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AF | PDBR | CY2013 | PD-2013-01838
Original file (PD-2013-01838.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW
NAME: XXXXXXXXXXXXXXX    CASE: PD‐2013‐01838
BRANCH OF SERVICE: MARINE CORPS  BOARD DATE: 20140723 SEPARATION DATE: 20040531
invalid font number 31506


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty Cpl/E‐4 (0121/Personnel Clerk) medically separated for a heart condition. The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS) or satisfy physical fitness standards. He was referred for a Medical Evaluation Board (MEB). The heart condition, characterized as “variable Atrioventricular (AV) block status post dual‐chamber pacemaker placement,” was the only condition forwarded to the Physical Evaluation Board (PEB) IAW SECNAVINST 1850.4E. The Informal PEB adjudicated “variable AV block status post dual‐chamber pacemaker placement” as unfitting, rated at 10%, with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD). The CI made no appeals and was medically separated.



CI CONTENTION: “Pacemaker was rated at 10% and my knee was rated at 10% too. I feel that a heart issue is more than 10% due to the fact if I don't have it I die.”



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 heart 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 Correction of Military Records.



RATING COMPARISON:

Service IPEB Dated 20040324 VA (7 Mos. Pre‐Separation)
Condition Code Rating Condition Code Rating Exam
Variable AV Block S/P Dual‐Chamber Pacemaker Placement
7018‐7015

10%
Variable Degrees of a AV Block (Symptomatic) s/p Insertion of a Permanent Dual‐Chamber Pacemaker Placement
7018‐7015

10%

20041006
Other X 0 (Note in Scope) Other x 4 20041006
Combined: 10% Combined: 20%
Derived from VA Rating Decision (VARD) dated 20041006 (most proximate to date of separation)



ANALYSIS SUMMARY: The Disability Evaluation System (DES) is responsible for maintaining a fit and vital fighting force. While the DES considers all of the member's medical conditions, compensation can only be offered for those medical conditions that cut short a member’s career and then only to the degree of severity present at the time of final disposition. However the Department of Veteran Affairs (DVA), operating under a different set of laws (Title 38, United States Code), is empowered to compensate service‐connected conditions and to

periodically re‐evaluate said conditions for the purpose of adjusting the Veteran’s disability rating should his degree of impairment vary over time.

Variable AV Block Status Post Dual‐Chamber Pacemaker Placement Condition. The CI fell out of a 5‐mile march at the halfway point with symptoms of dyspnea, nausea, chest pain and emesis on 16 October 2003. He was seen in the tactical mission command, he was asymptomatic and sent home with follow‐up appointment for the following Monday. The CI was seen in the clinic on 20 October 2003 and was completely asymptomatic, however the electrocardiogram (EKG) was abnormal, indicated a complete AV dissociation with a heart rate of 44 beat per minutes (normal beat per minutes 70‐80). The CI was transferred to Tripler Army Medical Center for further evaluation of third degree heart block. Although the CI remained hemodynamically stable, the repeat EKG that was taken in the emergency room confirmed earlier findings. A chest X‐ray done on admission was normal, the heart was not enlarged. An exercise stress test demonstrated a pacemaker syndrome physiology (dissociation between the atria and ventricles) was incomplete due to mild dyspnea (shortness of breath). An echocardiogram demonstrated a mitral inflow of blood pattern seen in first degree AV block. Holtor monitor results demonstrated long episodes of AV nodal block and periods of complete AV dissociation. The CI was evaluated by cardiology and underwent permanent dual chamber pacemaker placement. The commander’s statement indicated that, although the CI could not perform any physical training, he still made a significant contribution to accomplishing the unit’s mission. The commander further indicated that the CI could still excel at his duties and he should be re‐ evaluated once he reaches the end of his enlistment and at that time determine if the CI was worldwide deployable, or placed on the temporary/permanent disability retired list. The CI had a follow‐up appointment with cardiology, where he reported a lack of energy, but without angina, nor shortness of breath. The pacemaker mode was switched to rate responsiveness to attempt to improve fatigue, with positive results. He did report that his heart rate would become rapid while resting on his left side; however there were no problems with in other positions. A MEB narrative summary (dated omitted) documented that the CI had successfully undergone permanent pacemaker placement and had completed convalescence. The physical examination demonstrated a normal heart and lung exam. The MEB examiner opined that the prognosis was guarded and diagnosed variable AV block status post dual chamber pacemaker placement.

The VA Compensation and Pension (C&P) exam (approximately 4 months after separation), documented that the CI had sleep disturbance when he resting on his left side, he would awaken due to rapid heart rate and he had to reposition himself. He reported weekly occurrences of feeling fatigue with some weakness and lack of endurance; he also had shortness of breath while climbing a flight of stairs. However, he was beginning to run and had slowly increased his distance up to one mile. His cardiac exam was normal. In March 2005, the CI reported an episode of chest pain, but there were no associated symptoms of shortness of breath, dizziness nor nausea. The CI was re‐evaluated by cardiology in July 2005 and reported that he was doing better and was employed fulltime.

The Board directs attention to its rating recommendation based on the above evidence. The PEB coded the variable AV block status post dual‐chamber pacemaker placement condition as 7018 (implantable cardiac pacemakers) analogous to 7015 (atrioventricular block) and rated at 10%, for pacemaker required. The VA used the same coding for the variable degrees of an AV block (symptomatic) status post insertion of a permanent dual‐chamber pacemaker placement condition and also rated the condition at 10%. The rating criteria for VASRD coded under 7015 rely on cardiac symptoms, anatomic cardiac abnormalities and or workload metabolic equivalents (METS) documented by exercise stress testing. All documents in the service treatment record proximate to separation indicated that the CI responded well to the placement of the permanent pacemaker and had resolution of his symptoms. An echocardiogram demonstrated a normal heart size; there was no indication of cardiac

hypertrophy or dilatation; therefore no evidence of structural cardiac abnormalities. The evidence present for review documents only two cardiac stress tests. The first cardiac stress tests (2 months prior to pacemaker placement) results were a 12.9 METS and the second cardiac stress tests results (approximately nine years after separation) were 13.4 METS. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the variable AV block status post dual‐chamber pacemaker placement 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 variable AV block status post dual‐chamber pacemaker placement condition and IAW VASRD §4.104, the Board unanimously recommends no change in the PEB adjudication. There were no other conditions within the Board’s scope of review for consideration.



RECOMMENDATION: The Board, therefore, recommends that there be no re‐characterization of the CI's disability and separation determination.



The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20130906, w/atchs Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record




XXXXXXXXXXXXXXX
President
DoD Physical Disability Board of Review






MEMORANDUM FOR DIRECTOR, SECRETARY OF THE NAVY COUNCIL OF REVIEW BOARDS
Subj:    PHYSICAL DISABILITY BOARD OF REVIEW      (PDBR) RECOMMENDATIONS Ref:      ( a) DoDI 6040.44
(b) CORB ltr dtd 20 Jan 15

In accordance with reference (a), I have reviewed the cases forwarded by reference (b), and, for the reasons provided in their forwarding memorandums, approve the recommendations of the PDBR
that the following individual' s records not be corrected to reflect a change in either characterization of separation or in the disability rating previously assigned by the Department of the Navy' s Physical Evaluation Board:

-       
XXXXXXXXXXXXXXX, XXX XX XXXX, former USN
-       
XXXXXXXXXXXXXXX, XXX XX XXXX, former USMC
-       
XXXXXXXXXXXXXXX, XXX XX XXXX, former USN
-       
XXXXXXXXXXXXXXX, XXX XX XXXX, former USMC
-       
XXXXXXXXXXXXXXX, XXX XX XXXX, former USN
-       
XXXXXXXXXXXXXXX, XXX XX XXXX, former USN



                                                              




XXXXXXXXXXXXXXX
Assistant General Counsel
( Manpower & Reserve Affairs)






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