RECORD OF PROCEEDINGS

PHYSICAL DISABILITY BOARD OF REVIEW

NAME: BRANCH OF SERVICE: AIR FORCE

CASE NUMBER: PD1000619 SEPARATION DATE: 20080519

BOARD DATE: 20100713

______________________________________________________________________________

SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty Staff Sergeant (2W071, Munitions System Craftsman) medically separated from the Air Force in 2008. The medical basis for the separation was diabetes mellitus type I (DM I). The CI continued to perform all primary in-garrison military duties, but due to overseas assignment restrictions the CI was referred for a Medical Evaluation Board (MEB). Diabetes and pericarditis conditions were addressed in the narrative summary (NARSUM) and forwarded to the Physical Evaluation Board (PEB) on the AF IMT 618. Additional conditions supported in the Disability Evaluation System (DES) packet are discussed below, but were not forwarded for PEB adjudication. The PEB adjudicated the DM type I as unfitting, rated 20% with application of the Veterans’ Administration Schedule for Rating Disabilities (VASRD). The CI made no appeals, and was medically separated with a 20% disability rating.

CI CONTENTION: “When I was discharge from the military I was told that my pericarditis would not return. I was told that that issue had been resolved as documented on my AF Form 356. This is not true even a year after my discharge; I was hospitalized for this same issue. My heard [sic] doctor told me to take 30 days rest, I went back to the VA, fought the decision and was award 30% for my heart. Lost my second job because of this and now I am currently unemployed due to the stress and other disorders associated with this disability.”

RATING COMPARISON:

* Pericarditis increased to 30% and added adjustment disorder with depressed mood associated with pericarditis 50%, effective 20090501

ANALYSIS SUMMARY: The Board acknowledges the sentiment expressed in the CI’s application regarding the significant impact that his service-incurred conditions have had on his quality of life. However, the military services, by law, can only rate and compensate for those conditions that were found unfitting for continued military service based on the severity of the condition at the time of separation and not based on possible future changes. The VA, however, can rate and compensate all service connected conditions without regard to their impact on performance of military duties, including conditions developing after separation that are direct complications of a service connected condition. The VA can also increase or decrease ratings based on the changing severity of each condition over time. 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. It must also judge the fairness of PEB fitness adjudications based on the fitness consequences of conditions as they existed at the time of separation. The Board’s threshold for countering DES 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.

Type I Diabetes Mellitus. CI was diagnosed as type I insulin requiring DM in September 2007 and treated with insulin and diet without activity restriction. Service treatment records from November 2007 through separation document the CI as feeling well. At the February 14, 2008 follow up appointment he was feeling well and reported good exercise habits and regular exercise more than three times per week. There were no episodes of ketoacidosis or hypoglycemic episodes requiring hospitalizations or frequent visits to a diabetic care provider, or complications (e.g. end organ damage to eye, nerve, kidney, vascular system). Although the December 11, 2007 Wilford Hall Medical Center endocrinology note refers to a hospitalization for diabetic ketoacidosis in September 2007 (at time of initial diagnosis of diabetes), review of the primary medical documentation shows that the CI was seen in the emergency room and released, and that laboratory results did not show ketoacidosis. Post-separation VA compensation and pension (C&P) examinations document CI report of bilateral hand numbness and paresthesia, with onset about one year after separation, occurring intermittently resulting in service connected ratings for diabetic neuropathy of each upper extremity. However, there was no evidence of diabetic neuropathy prior to separation. There was no complaint of paresthesia or numbness prior to separation. Detailed sensory examination of the feet was normal on December 6, 2007; the December 11, 2007 endocrinology appointment recorded that there was “no tingling, no numbness, no numbness of both feet;” and a general sensory examination by his endocrinologist May 20, 2008 was also normal. At the time of separation, the CI’s condition did not meet DM rating criteria (7913) for either the 100% or the 60% rating levels since there were no episodes of ketoacidosis or hypoglycemic episodes requiring hospitalizations or frequent visits to a diabetic care provider, or complications. Because he required insulin and dietary restrictions, he met the 20% rating level. In addition to the requirement for insulin and dietary restrictions, the 40% rating requires that there be regulation of activities defined as avoidance of strenuous occupational and recreational activities. Evidence does not indicate a requirement for regulation of strenuous activities. All evidence considered, there is not reasonable doubt in the CI’s favor supporting a change from the PEB’s rating decision for DM, type 1, without complications (7913) at the time of permanent separation.

Other PEB Conditions. The CI contends his pericarditis condition was unfitting and warrants disability rating. Pericarditis was forwarded by the MEB, but was not adjudicated as unfitting by the PEB. The MEB NARSUM and service treatment records record a history of intermittent pericarditis occurring approximately once per year from late 2002 / early 2003 to the time of the MEB in January 2008. The CI was hospitalized for the initial episode while assigned in Germany. The next hospitalization was in November 2005 for three days of symptoms of recurrent pericarditis. The CI underwent comprehensive cardiology evaluation (including normal cardiac catheterization) confirming the diagnosis. He was treated with anti-inflammatory medication (indomethacin and colchicine), with resolution of symptoms by the time of follow up with his cardiologist two weeks later on December 5, 2005. A follow up cardiology appointment on February 21, 2007 documented one brief episode in the prior ten months and the CI was asymptomatic and exercising three days per week. He was hospitalized for five days, June 21 - 25, 2007 for recurrent pericarditis. By the July 13, 2007 Wilford Hall Medical Center cardiology evaluation, he was pain free. The CI reported four episodes in four years with full resolution (asymptomatic between episodes) and denied other symptoms such as fainting (post-separation C&P examinations record report of recurrent syncope). The electrocardiogram was normal. The CI remained asymptomatic at the time of a July 23, 2007 cardiology appointment and an echocardiogram on August 2, 2007 was normal (normal heart function without the abnormal fluid collection seen with the condition). Treatment with anti-inflammatory medication was continued. Service treatment records documented no symptoms until February 2008. A December 11, 2007 Wilford Hall Medical Center cardiology follow up appointment records the CI was asymptomatic and that “he has been physically active with no limitations.” The MEB NARSUM on January 9, 2008 records the CI was feeling well and had no complaint of chest pain, shortness of breath, or light headedness and had no duty restrictions. The CI was seen in the emergency room on February 10, 2008 for chest pain consistent with his recurrent pericarditis. The electrocardiogram was normal, without changes of pericarditis seen with prior episodes. He was released after six hours and treated with colchicine (previously very effective). On a follow up visit four days later, his symptoms were resolved, he was feeling well, and was exercising regularly, more than three times per week. An April 7, 2008 primary care encounter records mild symptoms for one week and the CI was advised to take the colchicine previously shown to be very effective. At the time of his separation physical examination there was no complaint of chest pain. Although the CI’s commander indicated concern for unpredictable recurrence, the cardiologist did not recommend any duty restrictions. The CI refers to hospitalization within one year of separation for his recurrent pericarditis. The June 13, 2009 VA rating decision cites an emergency room visit on December 9, 2008 but not hospitalization, for recurrent symptoms for which medications were adjusted. The CI followed up with cardiology on January 15, 2009 reporting continued symptoms. An April 24, 2009 C&P examination records CI report that he plays basketball for leisure pursuit. Although the pericarditis was recurrent, it occurred approximately once per year without evidence of impairment to performance of duties within his military specialty. The CI’s performance reports reflected excellent duty performance throughout the time he experienced this condition, with the last report closing April 2008. In addition, there was rapid complete response to routinely prescribed anti-inflammatory medication. In between episodes he was asymptomatic without physical limitations and the cardiologist did not recommend any restrictions. All evidence considered, there is not reasonable doubt in the CI’s favor supporting recharacterization of the PEB fitness adjudication for pericarditis.

Remaining Conditions. Other conditions identified in the DES file were hyperlipidemia and a torn medial meniscus of the left knee status post surgery in May 2007. Hyperlipidemia is a laboratory finding that, although treatment may be indicated, is not itself unfitting. The CI developed a torn medial meniscus of the left knee associated with sports activities. He underwent arthroscopic surgery in May 2007. At the orthopedics follow up on August 14, 2007 there was report of pain with running; otherwise, the CI could “walk and perform without much difficulty.” The physical examination was unremarkable and there were no instability, pain, or meniscus signs. At the September 13, 2007 orthopedics follow up, there were no changes and the surgeon recommended the cycle ergometry test instead of the run for fitness testing. The MEB NARSUM on January 9, 2008 stated the knee was repaired and not duty limiting. None of these conditions was clinically active during the MEB period, carried attached profiles and none were implicated in the commander’s statement. These conditions were reviewed by the action officer and considered by the Board. It was determined that none could be argued as unfitting and subject to separation rating. Additionally Osgood Schlatter disease of the right knee, left upper extremity diabetic neuropathy, right upper extremity diabetic neuropathy and several other non-acute conditions were noted in the VA rating decision proximal to separation, but were not documented in the DES file. 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 Board therefore has no reasonable basis for recommending any additional unfitting conditions for separation rating.

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. In the matter of DM type I and IAW VASRD §4.119, the Board unanimously recommends no change in the PEB adjudication at permanent separation. In the matter of the recurrent pericarditis condition, 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 therefore recommends that there be no recharacterization of the CI’s disability and separation determination, as follows:

The following documentary evidence was considered:

Exhibit A. DD Form 294 dated 20100525, w/atchs.

Exhibit B. Service Treatment Record

Exhibit C. Department of Veterans' Affairs Treatment Record

Deputy Director

Physical Disability Board of Review

SAF/MRB

1500 West Perimeter Road, Suite 3700

Joint Base Andrews, NAF-Washington, MD 20762

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2010-00619.

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 with severance pay.

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,

Director

Air Force Review Boards Agency

Attachment:

Record of Proceedings