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AF | PDBR | CY2013 | PD-2013-02634
Original file (PD-2013-02634.rtf) Auto-classification: Approved
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXX    CASE: PD-2013-02634
BRANCH OF SERVICE: Army  BOARD DATE: 20150729
SEPARATION DATE: 20051011


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Petroleum Supply Specialist) medically separated for asthma. The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty. He was issued a permanent P3 profile and referred for a Medical Evaluation Board (MEB). His profile allowed for an alternate aerobic event to satisfy physical fitness standards. “Asthma, moderate, persistent” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. The MEB also identified and forwarded five other conditions that met retention standards, (hypertension, allergic rhinitis, obesity, hypercholesterolemia and medication noncompliance) for PEB adjudication. The Informal PEB adjudicated “asthma” as unfitting, rated 0%, c iting non-compliance with medical management. The remaining conditions were determined to be not unfitting . The CI made no appeals and was medically separated.


CI CONTENTION: He was not evaluated for itching feet, erectile dysfunction, sleep deprivation or PTSD. His complete submission is at Exhibit A.


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 Veterans Affairs Schedule for Rating Disabilities (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 :

IPEB – Dated 20050808
 VA* - based on Service Treatment Records (STR)
Condition
 Code Rating Condition Code Rating Exam
Asthma 6602 0% Asthma 6602 10% STR**
Other MEB/PEB Conditions x 5 (Not In Scope)
 Other x 1
RATING: 0%
 RATING: 10%
* Derived from VA Rating Decision (VA RD ) dated 200 60520 (most proximate to date of separation ( DOS ) ) .
**Subsequent VARD dated 20061228 continued 10% Asthma, based on C&P exam dated 20060713

ANALYSIS SUMMARY: The Board notes that the VA Compensation and Pension (C&P) pulmonary examination was not available in the evidence before it. The missing evidence will be referenced below in relevant context. It is not suspected that the missing evidence would significantly alter the Board’s recommendations.

Asthma. The service treatment record (STR) initially reflected that the CI was being worked-up for a respiratory condition noting the first of many spirometry/pulmonary function tests (PFT’s) dated 22 May 2000 where he was diagnosed with “mild, obstructive ventilatory defect” and referred for further work-up. The CI presented a verbal history of having “asthma symptoms for 10 years.” On 7 June 2000, the CI underwent a methacholine challenge test (definitive and diagnostic test for asthma) which was mildly positive and Pulmonology diagnosed asthma. Subsequent spirometry tests (June 2003, December 2004, and May 2005) were normal regarding the values of FEV1 and FVC. The STR also contained diagnostic inconsistencies which included asthma, mild fixed obstructive disease consistent with early chronic central airway disease, and chronic obstructive pulmonary disease (COPD). Additionally, the CI frequently endorsed environmentally-related allergy type symptoms which often exacerbated his respiratory condition. An Internal medicine encounter dated 4 May 2005 clearly noted that in regards to the CI’s diagnosis of asthma… “The [CI] is experiencing problems now that pollen season has begun.” The examiner prescribed two separate inhaled steroids for treatment of the two associated conditions of asthma and allergically-related rhinitis (runny noise). He was also prescribed Albuterol (bronchodilator) rescue inhaler for symptomatic relief of shortness of breath. Despite allergen avoidance and medication use, his infrequent respiratory exacerbations continued to occur (allergy or exercise induced) and eventually he was referred to an MEB.

At the narrative summary examination performed on 5 May 2005 (5 months prior to separation) the CI’s chief compliant remained, “asthma.” The CI reported worsening of his control of asthma due to seasonal allergies using Albuterol inhaler daily in addition to his Flovent (inhaled steroid). His physical examination (PE) was normal; his FEV1 was 96% of predicted and the FEV1/FVC ratio was 74%; consistent with mild obstructive ‘respiratory’ defect. The examiner definitively listed the diagnosis as moderate persistent asthma and poorly controlled allergic rhinitis. The commander’s letter clearly implicated that CI’s “asthmatic condition” continued to halt any progress in the CI’s weight loss program and his inability to perform many of his required military duties.

The VA C&P specialty examination was not contained in the STR and evidence of impairment was obtained from the VARD nearest to the DOS. The VA noted that impairment was supported by the continued use of medication; specifically, Albuterol inhaler. The PFT results as referenced above, with §4.97-ratable treatment criteria, are summarized in the chart below.

Pulmonary Function
MEB ~ 10 Mo. P re-Sep

Pulmonary ~ 5 Mo. P re-Sep
FEV1 (% Predicted)
 96% 96 %
FEV1/FVC
 74% 9 1 %
Meds
 Flovent; Albuterol Flovent ; Albuterol

The Board directed attention to its rating recommendations based on the above evidence. The unequivocal VASRD code for rating asthma is 6602. VASRD §4.97 defines both PFT derived criteria and clinical treatment criteria for rating under 6602. The non-PFT derived criteria are: “intermittent inhalational or oral bronchodilator therapy” for 10%; “daily inhalational or oral bronchodilator therapy, or; inhalational anti-inflammatory medication” for 30%; and, “intermittent (at least 3 per year) courses of systemic (oral or parenteral) corticosteroids” for 60%. Absent use of oral steroids, the 60% impairment level was not supported. The PEB cited medication non-compliance (based upon pharmacy records) and a normal lung exam for basis of their 0% impairment rating, whereas the VA cited continued use of a rescue inhaler for a 10% rating. In considering only PFT derived criteria, Board members acknowledged that the MEB exam (10 months prior to separation) clearly met the 10% impairment level which was not revealed in a subsequent examination performed 5 months later by Pulmonology. In considering only medication based criteria, Board members acknowledged that both of the above charted examinations “reasonably” could be conceded to rate at the 30% impairment level considering the reported use of inhaled steroids; however, extensive deliberation ensued with regard to the fundamental reasoning for the use of steroids in treating the primary condition of actual asthma or for the chronic allergic rhinitis condition.

Clearly, the use of a “rescue medication” (bronchodilator) supported a VASRD 10% impairment level. In considering the use of inhaled steroids, the action officer opined that the STR contained sufficient evidence that the underlying medical condition causing the CI’s main respiratory symptoms/condition were seasonal allergies and that the prescribed use of inhaled steroids were indicated to a greater degree as treating the primary allergic condition versus any exacerbations of asthma. The evidence of noting mixed diagnostic issues regarding a firm respiratory condition only strengthened the fact of associated factors which influenced his overall respiratory symptoms (environmental allergens). Therefore, after due deliberation, considering the totality of the evidence throughout the entire case file and remaining mindful of VASRD §4.3 (reasonable doubt), the Board majority concluded that the use of inhaled steroids should not be primarily considered in a rating under asthma in this particular case. The Board recommends a final disability rating of 10% for the respiratory (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. As discussed above, PEB cited non-compliance for rating purposes in this case and the condition was adjudicated independently of that policy by this Board. In the matter of the respiratory (asthma) condition and IAW VASRD §4.97, the Board by a majority vote recommends a 10% disability rating, coded 6602. The single voter for dissent did not elect to submit a minority opinion. 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 his prior medical separation:

CONDITION
 VASRD CODE RATING
Asthma
6602 10%
RATING
 10%












The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20131205, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans Affairs Treatment Record





XXXXXXXXXXXXXXX
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 , AR20150013247 (PD201302634)
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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