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AF | PDBR | CY2013 | PD-2013-02475
Original file (PD-2013-02475.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXXXX       CASE: PD-2013-02475
BRANCH OF SERVICE: NAVY  BOARD DATE: 20150115
SEPARATION DATE: 20060301


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Hospital Corpsman) medically separated for systemic lupus condition. The condition could not be adequately rehabilitated to meet the physical requirements of her Rating or satisfy physical fitness standards. She was placed on limited duty and referred for a Medical Evaluation Board (MEB). The systemic lupus condition, characterized as “systemic lupus erythematosus,” “polyarthralgia,” “recurrent edema,” “fatigue,” and “insomnia/restless sleep,” were forwarded to the Physical Evaluation Board (PEB) IAW SECNAVINST 1850.4E. No other conditions were submitted by the MEB. The Informal PEB adjudicated “systemic lupus erythematosus” as unfitting, rated 10%, with application of the VA Schedule for Rating Disabilities (VASRD). The “recurrent edema,” “fatigue,” “insomnia/restless sleep,” and “polyarthralgia,” were determined to be Category II (conditions contributing to the unfitting condition). The CI made no appeals and was medically separated.


CI CONTENTION: “It should be increase to medical retirement. It is chronic conditions on which VA says it was warranted 90% disability. I do think that my PEB should of founded more. ” [sic]


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 20060106
 VA - (2 Mos. Post-Separation)
Condition
 Code Rating Condition Code Rating Exam
Systemic Lupus Erythematosus 6350 10% Systemic Lupus Erythematosus 6350 60% 20060517
Recurrent Edema Category II
Fatigue Category II
Insomnia/Restless Sleep Category II
Polyarthralgia Category II
Other x 0 (Not in Scope)
 Other x 5
Combined/Rating: 10%
 Combined: 70%
Derived from VA Rating Decision (VA RD ) dated 200 60920 ( most proximate to date of separation ( DOS ).

ANALYSIS SUMMARY:

Systemic Lupus Erythematosus Condition. The CI was diagnosed with systemic lupus erythematosus (SLE) in April 2002 manifesting as skin rash, joint pain and swelling of the hands, and positive blood tests consistent with the diagnosis and was prescribed medication (hydroxychloroquine). Rheumatologists noted her clinical presentation was consistent with subacute cutaneous lupus, a limited form of SLE. SLE is an autoimmune disease which can affect virtually any part of the body including kidney, lungs and blood forming tissues; however there was no evidence of involvement other than skin and joints in the CI. Treatment with the medication was stopped for pregnancy and nursing during 2003 from approximately December 2002 to December 2003. In December 2003 she experienced a return of symptoms following delivery of her child including joint pain of the fingers and ankles, leg swelling, fatigue, and oral ulcers. The medication was restarted; however, she became pregnant again in January 2004 and remained off of the medication through 2004. In July 2004, while pregnant and off of medication, she experienced joint pain for about 2 weeks. A rheumatology examination on 15 July 2004 recorded absence of active arthritis. A re-enlistment medical examination on 13 September 2004 noted the history of SLE and cleared the CI for reenlistment. Following delivery of her child, she experienced a return of symptoms of joint pain and rash in approximately November 2004. Laboratory testing (complete blood count was normal) and by a 9 February 2005 internal medicine appointment her symptoms had resolved and her physical examination was normal. The medication was resumed in February 2005 and service treatment records (STRs) reflect that she did well. An 8 June 2005 clinic appointment recorded there were no active symptoms of SLE and no pain. She was evaluated in the clinic on 14 July 2005 for leg pain associated with running however there were no symptoms of SLE. In October 2005 she experienced the return of increased bruising of the legs with swelling, joint pain, swelling of her fingers, facial rash, oral ulcer, and fatigue. On examination 26 October 2005, there was a facial rash (malar rash), an oral ulcer, and puffy fingers with nodules. Otherwise the examination was normal. There was no evidence of involvement of other organs or body sites and she was treated with steroids. On follow-up evaluation on 16 November 2005, the symptoms had improved and the examiner noted recent laboratory testing, obtained during the exacerbation of symptoms, was normal including complete blood count, chemistries (kidney, liver), urinalysis (kidney), and erythrocyte sedimentation rate (test for systemic inflammation which was normal). The MEB narrative summary on 23 November 2005, recorded CI report of chronic symptoms which had worsened over the prior one year including joint pain of knees, ankles, and fingers. On examination, there was a facial rash (malar rash) and mild hand swelling with normal range-of-motion. The examination was otherwise normal. At the time of follow-up with internal medicine on 13 December 2005, there were increased symptoms with reduction of the steroid dose. On examination, there as a mild facial rash but the examination was otherwise negative. The internal medicine evaluation on 6 January 2006, noted symptoms resolving and a normal examination with “no evidence of overt arthritis,” “no signs of SLE flare and all signs of prior flare now resolved.” There are no further service treatment record entries prior to separation from service on 1 March 2006.
At the VA Compensation and Pension (C&P) examination on 28 April 2006, 2 months after separation, the CI reported history of SLE with malar rash, fatigue, photosensitivity, swelling, joint pain of knees, ankles and fingers, and oral ulcers. She also reported Raynaud’s phenomenon (vasospasm causing blanching of the fingers) one-to-two times per month since May 2002 (not recorded in STRS). She reported exacerbations as often as two-to-three times per year lasing 4-to-20 weeks at a time. On examination, there was a facial rash (malar), and mild swelling of the legs. The fingers were noted to be red but no other problems were noted. There was pain with motion of the wrists, hips, knees and ankles reported by the CI, but the joint examination was otherwise normal. Gait was normal. The complete blood count was normal. At an eye examination on 1 May 2006, the CI reported her lupus felt in remission at that time. At a clinic appointment on 2 August 2006 the CI reported chronic persistent symptoms since the fall of 2005 (“prolonged flare of SLE since Oct 05”) including facial rash, rash on the arm, and joint pain. On examination there was a mild facial rash and some blotchy rash on the arms. At a civilian rheumatology appointment on 3 August 2006, the history of lupus manifested by photosensitivity, malar rash, arthritis, and oral ulcers was noted. The CI reported being on a steroid taper since May. On examination there was a mild facial rash present. There were no oral ulcers and the joint examination was normal.

The Board directed attention to its rating recommendation based on the above evidence. The PEB rated the SLE 10%, coded 6350 (Lupus erythematosus, systemic [disseminated]) based on the evidence of the STR. Symptoms associated with SLE referred by the MEB (recurrent edema, fatigue, insomnia/restless sleep, and polyarthralgia) were categorized by the PEB as Category II. The VA rated the SLE 60% (6350) citing the report of frequent exacerbations at the time of the post-separation VA C&P examination. Rating under VASRD diagnostic code 6350, is based on frequency and severity of exacerbations of disease. Acute disease with frequent exacerbations producing severe impairment of health supports a 100% rating. Exacerbations lasting a week or more, 2 or 3 times per year support a 60% rating. Exacerbations once or twice a year or symptomatic during the past 2 years supports a 10% rating. The Board noted that the CI’s SLE fell on the milder end of the spectrum of the disease. Since the time of diagnosis in April 2002, flares of her symptoms occurred while she was not on treatment due to pregnancy and occurred approximately once per year following the delivery of a child at the end of 2003 and the end of 2004. After resumption of treatment in February 2005, the CI did well until the exacerbation documented in the STRs beginning in October 2005. STRs reflect improvement with treatment by January 2006. Therefore the Board concluded the STRs reflected one exacerbation per year, including the last year in service. The Board noted that at the time of the VA C&P examination, 2 months after separation, the CI reported experiencing 2 to 3 exacerbations per year. However, the Board considered the evidence of the STRS to be more reflective of exacerbations of disease. The Board considered whether separate ratings would be appropriate for unfitting residuals of her SLE instead of an overall rating based on disease exacerbations. However, the STRS did not show permanent residuals and exacerbations best described the overall disability pattern. 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 SLE 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 SLE condition and IAW VASRD §4.88b, 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 20131110, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans Affairs Treatment Record








        
XXXXXXXXXXXXXXXXXXXX
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) RECOMMENDATION
Ref:     (a) DoDI 6040.44
(b) CORB ltr dtd 25 Jun 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:

-        XXXXXXXXXXXXXXXXXXXX, former USN
-        XXXXXXXXXXXXXXXXXXXX, former USN
-        XXXXXXXXXXXXXXXXXXXX , former USN
-        XXXXXXXXXXXXXXXXXXXX, former USN
-        XXXXXXXXXXXXXXXXXXXX , former USMC
-        XXXXXXXXXXXXXXXXXXXX, former USN
-        XXXXXXXXXXXXXXXXXXXX, former USN
-        XXXXXXXXXXXXXXXXXXXX, former USN
-        XXXXXXXXXXXXXXXXXXXX, former USMC
-        XXXXXXXXXXXXXXXXXXXX, former USN
-        XXXXXXXXXXXXXXXXXXXX, former USMC
-        XXXXXXXXXXXXXXXXXXXX, former USMC
-        XXXXXXXXXXXXXXXXXXXX, former USN
        




XXXXXXXXXXXXXXXXXXXX
Assistant General Counsel (Manpower & Reserve Affairs)

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