RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2014-02239
BRANCH OF SERVICE:  NAVY	BOARD DATE:  20140917
SEPARATION DATE:  20091218

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-3 (Machinist Mate) medically separated for congenital hypercoagulability.  The condition could not be adequately rehabilitated to meet the physical requirements of his Rating or satisfy physical fitness standards.  He was placed on limited duty (LIMDU) twice and referred for a Medical Evaluation Board (MEB).  The MEB forward hypercoagulability characterized as “venous embolism and thrombosis of deep vessels of distal lower extremity,” to the Physical Evaluation Board (PEB) IAW SECNAVINST 1850.4E.  The Informal PEB, adjudicated “congenital hypercoagulability secondary to prothrombin mutation (factor II heterozygous mutation); on lifelong Coumadin” as unfitting.  The remaining conditions: multiple episodes of superficial vein thrombosis, status post (s/p) right proximal deep vein thrombosis and history of greater saphenous vein ligation were found as Category III (not separately unfitting and do not contribute to the unfitting conditions).  Additionally, adjustment disorder with mixed anxiety and depression were found category IV (do not constitute a physical disability).  A Reconsideration PEB was conducted which increased the congenital hypercoagulability rating to 20% per the DES Pilot program all other IPEB findings were affirmed.  The CI made no appeals and was medically separated.

CI CONTENTION: “Please consider all conditions”

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 congenital hypercoagulability is addressed below.  Additionally, the three Category III conditions will be reviewed by the Board as well as the Category IV condition.  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 Naval Records.

RATING COMPARISON:

Service Recon PEB – Dated 20090914 | VA - (8 Mos. Pre-Separation)
Condition | Code | Rating | Condition | Code | Rating | Exam
Congenital Hypercoagulability….. | 7199-7121 | 20% | S/P DVT, Right Upper Leg (PEB referred to as Congenital Hypercoagulability…. | 7199-7121 | 20% | 20090424
Multiple Episodes of Superficial Vein Thrombosis | Category III | Multiple Episodes of Superficial Vein Thrombosis,…. | 7120 | 0% | 20090424
Adjustment Disorder | Category IV | Adjustment Disorder | 9440 | NSC | 20090424
S/P Right Proximal DVT | Category III | No VA Entry
History of Greater Saphenous Vein Ligation | Category III | No VA Entry
Other x 0 (Not in Scope) | Other x 0 | 20090424
Combined:  20% | Combined:  20%
Derived from VA Rating Decision (VARD) dated 20100503 (most proximate to date of separation).   VARD 20100913 inc. left leg to 10%.

ANALYSIS SUMMARY:  The Board determined that the conditions of multiple episodes of superficial vein thrombosis, s/p right deep vein thrombosis and greater saphenous vein ligation adjudicated by the PEB as not unfitting were related to the unfitting congenital hypercoagulability condition and as such all three contended not unfitting conditions were reviewed together in its deliberations of the unfitting hypercoagulation condition below.

Congenital Hypercoaguability.  The narrative summary notes that the CI fell, from a ship, approximately 40 feet into the water in September 2007.  Following the accident the CI coughed up blood, thought to be due to pulmonary contusion and had right leg pain and swelling.  In December 2007, 2 months later, he developed superficial vein clotting in his right leg and in January 2008, at the time of right saphenous vein ligation, a deep venous clot was found.  Anticoagulation was initiated and the CI was placed on LIMDU.  The CI did not have a prior history of clotting problems, but the hematology evaluation noted a family history of coagulation disorders.  The CI was tested and found positive for an inherited hypercoagulable state due to a gene mutation (Factor II heterozygosity).  At a hematology evaluation on 18 February 2009 the CI reported occasional swelling of both legs, right greater than left.  The examiner recommended long term oral anticoagulation for the clotting disorder; which prompted an MEB initiation.  In April 2009, the CI was sick for a few days and missed a few doses of his medication and experienced pain in his lower right thigh, was found to have swelling and inflammation of the superficial veins (phlebitis) and a recurrent deep venous blood clot.  At a follow-up visit (after the second blood clot), the CI reported persistent pain in the right leg, aggravated by activity, with swelling of the leg and tenderness of the right thigh noted on examination.  At a dermatology evaluation dated 5 October 2009, the CI reported dryness and itchiness of the lower extremity (LE) increased by LE swelling and the diagnosis was dermatitis of the bilateral LE.  The DD Form 2808, Report of Medical Examination, dated 21 October 2009 noted a normal physical examination, including the upper and lower extremities.  The MEB examination dated 20 February 2009 (10 months prior to separation), cited the same history as the hematology evaluation performed 2 days earlier (as noted above).  The CI reported pain in his legs, 2/10, with difficulty running or climbing stairs.  The MEB physical exam noted swelling in the right leg and none in the left, without other abnormalities.

At the VA Compensation and Pension (C&P) examination dated 24 April 2009 (performed 8 months prior to separation) a week following his second blood clot the CI was noted to be on oral and injectable anticoagulation.  The examination showed a limp on the left with normal bilateral lower extremity strength, sensation and reflexes.  The skin over the right leg thrombosis was noted to be red and indurated.  
There were five varicose veins of the right lower extremity noted and two of the left lower extremity (LLE), that were not tender to palpation but did bulge when the CI stood.  At a VA C&P examination dated 2 June 2010 (approximately 6 months after separation), the CI reported being on oral anticoagulation and that his last deep vein thrombosis DVT was in April 2009.  The examiner noted that the CI had a history of intermittent superficial thrombophlebitis of both legs, though none currently.  The CI reported aching and fatigue of the legs after prolonged walking and standing that was relieved by elevation or compression stockings.  During the examination, the examiner noted the history of right leg (DVT) but documentation of the right leg was omitted.  There was swelling of the left leg noted with small visible and palpable varicose veins.  Venous ultrasound imaging of the lower extremities noted abnormal blood flow and no evidence of deep or superficial venous thrombosis.  A VA C&P examination dated 3 August 2010 addressed the CI’s employability.  The examiner indicated that the CI’s history of right leg DVT and prescribed anticoagulation, although requiring some precautions, would not preclude gainful employment; and, neither would the history of left leg superficial venous thrombosis.

The Board directed attention to its rating recommendation based on the above evidence.  This case was adjudicated under the DES Pilot Program.  The PEB adjudicated congenital hypercoagulability as an unfitting Category I condition and listed “multiple episodes of superficial vein thrombosis,” “status post proximal deep vein thrombosis,” and “history of greater saphenous vein ligation” as not unfitting Category III conditions.  The VA proposed rating on 21 August 2009 was 20%, coded 7199-7121 (analogous to post-phlebitic syndrome of any etiology) for the PEB referred unfitting condition, at 0% rating coded 7120 (varicose veins) for multiple episodes of superficial vein thrombosis of the left leg.  The PEB accepted the VA proposed rating and coding for the congenital hypercoagulability condition.  The final VARD dated 3 May 2010 proposed the same rating.

The evidence in record supports the CI had a hereditary hypercoagulability condition which resulted in recurrent superficial and deep blood clots in the right lower extremity following trauma.  VASRD §4.104 (cardiovascular system) does not provide an overall code for rating the underlying disease in coagulopathies, but rather rates utilizing analogous coding to specific sequelae such as post-phlebitic syndrome (code 7121).  The Board’s rating recommendation will therefore be derived from one of the commonly applied analogous codes: 7121 (post phlebitis) or 7120 (varicose veins).  The code 7121 is a better clinical fit in this case, although the rating language for the spectrum of disease in evidence is identical in both codes.  In addition to assessing the fairness of the rating assignment itself, however, the Board is also faced with the §4.104 stipulation that, “these evaluations are for involvement of a single extremity. If more than one extremity is involved, evaluate each extremity separately and combine (under §4.25), using the bilateral factor (§4.26), if applicable.”  Both LE were symptomatic, but the right more so than the left.  The Board’s initial deliberation was whether the §4.104 stipulation just noted obligates the Board to address the right lower extremities (RLE) residuals separately from the LLE and satisfy the DES requirement that each condition remained unfitting before recommending a disability rating.  After deliberation, the Board consensus was that separate fitness determinations for each LE, based upon the standard of “a preponderance of evidence,” were required to recommend individual disability ratings.  

After lengthy deliberations, the Board consensus was that the PEB’s elucidated reasoning was sound.   The requirement for systemic anticoagulation was unfitting and the analogous rating of the hypercoagulation disorder included the effects on both the RLE and LLE.  However, the Board concurrently undertook the exercise of considering the extremities separately to see if this approach resulted in a higher combined rating for the CI.  The RLE was noted in all treatment notes in the service treatment record (STR), with reported residual discomfort, frequent swelling, difficulty with prolonged standing and running; noted on the two temporary limited duty periods; and cited in the non-medical assessment (NMA).  
The Board agreed that the preponderance of the evidence supported that RLE post-phlebitic syndrome, as an isolated condition, rendered the CI incapable of continued service within his Rating and accordingly merits a separate rating.  Members agreed that the evidence in record supported the 20% rating for the right leg under 7121, specified as “persistent edema, incompletely relieved by elevation, with or without beginning stasis pigmentation or eczema” but did not meet the next higher rating of 40%, specified as “persistent edema and stasis dermatitis.” 

The Board next considered the LLE condition.  The LLE was not noted to be swollen, or to have local areas that were red, hot or indurated on treatment visits in the STR, or at the MEB or pre-separation VA C&P examinations.  At the MEB examination the CI reported low level discomfort in the bilateral lower extremities and the VA C&P examination noted two varicose veins on the left that were not tender.  Members agreed that absent any consideration of the systemic anticoagulation treatment, there was not a preponderance of evidence that the LLE by itself would have been unfitting for continued service and therefore, could not be recommended for separate disability rating.  The Board thus found that considering the RLE and LLE extremities separately through the lens of fitness, resulted in the same rating recommendation as that of the PEB.  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 hypercoagulability condition.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the “status post proximal deep vein thrombosis,” “multiple episodes of superficial vein thrombosis,” and “history of greater saphenous vein ligation” conditions were not unfitting.  The Board’s threshold for countering fitness determinations is higher than the VASRD §4.3 standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  The contended not unfitting conditions were reviewed above with the unfitting congenital hypercoagulability disorder.  The “status post proximal deep vein thrombosis” refers to a history, in the past, of a DVT.  The residual disability due to the DVT history would be rated according to the same criteria considered in the rating recommendation for the hypercoagulability condition.  Therefore, the “status post proximal deep vein thrombosis” condition is not separately ratable IAW VASRD 4.14 (avoidance of pyramiding).

Greater saphenous vein ligation is a surgical procedure and following a convalescent period routinely confers no permanent disability.  Notes in the STR following the procedure indicated no complications.  Neither the superficial thrombophlebitis nor the vein procedure resulted in any period of limited duty, were mentioned in the NMA or judged to fail retention standards.  There was no performance based evidence from the record that superficial thrombophlebitis or greater saphenous vein ligation significantly interfered with satisfactory duty performance.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the any of the contended conditions and so no additional disability ratings are recommended.

Contended Mental Health (MH) Condition.  The Board’s main charge is to assess the fairness of the PEB’s determination that the CI’s MH condition was not unfitting.  The Board’s threshold for countering fitness determinations is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.

As noted in the discussion of the unfitting hypercoagulability condition, the CI experienced a fall from a ship into the water in September 2007 and experienced the noted subsequent medical problems.  A MH evaluation dated 13 March 2008 indicated that during this time there were also multiple medical problems involving the CI’s wife and mother.  
The CI reported anxiety and depression regarding his health and death related nightmares.  The mental status examination (MSE) noted a depressed mood and affect with anxiety, but without suicidal ideation (SI).  The Axis I diagnoses were depressive disorder, not otherwise specified (NOS) and anxiety disorder NOS, with a Global Assessment of Functioning (GAF) of 62.  Psychiatric evaluation following the CI’s evacuation from the ship indicated a normal MSE with the CI describing his mood as “I just want to get home.”  The diagnosis was adjustment disorder with anxiety and depressed mood.  At an evaluation by a psychologist when the CI reached the continental US, the CI indicated that he was motivated to complete his service.  The CI reported occasional alcohol use and denied substance abuse.  The CI reported symptoms of anxiety and depression and again MSE noted an anxious and depressed mood with an otherwise normal examination.  The diagnosis remained adjustment disorder, with a GAF in the mid 50’s (moderate impairment range).  At a MH visit on 4 April 2008, the CI reported improved sleep, losing some unwanted weight through diet, and some socializing with his wife.  The reported symptoms and diagnosis remained the same.  At the next MH follow up visit the CI reported anxiety but denied depression.  He reported he was “better” and socializing more.  The CI began couples counseling with his wife with a civilian psychologist at this time who diagnosed him with posttraumatic stress disorder (PTSD) symptoms related to his injuries.  At two service psychologist visits in May 2008 the CI reported that he and his wife were doing well and were expecting a baby.  He reported mild anxiety, but denied depression.  The diagnosis remained adjustment disorder with a GAF in the high 70’s (mild impairment range).

The initial VA C&P examination (within the DES Pilot process occurred) dated 3 June 2009, during the examination, the examiner noted that the CI was not currently in psychiatric treatment and during brief treatment for his MH symptoms in 2008 he was not hospitalized, was not suicidal and had not required any psychotropic medications.  At the VA C&P examination the CI denied being anxious or depressed and the examiner noted the CI was “without signs of ongoing anxiety, depression, or psychosis at this time.”  MSE was normal.  The examiner summarized that the CI had a stressful situation in 2008 with an adjustment disorder with depressed mood and anxiety that had resolved.  The Axis I diagnosis was adjustment disorder with mixed anxiety and depression with a GAF of 75.

The Informal PEB dated 14 September 2009, adjudicated the MH condition of adjustment disorder with mixed anxiety and depression as a Category IV condition which does not constitute a physical disability.

At a primary care (PCP) visit 10 days after the PEB, the CI reported insomnia with nightmares and a history of PTSD.  The PCP prescribed an antidepressant medication and an anti-anxiety medication and referred the CI for a psychiatric evaluation.  The psychiatric evaluation on 7 October 2009 diagnosed an adjustment disorder.  During two psychologist visits in October 2009 the CI reported anxiety and depression with medications for both.  The psychologist indicated that testing was consistent with major depression and traumatic stress.  Notes indicated an episode of domestic violence within the same week.  The MSE examinations noted depressed and anxious mood and the diagnoses were changed to major depression, single episode and delayed PTSD.  At the initial psychiatric evaluation dated 16 October 2009, the CI denied alcohol or drug abuse.  He reported nightmares of dying, insomnia and depression and anxiety symptoms, but reported an improved mood in anticipation of going home.  The CI noted significant stress over the past year including his health, marital issues, the PEB process and disappointment regarding his hopes for a long Navy career.  The examiner also noted a domestic altercation the night before that resulted in the CI spending the night in the emergency room.  The Axis I diagnosis was adjustment disorder, but noted rule out diagnoses of major depressive disorder (MDD) and PTSD.

At the VA C&P examination dated 3 June 2010 (performed approximately 6 months after separation), the CI reported severe PTSD symptoms, with anxiety and depression, anger management issues, nightmares one to two times per week.  The MSE noted an anxious mood but was otherwise normal.  The examiner diagnosed Axis I conditions of PTSD with dysphoric mood and active Amphetamine dependence.  The examiner noted that the Amphetamine dependence was not due to the PTSD condition and that assessment of a GAF for PTSD was difficult to determine due to the ongoing use of drugs and alcohol and referred to a primary care note that indicated the methamphetamine use was the primary problem at that time.

VA post-separation treatment notes after the post-separation C&P indicated that the CI reported “trying to get my life back in order without drugs or alcohol.”  He reported cocaine, Methamphetamine and Amphetamine use that began at age 17 with one period of substance abuse treatment in 2001 and denied drug use in the ensuing 9 years.  The MSE noted a depressed mood and otherwise normal evaluation.  The Axis I diagnoses were chronic PTSD, depressive disorder, NOS, Amphetamine dependence and alcohol abuse.  The CI was discharged from the program due to non-compliance during group sessions and disagreements with providers over his prescription medications.  At MH visits following his discharge the CI initially reported sobriety but beginning in October 2010, MH notes indicated domestic violence issues, active drug use and a suicide attempt by prescription drug overdose in February 2011 which led to a psychiatric hospitalization.  The hospital admission notes indicated that the CI reported ongoing abuse of illegal and prescription medications and that he had overdosed on his prescription medications in an effort to relax.  He was discharged from the hospital to outpatient treatment 4 days later.  No further MH records were noted in the available records.

The Board reviewed the evidence for support that the MH condition was unfitting at the time of separation.  The CI was diagnosed with an adjustment disorder during service by a treating psychologist and with adjustment disorder, resolved, by a VA psychiatrist at the C&P evaluation during the DES process.  Following the PEB adjudication of the adjustment disorder as a condition not eligible for rating IAW DoDI 1332.38, enclosure 5, the CI was diagnosed by the service psychologist with MDD and delayed PTSD, but an evaluation by a service psychiatrist a few days later continued the diagnosis of an adjustment disorder.  The Board opined that the assessment of the CI’s function as mildly impaired by both the service psychologist and psychiatrist and the VA examiner’s assessment of no active MH diagnosis prior to separation lend strong support for the conclusion that no MH diagnosis, no matter the specific diagnosis, was unfitting for continued military service at the time of separation.  At post-separation VA treatment visits in record (beginning 6 months after separation) the CI was noted to be actively abusing illegal drugs and alcohol.  The substance abuse was not thought to be due to the chronic PTSD diagnosis and was judged to be the CI’s primary problem at the time.  

During the post-separation VA C&P mental examination the examiner indicated that the functional impairment due to the MH diagnoses could not be accurately assessed in the presence of ongoing drug use and/or alcohol abuse.  Though the CI reported abstinence from drugs and alcohol at times after that in the record, the latest notes to February 2011 indicated ongoing substance abuse issues (14 months after separation).  The Board therefore, concluded that with the confounding substance abuse issues, also not eligible for disability rating IAW DoDI 1332.38, enclosure 5, there was not a preponderance of evidence in the record to support either a change to the service MH diagnosis of an adjustment disorder towards a more favorable, potentially ratable diagnosis such as depression or PTSD or to support that any MH disorder was unfitting prior to separation.  The adjustment disorder was not profiled or implicated in the NMA and was not forwarded by the MEB or judged to fail retention standards.  There was no performance based evidence from the record that any MH condition significantly interfered with satisfactory duty performance.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the mental health conditions and so no additional disability ratings are 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 multiple episodes of superficial vein thrombosis and history of greater saphenous vein ligation and IAW VASRD §4.104, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the MH conditions and IAW VASRD §4.130, 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 20140519, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

				
XXXXXXXXXXXXXXX
President
DoD Physical Disability Board of Review

MEMORANDUM FOR DIRECTOR, SECRETARY OF THE NAVY COUNCIL OF REVIEW
               BOARDS 

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS
 
Ref:   (a) DoDI 6040.44
         (b) CORB ltr dtd 18 May 15

      In accordance with reference (a), I have reviewed the cases forwarded by reference (b), and, for the reasons provided in their forwarding memorandums, approve the recommendations of the PDBR that the following individual’s records not be corrected to reflect a change in either characterization of separation or in the disability rating previously assigned by the Department of the Navy’s Physical Evaluation Board:

- XXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXX, former USMC

			  XXXXXXXXXXXXXXX
	     		  Assistant General Counsel
			  (Manpower & Reserve Affairs)

PD-2014-02239