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AF | PDBR | CY2013 | PD 2013 00908
Original file (PD 2013 00908.rtf) Auto-classification: Approved
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXXXX       CASE: PD-2013-00908
BRANCH OF SERVICE: air force     BOARD DATE: 20140131
SEPARATION DATE: 20040312


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SRA/E-4 (3P051/Security Forces Journeyman) medically separated for asthma. The CI had a history of seasonal allergic rhinitis and initially presented to his primary care manager on 23 September 2002 with a several month history of sub-sternal chest tightness and squeezing sensation. He was evaluated and diagnosed with asthma. The condition could not be adequately rehabilitated to meet the physical requirements of his Air Force Specialty or satisfy physical fitness standards. He was issued a P4E2 Physical Profile Serial Report and referred for a Medical Evaluation Board (MEB). The MEB characterized his condition as asthma and forwarded it to the Physical Evaluation Board (PEB) IAW AFI 48-123. The MEB forwarded no other conditions to the PEB. The PEB adjudicated asthma as unfitting rated 10%. The PEB also added seasonal allergic rhinitis and adjudicated it as a Category II condition (conditions that can be unfitting but not compensable or ratable). The CI made no appeals and was medically separated.


CI CONTENTION : “ I was given 30% for my asthma on 13 March 2004 from the VA and only 10% from the AF. My separation date from a ctive duty was 12 March 2004. ”


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. The remaining condition adjudicated as Category II by the PEB (seasonal allergic rhinitis) was not requested for review and thus is not within the defined scope. Any conditions or contentions 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 20040108 VA - (3 Mos. Post-Separation)
Condition Code Rating Condition Code Rating Exam
Asthma 6602 10% Asthma 6602 30% 20040603
Seasonal Allergic Rhinitis Category II Not Service Connected
No Additional MEB/PEB Entries Other x 3 20040603
Combined: 10% Combined: 40%
Derived from VA Rating Decision (VA RD ) dated 200 40802 ( most proximate to date of separation [ DOS ] ).


ANALYSIS SUMMARY:

Asthma Condition. The service treatment record (STR) revealed the CI had no pre-existing pulmonary history. He reported episodes of exercise induced dyspnea (difficult or labored breathing associated with activity) in 2000. His condition was treated symptomatically until September 2002 when he developed chest tightness, night-time cough with shortness of breath and was provisionally diagnosed with asthma based upon an improved, post-medication pulmonary function test (PFT). He was started on a “maintenance” medication of Singulair (oral indirect-acting “non-steroid” bronchodilator) and an “as needed”/rescue medication of Proventil (inhalational “non-steroid” bronchodilator [Albuterol]). He experienced minimal improvement over the next year and due to equivocal serial PFTs he was referred to pulmonology for a diagnostic chemical respiratory challenge test. A methacholine challenge test was positive on 24 November 2003, connoting a definitive diagnosis of asthma.

The MEB narrative summary (NARSUM) of 10 December 2002 summarized the history leading up to his current diagnosis and did not provide any further subjective complaints. It cited the original PFT of September 2002 as well as the improved follow-up PFT a month later after medication treatment. The MEB addendum dated 9 December 2003 noted the CI taking Flonase (inhalation steroid) and Zyrtec (antihistamine). His physical examination was normal. The diagnosis was mild persistent asthma currently well controlled and the examiner opined a “good prognosis” with continued treatment. There was no historical evidence of a requirement for emergent resuscitation, hospital admission or intermittent courses of systemic steroids. There were no pharmacy authored medication profiles in evidence. Regarding specific medications and refills, the STR revealed a primary care note of 21 May 2001 that indicated Beclomethasone (Beconase [steroid]) nasal spray was prescribed as 2 puffs daily in each nostril; noting last filled in June 2000 with 3 refills left to dispense; indicating a 3-4 month supply. The STR was absent any further comment or documentation regarding this medication. On 30 April 2002, via a telephone consultation, the CI requested a refill of his “allergy medication” and the provider stated “spoke with patient; he is doing well on the medication. Will refill medication for 131 days for him to take while deployed”…indicating a supply through August or September 2002; however, the identification or actual date filled of “the medication” was not in evidence. On 16 October 2002, the STR indicated a refill of 30 tablets of Singulair with 5 additional refills (6 months)…indicating a supply through March 2003. There were inconsistent histories with regard to continuous use of medication. There were three separate clinical encounters during September and October 2003 that indicated no current use of medication for asthma. One encounter reported “none” for medication use and two other encounters listed vitamins, antibiotics or anti-inflammatories. A pulmonologist note in November 2003 noted current medications to include Combivent (inhalational bronchodilator [Ipratropium/Albuterol]). The STR was absent any further comment or documentation regarding this medication.

At the VA Compensation and Pension examination performed 3 months after separation, the CI reported asthma triggers such as smoke, allergens and exercise, and reported taking Advair for the previous 6-7 months (indicating since December 2003, 3 months prior to DOS). He used the albuterol inhaler ‘as needed’ prior to the Advair. The physical examination was normal. The asthma diagnosis was unchanged and rated at 30% citing daily use of Advair. On 8 January 2004, the PEB adjudicated the asthma condition as unfitting with a disability rating of 10% citing inequities created in deployment/remote assignment obligations. The PFT evaluations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized below.

DOS 20040312
Pulmonary Exam PCC ~6 Mo. Pre-Sep
(20030915)
 PCC ~5.5 Mo. Pre-Sep
(20030930)
 Pulm~4 Mo. Pre-Sep
(20031118)
FEV1 (% Predicted) 95% 95% 100%
FEV1/FVC 93% 95% 99%
Meds None None Albuterol and Combivent
§4.97 Rating* 0% 0% 10%-30% **
              * Based on PFT criteria alone; treatment criteria for 10% and 30% ratings as below .

The NARSUM indicated that, at the early onset of his asthma, the CI was prescribed an inhaler for use on an as-needed basis as well as an oral medication of Singulair. The NARSUM specified daily use of the oral medication. Achieving good control while on the oral medication coupled with documentation of 6 months of refills and the examiner’s opinion of achieving a “good prognosis” with continued treatment would support a daily requirement in treating a condition that is known to be chronic in nature. The historical medication listings within the record, although not capturing quantities necessary to sustain constant daily dosing, was considered slightly restrictive; since, it cannot be assured that they represented the sole source for dispensing medication. The NARSUM addendum did establish the CI’s ongoing use of an inhalational anti-inflammatory near the time of separation. After considerable deliberation and favorably applying reasonable doubt, Board consensus was that the evidence was insufficient to conclude that the CI did not require daily treatment with medications in order to maintain good asthma control; and, therefore recommends 30% as the fair rating in this case.

The Board directs attention to its rating recommendation based on the above evidence. Based solely on PFT parameters this condition does not meet compensable disability criteria. A compensable rating for asthma in this case must be predicated therefore on the non-PFT criteria under VASRD code 6602. There was 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. Therefore the higher 60% or 100% ratings IAW 6602 criteria are not supported. 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 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 10% rating was premised on intermittent requirement, and the VA 30% rating was premised on daily requirement.


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 (by a vote of 2:1) recommends a disability rating of 30%, coded 6602 IAW VASRD §4.97. The single voter for dissent (who recommended adopting the VA rating 6602 at 10%) did not elect to submit a minority opinion. 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
Asthma 6602 30%
COMBINED 30%


The following documentary evidence was considered:

Exhibit A. DD Form 294, (not dated) w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record




XXXXXXXXXXXXXXX
President
Physical Disability Board of Review

PDBR PD-2013-00908


MEMORANDUM FOR THE CHIEF OF STAFF
         Having received and considered the recommendation of the Physical Disability Board of Review and under the authority of Title 10, United States Code, Section 1554a (122 Stat. 466) and Title 10, United States Code, Section 1552 (70A Stat. 116) it is directed that:
         The pertinent military records of the Department of the Air Force relating to XXXXXXXXX, be corrected to show that:

         a.  The diagnosis in his finding of unfitness for Asthma,VASRD Code 6602, was rated at 30% rather than 10%.
                  b.  On 11 March 2004, he elected not to participate in the Survivor Benefit Plan and on that same date, his spouse XXXXXXXXXXX concurred with his election.
                  c.  He was not discharged on 12 March 2004 with entitlement to disability severance pay; rather, on that date he was released from active duty and on 13 March 2004 his name was placed on the Permanent Disability Retired List.






XXXXXXXXXXX
Director
Air Force Review Boards Agency

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