AF | PDBR | CY2010 | PD2010-00735
The VA exam, one month prior to separation noted residual scar symptoms of the left hand to include itching and burning. RECOMMENDATION : The Board recommends that the CI’s prior determination be modified as follows and that the discharge with severance pay be recharacterized to reflect permanent disability retirement, effective as of the date of her prior medical separation: Subj: PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS
AF | PDBR | CY2010 | PD2010-00737
The PEB rating reflected presumptive application of DoDI 1332.39 since lumbar ROM was not measured as required by the VASRD, but its 10% determination was consistent with application of §4.59 (painful motion) or §4.40 (pain with use). Service Treatment Record I have carefully reviewed the evidence of record and the recommendation of the Board.
AF | PDBR | CY2010 | PD2010-00771
CI CONTENTION : “The U.S. Coast Guard MEB Board rated my cervical spine at 10%, however the VA has rated this same condition at 30%, therefore I feel my disability should be increased.” He mentions no additionally contended conditions. An abbreviated examination showed a normal motor and sensory exam, and “limited neck mobility.” Two months prior to separation, the CI underwent an additional evaluation “specifically to get his range of motion of [t]he neck measured,” presumably in support...
AF | PDBR | CY2010 | PD2010-00774
Low Back Pain (LBP) . The Board therefore recommends a rating of 10% for the low back pain condition. Additionally, PTSD and other conditions were noted in the VA rating decisions but were not in the DES file.
AF | PDBR | CY2010 | PD2010-00775
All evidence considered, there is not reasonable doubt in the CI’s favor supporting addition of any lower extremity radiculopathy as an unfitting condition for separation rating. Service Treatment Record. Exhibit C. Department of Veterans' Affairs Treatment Record.
AF | PDBR | CY2010 | PD2010-00776
In the matter of the bilateral cataracts, trigeminal neuralgia, bilateral knee pain, pes planus, tinnitus or any other medical conditions eligible for Board consideration; the Board unanimously agrees that it cannot recommend any findings of unfit for additional rating at separation. RECOMMENDATION : The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of his prior medical separation: Subj: PHYSICAL DISABILITY BOARD OF REVIEW (PDBR)...
AF | PDBR | CY2010 | PD2010-00777
The CI’s treating neurosurgeon five months prior to separation documented that the CI had severe degenerative changes and injury was likely to leave the CI with chronic back pain, limited mobility and physical disability. 5292 Spine, limitation of motion of, lumbar: There was no clear mechanism to separate out the CI’s radicular pain from his unfitting back condition and the primary focus on medical evaluations was the CI’s back and S1 radiating pain conditions.
AF | PDBR | CY2010 | PD2010-00806
CI CONTENTION : The CI states: “I was assigned less than 50% disability rating by the military for my unfitting PTSD upon discharge from active duty. After due deliberation considering all of the evidence for the permanent rating for PTSD, the Board recommends a separation rating of 30% for the PTSD. The VA did not rate this condition.
AF | PDBR | CY2010 | PD2010-00847
The PEB adjudicated the left ankle condition (status post osteochondral allograft for an osteochondral lesion of the talus) as unfitting, rated 10%, with application of the Veterans’ Administration Schedule for Rating Disabilities (VASRD). Service Treatment Record Exhibit C. Department of Veterans' Affairs Treatment Record
AF | PDBR | CY2010 | PD2010-00852
The CI was referred to the Physical Evaluation Board (PEB), found unfit for continued Naval service, and separated with a 10% disability using the Veterans Affairs Schedule for Ratings Disabilities (VASRD) and applicable Navy and Department of Defense regulations. The MEB Report of 20061030 reported the following: He first came to the attention of mental health in July 2005, as he was referred to psychiatry because of suicidal ideation. The Board also considered the Low Back Pain/Lumbar...
AF | PDBR | CY2010 | PD2010-00853
The core DES file consists of the MEB referral document, the PEB adjudication document, the NARSUM (including any addendums or referenced examinations), the MEB physical exam, the commander’s statement, the physical profile(s), and any written appeals or internal DES correspondence. Although the Board does not have the authority under DoDI 6040.44 to render fitness or rating recommendations for any conditions not considered by the DES, there was no evidence for concluding that PTSD or any...
AF | PDBR | CY2010 | PD2010-00863
I then went before the formal board and received 10% with a disability code of 7121 which allows up to 30% disability rating which would have allowed me to retire.” In block 14 of the DD Form 294 he notes: “The following is the VA decision on disability: I was rated at 60% disabled with the following determinations: Right Kidney Cortical Atrophy with Compensatory Left Kidney Hypertrophy with Residual Thinning & Scarring, Aortic Valve Insufficiency with Regurgitation, Mitral Valve...
AF | PDBR | CY2010 | PD2010-00865
The MEB forwarded “Status /Post (S/P) Left Knee Reconstruction, Symptomatic, Existed Prior to Service (EPTS) to the Physical Evaluation Board (PEB) on NAVMED 6100/1. No other conditions were rated by the VA at 0% within 12 months of separation. I have reviewed the subject case pursuant to reference (a) and, for the reasons set forth in reference (b), approve the recommendation of the Physical Disability Board of Review Ms. XXX’s records not be corrected to reflect a change in either her...
AF | PDBR | CY2010 | PD2010-00873
The PEB adjudicated the left radial head fracture with loss of extension condition as unfitting, rated 10%, with application of the Veterans’ Administration Schedule for Rating Disabilities (VASRD). Left Wrist Condition . The Board determined therefore that none of the stated conditions were subject to service disability rating.
AF | PDBR | CY2010 | PD2010-00874
5292 Spine, limitation of motion of, lumbar: The Board does not have the authority under DoDI 6040.44 to render fitness or rating recommendations for any conditions not considered by the DES. The diagnosis in his finding of unfitness was Arthropathy and Degenerative Disc Disease, Lumbar Spine, VASRD code 5292, rated at 40%; rather than Low Back Pain, Chronic, VASRD code 5295, rated at 10%.
AF | PDBR | CY2010 | PD2010-00880
VA psychiatric outpatient notes proximate to separation indicate the CI’s condition deteriorated significantly at that time, and he was diagnosed with PTSD in addition to bipolar disorder four days prior to separation. RECOMMENDATION : The Board recommends that the CI’s prior determination be modified as follows: TDRL at 50% for six months following CI’s prior medical separation (minimum of 50% IAW §4.129) and then a permanent 50% disability retirement as below. Absent the requirement for...
AF | PDBR | CY2010 | PD2010-00882
RECOMMENDATION : The Board recommends that the CI’s prior determination be modified as follows; TDRL at 50% for 6 months following CI’s prior medical separation (PTSD at minimum of 50% IAW §4.129 and DoD direction) and then a permanent combined 30% disability retirement as below. 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...
AF | PDBR | CY2010 | PD2010-00899
Back Condition . However, the Board considered the CI’s abnormal imaging and disc pathology was not purely aligned with a lumbosacral strain and that coding under the more general 5292 (spine, limitation of motion of, lumbar) criteria indicated the CI’s condition was closest to the moderate (20%) criteria than the slight (10%) limitation. Exhibit C. Department of Veterans' Affairs Treatment Record.
AF | PDBR | CY2010 | PD2010-00909
Left Ankle Condition . In the matter of the left ankle condition and compartment syndrome and all left lower extremity disability, the Board recommended coding of 5010-5262 and by a vote of 2:1 recommends a rating of 30% IAW VASRD §4.71a. In the matter of the left lower leg neurologic deficits, scars, and venous insufficiency conditions or any other medical conditions eligible for Board consideration; the Board unanimously agrees that it cannot recommend any findings of unfit for separate...
AF | PDBR | CY2010 | PD2010-00921
The “significant” bilateral ROM limitations described in the undated MEB physical exam were not consistent with the MEB “full” description of ROM, or ROM limitations described/measured elsewhere in the record, both pre- and post-separation. Given the CI’s capsular surgery and the left shoulder limited ROM below the compensable criteria for specific left shoulder codes, the 5019 coding was predominate for the left shoulder. The VA C&P exam was done after separation from active duty and in...
AF | PDBR | CY2010 | PD2010-00925
ConditionCodeRatingConditionCodeRatingExam Bilateral Hammer Toe Deformities52820%Bilateral Pes Planus w/ Bilateral Plantar Fasciitis S/P Bilateral Hammer Toe Repair of 2 nd , 3 rd and 4 th Toes527610%20070103Moderate Flat FootCat II↓No Additional MEB/PEB Entries↓Thoracolumbar Strain; DDD L5-S1523720%20070103Right Shoulder Strain5299- 502410%20070103Left Shoulder Strain5299-502410%20070103GERD and Hiatal Hernia734610%20070103Tinnitus626010%200701030% x 2 / Not Service Connected x 120070103...
AF | PDBR | CY2010 | PD2010-00928
The CI appealed to the Formal PEB (FPEB) and was adjudicated to be unfit for continued duty for anxiety disorder. Providing a correction to the individual’s separation document showing that the individual was separated by reason of permanent disability retirement effective the date of the original medical separation for disability with severance pay. Providing orders showing that the individual was retired with permanent disability effective the date of the original medical separation for...
AF | PDBR | CY2010 | PD2010-00945
The VA rated this examination at 50% IAW §4.130 criteria. The CI’s GAF was considered mild (GAF=65) and there was no improvement in his symptoms since his initial TDRL entry examinations. RECOMMENDATION : The Board recommends that the CI’s prior separation be recharacterized to reflect that, rather than discharged with severance pay, the CI was placed on the TDRL at 70% (PTSD at 50% IAW §4.129 and DoD direction) and then permanently retired by reason of physical disability with a final 50%...
AF | PDBR | CY2010 | PD2010-00946
However, the CI’s PTSD symptoms are very clearly documented by the MEB examiner. The examiner opined that, “although the veteran is exhibiting signs and symptoms of PTSD, he is also and probably more predominantly focused on his physical problems.” The examiner noted generally mild PTSD symptoms except for “significant irritability and/or sleep disturbance. Exhibit C. Department of Veterans' Affairs Treatment Record.
AF | PDBR | CY2010 | PD2010-00957
IAW DoDI 6040.44 and DoD guidance (which applies current VASRD 4.129 to all Board cases), the Board is obligated to recommend a minimum 50% PTSD rating for the TDRL period. The VA performed another review and rating determination of the CI’s condition based upon the service TDRL re-evaluation, and continued the PTSD rating at 30%. The VA assigned a 30% rating for the PTSD condition based on §4.130 criteria without relying on the provisions of §4.129, as the CI had not been separated from...
AF | PDBR | CY2010 | PD2010-00958
In the matter of the PTSD condition, the Board unanimously recommends by a vote of 2:1 a 10% permanent rating IAW VASRD §4.130. After consideration of all available evidence and mindful of VASRD §4.3 (reasonable doubt), this Board member recommends a permanent separation rating of 30% disability and retirement for the Posttraumatic Stress Disorder (PTSD) condition. The CI’s level of impairment did improve by the time of the TDRL evaluation on 11 May 2006.
AF | PDBR | CY2010 | PD2010-00973
The MEB and narrative summary (NARSUM) exam at four months prior to separation noted that the CI complained of chronic pain in the shin and foot, was unable to run without pain and rated this pain as 3-4 out of 10, with 10 being the worst. The Board noted that the CI’s condition was only somewhat improved by arch supports and there was no painful motion of the ankle or abnormal gait at the VA exam. In the matter of the right hip, right knee and migraine headaches conditions, and any other...
AF | PDBR | CY2010 | PD2010-00975
The ratings assigned to unfitting conditions is based on the severity of the condition at the time of separation, and then at the time of removal from TDRL, and not based on possible future changes. In the matter of the left and right shoulder conditions, the Board unanimously recommends no change in the rating at the time of initial placement on the TDRL and a permanent rating after removal from the TDRL of 10% each, coded 5304 IAW VASRD §4.71a. After careful consideration of your...
AF | PDBR | CY2010 | PD2010-00976
Left Knee Pain Condition . Other PEB Conditions . 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.
AF | PDBR | CY2010 | PD2010-00977
PHYSICAL DISABILITY BOARD OF REVIEW ConditionCodeRatingConditionCodeRatingExam Spondylolysis, Left L5 Pars Interarticularis523710%Spondylolysis, Left L5 Pars Interarticularis5299-523910%20080721Closed Fracture of the AnkleNot Service ConnectedResiduals From Right Ankle Fracture52710%20080721↓No Additional MEB/PEB Entries↓0% x 1/Not Service Connected x 720070721 Combined: 10%Combined: 10% * Limited to effective rating dates within 12 months of separation. Physical Disability Board of Review
AF | PDBR | CY2010 | PD2010-00978
CI CONTENTION : The CI states, “Request is in reference to the regulation governing the PDBR DOD instruction (6040.44)- board will review not only conditions on which ratings are based but conditions identified by the PEB this should include any condition listed in the narrative summary of the medical evaluation board to the PEB which set the ratings. As noted above, the Army PEB found him unfit due to left TOS, and he was separated with a rating of 20%. The Board determined therefore,...
AF | PDBR | CY2010 | PD2010-00979
BAV and chest pain (exertion related) were the only conditions on the MEB’s submission to the Physical Evaluation Board (PEB). The CI made no appeals and was medically separated with a 10% disability rating. I have reviewed the subject case pursuant to reference (a) and, for the reasons set forth in reference (b), approve the recommendation of the Physical Disability Board of Review Mr. XXXX’s records not be corrected to reflect a change in either his characterization of separation or in...
AF | PDBR | CY2010 | PD2010-00982
The Board evaluates DVA evidence proximal to separation in arriving at its recommendations, but its authority resides in evaluating the fairness of DES fitness decisions and rating determinations for disability at the time of separation. The Board also acknowledges the CI's contention suggesting that service ratings should have been conferred for other conditions documented at the time of separation and for conditions not diagnosed while in the service (but later determined to be...
AF | PDBR | CY2010 | PD2010-00988
SAFPC, on 27 May 2008, found only the low back pain condition unfitting with a 10% rating, coded 5242. The Board noted that the profiles do not specify limitations based on ankle pain versus low back pain. 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.
AF | PDBR | CY2010 | PD2010-00995
At the time of the C&P examination, three weeks after separation, the flexion was significantly decreased compared to the NARSUM and the examiner recorded CI report of right leg pain radiation (service treatment records document left leg pain, not right). The next higher rating of 20% for the CI’s back condition would not result in any change in his military disability separation benefits. In the matter of the back condition (chronic mechanical low back pain with degenerative disc disease)...
AF | PDBR | CY2010 | PD2010-00996
The Board therefore has no reasonable basis for recommending the ankle condition for separation rating. The Board therefore has no reasonable basis for recommending any additional unfitting conditions for separation rating. I have reviewed the subject case pursuant to reference (a) and, for the reasons set forth in reference (b), approve the recommendation of the Physical Disability Board of Review Mr. XXXX’s records not be corrected to reflect a change in either his characterization of...
AF | PDBR | CY2010 | PD2010-00997
The Board’s role is confined to the review of medical records and all evidence at hand to assess the fairness of PEB rating determinations, compared to VASRD standards, based on severity at the time of separation. Regardless of the criteria used, the IPEB rating is consistent with the VA rating at 10% nearly two years after separation, and code 7820 does allow rating under code 7806, used by the VA and supporting a 10% rating. After careful consideration of all available evidence the Board...
AF | PDBR | CY2010 | PD2010-00999
The CI’s application asserts that compensable ratings should be considered for migraine headaches. In the matter of the migraine headache condition, the Board unanimously agrees that it cannot recommend a finding of unfit for additional rating at separation. I have carefully reviewed the evidence of record and the recommendation of the Board.
AF | PDBR | CY2010 | PD2010-01004
Right Ankle Pain . One week later, at his VA C&P exam, the CI reported symptoms of headache, memory loss and trouble concentrating. His MH symptoms did not cause any duty performance, functional, relationship or cognitive impairments.
AF | PDBR | CY2010 | PD2010-01015
At the MEB examination, 25 August 2004, just under three months prior to separation, the CI noted that her pain was aggravated by standing and sitting and that she had swelling at the ankle and pain at the knee incision site. Board considered use of the 5262 code for malunion of the tibia and fibula with ankle impairment as it also described the medical condition including the pain which affected ankle function. Accordingly, the Board cannot use both code 8520 and 5262 for the right lower...
AF | PDBR | CY2010 | PD2010-01020
The most proximate source of comprehensive evidence on which to base the permanent rating recommendation in this case is the TDRL Re-evaluation performed 25 months after being placed on TDRL and 1 month prior to permanent separation. Since both of these evaluations fall well outside the 12-month window specified in DoDI 6040.44 regarding Board consideration of post-separation VA evidence, the Board assigns little probative value to them relative to its permanent rating recommendation. The...
AF | PDBR | CY2010 | PD2010-01022
Since this was not the case, the Board will rate the total psychiatric impairment as if the two conditions were a single unfitting condition under code 9411 for PTSD with MDD. After this examination his VA disability rating was increased to 100% for an exacerbation of his condition and was not considered permanent. At the time of his separation from the TDRL in 2008 his VA disability rating was 70%.
AF | PDBR | CY2010 | PD2010-01024
In debating the appropriate permanent disability rating, the Board noted that the evidence in this case best fit a 10% final separation rating recommendation based on the TDRL examination; that his symptoms appeared to have stabilized; and his overall social and occupational functioning (with respect to PTSD symptoms) was intact; although the 30% rating is arguable by invoking some continuation of symptoms and evidence of mild social difficulties outside of family. There were no repeat...
AF | PDBR | CY2010 | PD2010-01025
The CI was treated with medications and outpatient therapy, but failed to improve adequately to meet the operational requirements of his Military Occupational Specialty (MOS). The PEB of 31 May 2005 found the CI unfit for PTSD, VA Code 9411, but stated that the CI was “non-compliant with refusal to discontinue excessive alcohol and narcotic usage.” The PEB removed him from TDRL and assigned a 10% final disability rating stating, “rating apportioned downward for non-compliance.” The CI...
AF | PDBR | CY2010 | PD2010-01027
After due deliberation, in consideration of the totality of the evidence, the Board recommends that contact dermatitis be added as a separately unfitting condition rated 10% at TDRL entry and a permanent 0% rating at the time of removal from the TDRL. RECOMMENDATION : The Board recommends that the CI’s prior separation be modified to reflect that the CI was placed on the TDRL at 60% (PTSD at 50% IAW §4.129 and DoD direction) and then permanently separated with severance pay by reason of...
AF | PDBR | CY2010 | PD2010-01031
An Informal PEB adjudicated the PTSD condition as unfitting, rated 30%, with application of the DoDI 1332.39, and placed the CI on the Temporary Disability Retired List (TDRL). After more than four years on TDRL, the PEB assigned a permanent separation rating of 10% for the PTSD condition. 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...
AF | PDBR | CY2010 | PD2010-01039
The CI made no appeals, and was medically separated with a permanent 10% disability rating. As noted above, the July 2008 PEB found the PTSD stable for final rating, and the CI was permanently separated from the Army with a 10% disability rating. Providing a correction to the individual’s separation document showing that the individual was separated by reason of permanent disability retirement effective the date of the original medical separation for disability with severance pay.
AF | PDBR | CY2010 | PD2010-01040
The VA assigned a 10% evaluation based on VA examination findings of painful motion and tenderness of the thoracolumbar spine with full ROM. RECOMMENDATION : The Board, therefore, recommends that there be no recharacterization of the CI’s disability and separation determination, as follows: I have carefully reviewed the evidence of record and the recommendation of the Board.
AF | PDBR | CY2010 | PD2010-01079
During treatment the CI was diagnosed with PTSD in addition to her Anxiety Disorder. The mental health symptoms from PTSD and Generalized Anxiety Disorder were not independently evaluated or separated regarding individual contribution to disability by any examiner. Therefore, all of the CI’s mental health symptoms and disability are considered under the CI’s unfitting PTSD rating.
AF | PDBR | CY2010 | PD2010-01080
The most proximate source of comprehensive evidence on which to base the permanent rating recommendation in this case is the VA psychiatric rating evaluation four months after separation. The CI was in treatment by the Worchester VA for three months before the MEB evaluation. Exhibit C. Department of Veterans' Affairs Treatment Record.