Search Decisions

Decision Text

AF | PDBR | CY2012 | PD2012 01313
Original file (PD2012 01313.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:    CASE NUMBER: PD120 1313
BRANCH OF SERVICE: Army   BOARD DATE: 2013 0 5 16
DATE OF PLACEMENT ON TDRL: 20000828
Date of Permanent SEPARATION: 20020530

SUMMARY OF CASE : Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve SPC/E-4 (46Q / Public Affairs Specialist), medically separated for fatigue and depression as a residual of sarcoidosis. The CI's symptoms began in 1996 upon her return from a 2 week annual training at Fort Polk where the CI was noted to have some cervical adenopathy, leading to a diagnosis of sarcoidosis. The CI was deployed with her Public Affairs Unit to Bosnia in 1999 and soon thereafter she was evaluated at Landstuhl Army Medical Center because of her shortness of breath (SOB) and fatigue. The CI continued to exhibit these problems and was also treated for anxiety disorder, depression and social phobia.
Despite the numerous and extensive r heumatology, d ermatology and p hysical t herapy (PT) evaluations, the CI failed to meet the physical requirements of her Military Occupational Specialty (MOS) or satisfy physical fitness standards. She was issued a permanent P3/S3 profile and referred for a Medical Evaluation Board (MEB). The MEB forwarded “ 1. S arcoidosis causing joint aches and general fatigue; 2. Axis I: 1. Major Depression related to h er general medical condition and her inability to work and to function well because of fatigue . 2. Social phobia 3. Acrophobia , mild. 3. Axis II: Mixed personality disorder with obsessive-compulsive, passive- dependent and schizoid features. Axis III: 1. Sarcoidosis 2. Chronic Anemia 3. Fatigue related to sarcoidosis and/or the anemia and/or the depression and/or chronic fatigue syndrome, possibly. Axis IV: 1 . Inability to function on the job 2. Inability to function at home se condary to fatigue. Axis V: 60” were forwarded to the Informal Physical Evaluation Board ( I PE B) IAW AR 40-501. The I P EB adjudicated “sarcoidosis with associated excessive fatigue, depression and joint pain” as unfitting, rated 30% with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD). The CI made no appeals and was placed on the Temporary Disability Retired List ( TDRL) on 28 August 2000. The IPEB proceedings of 18 March 2002 removed the CI from the TDRL and she was permanently separated with a 10% disability for sarcoidosis with residual fatigue, depression. The CI appealed to the Formal PEB (FPEB) which affirmed the IPEB finding and rating. The CI rebutted the FPEB finding and the U S Army Physical Disability Agency (USAPDA) affirmed the FPEB finding. T he CI made no appeals, and was medically discharged.


CI CONTENTION : “The rating for sarcoidosis should be changed because it is alleged the condition preexisted. There is no evidence the condition preexisted. The posterior cervical lymphadenopathy appeared while on active duty. It did not exist prior to my active duty time. According to Dr. V -- - , it was reactive. Even if the condition was present, it was dormant until the active duty time. This constitutes “worsening of the condition.” I have continued to suffer w/ sarcoidosis SINCE that active duty time. Never before. That would constitute permanent worsening. The condition has progressed to nuero sarcoidosis since that time. I am required to take medication daily to maintain the illness.”
______________________________________________________________________________

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 sarcoidosis with residual fatigue and depression 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 C orrection of Military Records.


RATING COMPARISON :

Final Service FPEB - 20020417
 VA (12 Mo. Post-TDRL Entry and 30 Mo. Post-TDRL exit)
On TDRL - 20000828
 Code Rating Condition Code Rating Exam
Condition
 TDRL Sep.
Sarcoidosis with associated Excessive Fatigue, Depression, and Joint Pain
 6846 30% Sarcoidosis 6846 Not Service Connected
(NSC)		 20010818
Major Depression 9434 NSC 20010818
Social Phobia; Acrophobia, Mild; and Mixed personality Disorder
 Not Unfitting No VA Entry
Sarcoidosis with Residual Fatigue and Depression
 6846-9434 10% Sarcoidosis 6846 NSC 20041030
Major Depression 9434 NSC 20041030
Iron Deficiency Anemia
 Not Unfitting No VA entry
Combined: 30% → 10%
 Combined: NSC
invalid font number 31502

ANALYSIS SUMMARY : The Board acknowledges the CI’s information regarding the significant impairment with which her service-connected condition continues to burden her; but, must emphasize that the Disability Evaluation System has neither the role nor the authority to compensate members for anticipated future severity or potential complications of conditions resulting in medical separation. That role and authority is granted by Congress to the Department of Veteran s Affairs, operating under a different set of laws. Post-separation evidence is probative to the Board’s recommendations only to the extent that it reasonably reflects the disabi lity at the time of separation.

Sarcoidosis with associated Excessive Fatigue, Depression, and Joint Pain Condition. The CI’s condition was well documented in the numerous service treatment records . The CI first presented with symptoms of bilateral cervical adenopathy in 1995 . A cervical node biopsy was performed in November 1995 and pathology confirmed the diagnosis of sarcoidosis. In 1997, the CI underwent the biopsy of lesions on her face-lip area which were consistent with sarcoidosis. The CI was seen by d ermatology in 1999 for sarcoid lesions , i nternal m edicine for iron deficiency anemia , and gynecology for bilateral breast lesions. The r heumatologist noted profound fatigue and that the CI had developed significant problems with depression after treatment with P rednisone since the onset of the sarcoidosis. A p ulmonary f unction t est (PFT) demonstrated a mild to moderate lung disease. A cardiology consult was negative for sarcoid involvement. The r heumatologist in November 1999 noted a depressed affect . The i nternist noted chronic fatigue, mild l ymphadenopathy and depression.

The CI was initially referred to mental health in 1999 for a history of anxiety which increased with stress in social situations and she was diagnosed with social phobia. The CI was followed extensively by a psychiatric social worker and a psychiatrist for a mood disorder due to a general medical condition (sarcoidosis) . The c ommander’s s tatement noted that the CI's chronic fatigue, sarcoidosis, depression , and SOB interfered with her performing the duties required of her MOS. The MEB h istory and physical exam approximately 6 months prior to TDRL entrance noted that the CI had suicidal ideation when she was in Bosnia; h owever , the examiner opined that “it would appear that the general medical condition is what incapacitates her and th at the depression is secondary ” and “if she is to be medically discharged from the Army it would not be appropriate to do that from a psychiatric point of view, but to tie her discharge to her general medical condition . ” The MEB narrative summary ( NARSUM ) exam approximately 5 months prior to TDRL entrance noted that the CI continued to have chronic and unrelenting fatigue and SOB with slight and frequent joint pain. A PFT demonstrated moderate obstructive defect in small airways. At the time of the MEB NARSUM, the CI was currently taking an anti-inflammatory medicine, hydroxychloroquine sulfate (Plaquenil) 200 mgs 2 per day, Prozac, and iron tablets for treatment of a chronic iron deficiency anemia. The CI was given a P3 / S3 permanent p rofile for sarcoidosis and major depression. The CI was referred to PT with joint pains for quadriceps and hamstring strengthening. The CI was placed on TDRL in August 2000 .

The Board directs attention to its rating recommendation at TDRL entry bas ed on the above evidence. At TDRL entry, the PEB coded the s arcoidosis with associated e xcessive f atigue, d epression, and j oint pain as 6846 . The TDRL entry IPEB rated the condition at 30% based on pulmonary involvement with persistent symptoms requiring chronic low dose (maintenance) or intermittent corticosteroids. Based on a review of treatment records, t he VA determined that 6846 s arcoidosis was not service - connected (NSC) based on the finding that it had existed prior to service (EPTS) and it had not been permanently worsened as a result of service. The VA also determined that 9434 d epression was NSC because the records did not show any treatment for depression and it could not be shown that this condition was either incurred in or aggravated by military service. The MEB NARSUM exam approximately 6 months prior to TDRL entrance noted that the CI continued to have chronic and unrelenting fatigue and SOB with slight and frequent joint pain. At the time of TDRL entry, the CI had a well-documented history of SOB and dyspnea. While Plaquenil is not a corticosteroid but an antimalarial medication, it is used to reduce inflammation in rheumatologic diseases instead of corticosteroids and can be considered similar for rating purposes. With continued symptoms and chronic use of this medication, the CI exceeded the requirements for the 0% rating. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 Reasonable doubt, the Board recommends no recharacterization of the TDRL entry rating decision of 30%.

 The Board turned its atten tion to the accompanying symptoms of depression and discussed the possibility of rating this as a separately unfitting condition. The r heumatologist in November 1999 noted a depressed affect. The i nternist noted chronic fatigue, mild lymphadenopathy , and depression. The CI was initially referred to mental health in June 1999 for a history of anxiety that increased with stress in social situations and she was diagnosed with social phobia. The CI was followed extensively by a psychiatric social worker and a psychiatrist for a mood disorder due to a general medical condition (sarcoidosis). The CI was seen by mental health who, in November 2000, noted that she was diagnosed with social phobia and depression as a result of her tour in Bosnia. The following month a psychiatrist opined that although the CI had “severe major depression (may or may not be due to sarcoidosis).” The MEB NARSUM p sychiatric a ddendum approximately 8 months prior to TDRL entrance noted that the CI had suicidal ideation when she was in Bosnia. H owever , the examiner opined, “it would appear that the general medical condition is what incapacitates her and th at the depression is secondary” and “if she is to be medically discharged from the Army it would not be appropriate to do that from a psychiatric point of view, but to tie her discharge to her general medical condition . ” The Board reviewed the above evidence and concluded that based on the preponderance of evidence, the depression wa s an inherent as part of the CI’s sarcoid osis and it was not separately unfitting .

 While on the TDRL, the CI continued to have intermittent fatigue, joint arthralgias, anemia, depression, and flares of new sarcoid lesions. Her medications included Plaquenil , an anti-depressant, a series of corticosteroids , and a NSAID. Two PFT’s demonstrated a moderate obstructive defect in the small airways. A chest X -ray in December 2001 indicated increased interstitial markings consistent with sarcoidosis. A repeat chest X -ray 2 months later noted chronic changes in both perihilar regions, more prominent on the right and probably secondary to sarcoidosis. The CI continued to have r heumatology evaluations for arthralgias and dyspnea and dermatology evaluations for ongoing skin lesions. At the MEB TDRL e xit NARSUM approximately 6 months prior to final separation, the CI had stopped taking Plaquenil against medical advice. She had not received any prescriptions for corticosteroids in the previous year, had no emergency room visits, and had not been using any inhalers . She was using an NSAID for joint pain a few times a week and had periodic steroid injections for skin lesions. She was working 40 hours per week and she stated she was “exhausted” after an 8 hour day. The physical examination noted only multiple 2 cm anterior and posterior cervical and submandibular lymph nodes that were all soft and mobile. The pulmonary exam was clear and PFTs in November 2001 documented no change with a bronchodilator, a very mild decrease in diffusion, no obstruction, and no restriction. As depression was a residual of the CI’s sarcoidosis, it was evaluated by both the VA and the service. The VA p sychiatric C &P examination approximately 9.5 months prior to permanent separation noted a Global Assessment of Functioning ( GAF ) of 70 ( s ome mild symptoms). The examiner opined that the CI’s “depression was aggravated by her military service from 26 February 1999 to 11 July 1999. The MEB TDRL e xit p sychiatric a ddendum exam approximately 3 months prior to permanent separation, noted that the depression was in full remission with daily Prozac and regular outpatient psychiatric treatment . There is documentation in the STR that the CI continued to be followed by mental health and there was an exacerbation of the depression. She was advised to double the anti-depressant dosage and return to the clinic in a week for a reevaluation . The CI continued to be monitored by mental health and had a GAF of 50 ( s erious symptoms) at VA outpatient appointments in both May and July 2002 . There was minimal information about her functioning at work was available although in July 2002 the CI reported, “work is going okay.”

The Board directs attention to its permanent separation rating recommendation at TDRL exit based on the above evidence. The IPEB rated the sarcoidosis with residual fatigue and depression as 6846 s arcoidosis with 9434 major depression. A 10% disability rating was assigned based on the 9434 code and a “mild social and industrial impairment.” The CI appealed and both a FPEB and USAPDA affirmed the 10% disability rating. In December 2001, the VA determined that both sarcoidosis and depression had EPTS and neither had been aggravated by service. Therefore, neither condition was service-connected. The VA cited evidence that sarcoidosis originated in August 1995, 4 years prior to service, and that while the etiology of sarcoidosis is unknown, it was unlikely to have resulted from the CI’s military service. The VA had previously denied service-connection of depression based on lack of a diagnosis. However, at the time of this rating decision, it had obtained evidence the CI had been treated for depression prior to service in August 1998 and that the depression had not been permanently aggravated by military service. The evidence shows the CI had little to no pulmonary problems and was no longer taking Plaquenil or any chronic or intermittent corticosteroids at the time of the TDRL exit NARSUM. Therefore, if 6846 sarcoidosis alone was used for rating, a disability rating greater than 0% would not be warranted. However, if the general rating formula for mental disorders is applied to rate the depression as an extra-pulmonary residual of sarcoidosis, a 10% rating can be assigned based on the diagnosis of depression with symptoms controlled with medication. After due deliberation, considering all of the evide nce and mindful of VASRD §4.3 (r easonable doubt ) , the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the permanent separation rating of 10% for the sarcoidosis with residual fatigue and depression 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 sarcoidosis with residual fatigue and depression condition and IAW VASRD §4. 97 , the Board unanimously recommends no change in the PEB adjudication for TDRL entry rating or the permanent separation rating. 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
TDRL PERMANENT
Sarcoidosis with Residual Fatigue and Depression
 6846-9434 3 0% 1 0%
COMBINED
 3 0% 1 0%
invalid font number 31502

The following documentary evidence was considered:
Exhibit A. DD Form 294, dated 20 120625 , w/atchs
Exhib it 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 AR20130012146 (PD201201313)


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                                                 
                                                      (Army Review Boards)

CF:
( ) DoD PDBR
( ) DVA

Similar Decisions

  • AF | PDBR | CY2011 | PD2011-00424

    Original file (PD2011-00424.docx) Auto-classification: Approved

    Hip Condition . In the matter of the hip condition, the Board unanimously recommends permanent separation rating of 10% for each hip, coded 5299-5255 IAW VASRD §4.40, §4.45, §4.59, and §4.71a. 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 | CY2014 | PD-2014-02255

    Original file (PD-2014-02255.rtf) Auto-classification: Denied

    The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition at the time of separation. The CI ultimately responded to a 10-day, followed by a 21-day, taper of decreasing doses of oral steroids.A subsequent dermatology consultation from March 2008 (8 months prior to separation) described the previous...

  • AF | PDBR | CY2014 | PD-2014-02007

    Original file (PD-2014-02007.rtf) Auto-classification: Denied

    SEPARATION DATE: 20080804 The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the VASRD standards to the unfitting medical condition at the time of separation. The rating was based on clinical records that documented in October 2011 the CI reported pain and inflammation, and the VA respiratory examination in June 2012 that documented continued complaints of fatigue and intermittent chest...

  • AF | PDBR | CY2013 | PD-2013-01644

    Original file (PD-2013-01644.rtf) Auto-classification: Denied

    The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of theVeterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition at the time of separation. RECOMMENDATION : The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of her prior medical separation: I have carefully reviewed the evidence of record and the...

  • ARMY | BCMR | CY2001 | 2001053972C070420

    Original file (2001053972C070420.rtf) Auto-classification: Denied

    On 2 December 1998 a PEB considered the applicant’s condition as indicated by the TDRL examination and determined that she was physically unfit, recommended a 10 percent disability rating and that she be separated with severance pay. Her renal disease was in remission, however, she had received inadequate therapy due to the continued low white blood cell count which was probably secondary to some systemic activity of lupus. She stated the VA has evaluated her condition as 100 percent disabling.

  • AF | PDBR | CY2012 | PD 2012 01453

    Original file (PD 2012 01453.txt) Auto-classification: Approved

    RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW NAME: XXXXXXXXXXXXXXX BRANCH OF SERVICE: ARMY CASE NUMBER: PD1201453 DATE OF PLACEMENT ON TDRL: 20020129 BOARD DATE: 20130307 DATE OF PERMANENT SEPARATION: 20040704 SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (91B/Medic) medically separated for asthma. Based on the evidence in the treatment record, the Board has no basis to recommend a...

  • AF | PDBR | CY2009 | PD2009-00431

    Original file (PD2009-00431.docx) Auto-classification: Denied

    The CI was referred to the Physical Evaluation Board (PEB), found unfit for the condition, determined unfit for continued military service and separated at 10% disability using the Veterans Affairs Schedule for Ratings Disabilities (VASRD) and applicable Navy and Department of Defense regulations. While chronic vertigo with associated ataxia was the condition for which the CI was initially placed on TDRL, further diagnostic work-up revealed that her symptoms were due to chronic B12...

  • AF | PDBR | CY2013 | PD-2013-02345

    Original file (PD-2013-02345.rtf) Auto-classification: Denied

    The back condition and anemia, characterized as “mechanical low back pain (LBP)” and “anemia,” were the only conditions forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. A neurosurgical examination on 23 August 2004 (10 months prior to separation) showed normal spine contour and normal gait. RECOMMENDATION : The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.

  • AF | PDBR | CY2010 | PD2010-01268

    Original file (PD2010-01268.docx) Auto-classification: Approved

    There was mild social impairment, but no documented occupational impairment. In the matter of the headache and hypertension conditions, or any other medical conditions eligible for Board consideration; the Board unanimously agrees that it cannot recommend any findings of unfit for additional service disability rating. RECOMMENDATION : The Board recommends that the CI’s prior separation be modified to reflect that the CI was placed on the TDRL at 50% for a period of 6 months (PTSD at 50%...

  • AF | PDBR | CY2013 | PD-2013-02236

    Original file (PD-2013-02236.rtf) Auto-classification: Denied

    In December 2004 theMEB found the asthma condition had stabilized sufficiently and the PEB adjudicated “exertion asthma” unfitting, rated at 10% disability and the CI was removed from the TDRL on 30 December 2004. The Board deliberated if the TDRL NARSUM current medications’listing oral Singulair was supported by the record and if it met the VASRD 6602 30% rating criteria for daily oral bronchodilator therapy.The Board discussed the evidence of record concerning Singulair use.Singulair was...