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AF | PDBR | CY2012 | PD2012 00801
Original file (PD2012 00801.rtf) Auto-classification: Approved
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX         CASE: PD1200801
BRANCH OF SERVICE: Army  BOARD DATE: 20120318
SEPARATION DATE: 20040223


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (95B/Military Police) medically separated for an asthma condition. The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty or satisfy physical fitness standards. He was issued a permanent P3 profile and referred for a Medical Evaluation Board (MEB). The asthma condition was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. No other conditions were submitted by the MEB. The Informal PEB adjudicated “asthma” as unfitting, rated 0%, citing criteria of the VA Schedule for Rating Disabilities (VASRD). The CI made no appeals and was medically separated.


CI CONTENTION: “The condition caused the inability to fulfill duties and meet physical/weight requirements. The condition was also instantly rated at a higher rate by the VA.”


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 asthma condition is 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 IPEB – Dated 20031118
 VA - (8 Mos. Post-Separation)
Condition
 Code Rating Condition Code Rating Exam
Asthma 6602 0% Asthma 6602 10% 20041008
No Additional MEB/PEB Entries
 Other x 7 20041008
Combined: 0%
 Combined: 30%
Derived from VA Rating Decision (VA RD ) dated 20041213 ( most proximate to date of separation [ DOS ] ).


ANALYSIS SUMMARY:

Asthma Condition. The narrative summary (NARSUM), performed in November 2003, 3 months prior to separation, documented the presence of asthma symptoms most apparent during exercise. He reported shortness of breath and cough after a few minutes of running. Chronic medications of Albuterol (Proventil, inhaled bronchodilator) and Flovent (Fluticazone propionate, inhalational steroid) taken over the last year showed significant improvement on peak flow measurements from 300 to 600 liters per minute. There was no documented history of pulmonary disease, but rather some “childhood asthma-like symptoms” during his early teenage years. The physical examination was normal. An Internal Medicine outpatient encounter noted “[CI] has needed multiple emergency room visits secondary to asthma after physical training” but the service treatment record (STR) revealed only a single emergency room visit in 2002. No hospital admissions or courses of systemic steroids were required. A methacholine challenge test (definitive test) was positive; indicating a “mild” degree of asthma. A clinic note dated 14 August 2003 indicated that his prior medications were “discontinued” and specifically listed, “…no active outpatient prescriptions;” however, both medications were re-prescribed at that same visit. A clinic visit on 3 September 2003, listed both Albuterol and Flovent as current medications. A medication profile accessed as of 19 February 2004 revealed the last filling of his asthma prescriptions was 27 March 2003.

At the VA Compensation and Pension examination performed 8 months after separation, the CI reported chest tightness and cough after a slow-paced run of 1.5 to 2 miles. He takes his medications “when his symptoms are present” and quantifies dosing as usually 3-4 times per week, 1 or 2 times a day. His physical examination was normal. His diagnosis was exercise induced, moderate persistent asthma. The examiner stated, “[the condition] has had no effect on his current occupation as a full-time student.” The pulmonary function test (PFT) evaluations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized below.

DOS 20040223
Pulmonary Exam
 Resp.~11 Mo. Pre-Sep
(20030327)		 Resp.~9 Mo. Pre-Sep
(20030528)		 Resp.~6 Mo. Pre-Sep
(20030814)
FEV1 (% Predicted)
 107% 98% 99%
FEV1/FVC
 98% 97% 76%
Meds
 Albuterol and Flovent Albuterol and Flovent -
§4.97 Rating*
 10%-30% 10%-30% 10%
     * Based on PFT criteria alone; treatment criteria for 10% and 30% ratings as below.

The Board directs attention to its rating recommendation based on the above evidence. Based solely on PFT parameters this condition meets the 10% disability criteria with an FEV1/FVC between 71 and 80 percent predicted value. Board members considered non-PFT criteria under VASRD code 6602 for a higher rating. The higher 100% or 60% ratings IAW 6602 criteria were not supported by having no evidence for respiratory failure, frequent exacerbations requiring physician intervention, daily use of high dose corticosteroids or immune-suppressive medications, or frequent use of systemic corticosteroids. The treatment criteria underpinning the 10% and 30% ratings are the pivotal points for decision in this case. The Board must make a critical judgment as to the requirement for daily or intermittent use of medication at the time of separation. The 10% rating requires “intermittent inhalational or oral bronchodilator therapy;” the 30% rating requires “daily inhalational or oral bronchodilator therapy, or; inhalational anti-inflammatory medication.” The PEB’s 0% rating was premised on medical non-compliance for pharmacy records noted the last refill of medication was 8 months earlier in March 2003. The VA’s 10% rating was based upon PFT parameters.

The outpatient medication profiles revealed dated 9 January and 27 March 2003 as refill dates of his asthma medication. Based upon the prescribed dosing of the January dispensed medication, the albuterol (200 puffs per canister) “could” last many months (prescribed on an “as needed” basis) whereas flovent (120 inhalations per canister) would last only 2 months; indicating scheduled refills in February (if Albuterol is taken continuously) and March 2003 respectively. On 27 March 2003, records indicate that his Flovent dosage doubled to two puffs twice a day. That new dosage would have caused the January dispensed prescription to be completed on 7 April 2003. It is a reasonable inference that the March 2003 dispensed medication was started on 8 April 2003; and therefore, noting a new scheduled refill date would be 50 days later (200 puffs per can; taking 4 puffs per day = 50 Days) on 28 May 2003. There was no documentation of any further medication dispensed after 27 March 2003. The STR is consistent with the above calculations as indicated by the 14 August 2003 outpatient note showing the medications as “discontinued” although not specific as to the actual date they were stopped. Nonetheless, the STR noted the medications were prescribed back into the CI’s treatment regime in August 2003, indicating support for daily requirement. The STR medication profiles, although not capturing quantities necessary to sustain constant daily dosing (as described above), were considered slightly restrictive; since, it cannot be assured that they represent the CI’s sole source for dispensing medication.

The NARSUM established the CI’s current use of both prescribed medications without any indication they were utilized on an intermittent or daily basis; whereas, the VA examination (8 months post separation) clearly depicted intermittent use. Clearly, the PFT of August 2003 unequivocally meets the 10% disability criteria. Board members then deliberated if the 30% criterion for medication use was applicable. There was no evidence that the CI was receiving any prescription medications from a pharmacy outside of the servicing military treatment facility and therefore, the medication profile in evidence reflects the CI’s sole sourcing of his prescriptions. Such determination indicates that the CI would not possess and therefore, not actively be taking the previously prescribed medications near the time of Service separation. After considerable deliberation, and favorably applying reasonable doubt, the Board recommends a disability rating of 10% for the asthma condition.


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 asthma condition, the Board unanimously recommends a disability rating of 10%, coded 6602 IAW VASRD §4.97. 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, effective as of the date of his prior medical separation:

UNFITTING CONDITION
 VASRD CODE RATING
Asthma 6602 10%
COMBINED
 10%



The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20120613, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record








                                   
XXXXXXXXXXXXXXXXXX
President
Physical Disability Board of Review


 SAMR-RB                                                                         


MEMORANDUM FOR Commander, US Army Physical Disability Agency
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557


 SUBJECT: Department of Defense Physical Disability Board of Review Recommendation
for XXXXXXXXXXXXXXXXXX , AR20140018660 (PD201200801)
1. 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 to modify the individual’s disability rating to 10% without recharacterization of the individual’s separation. This decision is final.

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.

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                                                  XXXXXXXXXXXXXXXXXX
                                                      Deputy Assistant Secretary
                                                      (Army Review Boards)

CF:
( ) DoD PDBR
( ) DVA

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