RECORD OF PROCEEDINGS 

PHYSICAL DISABILITY BOARD OF REVIEW 

 

NAME: XXXXXXXXXXXXXXX BRANCH OF SERVICE: ARMY 

CASE NUMBER: PD1201325 SEPARATION DATE: 20020919 

BOARD DATE: 20130315 

 

 

SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this 
covered individual (CI) was an active duty SPC/E-4 (92R10/Parachute Rigger), medically 
separated for headaches following head trauma and a subjective sense of dizziness. He 
suffered head trauma with loss of consciousness following a parachute jump mishap in May 
2000 when his chute collapsed. He reported post-injury problems with memory, speech, and 
emotional regulation along with chronic headaches and vertigo. He had persistent daily 
headaches aggravated by movement and exertion with occasional photophobia and 
disequilibria. Despite prophylactic medications the CI did not improve adequately with 
treatment to meet the physical requirements of his Military Occupational Specialty (MOS) or 
satisfy physical fitness standards. He was issued a permanent P3 profile and referred for a 
Medical Evaluation Board (MEB). Cognitive disorder and adjustment disorder conditions, 
identified in the rating chart below, were also identified and forwarded by the MEB. In January 
2002 the Informal Physical Evaluation Board (IPEB) adjudicated the post-traumatic headache 
condition as unfitting, rated 30% with application of the Veteran’s Affairs Schedule for Rating 
Disabilities (VASRD) and recommended that the CI be placed on the Temporary Disability 
Retired List (TDRL). The remaining conditions were determined to be not unfitting and 
therefore not ratable. The CI appealed for reconsideration by the IPEB and a month later the 
narrative was changed, but the rating and TDRL recommendation were not. In April of 2002 the 
United States Army Physical Disability Agency (USAPDA) revised the IPEB findings to a final 
disability percentage of 10% with separation and severance pay. The reason given for the 
revision was insufficient evidence to support the rating percentage. They went on to state the 
symptoms were subjective and even with them the soldier worked all day, every day. The 
soldier was considered unfit only because his medical status prevented his parachute rigger and 
jump duties. Finally they stated the VASRD limits recovery to 10% in such cases unless there is 
evidence of multi infarct dementia, which was not present. Even absent the VASRD 8045 rule, 
they stated there was no reasonable basis for rating the soldier at 30%. The CI then appealed 
to a Formal PEB (FPEB) who affirmed the USAPDA determination of 10% in accordance with 
VASRD instruction 8045; placement on TDRL was not recommended. The CI was then medically 
separated with a 10% disability rating. 

 

 

CI CONTENTION: “ISSUE #1: I feel the leagle [sic] repesenitive [sic] did not look or work in the 
my case in my best intrest [sic] his ansewrs [sic] were premditad [sic] and geard [sic] for 
protection on MEB ISSUE 2: I beleave [sic] that MEB members did not review medical records 
to give an approprat [sic] rating. ISSUE 3: Evory [sic] time my case revied [sic] by MEB my rating 
decreaced. [sic] ISSUE 4: My case was started in Vicenza Italy with the MEB or PEBO in 
Landstule Germany. My first rating was 60% then 30% then I did agree at 30% but then sent to 
Walter Reed MEB. Where it was reduced to 10%. ISSUE 5: As a detachment my document 
were not given to me by Stf. Sargont [sic] Ramos Barlosa. Who also violated my Hipa Rights to 
Alter medical records. ISSUE 6: I was told if I did not sine [sic] at 10% to agree I would get 0% 
and still be removed from Army.” 

 

 

SCOPE OF REVIEW: The Board wishes to clarify that the scope of its review as defined in DoDI 
6040.44, Enclosure 3, paragraph 5.e.(2) is limited to those conditions which were determined 


by the PEB to be specifically unfitting for continued military service; or, when requested by the 
CI, those condition(s) “identified but not determined to be unfitting by the PEB.” The ratings 
for unfitting conditions will be reviewed in all cases. The cognitive disorder and adjustment 
disorder conditions which were implied for consideration in the application do meet the criteria 
prescribed in DoDI 6040.44 for Board purview; and, are addressed below, in addition to a 
review of the ratings for the unfitting conditions. 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 Army Board for Correction of Military Records. 

 

 

RATING COMPARISON: 

 

Service FPEB – Dated 20020701 

VA (8 Mos. Post-Separation) – All Effective Date 20020920 

Condition 

Code 

Rating 

Condition 

Code 

Rating 

Exam 

Headaches 

8045-9304 

10%* 

Post Concussion Syndrome w/ 
Headaches 

8099-8045 

0%** 

20030624 

Cognitive Disorder 

Not Unfitting 

NO VA ENTRY 

Adjustment Disorder 

Not Unfitting 

NO VA ENTRY 

.No Additional MEB/PEB Entries. 

Residuals of Glaucoma 

6099-6013 

10% 

20030618 

Bilateral Tinnitus 

6260 

10% 

20030618 

0% X 4/ Not Service-Connected x 3 

20030624 

Combined: 10% 

Combined: 20% 



*The original IPEB of 20020124 rated him at 30% and put him on TDRL. This was later changed by the USAPDA to 10% with 
severance and upheld by the FPEB. 

** A 20050518 VARD changed this rating to 50% combining conditions of mood disorder with depressive features associated 
with post concussion syndrome with headaches; however, it was only postdated effective from 20031006 – a year post 
separation. 

 

 

ANALYSIS SUMMARY: The Board acknowledges the CI’s contentions in the DD Form 294. It is 
noted for the record that the Board does not have the jurisdiction to scrutinize or render 
opinions in reference to asserted service improprieties in the disposition of a case. The Board’s 
authority, as defined in DoDI 6044.40, resides in evaluating the fairness of Disability Evaluation 
System (DES) fitness determinations and rating decisions for disability at the time of separation. 
The DES has neither the role nor the authority to compensate members for anticipated future 
severity or potential complications of conditions resulting in medical separation. This role and 
authority is granted by Congress to the Department of Veterans Affairs (DVA). The DVA, 
operating under a different set of laws (Title 38, United States Code), is empowered to 
compensate service-connected conditions and to periodically re-evaluate said conditions for 
the purpose of adjusting the Veteran’s disability rating should the degree of impairment vary 
over time. The Board utilizes DVA evidence proximal to separation in arriving at its 
recommendations; and, DoDI 6040.44 defines a 12-month interval for special consideration to 
post-separation evidence. Post-separation evidence therefore is probative only to the extent 
that it reasonably reflects the severity of disability at the time of separation. 

 

Headaches Following Head Trauma and Subjective Dizziness Condition. Headaches and a sense 
of instability began soon after the head trauma. Brain imaging studies were negative; an initial 
electronystagmogram (ENG) was normal except for failure of fixation suppression, but a repeat 
study was reportedly normal. Otolaryngology examination concluded that there was no 
evidence of middle ear pathology as an explanation of symptoms. A neurology MEB narrative 
summary (NARSUM) in January 2001, 20 months prior to separation, noted daily, variable 
headaches, occasional blurred vision, sensitivity to light and noise, and vertigo provoked by 
motion. His headaches were worsened by noise and exertion, and improved with sleep, rest, 
and occasional abortive medication. He described emotional lability, including outbursts of 
anger and crying episodes. He continued to work as a rigger more than eight hours a day. The 
neurologic exam was normal. The condition was assessed as post-traumatic headaches and 


post-traumatic motion provoked disequilibrium. At a neurology MEB reevaluation in 
September 2001, a year prior to separation, the CI reported persistent, daily, right-sided 
headaches, lasting 10-11 hours per day, which were mildly improved over the preceding 
months. The headaches were occasionally associated with nausea, photophobia, and 
decreased equilibrium; and were worsened by movement and exertion, and improved with 
rest. He described the headache severity as 5-6 out of 10 (1-10 scale) and occasionally 8 out of 
10. He continued to work as a parachute rigger and to run with his unit during physical training. 
The neurologic exam was normal. The condition was assessed as a post-concussion syndrome. 
At the VA Compensation and Pension (C&P) exam in June 2003, 9 months after separation, the 
CI reported constant, daily, right-sided headaches characterized as sharp, throbbing, and 
squeezing and sometimes associated with photophobia. The headaches were worsened by 
extreme heat, cold, and moving his head. He reported daily episodes of mild-moderate vertigo, 
associated with nausea and vomiting, and aggravated by activities such as driving and walking. 
His headaches and vertigo resulted in decreased sleep and feelings of fatigue and weakness. 
The neurologic exam was normal. The examiner noted a CT scan of the head in November 2002 
which was reportedly normal. 

 

The Board directs attention to its rating recommendation based on the above evidence. The 
PEB assigned a 10% rating for code 8045 (traumatic brain injury) analogously rated as 9304 
(dementia due to head trauma) IAW the concurrent VASRD §4.124a which states: 

 

Purely subjective complaints such as headache, dizziness, insomnia, etc., recognized as symptomatic of brain trauma, will be rated 10 percent and no more under diagnostic code 9304. This 10 percent rating will not be combined with any other rating for a disability due to brain trauma. Ratings in excess of 10 percent for brain disease due to trauma under diagnostic code 9304 are not assignable in the absence of a diagnosis of multi-infarct dementia associated with brain trauma. 

 

The VA assigned a noncompensable disability evaluation for a post-concussion syndrome, 
coded 8099-8045. The CI had a post-concussion syndrome manifested by headaches and 
motion-provoked disequilibrium. The Board members agreed the post-concussion syndrome 
was consistent with a 10% rating under VASRD §4.124a in effect at the time of separation. The 
option of applying the 8100 coding criteria (migraine headaches) was deliberated at length. 
Although the VA declined to adopt this approach, Board members debated whether it was 
justified by VASRD §4.7 (higher of two evaluations) and §4.3 (reasonable doubt). In spite of his 
headache condition the CI was able to run, perform strenuous military training, and wear a 
Kevlar helmet and a rucksack; he continued to work eight or more hours per day and run with 
his unit. Although the CI had chronic daily headache graded as 5-6 on a 0-10 point severity 
scale, clinic examiners observed him to be in no acute distress. The Board concluded that there 
was no documentation of prostrating headaches to support consideration of an analogous 
rating under code 8100 (migraine headaches). 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 headaches and 
dizziness following head trauma condition. 

 

Contended PEB Conditions. The contended conditions adjudicated as not unfitting by the PEB 
were cognitive disorder and adjustment disorder. The Board’s first charge with respect to these 
conditions is an assessment of the appropriateness of the PEB’s fitness adjudications. 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. At a neuropsychological evaluation on 21 March 
2001, the CI reported memory disturbance, word articulation problems, and diminished 
problem-solving abilities since the parachute accident. He reported feeling “somewhat 
depressed and anxious due to uncertainty about his future and his medical condition” and more 
easily frustrated. The examiner noted a history of academic difficulty in English and spelling. 


Intellectual functioning was in the low average to average range, generally consistent with the 
estimated premorbid (pre-injury) level of functioning. The test results suggested that there 
may be relatively mild residual cognitive impairments related to the injury. The assessment of 
emotional functioning could not be reliably completed due to inconsistent responses. The 
examiner assigned the following Axis I diagnoses: cognitive disorder not otherwise specified, 
mild; adjustment disorder unspecified; and psychological factors affecting medical condition. In 
the report of medical history dated 4 June 2001 the CI indicated that he had not been evaluated 
or treated for a mental condition. Neither of these conditions was profiled, implicated in the 
commander’s statement or judged to fail retention standards. Both were reviewed by the 
action officer and considered by the Board. There was no indication from the record that these 
conditions 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 either of the 
contended conditions; and, therefore, no additional disability ratings can be 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 headaches with dizziness condition and IAW VASRD 
§4.124a, the Board unanimously recommends no change in the PEB adjudication. In the matter 
of the contended cognitive disorder and adjustment disorder conditions, the Board 
unanimously recommends no change from the PEB determinations as not unfitting. 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, as follows: 

 

UNFITTING CONDITION 

VASRD CODE 

RATING 

Headaches with Dizziness Following Head Trauma 

8045-9304 

10% 

COMBINED 

10% 



 

 

The following documentary evidence was considered: 

 

Exhibit A. DD Form 294, dated 20120617, w/atchs 

Exhibit B. Service Treatment Record 

Exhibit C. Department of Veterans’ Affairs Treatment Record 

 

 

 

 

 xxxxxxxxxxxxxxxxxxxx, DAF 

 Acting Director 

 Physical Disability Board of Review 

 


SFMR-RB 


 

 

MEMORANDUM FOR Commander, US Army Physical Disability Agency 

(TAPD-ZB / xxxxxxxxxxxxx), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557 

 

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for 
xxxxxxxxxxxxxxxxxxxxxxx, AR20130006868 (PD201201325) 

 

 

I have reviewed the enclosed Department of Defense Physical Disability Board of Review (DoD 
PDBR) recommendation and record of proceedings pertaining to the subject individual. Under 
the authority of Title 10, United States Code, section 1554a, I accept the Board’s 
recommendation and hereby deny the individual’s application. 

This decision is final. The individual concerned, counsel (if any), and any Members of Congress 
who have shown interest in this application have been notified of this decision by mail. 

 

 BY ORDER OF THE SECRETARY OF THE ARMY: 

 

 

 

 

Encl xxxxxxxxxxxxxxxxxxx 

 Deputy Assistant Secretary 

 (Army Review Boards) 

 


 

SFMR-RB 


 

 

MEMORANDUM FOR Commander, US Army Physical Disability Agency 

(TAPD-ZB / xxxxxxxxxxxx), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557 

 

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation 
for xxxxxxxxxxxxxxxxxxxxx, AR20130006868 (PD201201325) 

 

 

I have reviewed the enclosed Department of Defense Physical Disability Board of 
Review (DoD PDBR) recommendation and record of proceedings pertaining to the 
subject individual. Under the authority of Title 10, United States Code, section 1554a, 
I accept the Board’s recommendation and hereby deny the individual’s application. 

This decision is final. The individual concerned, counsel (if any), and any Members of 
Congress who have shown interest in this application have been notified of this decision 
by mail. 

 

 BY ORDER OF THE SECRETARY OF THE ARMY: 

 

 

 

 

Encl xxxxxxxxxxxxxxxxxx 

 Deputy Assistant Secretary 

 (Army Review Boards)