RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00205
BRANCH OF SERVICE:  AIR FORCE	BOARD DATE:  20140812
SEPARATION DATE:  20071029

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty A1C/E-3 (3P03/Security Forces) medically separated for asthma.  The asthma condition could not be adequately rehabilitated to meet the physical requirements of his Air Force Specialty or satisfy physical fitness standards.  He was issued a P4 profile and referred for a Medical Evaluation Board (MEB).  “Asthma” was forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123.  No other conditions were submitted by the MEB.  The Informal PEB adjudicated “asthma” as unfitting, rated 10%, citing application of Department of Defense and VA Schedule for Rating Disabilities (VASRD) guidelines.  The CI made no appeals and was medically separated.

CI CONTENTION:  “I am not requesting a change in rating.  I currently do not know what my rating is.”

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 asthma 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 20070830 | VA - (3 Mos. Post-Separation)
Condition | Code | Rating | Condition | Code | Rating | Exam
Asthma | 6602 | 10% | Asthma | 6602 | 30% | 20080207
Other x 0 (Not in Scope) | Other x 0 (Not in Scope) |
Rating:  10% | Rating:  30%
Derived from VA Rating Decision (VARD) dated 20080627 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Asthma Condition.  On 23 May 2007, the CI had a positive methacholine challenge test that revealed a 25% decrease in FEV1 which definitively established the diagnosis of asthma.  A chest X-ray was normal.  His symptoms of shortness of breath (SOB) and wheezing worsened with running or exercise.  Initially treated with an “as needed” rescue medication of Proventil (inhalational bronchodilator [Albuterol]), Flovent (inhalational steroid), was added on 5 June 2007.  The treatment record contained a paucity of source documents with only two clinical encounters with radiology and labs tests.

The narrative summary (NARSUM) performed on 13 June 2007 (4 months prior to separation), the CI reported “consistently feels SOB with exertion.”  His physical examination (PE) was normal and the corresponding pulmonary function test (PFT) was 96% and 93% predicted for FEV1 and FVC respectively.  There was no history of hospital admissions or use of systemic steroids.  His listed respiratory medication was Albuterol and the examiner explicitly noted, “Besides the albuterol inhaler, I don’t feel there are any other medical interventions that would alleviate his symptoms.”  His diagnosis was asthma.  

The commander’s letter reflected that the CI’s medical condition did not impact his ability to complete any assigned tasks nor had he lost workdays because of it.  

A medication profile indicated both Albuterol and Flovent were last filled at a military treatment facility in May and June 2007, respectively; approximately 5 months prior to separation.  Specifically, the Flovent was filled 8 days prior to the NARSUM where the examiner opined the need for only a bronchodilator.  As prescribed, the dosage of Flovent would be available as a single month supply and absent evidence of a refill the medication would be consumed by early July 2007, 4 months prior to separation.  The case file also contained a personal letter from the CI (dated 13 July 2007) whereby he stated, “…currently I am on two inhalers the first to ease the long term effects and taken on a daily basis, the other for periodic use.”

At the VA Compensation and Pension evaluation (3 months after separation), the CI summarized his past onset of symptoms and treatment history using “inhalers.”  He reported having “good control of his symptoms with daily use of inhaler” and reported his last asthmatic episode was 4 months prior.  The PE was brief and unremarkable.  A repeat PFT was normal and indicated his medication use as Albuterol.  His diagnosis remained unchanged.  The VA listed the previously mentioned two prescription medications under the heading of “other comments,” but did not clearly delineate if the medication was current treatment or referencing prior use.

The Board directs attention to its rating recommendation based on the above evidence.  The PEB coded the asthma condition utilizing the unequivocal asthma VASRD code of 6602; citing continued symptoms with exertion.  The VA coded the same, rated at 30% citing the use of daily inhalers for asthma control.  VASRD §4.97 defines both PFT-derived criteria and clinical treatment criteria for rating under 6602.  The evidenced PFT’s did not support a VASRD compensable rating.  The non-PFT derived criteria under 6602 are: “intermittent inhalational or oral bronchodilator therapy” for 10%; “daily inhalational or oral bronchodilator therapy, or; non-daily inhalational anti-inflammatory medication” for 30%; and, “intermittent courses of systemic corticosteroids” for 60%.  The record did not reflect the CI being placed on corticosteroids; therefore, Board members deliberated if the CI’s asthma condition supported either the 10% or 30% criteria level as described above.  Clearly, the record and medication profile supported the intermittent use of inhalation bronchodilator therapy thus supporting 10%.  However, the variations and unclear documentation of inhalational steroids near the time of separation left the Board with a questionable basis for arguing that the inhaled steroid was either not prescribed or not being utilized at that time.

Board members considered and debated over the documented inconsistencies of medication use and its prescribed timing in this case.  Additionally, secondary to the inconsistent documentation, members also considered the probative value between the MEB and VA examination and concluded that the MEB examination being more clinically in-depth and free of unclear documentation is assigned a higher probative value as a basis for its recommendation.

Clearly, the NARSUM (with physician comment) and the VA PFT indicated the sole use of the bronchodilator medication.  Board members acknowledged the CI’s own words as authored in his personal letter that “…currently, I am on two inhalers…,” but the date of that letter corresponded to a week after the need for a refill of the inhaled steroid when extrapolated from the initial (and only) prescription being filled on 05 June 2007.  Members conceded that near the time of the written letter, the CI most likely was on both the bronchodilator and steroid medication, but the steroid use was (if taken as prescribed) very near empty and thus without refill, would not be using at the time of separation.  After considerable deliberation, the Board consensus was that the evidence was insufficient to conclude that the CI required treatment with inhalational anti-inflammatory medication in order to maintain good asthma control; and, therefore concluded that there was insufficient cause to recommend a change in the PEB adjudication for the asthma 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 asthma 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 20140101, 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-2014-00205.

	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-2014-00205