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AF | PDBR | CY2013 | PD 2013 00954
Original file (PD 2013 00954.rtf) Auto-classification: Approved
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXX    CASE: PD-2013-00954
BRANCH OF SERVICE: AIR FORCE    BOARD DATE: 20140313
DATE OF PLACEMENT ON TDRL: 20001114
Date of Permanent SEPARATION: 20020623


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SSGT/E-5 (4N051/Medical Tech) medically separated for chronic pelvic pain associated with chronic interstitial cystitis (IC). The CI was initially evaluated in 1998 for urinary tract infections (UTIs) which had been frequent since childhood. She also complained of intermittent, severe suprapubic and pelvic pain. She was diagnosed with IC in early 2000. Despite treatment, the condition could not be adequately rehabilitated to meet the physical requirements of her Air Force Specialty or satisfy physical fitness standards. She was issued a temporary P4 profile and referred for a Medical Evaluation Board (MEB). The chronic pelvic pain condition, characterized as “chronic interstitial cystitis” and “history of recurrent urinary tract infections,” was forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123. The MEB also identified and forwarded migraine headaches, frequent and incapacitating, as well as pain disorder and major depressive disorder (MDD) for PEB adjudication. The PEB adjudicated “chronic pelvic pain syndrome associated with chronic interstitial cystitis and pain disorder as unfitting, rated 30% with application of the VA Schedule for Rating Disabilities (VASRD) and placed the CI on the Temporary Disability Retired List (TDRL). The PEB also adjudicated the migraine headaches as a Category II condition (one that can be unfitting but is not currently compensable or ratable). The mental health (MH) condition “pain disorder” was addressed as an associated condition of the unfitting pelvic pain. The MDD was not cited at TDRL entry. The TDRL exit PEB adjudicated the chronic pelvic pain at 10% and identified the major depression as a Category II condition, stating that “member’s major depression is a new finding since member was placed on the TDRL and therefore is neither ratable nor compensable.” The pain disorder condition was not addressed at TDRL exit. The CI made no appeals and was medically separated.


CI CONTENTION: The CI writes: “incorrect application of existing regulations and diagnostic codes resulted in 10% rating.” The CI also attached a 2 page statement to her application which was reviewed by the Board and considered in its recommendations.


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 chronic pain condition is addressed below. The contended migraine and depression conditions are also within scope. 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 :

Final Service PEB - 20020517
 VA (2 Mo. Post TDRL Placement*) - Effective 20001114
On TDRL - 20001114
 Code Rating Condition Code Rating Exam
Condition
 TDRL Sep.
Chronic Pelvic Pain Associated w/Chronic IC 7629 30% 10% Chronic IC 7512 60% 20010122
Migraines 8100 Category II Not adjudicated Migraines 8100 30% 20010116
Major Depression 9434 Not adjudicated Category II No VA Entry
No Additional MEB/PEB Entries.
 Other x 3 20010122
Combined: 30% → 10%
 Combined: 70%
*Reflects VA rating exam proximate to TDRL placement. VARD of 20020926, rated Major Depression, Associated w/ Chronic IC , coded 9434, at 30% , increasing the combined rating to 80%, effective 20020429 , 18 months after TDRL placement .


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 (DES) 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 Veterans Affairs (DVA), operating under a different set of laws. The Board considers DVA evidence proximate 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 is probative to the Board’s recommendations only to the extent that it reasonably reflects the disability at the time of separation. The Board likewise acknowledges the CI’s implied contention for rating of her MH and migraine conditions which were determined to be Category II conditions by the PEB. It emphasizes that disability compensation may only be offered for those conditions that cut short the member’s career. Should the Board judge that any contested condition was most likely incompatible with the specific duty requirements; a disability rating IAW the VASRD, and based on the degree of disability evidenced at separation, will be recommended.

Chronic Pelvic Pain Associated w/Chronic Interstitial Cystitis. The CI was first seen for a UTI on 24 March 1998 and managed with medications. She was evaluated several more times over the next year. On 15 January 1999, she reported UTIs every 3 months since childhood as well as suprapubic pain. She was next seen on 26 January 1999 in Urology and again reported frequent UTIs since childhood with frequent hospitalizations. She had been doing better until childbirth 2 years earlier. She was started on suppressive antibiotics. However, she did not improve with antibiotics. An evaluation including an intravenous pyelogram (a radiology test to look at the anatomy of the kidneys, ureters and bladder), voiding cystourethrogram (a test to determine proper urinary flow) and cystoscopy (examination of the bladder and urethra with a lighted instrument) was normal. The cystoscopy also showed a normal bladder capacity of 700 and 800 cc of fluid. Her symptoms persisted and she was eventually diagnosed with IC (as opposed to frequent UTIs) based on clinical presentation. A cystometrography (CMG - a test to measure bladder pressure with increasing volume) conducted on 14 January 2000 was normal, although the capacity was 234 cc, a decrease from a previous measurement. She noted urgency and pain as when the bladder neared capacity at 190 cc. There were no uninhibited contractions (seen in urge incontinence). No evidence of obstruction was reported as present on any of the above testing. She continued to be seen frequently and was also treated with intravesicle (in the bladder) medications with improved symptoms. At a second urologic opinion on 29 June 2000, the CI reported urinary frequency of over 30 times a day and nocturia (nighttime urination) of 8-10 times a night. She denied stress incontinence. Residual urine after catheterization was normal. The CI was thought to have chronic IC based on her symptoms. She underwent repeat cystoscopy on 28 July 2000 and had diffuse glomerulation (a finding of with IC) after hydro-distention (dilation of the bladder with water, done to improve visualization of the bladder and therapeutically) and a normal bladder (cystoscopic) capacity of 900 and 1000 cc. (The action officer observed that the bladder capacity is typically greater when under anesthesia, such as during cystoscopy, compared to the CMG done when awake and sensitive to the pressure from filling the bladder.) The urology narrative summary (NARSUM) was dated 16 August 2000, 3 months prior to TDRL entry. The CI reported dysuria and suprapubic pain especially when her bladder was full. The examiner noted that her evaluation had been normal. The CI had been treated with oral and intravesicular medications with improvement in her symptoms. It was noted that she had had two UTIs the past year. The CI submitted an undated rebuttal to the NARSUM stating that she had not had UTIs since childhood and had only had two the past year. The Board noted that this was not consistent with two separate clinical notes early in her evaluation. At the VA Compensation and Pension (C&P) gynecology examination performed 2 months after TDRL entry, the CI reported that the IC developed after the birth of her first son. It was characterized as a chronic, intermittent problem. It noted that she performed a self-catheterization each and every morning, but without stating why it was done. The CI also accomplished intravesicular irrigation for pain as needed. The general medical examination completed on the same day noted that she did the irrigation three times a week. It noted that she had had hydrodistention in June 1999 and June 2000. On examination, suprapubic tenderness was present. The examiner determined that the CI had moderately severe IC with problems sitting for any length of time secondary to bladder spasms. No comment was made on frequency, leakage (incontinence) or obstruction.

The PEB TDRL reevaluation was dated 19 April 2002, 2 months prior to TDRL exit, by the physician who had treated her on active duty and dictated the initial TDRL NARSUM. He noted that the bladder capacity of 235 cc was reduced (smaller bladder capacity; previously, he had recorded this as normal) and that she was doing very well on her medication regimen. He noted that she accomplished self-catheterization for intravesicular medications, but did not document the use of a catheter otherwise. No comment was made on her current frequency and/or nocturia, presence of incontinence or obstructive symptoms. A rheumatology evaluation on 19 May 2003 noted that she woke up every night every hour to urinate and was asleep from 7 to 8 hours. The 2 June 2003 genitourinary C&P, a year after TDRL exit, documented that the CI had complained of frequency of every 30 minutes during the daytime and nocturia 10-12 times a night when he had seen her the previous October. When she was seen 3 months later in January 2003, she reported that both her daytime and nighttime frequency had improved. However, she reported frequency every 30 minutes during the daytime and nocturia 8-10 times a night at the time of the examination. At a gynecology appointment on 15 September 2003, she reported good bladder control.

The Board directs attention to its rating recommendation based on the above evidence. The VASRD directs that IC, coded 7513, be rated as voiding dysfunction. The PEB coded the chronic pelvic pain condition as analogous to endometriosis, 7699-7629 at TDRL entry and retained the 7629 code at TDRL exit, rating it 30% and 10%, respectively. The VA used the generic code for (bladder) cystitis, 7512, and rated it 60% on the 26 September 2002 decision. This was secondary to the use of a catheter on a daily basis. The Board considered the rating criteria for voiding dysfunction. The use of a catheter, a urinary appliance, supports a 60% rating in the presence of incontinence, which was not recorded, or after surgery, which was not accomplished. Accordingly, this rating is not supported by the evidence as there is no indication that the CI was incontinent. The other criteria for voiding dysfunction include frequency or obstruction. Obstruction was not demonstrated on multiple studies. The remaining criterion is frequency. Five months prior to separation, at the urological second opinion, the CI endorsed urination of up to 30 times a day and nocturia of 8-10 times a night. The frequency was not otherwise recorded proximate to separation. The June 2003 C&P recorded a frequency of every 30 minutes during the daytime and nocturia 10-12 times a night in October 2002, 4 months after TDRL exit. Again, it was not otherwise recorded proximate to TDRL exit. This degree of frequency supports a 40% rating at both TDRL entry and exit using VASRD code 7513. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 40% for the IC condition at TDRL entry and exit.

Contended PEB Conditions. The Board’s main charge is to assess the fairness of the PEB’s determination that the MH and migraine conditions were not unfitting. 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. Neither condition was formally profiled although the MEB neurologist noted that she had a temporary P4 profile (but did not specify why) and the MEB psychiatrist recommended a temporary S4 profile. The commander noted that the CI had been able to perform her duties in a peace-time capacity, but that she could not deploy or be mobilized. The MEB listed the migraine headaches as frequent and incapacitating and the MH conditions of pain disorder and MDD, single episode. The TDRL entry PEB determined the migraine headache condition to be Category II and listed the pain disorder as an associated condition for the pelvic pain and was silent regarding the MDD. The TDRL exit PEB rated the MDD as a Category II condition, but noted that it had developed since placement on TDRL which was not accurate. The Board then reviewed the medical records in evidence.

The migraine condition developed in 1997 following viral meningitis. She was seen on 5 February 1998 complaining of a headache for the past 2 weeks and treated with medications. She was seen again in July with the complaint of headache and treated with intravenous fluids due to vomiting. She was then seen a year later in neurology for a routine follow-up and medication refill. The next recorded visit was 12 July 1999 when she was placed on quarters for 24 hours. This is the only recorded absence from work for her migraines in the year prior to TDRL entry. Two memoranda from supervisors were included in the record dated 19 and 20 July 2000. The first noted the presence of the IC, headaches and depression, but focused on the abdominal pain. The second did not mention the headaches and also focused on the abdominal pain. The final clinical note was dated 26 July 2000 and noted that she had migraines about once a week and self-medicated with a headache abortant (Imitrex.) Two weeks later, she was seen by a neurologist for the MEB and reported headaches one to two times a week. She was thought to have frequent and incapacitating headaches. The Board observed that the record does not support a finding that these significantly impaired duty.

The CI was initially seen in life skills on 11 January 1999 due to her chronic pain. She was seen periodically over the next year and had no MH diagnosis. She was seen on 23 March 2000 with increased symptoms. She was diagnosed with MDD and started on Wellbutrin. The MEB psychiatric evaluation 5 days later assigned a temporary S4 profile and recommended MEB. On 18 April 2000 she noted to be improved on psychotropic medications. She was seen in psychiatry a month later on 18 May 2000 and noted to be in early, full remission. A psychiatric addendum to the prior report was dated 26 July 2000, less than 4 months prior to TDRL entry. She stated that “aside from the physical problems her health is pretty well…” On mental status examination (MSE), she became tearful when describing her frustration with the medical system and the emotional turmoil and pain that she experiences. She endorsed seeing spiders on the floor twice when she was very frustrated and some suicidal ideation. Her profile was continued and medication changes recommended. She was very frustrated with her condition and care, but her MSE was otherwise relatively normal. There were no further records in evidence until proximate to TDRL exit. The Board considered the MEB narratives and noted that the S4 profile was continued twice. However, the commander noted that she performed her duties in a peace-time capacity. After starting treatment, she was noted to improve and also to be in early, full remission prior to the second MEB narrative. The preponderance of evidence does not support the addition of a MH condition, regardless of diagnosis, as an additionally unfitting condition. Both contended conditions were reviewed by the action officer and considered by the Board. While there was some performance-based evidence from the record that both conditions 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 contended condition and so no additional disability ratings are 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 IC condition, the Board unanimously recommends a disability rating of 40%, coded 7513 IAW VASRD §4.115a. In the matter of the contended migraine headache and MH 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 recommends that the CI’s prior determination be modified as follows; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of her prior medical separation:

UNFITTING CONDITION VASRD CODE RATING
TDRL PERMANENT
Interstitial Cystitis 7513 40% 40%
COMBINED 40% 40%


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20130702, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record








                          
XXXXXXXXXXXXXX
President
Physical Disability Board of Review








 PDBR PD-2013-00954



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 XXXXXXXXXXXXXX, be corrected to show that:

                   a. The covered individual was placed on the Temporary Disability Retired List with a disability rating of 40% rather than 30%.

                  b. Upon permanent disposition, the diagnosis in her finding of unfitness was Interstitial Cystitis, VASRD code 7513, rated at 40%; rather than Chronic Pelvic Pain Associated w/Chronic IC, VASRD code 7629, rated at 10%.      

                  c. She was not discharged on 23 June 2002 with entitlement to disability severance pay; rather, on that date she her name was placed on the Permanent Disability Retired List.







        
XXXXXXXXXXXXXX
Director
Air Force Review Boards Agency

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