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AF | PDBR | CY2013 | PD-2013-02193
Original file (PD-2013-02193.rtf) Auto-classification: Approved
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXX  CASE: PD-2013-02193
BRANCH OF SERVICE: Army  BOARD DATE: 20140625
SEPARATION DATE: 20051130


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SSG/E-6 (42A/Human Resources Specialist) medically separated for Crohn’s colitis. The condition could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty or satisfy physical fitness standards. She was issued a permanent P3 profile and referred for a Medical Evaluation Board (MEB). The regional enteritis of unspecified site and inflammatory conditions of the jaw conditions, characterized as medically unacceptable was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. No other conditions were submitted by the MEB. The Informal PEB adjudicated chronic colitis as unfitting rated 10%, with application of the VA Schedule for Rating Disabilities (VASRD). The remaining condition was determined to be not unfitting. The CI made no appeals and was medically separated.


CI CONTENTION: “I was diagnosed with Crohn’s disease and had a tumor removed from my jaw. I under went intensive and numerous reconstruction surgery for my jaw. I think the Army did me an injustice because I see many soldiers with less illness get more percentage.”


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 Crohn’s colitis condition is addressed below. The not unfitting contended jaw condition is likewise addressed below. Any other condition 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 20050829
 VA* - (~8 Mos. Post-Separation)
Condition
 Code Rating Condition Code Rating Exam
Crohn’s Colitis Disease 7399-7323 10% Crohn’s Disease with Anemia 7323 30% 20060802
Inflammatory Conditions of Jaw Not Unfitting Osteomyelitis 5000 20% 20060821
Loss of Part of Ramus 9906 20% 20060821
Loss of Coronoid Process 9909 10% 20060821
Loss of Part of Hard Palate 9911 10% 20060821
Scar Left Neck 7800 10% 20060821
Partial Paresthesia Face/Mouth 8207 10% 20060821
Other x 0 (Not in Scope)
 Other x 0 20060821
Combined: 10%
 Combined: 70%
* Derived from VA Rating Decision (VA RD ) dated 200 60921 (most proximate to date of separation ( DOS ) )


ANALYSIS SUMMARY: The Board acknowledges the CI’s contention for rating of her jaw condition which was determined to be not unfitting by the PEB. Disability compensation may only be offered for those conditions that cut short the member’s career. Should the Board judge that this contested condition was most likely incompatible with military service, a disability rating IAW the VASRD, based on the degree of disability evidenced at separation, will be recommended.

Crohn’s Colitis Condition. The CI developed diarrhea in May 2002 that was initially assessed as a colitis (inflamed colon), likely due to Crohn’s disease. Symptoms initially responded well to oral steroids and anti-inflammatory medication. A disease flare-up in the fall of 2003 responded to a course of oral steroids that completed in January 2004. Repeat endoscopic evaluations were most consistent with Crohn’s disease. Gastroenterology follow-up in March 2004 reported that the condition was “currently in remission” on an oral anti-inflammatory. At a visit for a requested profile renewal in May 2004, the CI reported that symptoms of cramps or diarrhea only occurred “when she gets nervous” such as prior to taking a physical training test. The narrative summary (NARSUM) examiner on 1 March 2005 (9 months prior to separation) reported that the CI experienced a disease flare-up in the summer 2004 that required another course of oral steroid medication, which again resulted in remission of symptoms. Because oral steroids were not considered appropriate long-term therapy, they were discontinued. However, symptoms were incompletely controlled on anti-inflammatory agents, although dehydration or significant anemia was not present. Long-term immunosuppressant medications were considered to be the best treatment option, but could not yet be started pending healing of her jaw condition. Examination showed a weight of 176 pounds. Abdomen was non-tender.

A gastroenterology note on 18 March 2005 reported that the CI was experiencing 8-10 bowel movements per day and that “overall can’t sleep, feels horrible.” A follow-up note on 28 April 2005 reported no change despite taking a moderate dose of oral steroids for a month. However, by 26 May 2005 bowel movement frequency had decreased from 8-10 per day to 2 per day since starting two immunosuppressive medications. Laboratory evaluation on 14 June 2005 (5.5 months prior to separation) revealed a hematocrit of 36.4 consistent with a mild anemia (normal 38 – 47). The commander’s statement on 24 June 2005 indicated that due to the Crohn’s illness, the CI “occasionally has difficulty coping with all of the duty demands placed upon her.” The illness was “apparently not under control” and seemed to cause “both stress and occasional personal embarrassment.” An outpatient note on 29 July 2005 stated that the CI had started another course of oral steroids three days previously, but the indication and dosing was not specified. At the MEB separation exam on 4 August 2005 (4 months prior to separation), the CI checked “Yes” for “Currently in good health” and “No” for “Recent unexplained gain or loss of weight.” She also denied frequent indigestion or intestinal trouble. She indicated that the immunosuppressive medications caused an “adverse reaction” but they were still listed as current medications. The MEB physical exam noted a weight of 164 pounds.

At the VA Compensation and Pension (C&P) exam on 2 August 2006 (8 months after separation) the CI reported frequent diarrhea that hindered sleep and social interactions. A 29 pound weight loss in a year was reported but the timing was not specified. She also complained of frequent lower abdominal pain and nausea and vomiting as often as once per week that was usually produced by certain types of food. She was taking one anti-inflammatory medication which was not helpful for her Crohn’s symptoms. Physical examination showed a weight of 167 pounds. She appeared well-nourished and in no apparent distress. The abdomen was non-tender. Laboratory evaluation revealed a mild anemia (hematocrit 34) which the examiner opined was likely due to Crohn’s disease.

The Board directs attention to its rating recommendation based on the above evidence. The PEB assigned a 10% rating under an analogous 7323 code (ulcerative colitis) and described the condition as “multiple episodes of exacerbations requiring aggressive medication management.” The VA rated the condition at 30% under the same code. Board members agreed that the 60% rating described by “numerous attacks a year and malnutrition, the health only fair during remissions” was not reflected in the evidence. In deliberating between the 10% (“moderate; with infrequent exacerbations”) and the 30% rating criteria (“moderately severe, with frequent exacerbations”), Board members considered that there were one and possibly two disease exacerbations requiring steroids during the year prior to separation, that disease activity and symptoms were significant enough to require the use of immunosuppressive agents and that the commander noted the disease to not be under control, although impact on duty was noted to be “occasional.” The Board concluded that the evidence at the time of separation described the presence of gastrointestinal symptoms best depicted by “moderately severe, with frequent exacerbations” under the 7323 code. The Board finally noted that the only other applicable coding pathway under VASRD §4.114 (7319-irritable colon syndrome) does not permit a rating higher than 30%. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 30% for the Crohn’s colitis condition.

Contended PEB Conditions. The Board’s main charge is to assess the fairness of the PEB’s determination that “inflammatory conditions of jaw” was 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. An ameloblastoma (benign but locally aggressive tumor) of the left mandible (lower jaw) was treated surgically in January 2000. The surgery involved resection of the middle part of the mandible, which was replaced with surgical hardware, and the removal of several teeth. Subsequent reconstruction of the mandible was performed and although complications including infection and sensory nerve damage occurred, dental implants were successfully inserted in 2004.

By the time of the NARSUM addendum in March 2005, there was no other dental treatment required other than placement of crowns and regular follow-up to ensure no recurrence of the tumor. The permanent profile in May 2005 included “inflammatory conditions of the jaw” in a P3 profile with Crohn’s disease. The commander’s statement in June 2005 made no mention of duty impairment from the jaw condition. On the separation exam in August 2005, the CI checked “No” for “severe tooth or gum trouble.” The profiling section of the separation exam in August 2005 only listed Crohn’s disease.

At the VA C&P exam 8.5 months after separation, the CI complained of an “inability to chew on the left side, sensitivity and bleeding adjacent to middle implant, numbness or altered sensation to the left side of face.” The examiner’s diagnosis was partial paresthesia (numbness) of the face and mouth and partial edentulism (missing teeth) restored with dental implants.

Although the inflammatory conditions of jaw condition was included in a permanent profile and judged to fail retention standards by the MEB, the NARSUM addendum examiner indicated no further dental treatment (aside from crown placement) was needed and the VA examiner noted impairment was limited to loss of sensation. The commander’s statement did not indicate that duty impairment on the basis of a jaw condition was present. This condition was reviewed by the action officer and considered by the Board. There was no performance based evidence from the record that the inflammatory conditions of jaw condition significantly 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 the contended 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. In the matter of the Crohn’s colitis condition, the Board unanimously recommends a disability rating of 30%, coded 7399-7323 IAW VASRD §4.114. In the matter of the contended inflammatory conditions of jaw condition, the Board unanimously recommends no change from the PEB determination 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 recharacterized to reflect permanent disability retirement, effective as of the date of her prior medical separation:

UNFITTING CONDITION VASRD CODE RATING
Crohn’s Colitis 7399-7323 30%
COMBINED 30%


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 2013102, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record









                 
XXXXXXXXXXXXXXXXX
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 XXXXXXXXXXXXXXXXX, AR20150002590 (PD201302193)
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                                                  XXXXXXXXXXXXXXXXX
                                                      Deputy Assistant Secretary of the Army
                                                      (Review Boards)
                                                     
CF:
( ) DoD PDBR
( ) DVA

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