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AF | PDBR | CY2012 | PD2012 00696
Original file (PD2012 00696.rtf) Auto-classification: Approved
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:    CASE: PD1200696
BRANCH OF SERVICE: Army  BOARD DATE: 20130423
SEPARATION DATE: 20031206


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (91Q/Pharmacy Specialist) medically separated for irritable bowel syndrome (IBS) with controlled Crohn’s disease. The CI experienced symptoms of IBS and Crohn’s Disease and was admitted in August of 2002 for management of his pain. He was determined to have severe colitis and was diagnosed with IBS and Crohn’s. He was treated with medications but continued to experience pain and symptoms. The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty. He was issued a permanent P3 profile and referred for a Medical Evaluation Board (MEB). The IBS/Crohn’s Disease conditions, characterized as Crohn’s colitis and perianal fistula, perirectal abscess and recurrent elevations of liver enzymes, were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. The Informal PEB combined the “Crohn’s colitis and the “perirectal abscess” and adjudicated it as unfitting, rated 10% and adjudicated the other MEB conditions as not unfitting. The CI appealed to the Formal PEB which adjudicated the condition as IBS with controlled Crohn’s disease unfitting, rated at 10%, again determining the remaining conditions as not unfitting. The CI was then medically separated.


CI CONTENTION: “Medical condition frequently affects service member to maintain gainful employment. Service member now has to live with port in chest for venous access to receive medication. Service member suffers from irritable bowel and chronic fatigue syndrome.” [sic]


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 IBS and Crohn’s disease conditions are 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 FPEB – Dated 20030903
 VA - (2 Mos. Pre-Separation)
Condition
 Code Rating Condition Code Rating Exam
Irritable Bowel Syndrome and Controlled Crohn’s Disease 7399-7323-7319 10% Crohn’s Disease 7399-7323 60% 20031002
Irritable Bowel Syndrome 7319* 10% 20031002
No Additional MEB/PEB Entries
 Other x 3 20031002
Combined: 10%
 Combined: 70%
Derived from VA Rating Decision (VA RD ) dated 200 40123 ( most proximate to date of separation [ DOS ] ).
* VARD dated 20070202 cited a Clear and Unmistakable Error on the part of the VA that stated the IBS should have been rated as part of the Crohn’s Disease and not rated separated. It was changed to reflect that mistake at that time.

ANALYSIS SUMMARY: The Board acknowledges the sentiment expressed in the CI’s application regarding the significant impact that his service-incurred condition has had on his current earning ability and quality of life. It is a fact, however, that the Disability Evaluation System (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 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. The Board’s authority as defined in DoDI 6040.44, however, resides in evaluating the fairness of DES fitness determinations and rating decisions for disability at the time of separation. Post-separation evidence therefore is probative only to the extent that it reasonably reflects the disability and fitness implications at the time of separation.

Irritable Bowel Syndrome and Crohn’s Disease Condition. The enlistment medical history in 1996 indicated no history of frequent indigestion, or stomach, liver or intestinal trouble. Weight was 139 pounds. The CI’s weight in October 2001 was 152 pounds. The CI was hospitalized from 15-18 August 2002 for abdominal pain, bowel movements every 15 minutes, and rectal pain which the CI rated as 9/10 (1-10 scale). The physical exam noted that the abdomen was “firm but not tense” and rectal pain was “out of proportion to any external finding.” He was re-hospitalized from 20-23 August 2002; a colonoscopy reportedly showed exudative colitis, and an upper endoscopy and barium swallow (August 2002) were normal. X-rays of the rectum in September 2002 showed a large rectal abscess which required surgical treatment. He began Infliximab (antibody) intravenous therapy in September 2002 for Crohn’s colitis with fistula. The separation physical exam in March 2003 noted a weight of 155 pounds and rectal tenderness. The gastroenterology narrative summary (NARSUM) dated 25 March 2003 (9 months prior to separation) noted the diagnosis by colonoscopy of severe colitis consistent with IBS. A magnetic resonance cholangiopancreatography (September 2002) and laboratory results, including liver function (December 2002), were all normal. At the time of the MEB, he reported occasional abdominal pain, loose stools, and mild rectal pain without bleeding. The gastroenterologist noted rectal tenderness around the surgical site without drainage. He continued to experience rectal pain and occasional abdominal pain and diarrhea. The gastroenterologist diagnosed the condition as Crohn’s colitis which was “currently in remission after repeated hospitalizations;” he opined that the CI “…will likely require repeated... Infliximab to assure remission, based on initial presentation and severity.” A memorandum for record dated 27 May 2003 by the assistant chief of the CI’s workplace noted that since October 2002 the CI had worked four hours or less per day due to reported pain and flare-ups. The gastroenterology addendum on 28 May 2003 noted the CI’s complaint of nausea after eating, abdominal pain, loose stools several times weekly; and occasional blood in his stools, without perianal discharge, fever, or chills. The CI reported a 9-10 pound weight loss over the prior few months, but actual weight measurements were not cited. He was prescribed narcotic medication as needed for pain. The abdominal exam was normal except for discomfort with deep palpation. The rectal exam found no tenderness. The examiner reported that a colonoscopy performed in April 2003 found evidence of mild anorectal Crohn’s Disease, with mild rectal stenosis and inflammation; biopsies showed no active colitis. The examiner’s assessment was “fistulizing Crohn’s disease” and “recurrent abdominal symptoms of unclear etiology.” He opined that, “Though it is possible he has underlying irritable bowel syndrome, active Crohn’s disease cannot be excluded at this time.” A maintenance regimen of Infliximab for “aggressive management of Crohn’s disease” was continued. The commander’s statement on 29 May 2003 noted the CI’s apparent weight loss and a decline from previous outstanding performance; and that he had been unable to work a full day for the past few months due to reported fatigue, weakness, and cramps. A second gastroenterology addendum, dated 31 July 2003 (4 months prior to separation), in response to a PEB diagnostic inquiry, noted that the CI continued to have “frequent episodes of abdominal pain, cramping, and loose stools which have prevented him from maintaining his duty station…over the past few months.” The examiner described episodic abdominal pain, cramping, urgency, and loose stools, intermixed with normal bowel movements 1-2 times a day, and occasionally 6-8 bowel movements a day. These symptoms lasted minutes to hours and occurred “every 1 to 2 weeks.” They were thought to be secondary to IBS because recent evaluations with colonoscopy, radiologic studies and laboratory tests did not show “clear evidence of active Crohn’s disease.” An immunosuppressant drug (6-mercaptopurine) was added to the Infliximab regimen. The gastroenterologist opined that, “…his Crohn’s disease appears to be under well managed control, but he has underlying irritable bowel syndrome of a frequent nature” which limited “his ability to even perform his garrison mission.” At the VA Compensation and Pension exam in October 2003 (2 months prior to separation) the CI reported frequent episodes of abdominal pain, diarrhea, and emergency room visits. The Crohn’s condition was being treated with Infliximab and 6-mercaptopurine. The examiner noted the service diagnosis of IBS. The CI was able to carry out common daily activities without difficulty. Although he reported a history of weight loss to 148 pounds from his usual weight of 165 pounds, his current weight was 162 pounds. The abdominal exam was normal. The rectal exam noted a fistulectomy scar, but no loss of sphincter tone, fissure, or ulcerations. Lab studies identified normal hematocrit and hemoglobin values.

The Board directs attention to its rating recommendation based on the above evidence. The PEB’s 10% rating was based on a combined 7319 code (IBS) and analogous 7323 code (ulcerative colitis). The VA assigned a 60% rating under an analogous 7323 code for Crohn’s disease deemed to be “severe; with numerous attacks a year and malnutrition, the health only fair during remissions.” However, the VA additionally assigned 10% for separately rated irritable bowel syndrome. Although the CI was considered to have some elements of IBS superimposed on Crohn’s disease, the PEB appropriately applied only a single rating for an abdominal condition, IAW VASRD §4.113 and §4.114. In a later decision the VA acknowledged a “clear and unmistakable error” in assigning a separate evaluation for IBS, and discontinued that rating. Although the last gastroenterologist addendum stated the Crohn’s disease appeared “under well managed control,” Board members considered that symptoms were acknowledged by the examiner and supervisors to frequently interfere with work duties; and a second immunosuppressant drug was added for treatment of Crohn’s. Board members agreed that persistent symptoms despite aggressive therapy exceeded the 10% rating criteria (moderate, with infrequent exacerbations). In deliberating between the 30% (moderately severe; with frequent exacerbations) and 60% rating criteria, Board members debated if evidence of malnutrition was present. Although the commander’s statement, NARSUM and VA examiners referred to a history of weight loss, the clinical record does not support that significant weight loss occurred. Furthermore, it was decided that the “health only fair during remissions” stipulation of the 60% criteria was not an accurate description of the condition. Ultimately, the Board concluded that the 30% criteria most accurately characterized the condition at the time of separation. Under the only optional coding pathway available, 7319, the highest rating possible is 30%; therefore, this alternative offers no benefit to the CI. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 30% for the IBS and Crohn’s Disease condition coded 7399-7323.


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 IBS and Crohn’s Disease condition, the Board unanimously recommends a disability rating of 30%, coded 7399-7323 IAW VASRD §4.114. There were no other conditions within the Board’s scope of review for consideration.
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 his prior medical separation:

UNFITTING CONDITION
 VASRD CODE RATING
Irritable Bowel Syndrome and Crohn’s Disease 7399-7323 30%
COMBINED
 30%


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20120612, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record




         Physical Disability Board of Review


 SFMR-RB                                                                         


MEMORANDUM FOR Commander, US Army Physical Disability Agency
(TAPD-ZB),


SUBJECT: Department of Defense Physical Disability Board of Review Recommendation
for AR20130010789 (PD201200696)


1. Under the authority of Title 10, United States Code, section 1554(a), I approve the enclosed recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) pertaining to the individual named in the subject line above to recharacterize the individual’s separation as a permanent disability retirement with the combined disability rating of 30% effective the date of the individual’s original medical separation for disability with severance pay.

2. I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum:

         a. 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.

         b. Providing orders showing that the individual was retired with permanent disability effective the date of the original medical separation for disability with severance pay.

         c. Adjusting pay and allowances accordingly. Pay and allowance adjustment will account for recoupment of severance pay, and payment of permanent retired pay at 30% effective the date of the original medical separation for disability with severance pay.

         d. Affording the individual the opportunity to elect Survivor Benefit Plan (SBP) and medical TRICARE retiree options.

3. I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

BY ORDER OF THE SECRETARY OF THE ARMY:




Encl                                                 
                                                      (Army Review Boards)

CF:
( ) DoD PDBR
( ) DVA

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