24.99 normal; 25-29.99 overweight 30 –34.99 moderately severe obesity; >35 severe obesity).  A diagnosis of “sarcoidosis” a granuloma disease of the lung substance was made but not confirmed on subsequent studies.  No treatment for this disease was reported in the record in evidence and the diagnosis was dismissed.  No other etiologic diagnoses were assigned to the condition.  At the pulmonary clinical examination performed on 18 September 2003, the CI reported continued intermittent SOB with DOE and stated that he received “no benefit from the inhaled asthma medication”.  On physical examination the CI did not complain of SOB, chest exam was normal and PFT revealed FEV-1 of 80% and FEV-1/FVC (RATIO) of 89%, consistent with mild restrictive disease.  BMI at this time was 32.4.  On 15 December 2003, the CI was asked by his providers to lose weight as they felt “his restrictive disease was likely secondary to his body habitus.”  At his follow-up evaluation dated 3 February 2004, the CI reported not taking pulmonary medication and was able to run 1.5 miles in 15 minutes.  The examiner opined that the diagnosis of sarcoidosis had been ruled out and the CI had restrictive airway disease, “most probably related to his morbid obesity.”  The CI was seen 19 August 2004 and reported taking albuterol as needed with some relief of his SOB.  On this exam lungs were clear; BMI was reduced to 30 with efforts at weight control.  PFT on 14 December 2004 again revealed mild restrictive disease with FEV-1 of 88% and RATIO of 112% with a BMI of 32.  At the pulmonary evaluation dated 1 February 2005, 5 months prior to the NARSUM, the CI was no longer using his asthma medication, his chest auscultation was normal and his BMI at that time was 34.4.  PFT revealed FEV-1 of 83% and RATIO of 89%.  The examiner again, opined that the “body habitus” could be the cause of his restrictive disease, as no evidence of obstructive disease (viz asthma) is seen on testing.  At the MEB NARSUM evaluation on 8 July 2005, 2 months before separation, the CI reported taking daily asthma medication, his BMI was 32 and his chest exam was clear.  The examiner opined that “no definitive diagnosis or etiology of his lung disorder has been determined despite extensive workup.”
At the VA Compensation and Pension (C&P) pulmonary examination on 17 November 2005, PFT revealed FEV-1 of 60% and RATIO of 92% with an interpretation of restrictive airway disease.  At the VA C&P general examination on 1 December 2005, the CI reported being able to walk 1.5 mile and ascend two flights of stairs without extreme SOB.  He reported using asthma medication on a regular basis but being out of medication at that time.  On examination the CI had no complaints of SOB and both pulmonary and cardiac examinations were normal.
The Board directs attention to its rating recommendation based on the above evidence.  The PEB rated the lung condition analogous to asthma rated under code 6602 at 10%, citing the presence of “restrictive airway disease.”  A rating of 10% under this code requires an FEV-1 of 71% to 80%, or FEV-1/FVC of 71% to 80% on PFT, or intermittent use of inhalational or bronchodilator therapy.  The next higher rating of 30% requires FEV-1 of 56% to 70% or FEV-1/FVC of 56%to 70% on PFT; or daily inhalational or oral bronchodilator therapy; or inhalational anti-inflammatory (steroid) medication.  The VA coded the lung condition analogous to chronic bronchitis as 6600 rated at 30% citing an FEV-1 of 60% from the PFT dated 17 November 2005 The rating requirements for this code are the same as for code 6602 excluding the medication requirement.  The Board undertook a rating of the condition under code 6602.  The Board noted the PEB to assign a diagnosis of “restrictive disease” to the lung condition but to rate it analogous to asthma, an “obstructive” lung condition.  The preponderance of clinical and evaluative evidence in record supports that the condition was not asthma or any obstructive type of pulmonary condition.  For clarification, the Board reviewed the VASRD §4.20 statue for analogous rating.  The statute requires: “the anatomical localization and symptomatology are closely analogous” and states: “conjectural analogies will be avoided, as will the use of analogous ratings for conditions of doubtful diagnosis, or for those not fully supported by clinical and laboratory findings; nor will ratings assigned to organic diseases and injuries be assigned by analogy to conditions of functional origin.”  The Board unanimously agreed that rating under code 6600 (bronchitis chronic) a “restrictive” pulmonary disease; more accurately approximated the clinical condition.  The Board, thus considered a rating under code 6600.  The Board noted the PEB to adjudicate the obesity condition as a Category III condition.  The Board, upon review, unanimously agreed that well-established medical principles document that restrictive airway symptoms are a known consequence of obesity.  The Board noted the evidence in record to suggest the airway condition to be related to the obesity condition in the absence of any definitive etiologic diagnosis.  The PEB chose not to relate these two conditions in its adjudication and the Board chose not to enter this arena.

The Board noted the significant differences between the PFT for the PEB and the VA.  The Board agreed the PFT results for the VA, suggesting severe pulmonary disease, were internally inconsistent with the clinical status of the CI at the time and with the preponderance of evidence in record.  The Board thus, assigned higher probative value to the NARSUM exam in its deliberation.  The Board agreed that the evidence supported a 10% rating and no higher under code 6600 at the time of separation.  The Board considered a rating under code 6846, (sarcoidosis) but demurred as this diagnosis was never established.  The Board found no other appropriate codes for consideration.  In précis, the Board recommended a 10% rating for the pulmonary condition.  As this provides no rating advantage to the CI, the Board, under precedent, recommended no change in the PEB adjudication.  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 reactive airway disease 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.  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 reactive airway disease 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 recharacterization of the CI’s disability and separation determination. 

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131121, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

			
	XXXXXXXXXXXXXX
		President
		Physical Disability Board of Review

SAF/MRB

Dear XXXXXXXXXXXXXX:

	Reference your application submitted under the provisions of DoDI 6040.44 (Title 10 U.S.C. § 1554a), PDBR Case Number PD-2013-02461

	After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

	I have carefully reviewed the evidence of record and the recommendation of the Board.    I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.

							Sincerely,

							
XXXXXXXXXXXXXX
Director
Air Force Review Boards Agency

Attachment:
Record of Proceedings

PD-2013-02461