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AF | PDBR | CY2013 | PD-2013-02334
Original file (PD-2013-02334.rtf) Auto-classification: Approved
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXX    CASE: PD-2013-02334
BRANCH OF SERVICE: Army  BOARD DATE: 20150120
SEPARATION DATE: 20031120


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Ammunition Specialist) medically separated for asthma. The condition could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty; however, her profile indicates she could take a modified fitness test. She was issued a permanent P3 profile and referred for a Medical Evaluation Board (MEB). The asthma condition was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501, in addition to three other conditions (back pain, headaches, and depression; none failing retention standards). The Informal PEB adjudicated asthma as unfitting, rated 0%, citing criteria of the VA Schedule for Rating Disabilities (VASRD). The remaining conditions were determined to be not unfitting . An initial request for a Formal PEB was withdrawn and the CI was medically separated.


CI CONTENTION: “The PEB based part (or all) of their decision on the fact that I didn’t use my medication (Albuterol) on a regular basis. However, once I was issued a permanent profile, I was no longer required to run or perform any other activity that may have exacerbated my asthma including the gas chamber. Also the PEB reported that a lung exam was normal but methacholine testing did test positive for asthma. Upon receiving a permanent profile, my physical activity was limited which lowered my dependence to inhalers.”


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 when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting. Any conditions outside the Board’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the Board for Correction of Military/Naval Records. Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate. The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the VASRD standards to the unfitting medical condition at the time of separation. The Board has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions. That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws. The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation.


RATING COMPARISON :

Service IPEB – Dated 20030520
 VA (1 Month Pre-Separation)
Condition
 Code Rating Condition Code Rating Exam
Asthma 6602 0% Asthma 6602 10% 20031022
Other x 3 (Not In Scope)
 Other x 7
Combined: 0%
 Combined: 30%
Derived from VA Rating Decision (VA RD ) dated 200 31216 ( most proximate to date of separation [ DOS ] ).
ANALYSIS SUMMARY :

Asthma Condition. The earliest entry (relevant to this condition) in the available service treatment record (STR) is a presentation for bronchitis from July 1998, citing a history of asthma and use of an inhaler. There are fairly frequent STR entries for asthma starting in 2000, documenting use of daily maintenance medications (at least periodically); noting exacerbations of asthma mostly associated with running and exertion; and, resulting in temporary P3 profiles. The last STR treatment note in evidence is from August 2002 (15 months prior to separation), although the MEB was suspended in January 2002 because of pregnancy. A Methacholine Challenge Test (also in August 2002) was interpreted as “mild” airway hyperactivity by pulmonology, and multiple pulmonary function tests (PFT) are in evidence. Measurements of FEV1 ranged from 95% predicted to 102% predicted; and, FEV1/FVC ratios ranged from 90% to 116%. Although there are no associated clinical notes documenting asthma medication usage in the period leading up to separation, the medication profile is in evidence; and, lists the last refill for asthma medications on 15 April 2003 (7 months prior to separation). These consisted of Albuterol (rescue inhaler, bronchodilator), Flonase (inhaled steroid anti-inflammatory), Advair (inhalational steroid/bronchodilator combination), and Singulair (oral bronchodilator/anti-inflammatory). Calculating from the dispensed amounts and manufacturer’s capacity of the inhalers; and, applying standard dosages (or documented ones from evidence to follow); the maximum treatment time with daily dosing was 50 days for albuterol, 60 days for Flonase, 30 days for Advair, and 90 days for Singulair.

The narrative summary was conducted on 13 August 2002 (15 months prior to separation); and, listed the same asthma medications as noted above without specifying dosage or frequency of use. The examiner stated, “She states that her medications control her symptoms fairly well. Because she does not do any physical training, she does not have symptoms from trying to run. However, her symptoms do increase with exercise such as stairs or walking up hill ... [also detailing exacerbation by environmental allergens] ... no significant change in her asthma symptoms in the past six months.”

A VA Compensation and Pension (C&P) examination was conducted on 22 October 2003 (a month prior to separation). The examiner did not elaborate severity or limitations with regard to asthma; but, specified “she has been on preventive as well as therapeutic medication consisting of Advair which she takes twice daily, Singulair once daily and Albuterol two puffs every morning and two at night.” The VA’s PFT measurements were FEV1 of 99% predicted and FEV1/FVC ratio of 87%.

The Board directed attention to its rating recommendation based on the above evidence. The VASRD rating guidance for asthma is based on the number and severity of clinical exacerbations; the type and the frequency of medications used to treat the condition; and objective PFT findings. None of the PFT or clinical rating criteria for a 60% rating under VASRD §4.97 code 6602 (asthma) were supported in this case. The §4.97 criteria for a 30% rating are “FEV-1 of 56- to 70-percent predicted, or; FEV-1/FVC of 56 to 70 percent, or; daily inhalational or oral bronchodilator therapy, or; inhalational anti-inflammatory medication;” and, those for 10% are “FEV-1 of 71- to 80-percent predicted, or; FEV-1/FVC of 71 to 80 percent, or; intermittent inhalational or oral bronchodilator therapy.” The PEB’s DA Form 199 in support of a 0% rating stated, “Asthma for which soldier is supposed to be using medications on a regular basis, however this is not supported by the ... Pharmacy record.” The VARD for its 10% determination cited the C&P PFT measurements and listed the asthma medications “to be used on an as needed basis.” The latter conclusion must be assumed to have been derived from the records or elsewhere, since this was not articulated in the C&P examination.

It is obvious that the PFT evidence in this case does not support the minimum 10% criteria. The Board’s recommendation must rest on member judgment as to whether “intermittent inhalational or oral bronchodilator therapy” is reasonably supported for a 10% recommendation (as conceded by the VA, but not the PEB); or, whether daily therapy, as specified in the C&P exam near separation, should be conceded IAW VASRD §4.3 (reasonable doubt); thus satisfying criteria for a 30% recommendation. All members readily agreed that it was reasonable to concede at least intermittent medication use up to the time of separation, satisfying the 10% criterion. The issue of endorsing the daily medication criterion for a 30% rating was then deliberated. The documentation of daily dosing by the C&P examiner was logically derived from either the CI’s reported history or from the prescribed dosing information. The objective pharmacy evidence documents a wide gap between actual dispensing and daily use; and, the VA rater did not find adequate support from the record to conclude that daily dosing was in effect. It is also noted that the CI’s own statement in the application (quoted in contention) indicates that at the time of separation she was not dependent on daily use of her inhalers, after cessation of the exertional activities demanded by military requirements. After due deliberation, considering all of the evidence and incorporating reasonable doubt, the Board recommends a 10% rating for the asthma 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 asthma condition, the Board unanimously recommends a Service disability rating of 10%, coded 6602, IAW VASRD §4.97. 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, effective as of the date of her prior medical separation:

UNFITTING CONDITION VASRD CODE RATING
Asthma 6602 10%
COMBINED 10%


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20131112, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans Affairs Treatment Record






XXXXXXXXXXXXXX
President
DoD 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, AR20150010421 (PD201302334)


1. I have reviewed the enclosed Department of Defense Physical Disability Board of Review (DoD PDBR) recommendation and record of proceedings pertaining to the subject individual. Under the authority of Title 10, United States Code, section 1554a, I accept the Board’s recommendation to modify the individual’s disability rating to 10% without recharacterization of the individual’s separation. This decision is final.

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.

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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