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AF | PDBR | CY2013 | PD-2013-01201
Original file (PD-2013-01201.rtf) Auto-classification: Approved
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXX    CASE: PD-2013-01201
BRANCH OF SERVICE: Army  BOARD DATE: 20140321
SEPARATION DATE: 20070302


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty MAJ/0-4 (91A/Ordnance Officer) medically separated for systemic lupus erythematosus (SLE) and hypercoagulable syndrome with pulmonary embolus. The CI experienced constant fatigue during a deployment to Iraq from September 2004 to August 2005. Three months after return to home station, symptoms expanded to included shortness of breath, chest pain, unexplained pain in her shoulders, hands, wrists and knees. An X-ray and magnetic resonance imaging first confirmed a pulmonary embolism for which she was hospitalized. Further evaluation resulted in a diagnosis of SLE. The SLE and pulmonary conditions could not be adequately rehabilitated to meet the physical requirements of her officer area of concentration or satisfy physical fitness standards. She was issued a permanent P3, U3, L3 profile and referred for a Medical Evaluation Board (MEB). The conditions, characterized as “systemic lupus erythematosus” and “hypercoagulable syndrome with pulmonary embolus” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501 and AR 40-301, respectively. The MEB also identified and forwarded three other conditions, chronic back pain, adjustment disorder with depressed mood and migraine headaches, for PEB adjudication. The Informal PEB adjudicated “systemic lupus erythematosus” and “hypercoagulable syndrome with pulmonary embolus” as unfitting, rated 10% and 10% respectively. The remaining conditions were determined to be not unfitting and not ratable. The CI appealed to the Formal PEB (FPEB) and the US Physical Disability Agency, which affirmed the PEB findings and ratings.


CI CONTENTION: “Conditions that render me to be unfit prohibit me from gaining employment.”


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 ratings for the unfitting SLE and pulmonary embolism conditions are 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 FPEB – Dated 20061208
 VA - based on Service Treatment Records (STR)
Condition
 Code Rating Condition Code Rating Exam
Systemic Lupus Erythematosis (SLE) with onset of arthralgias 6350 10% Systemic Lupus with manifestation of chronic Glomerulonephritis 6350-7502 30% STR
Analogous to Hyper-coagulable State presenting with a Pulmonary Embolus 7199 7121 10% Pulmonary Embolus 6899-6817 0% STR
Chronic Back Pain Not Unfitting
Not Ratable
 Lumbar Spondylosis (claimed as Chronic Low Back Pain) 5242-5003 10% STR
Migraine No VA Entry
Adjustment D/O w/Depressed Mood No VA Entry
No Additional MEB/PEB Entries
 Tenosynovitis De Quervains 5024 0% STR
Other x 2 STR
Combined: 20%
 Combined: 40%
Derived from VA Rating Decision (VA RD ) dated 200 70612 ( most proximate to date of separation [ DOS ] ).


ANALYSIS SUMMARY:

Systemic Lupus Erythematosis (SLE). The narrative summary (NARSUM) written by the Chief, Rheumatology Services in October 2006 notes evaluation beginning in December 2005 for chronic fatigue and arthralgias (joint pains) with findings of high-titers of multiple inflammatory disease markers (ANA, dsDNA, RNP and IgG cardiolipin antibody) as well as mild low blood platelets (thrombocytopenia). A diagnosis of SLE was made by rheumatology. She was treated for a documented pulmonary embolus (blood clot in the lungs) and was stable on medications for SLE and anticoagulants (blood thinners). She was evaluated for chronic fatigue syndrome and sleep apnea both of which were negative. Records indicate emergency department visits in December 2005 and April 2006 for dizziness and fatigue. At the MEB exam, the CI reported chronic joint pains. Low back pain was noted by rheumatology to not be related to SLE (lumbar spine arthritis) and a recent diagnosis of depression following the death of her spouse. The MEB physical exam noted a “well-developed and nourished appearing female in no distress.” Back exam was deferred to Physical Medicine and there was otherwise no abnormalities noted in the skin, extremities or joints; and “joint range of motion was preserved throughout.” A nephrology MEB addendum diagnosed chronic glomerulonephritis (kidney disease) with “most probable lupus nephritis,” indicated persistent microscopic hematuria since 2003 and intermittent proteinuria. Lab findings indicated “numerous classically dysmorphic RBCs visualized on urine sediment” with rare granular casts. Record indicated, “persistent microscopic hematuria since 2003, and intermittent trace to 1+ proteinuria over the past few years.” Glomerular filtration rate (GFR-a measure of kidney function) was preserved, so no biopsy was indicated. Since the CI was pregnant, monthly follow-up lab testing was recommended.

Records indicated emergency department visits in 19 November 2005 for fatigue, with a 5-day hospitalization for treatment of pulmonary embolisms (PE) on 6 December 2005 for “feels like passing out” with dizziness and headaches; 2 April 2006 for chest wall pain and 9 October 2006 for dizziness and headache. The commander’s statement dated 8 September 2006 indicated that the CI suffered from various joint pains that routinely prevent her from performing normal day-to-day tasks “such as walking properly or typing on the computer.”

Following the 10% PEB rating for SLE, the Chief Rheumatology Services wrote an MEB addendum (memo) in November 2006 stating “While her condition is currently stable with immunosuppressive therapy, she continues to have significant fatigue and recurrent arthralgias (joint pains). While she has not missed prolonged periods of work due to these symptoms, this is because she has continued to perform her duties in the face of ongoing symptoms, not because they are mild or absent.” While I do not have the most current version of VA Schedule for Rating Disabilities (VASRD), the 1992 edition states that her ongoing "symptomatology productive of moderate impairment of health" corresponds to a 30% disability rating.” The remainder of the addendum addresses the linkage of SLE to recurrent thromboembolic disease (like PE) and the likely progression to multi-organ involvement from SLE. The FPEB 10% rating indicated “Rated for being symptomatic in the past two years.”

The Board directs attention to its rating recommendation based on the above evidence. The PEB rating of 10% was coded as 6350 (SLE), while the VA rating of 30% was 6350-7502 (SLE with chronic glomerulonephritis). The VASRD in effect at the time of separation states the following disability criteria:

6350 Lupus erythematosus, systemic (disseminated)
                  Not to be combined with ratings under DC 7809 [skin lupus rating]
                  Acute, with frequent exacerbations, producing severe impairment
                           of health        100
                  Exacerbations lasting a week or more, 2 or 3 times per year      60
                  Exacerbations once or twice a year or symptomatic during the
                           past 2 years     10
Note: Evaluate this condition either by combining the evaluations for residuals under the appropriate system, or by evaluating DC 6350, whichever method results in a higher evaluation.

The evaluation criteria for disability code 6350 had been changed effective on 30 August 1996; However, the MEB addendum assessment of “moderate impairment of health” IAW VASRD of 1992 criteria was considered. The CI was on chronic immunosuppressive medications and had four (4) emergency department visits in the 2 years prior to separation that may be considered exacerbations of SLE (PE, dizziness, fatigue and chest wall pain). The hospitalization for PE in November 2005 was approximately one week and may be attributable to the SLE since no other cause was identified (no clots in the legs; deep vein thrombosis-post-phlebitic syndrome). Only the hospitalization for PE was clearly documented as lasting a week or more.

The Board deliberated at length regarding the appropriated coding and rating options, with a focus on the CI’s symptoms, diagnoses and consideration of VASRD §4.1 (essentials of evaluative rating). The rheumatologist indication of “moderate impairment of health” and recurrent arthralgias (versus constant low-level symptoms) was not cleanly aligned to a specific 6350 rating level under the VASRD in effect at the time of separation; however, it indicated that the severity of disease was greater than that envisioned under the 10% criterion. The nephrology specialist indicated that the organ kidney disease (glomerulonephritis) due to the SLE had already occurred. The commander’s comments, although from a lay-person perspective, also indicated significant functional impact of the disease on walking and typing, which were most likely episodic, but not categorized as to duration. The Board adjudged that this represented a greater SLE disability than that represented by the 10% 6350 criteria, although it was not clearly a picture that “more nearly approximates the criteria required” for the 60% rating under a straight 6350 coding. Given the CI’s kidney disease related to SLE, the VASRD note for rating under 6350, the VA’s rating at separation based on the treatment record and the totality of evidence in the case; the Board determined that the CI’s disability more nearly approximated the disability picture of 30% using analogous coding of 6350-7502 (SLE with renal disease). After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), and §4.7 (higher of two evaluations) that the fair and equitable rating in this case was 6350-7502 at 30%.

Analogous to Hyper-coagulable State Presenting with a Pulmonary Embolus (PE). The CI presented to the emergency department on 19 November 2005 with complaints of fatigue tiredness and chest pain with deep breaths. She was diagnosed with PE, hospitalized and treated with anticoagulants. Special studies (CT angiopulmonary) documented a left pulmonary artery segmental filling defect (clot in the lung) and left lower lobe atelectasis (collapse of lung) and small pleural effusion (fluid around lung). The CI was discharged on 25 November and no cause other than a possible hypercoagulable state (ANA status [related to later diagnosed SLE]) was noted. Laboratory evaluations demonstrated anti-phospholipid antibody (an immune system marker). The NARSUM noted no continuing symptoms of PE, normal lung and chest exams and noted good compliance on anticoagulant medication. There were no extremity abnormalities (clubbing, cyanosis or edema) and the skin exam was normal. Treatment notes did not indicate any varicose veins or use of compression hosiery of the lower extremities (to decrease swelling, pain or clots). There were notes indicating subjective fatigue in the legs after prolonged standing or walking.

The Board directs attention to its rating recommendation based on the above evidence. The FPEB rated this condition as 7199-7121, analogous to post-phlebitic syndrome of any etiology at 10% stating it was IAW AR 635-40. The VA rated this condition as 6899-6817, analogous to pulmonary vascular disease at 0%. The Board considered that there were no symptoms following resolution of pulmonary thromboembolism (PE) and the CI was on lifelong anticoagulation therapy. Although the PE was considered evidence of a deep thrombosis, there was no evidence that it originated in the lower extremities. The aching and fatigue in the legs after prolonged standing or walking, did appear to be relieved by rest, but elevation and/or compression hosiery was not specified. The lower extremity fatigue and pain was considered and more likely than not related to the SLE rather than due to a post-phlebitic syndrome (deep vein thrombosis) of any etiology. Symptoms were considered in the above rating for SLE. In accordance with VASRD-only criteria, the rating of this condition would be 0%. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt) and IAW VASRD rules only, the Board recommends a disability rating of 0% for the hypercoagulable state requiring anticoagulation therapy with presentation from a PE (resolved) condition, coded 6899-6817.


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. As discussed above, PEB reliance on AR 635-40 for rating hypercoagulable state presenting with pulmonary embolus was operant in this case and the condition was adjudicated independently of that instruction by the Board. In the matter of the SLE condition, the Board unanimously recommends a disability rating of 30%, coded 6350-7502 IAW VASRD §4.118 and §4.115b. In the matter of the hypercoagulable state presenting with a PE condition and IAW VASRD §4.104 and §4.96, the Board unanimously recommends a change in the PEB adjudication to 0% coded 6899-6817. 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 her prior medical separation:

UNFITTING CONDITION VASRD CODE RATING
Systemic Lupus Erythematosis (SLE) with Manifestation of Chronic Glomerulonephritis 6350-7502 30%
Analogous to Hyper-coagulable State presenting with a Pulmonary Embolus 6899-6817 0%
COMBINED 30%


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20130904, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record








                                   
XXXXXXXXXXXXXXX
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 XXXXXXXXXXXXXXX, AR20140019508 (PD201301201)
1. Under the authority of Title 10, United States Code, section 1554(a), I approve the enclosed recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) pertaining to the individual named in the subject line above to recharacterize the individual’s separation as a permanent disability retirement with the combined disability rating of 30% effective the date of the individual’s original medical separation for disability with severance pay.

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:

         a. 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.

         b. Providing orders showing that the individual was retired with permanent disability effective the date of the original medical separation for disability with severance pay.

         c. Adjusting pay and allowances accordingly. Pay and allowance adjustment will account for recoupment of severance pay, and payment of permanent retired pay at 30% effective the date of the original medical separation for disability with severance pay.

         d. Affording the individual the opportunity to elect Survivor Benefit Plan (SBP) and medical TRICARE retiree options.

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                                                  XXXXXXXXXXXXXXX
                                                      Deputy Assistant Secretary of the Army
                                                      (Review Boards)
                                                     
CF:
( ) DoD PDBR
( ) DVA

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