Search Decisions

Decision Text

AF | PDBR | CY2013 | PD 2013 01089
Original file (PD 2013 01089.rtf) Auto-classification: Approved
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXX    CASE: PD-2013-01089
BRANCH OF SERVICE: AIR FORCE    BOARD DATE: 20130313
DATE OF PLACEMENT ON TDRL: 20021011
Date of Permanent SEPARATION: 20040229


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty A1C/E-3 (2A333E/Crew Chief) medically separated for eosinophilic fasciitis. The CI first noted physical changes in the fall of 2001, approximately 4 months after joining the Air Force. The condition could not be adequately rehabilitated to meet the physical requirements of his Air Force Specialty (AFS) or satisfy physical fitness standards. He was issued a temporary P4 profile and referred for a Medical Evaluation Board (MEB). The eosinophilic condition, characterized as “eosinophilic fasciitis,” “generalized morphea,” and “IgM Nephropathy,” was forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123. No other conditions were submitted by the MEB. The Informal PEB (IPEB) adjudicated “eosinophilic fasciitis associated with morphea and sclerodermoid changes and generalized morphea, as existed prior to service (EPTS) without service aggravation,” as unfitting, and “IgM nephropathy,” as a Category II condition, one that can be unfitting but not currently compensable or ratable, citing the Department of Defense Instruction (DoDI) 1332.38, Part 4, E.4.a (the 180-day rule), and the VA Schedule for Rating Disabilities (VASRD). The CI appealed to the Formal PEB (FPEB) which overturned the IPEB and adjudicated the “eosinophilic fasciitis associated with morphea and sclerodermoid changes and generalized morphea” as unfitting, rated 10% with application of the VASRD, and the “IgM nephropathy” as a Category II condition. The CI non-concurred with the FPEBs findings and petitioned the Board of Correction of Military Records (BCMR) who overturned the FPEB and placed the CI on the Temporary Disability Retired List (TDRL), effective on 11 October 2002, at 30% citing VASRD code 7821, cutaneous manifestations of collagen-vascular diseases, not listed elsewhere. Sixteen months later, a PEB removed the CI from the TDRL on 29 February 2004, and medically separated him with at 10% rating using VASRD code 7821.


CI CONTENTION: The CI writes: “I was discharged with severance from the United States Air Force for service connected disabilies at 10 percent disabling. Later, I was placed on TDRL at 30 percent disabling. After a medical evaluation, I was discharged with severance at 10 percent disabling. The MEB/PEB determined that I was unfit for duty and service connected for eosinophilic fasciitis, IGM neuropathy, mood disorder, and morphia. When I was diagnosed in 2002 with eosinophilic fasciitis while in the service, there were only 1,000 reported cases. The military doctor stated that I had better chances of winning the lottery than get this illness. Due to the lack of documentation and medical understanding at the time of my military service, my discharge was under rated. After all the changes with my status with the DoD, I was unaware that I could request a review of my discharge until now. I have been informed that service members discharged between 2001 and 2009 can request a review of their DoD rating. The VA gave me 80 percent disability effective the day of my discharge. Over the years, my rating has gone from 80 to 60 then back to 80 percent disabling. Last year, the Va decided my condition is permanent. Since my discharge, I have been hospitalized due to my service connected kidneys. The VA has service connected GERD as well. I was unaware that GERD was a ratable condition until a few years ago. I no longer have any more future disability evaluation examination by the VA and have been deemed permanent. My VA disability rating at discharge was 80 percent and ten years later deemed permanent for the same disablilites rated by the PEB/MEB. Due to the vast difference between the DoD and VA ratings, the DoD rating did not reflect an accurate evaluation of my disability.”


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 eosinophilic fasciitis associated with morphea and sclerodermoid changes and generalize morphea condition is addressed below along with the Category II condition of IgM nephropathy. 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 BCMR.


RATING COMPARISON:

Final Service PEB - 20040122
 VA* - Effective 20021011
On TDRL - 20021011
 Code Rating Condition Code Rating Exam
Condition
 TDRL Sep.
EOSINOPHILIC FASCIITIS 7821 10%
30% (BCMR)		 10% EOSINOPHILIC FASCIITIS 7899-7821 60% 20030124
IgM NEPHROPATHY 7599-7536 30% 20030124
No Additional MEB/PEB Entries.
 Other x 1 20030124
Combined: 10% → 10%
 Combined: 80%
*Reflects VA rating exam proximate to separation. CI was placed on TDRL by AFBCMR on 11 October 2002 and removed on 29 February 2004. VARD of 1 May 2003 used for chart.


ANALYSIS SUMMARY: The Board acknowledges the CI’s information regarding the significant impairment with which his service-connected condition continues to burden him; 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 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 his IgM nephropathy condition noted above which was determined to be Category II by the PEB; and, emphasizes that service 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.

EOSINIPHILIC FASCIITIS. The service treatment record (STR) historically summarized that while in basic training (September 2001), the CI developed darkening and painful swelling in his extremities with a skin tightening sensation in his hands and feet which progressed to distal joint pain and causing limited mobility. Skin biopsies revealed dermal fibrosis (thick fibrous tissue). He was empirically started on steroids for what was believed to be a collagen vascular disease (a term used to describe a group of diseases that cause collagen complications in the body). There was dramatic improvement in his symptoms only while taking oral steroids. At a rheumatology evaluation on 15 April 2002 the CI endorsed symptoms of fatigue, morning stiffness, general muscle aches and a feeling of muscle weakness. The examination revealed diffuse induration (hardening) and swelling to his upper and lower extremities with “orange peel skin” over both arms and inner thighs; sparing his fingers and toes. “There was decreased flexion and extension of his wrists with poor hand grip and finger lag” (the amount of drooping at a weakened joint that can extend only passively, no longer actively). He was diagnosed with eosinophilic fasciitis based upon laboratory findings coupled with his historical and current presenting examination. He resumed his oral steroid medication, continued occupational therapy and was further evaluated for possible associated underlying disorders which are common with eosinophilic fasciitis. A revised temporary profile of April 2002 listed a category of conditions that includes eosinophilic fasciitis and was P4 under the P-U-L-H-E-S (Physical capacity/stamina, upper extremities, lower extremities, hearing/ear, eyes, psychiatric) classification system. The commander’s letter of May 2002 commented on the CI’s interference of performing required strenuous work duties.

The dermatology NARSUM of 20 June 2002 (4 months prior to TDRL entry), was without comment on current symptomatology. The examination revealed firm, discolored skin on his extremities to include fingers and toes. In light of additional physical and laboratory analysis, the CI was diagnosed with scleroderma (a group of rare diseases that involve the hardening and tightening of the skin and connective tissues). The examiner noted, “…the condition is progressive and historically is very difficult to manage, it is uncertain when or if [he] will be able to return to unrestricted duty in the Air Force.”

A rheumatology addendum to the NARSUM performed on 21 June 2002 reported the CI as having an hour of morning stiffness, new onset rash over chest, arms and legs, decreased motion of elbows, knees and ankles due to skin tightening and general muscle aches. He denied extremity swelling, loss of strength, or joint tenderness. His current medication was prednisone (steroid) at 40 milligrams daily. “He has been on nearly continuous corticosteroid therapy since December [2001].” Examination revealed flexion contractures of both elbows and decreased motion to knees and ankles. The skin was very similar to the dermatology NARSUM examination a day prior. The examiner’s diagnostic opinion was consistent with prior rheumatologic evaluation indicating eosinophilic fasciitis. The Rheumatologist provided a brief summary of the condition, prognosis, and treatment which is excerpted below.

“It is impossible to provide a definitive prognosis, as the natural course of this disease [EF] has not been established. From the limited number of cases discussed in the medical literature, most patients appear to have a self-limited course over two to five years. Severe joint contractures and subsequent entrapment neuropathies are the most debilitating complication of this disorder, requiring aggressive physical therapy to minimize patient loss of mobility and maximize functional status. Treatment is otherwise addressed toward reducing inflammation in the fascia, with the hopes of preventing further spread of skin fibrosis. Most treatments are used anecdotally due to the rarity of this disorder and lack of controlled clinical trials.”

The initial PEB of 17 July 2002 found the eosinophilic fasciitis as a C ategory II condition . Six weeks later, the FPEB found the eosinophilic fasciitis as unfitting at 10% under the analogous code of 6399- 6350 ( l upus erythematosus) . Further appeal to the BCMR resulted in TDRL entry at 30% on 11 October 2002 .

At the VA Compensation and Pension (C&P) examination performed on 24 January 2003, (3 months after initial TDRL entry) the CI reported constant itching with hardening of the skin about his hands causing decrease range-of-motion, stiffness and problems with fine motor skills. Additionally, he endorsed painful flare-ups of the joints in his hands and knees about 4-5 times a week, lasting 4-5 hours. His medications included Prednisone at 10 milligrams daily; and, at least that dosage has been maintained since December 2001. The physical examination revealed thick, tight skin over bilateral forearms and lower legs. The examiner simply noted under skin examination as “there is disease present,” without further description. The exposed area of skin involvement was listed at 1% or 2% and non-exposed area was at 15%. There was no evidence of skin ulceration, exfoliation or crusting. There was no edema present. The diagnosis of eosinophilic fasciitis remained. The examiner listed the described occupational impairment as the inability to lift heavy items.
A civilian consultation on 27 January 2003 (3 days after the C&P examination) noted, “He is now taking Prednisone 10 mg a day and has been on that dosage on and off for the last 13 months” and furthermore, “He needs to be on this medication to prevent flare up of physical symptoms like swelling and contractures.” A progress note of 5 December 2003 listed Plaquenil and Colchicine as daily medications. Far remote, medicine profile records of March 2008 indicated the continued use of Plaquenil.

At the TDRL NARSUM performed on 8 January 2004 (a month prior to TDRL exit) the CI reported symptom improvement with skin softening in some areas of his upper extremities. Skin involvement remained in his lower legs and right hip area. The examination revealed slight induration over upper arms extending to his forearms and back of hands. Discoloration and induration was present over the right hip and bilateral legs. He reported self-tapered off of the prednisone, but still taking plaquenil. The examiner opined continued TDRL status, stating, “He appears to be following the most common course for eosinophilic fasciitis, with gradual resolution over 2 to 5 years. While he has improved, he does not have resolution of cutaneous (skin) findings. At this time, I recommend continued TDRL status to allow additional time for resolution of his manifestations.”

The Board directs attention to its rating recommendation based on the above evidence. The final PEB and VA both rated the eosinophilic fasciitis condition under VASRD §4.118 general rating formula for the skin, code 7821 criteria at 10% and 60% respectively. The PEB cited the CI’s level of functionality for its 10% rating. The VA cited medication use to control symptoms during the preceding 12-month period. The appropriate descriptive code for rating this condition is 7821, and the VASRD §4.118 rating schedule is based upon the presence of either two distinct criterion; the body percentage of involved skin or the requirement for medication use in the preceding year.

Board members first considered if there was evidence for a §4.118 rating higher than the BCMR’s 30% at time of TDRL entry. The area of skin involvement (< 20% surface area) does not meet criteria above the 10% rating level and therefore, the main issue in this case in regards to a higher rating was the type of medication required and its frequency of use. Code 7821 offers 30% for “non-constant” use of systemic medication (steroids or immunosuppressive drugs) for at least 6 weeks during the previous 12 months and 60% for “constant” or “near constant” use of the same for 12 months.

Board members extensively deliberated the issue of his medication requirement meeting the “constant” or “near constant” level of use. Member consensus was that the recorded evidence 3 months prior to TDRL entrance of “He has been on nearly continuous corticosteroid therapy since December [2001]” and “His medications included prednisone at 10 milligrams daily; and, at least that dosage has been maintained since December 2001” noted 3 months after TDRL entry, indicated a constant or near-constant use of corticosteroids. After due deliberation, considering the totality of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a TDRL entry disability rating of 60% in this case.

The Board then considered if there was evidence for a §4.118 rating higher than the 10% permanent rating adjudicated by the PEB at TDRL termination. Board members considered if the Plaquenil, which appeared to remain a constant component of his treatment met the basic criteria of code 7821. The criteria specifically states, “…therapy such as corticosteroids or other immunosuppressive drugs.” Plaquenil is primarily classified as an anti-malarial drug with a secondary classification as a disease-modifying anti-rheumatic drug. By strict definition, it is neither a corticosteroid nor an immunosuppressant. However, its biological process is known to slow the underlying disease process by some (not well understood) mechanism modifying the immune system. Board members deliberated if having such an immune system effect would meet the code 7821 medication criteria of an immunosuppressant drug. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that the daily dose of Plaquenil medication does meet the criteria of an immunosuppressant drug and therefore, recommends a permanent disability rating of 60% for the skin condition.

IgM Nephropathy. The Board considered whether the IgM nephropathy was unfitting. Secondary to blood in his urine, the CI had multiple kidney biopsies which confirmed the IgM nephropathy in May 2002. The rheumatology addendum noted that although this condition was diagnosed concurrently during the prolonged work-up for his primary skin condition, they appeared to be separate unrelated conditions. The VA C&P examiner noted prior history of blood in his urine currently controlled with prednisone 10 milligrams per day. The examination documented normal urinary frequency and flow initiation without incontinence (involuntary loss of urine). The CI did not require any type of genital-urinary device or procedure. Although the VA did service-connect the IgM nephropathy condition, code 7536 (glomerulonephritis), and assign a 30% rating, the PEB adjudicated the condition as Category II; could be unfitting, but not currently compensable or ratable. The condition was implicated on the temporary profile and was not specifically noted in the commander’s letter. 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. In this case, there was no performance based evidence in the STR that the IgM nephropathy condition significantly interfered with satisfactory AFS duty requirements. 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 Category II determination for the IgM nephropathy condition and so no additional disability rating is 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 eosinophilic fasciitis condition, the Board unanimously recommends a disability rating of 60% for the period of TDRL and a 60% permanent rating, coded 7821 IAW VASRD §4.118. In the matter of the IgM nephropathy condition and IAW VASRD §4.115b, the Board unanimously recommends no change in the PEB adjudication as a Category II condition. 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 to reflect a disability rating of 60% for the prescribed period of temporary retirement, and then permanently separated with severance pay by reason of physical disability with a final 60% rating effective as of the date of his prior medical separation:

UNFITTING CONDITION VASRD CODE RATING
TDRL PERMANENT
Eosinophilic Fasciitis 7821 60% 60%
IgM Nephropathy 7536 Category II
COMBINED 60% 60%


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20130730, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record

                          
XXXXXXXXXXXXXX
President
Physical Disability Board of Review



 PDBR PD-2013-01089

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 60% rather than 30%.

                  b. The diagnosis in his finding of unfitness for Eosinophilic Fasciitis, VASRD code 7821, rated at 60% rather than 30%.

                   c. He was not discharged on 29 February 2004 with entitlement to disability severance pay; rather, on that date his name was placed on the Permanent Disability Retired List.



XXXXXXXXXXXXXX
Director
Air Force Review Boards Agency

Similar Decisions

  • AF | BCMR | CY2003 | BC-2002-03318

    Original file (BC-2002-03318.DOC) Auto-classification: Approved

    The IPEB recommended that he be discharged from the Air Force with an EPTS condition. The applicant was discharged from the Air Force on 10 Oct 02, with a compensable disability rating of 10 percent. This code assigns disability rating based on percent of body surface and use of medications.

  • AF | PDBR | CY2013 | PD 2013 00220

    Original file (PD 2013 00220.rtf) Auto-classification: Approved

    Prior to TDRL removal) - Effective 20040616On TDRL - 20040616Code Rating Condition CodeRatingExam ConditionTDRL Sep.Pemphigus Vulgaris781530%0%Pemphigus Vulgaris781560%*20041028No Additional MEB/PEB Entries.Other x 120041028 Rating: 30% → 0% Combined: 60% *Reflects VA rating exam proximate to TDRL placement. In March 2006, the condition deteriorated and new treatment was begun with IV Rituximab given weekly with continuation of prior oral medications.In August 2006, after 8 weeks of...

  • AF | PDBR | CY2013 | PD-2013-02232

    Original file (PD-2013-02232.rtf) Auto-classification: Denied

    The MEB characterized the CI’s skin condition as “solar urticaria” (a condition in which exposure to the sun [or ultraviolet radiation] induces urticaria or hives)and forwarded this to the Physical Evaluation Board (PEB) for consideration. 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...

  • 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 | CY2012 | PD 2012 00691

    Original file (PD 2012 00691.txt) Auto-classification: Denied

    TDRL RATING COMPARISON: Final Service PEB - 20021105 VA (12 months prior to separation) –Effective 20020311 On TDRL - 20010512 Code Rating Condition Code Rating Exam Condition TDRL Sep. SLE 6350 60% 10% SLE 6350 60%* STR from 20020311 to 20021220 and Civilian records from 20030103 to 20031215 All others x 4/ Not Service Connected X 3 Combined: 60% . The Board also agreed the rating at the time of TDRL placement is consistent with a 60% rating for an unstable condition that had resulted in...

  • AF | PDBR | CY2009 | PD2009-00494

    Original file (PD2009-00494.docx) Auto-classification: Denied

    MCTD can affect multiple organ systems and the CI manifested fatigue, sclerodermatous skin changes of the face, forearms, and hands, Raynaud’s phenomenon, muscle fatigue with use, difficulty swallowing due to esophageal dysmotility with gastroesophageal reflux and esophageal stricture, and shortness of breath on exertion that was initially thought to be due to interstitial lung disease, a manifestation affecting some patients with MCTD. There are VASRD rating criteria for several of the...

  • AF | PDBR | CY2013 | PD-2013-01602

    Original file (PD-2013-01602.rtf) Auto-classification: Approved

    DATE OF PLACEMENT ON TDRL: 20030706Date of Permanent SEPARATION: 20040720 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 and...

  • AF | PDBR | CY2012 | PD2012-00464

    Original file (PD2012-00464.pdf) Auto-classification: Denied

    The Board’s role is thus confined to the review of medical records and all evidence at hand to assess the fairness of PEB rating Combined: 10% that indicated determinations, compared to VASRD standards, based on ratable severity at the time of separation; and, to review those fitness determinations within its scope (as elaborated above) based on MOS performance limitations in evidence at separation. The MEB physical exam performed approximately 8 months prior to separation, noted scalp...

  • AF | PDBR | CY2014 | PD-2014-00468

    Original file (PD-2014-00468.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 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 psoriasis (skin condition) and IAW VASRD §4.118, the Board unanimously...

  • AF | PDBR | CY2012 | PD2012 01313

    Original file (PD2012 01313.rtf) Auto-classification: Denied

    Sarcoidosis 2. 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. SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for AR20130012146 (PD201201313)I have reviewed the enclosed Department of Defense...