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AF | PDBR | CY2013 | PD-2013-02675
Original file (PD-2013-02675.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXX    CASE: PD-2013-02675
BRANCH OF SERVICE: NAVY  BOARD DATE: 20150219
SEPARATION DATE: 20050825


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Cryptologic Maintenance Technician) medically separated for chronic anticoagulation therapy. The condition could not be adequately rehabilitated to meet the physical requirements of his Rating or satisfy physical fitness standards. He was placed on limited duty and referred for a Medical Evaluation Board (MEB). The MEB forwarded “aortic valve disorder” to the Physical Evaluation Board (PEB) IAW SECNAVINST 1850.4E. No other conditions were submitted by the MEB. The Informal PEB adjudicated “hypercoagulable state requiring chronic anticoagulation therapy” as unfitting, rated 0%, and determined that the bicuspid aortic valve ( status post replacement ) was a C ategory III condition , not separately unfitting and not contributing to the unfitting condition. The CI made no appeals and was medically separated.


CI CONTENTION: “Prior to separation from active military service, I was assisted in filing a claim for compensation benefits with the USVA under the TAP/BDD process. USVA, looking at the same conditions for which a PEB found me unfit for continued military service at 0% evaluation, awarded me a disability rating of 30% for aortic valve replacement, 10% for a right ankle condition and 10% for migraine headaches with vasovagal syncope. Attached herewith is VA letter of 10/24/2011. The correspondence of 10/2011 found clear and unmistakable error in the original VA decision of 10/24/2005 and retroactively awarded increased evaluation to 30% disabling for aortic valve replacement from 08/26/2005.”


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 :

Service IPEB – Dated 20050707
 VA - (1 Mos. Pre-Separation)
Condition
 Code Rating Condition Code Rating Exam
Hypercoagulable State… 7199-7121 0% Hypercoagulable State… No VA Entry
Aortic Valve Replacement Category III Aortic Valve Replacement 7016 30% 20050706
Other x 0 (Not in Scope)
 Other x 3
Combined: 0%
 Combined: 30%
Derived from VA Rating Decision (VA RD ) dated 20051014 ( most proximate to date of separation [ DOS ] ) as corrected by the 20111019 VARD

ANALYSIS SUMMARY: The Board observed that the history of the cardiac condition and the unfitting anti-coagulation therapy are so intertwined as to present the history of the conditions separately is not feasible. However, each is discussed separately for disability evaluation considerations.

Hypercoagulable State Requiring Chronic Anticoagulation Therapy. The CI was evaluated with an echocardiogram (ECHO) on 5 January 2004 for a 1-year history of lightheadedness. He was noted to have bicuspid aortic valve with insufficiency (retrograde flow). He was followed in cardiology and on 24 August 2004 it was noted on ECHO that his condition had worsened. On 1 September 2004, he had the valve replaced with a mechanical valve and placed on anticoagulation therapy. Clotting studies were normal prior to surgery. A cardiology evaluation on 15 December 2004 noted that the chamber size was normal with good systolic (contraction) function. The valve was well seated with normal function. The record shows that the CI steadily improved over time. The narrative summary was dated 24 January 2005, 7 months prior to separation. The CI had reported occasional dizzy spells at his last cardiology appointment (above) which were not attributed to the valve replacement. His examination was unremarkable other than the expected findings after a valve replacement. He was on anti-coagulation due to the mechanical aortic valve. The examiner noted that “Due to his ongoing need for anticoagulation, the patient is not fit for duty in the United States Navy. Although the patient’s current job duties are not limiting in any way, it is likely that the patient would be undeployable because of his ongoing need for anticoagulation as well as close cardiology followup.” At the VA Compensation and Pension exam performed on 6 July 2005, 6 weeks prior to separation, the CI reported that he still felt dizzy, but that he had not fainted and that his symptoms had improved since the surgery. He exercised 3 times a week for 25 minutes on a cross-trainer or exercise bike. The cardiovascular examination was normal. The scar was well (healed). An electrocardiogram (ECG) was significant for voltage criteria for left ventricular hypertrophy. He was last seen in cardiology on active duty on 1 August 2005, 3 weeks prior to separation. He was noted to be doing well and exercising without symptoms. An ECHO on 30 March 2007, showed good function with a 54% ejection fraction and was without left ventricular hypertrophy. Coagulation studies before and after separation showed that the CI remained in a therapeutic range.

The Board directed attention to its rating recommendation based on the above evidence. The PEB rated the CI at 0% using the code 7199-7121, analogous to post-plebitic syndrome (following a clot). The VA rated the CI for the valve replacement, but did not separately rate the chronic Coumadin therapy. There is no specific code for the use of an anti-coagulant and the CI had normal clotting studies prior to the initiation of anti-coagulation therapy following surgery. The Board observed that the need for anti-coagulation therapy was directly tied to the valve replacement. The Board majority determined that this supported the use of an analogous code of 7099-7016 (valve replacement) for the use of medication after a valve replacement. After due deliberation, considering all of the evidence and mindful of Veterans Affairs Schedule for Rating Disabilities (VASRD) §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the “hypercoagulable state” condition coded 7099-7016.

Contended PEB Conditions. The Board’s main charge is to assess the fairness of the PEB’s determination that the “bicuspid aortic valve, status post replacement” 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. A bicuspid aortic valve is typically a congenital condition. The natural history is that over time, due to turbulent flow, there is calcification of the valve with resulting narrowing (stenosis) and the insufficiency, usually after the fourth decade of life. The CI had the onset of insufficiency earlier than normal, but not outside the normal range. The treatment is valve replacement which was done in this case. The action officer observed that a valve replacement places no general restrictions on the individual. However, the type of replacement does place different requirements for follow-up. The use of a tissue valve permits the individual to remain off of anti-coagulation. These are less durable, as noted above, and are not as suitable as a mechanical valve for younger or active individuals. After recovery from surgery, there are typically no limitations in activity other than those from anti-coagulation therapy, if prescribed. The valve replacement was not implicated in the commander’s statement; the duty limitations cited were from the surgery itself and would be lifted after healing. The aortic valve disorder was judged to fail retention standards though. The valve replacement was reviewed by the action officer and considered by the Board. There was no performance based evidence from the record that the aortic valve replacement significantly interfered with satisfactory duty performance after recovery from the surgery. 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 the contended “bicuspid aortic valve status post replacement” condition and so no additional disability rating is recommended. The Board noted that the VA rated this condition at 30% based on the left ventricular hypertrophy present on the ECG. In fact, the follow up test, an ECHO, is a more accurate evaluation and was normal.


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 hypercoagulable state requiring chronic anticoagulation therapy condition and IAW VASRD §4.104, the Board, by a majority vote, recommends disability rating of 10%, coded 7099-7016. In the matter of the contended bicuspid aortic valve 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, effective as of the date of his prior medical separation:

UNFITTING CONDITION VASRD CODE RATING
“Hypercoagulable State…” 7099-7016 10%
Arotic Valve Replacement 7016 Cat III
COMBINED 10%







The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20131216, 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 COMMANDER, NAVY PERSONNEL COMMAND
 DEPUTY COMMANDANT, MANPOWER & RESERVE AFFAIRS
         
Subj: PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS

Ref:     (a) DoDI 6040.44
 (b) PDBR ltr dtd 24 Jun 15 ICO XXXXXXXXXXXXXXXXXX
(c) PDBR ltr dtd 19 Jun 15 ICO XXXXXXXXXXXXXXXXXX
(d) PDBR ltr dtd 12 May 15 ICO XXXXXXXXXXXXXXXXXX
(e) PDBR ltr dtd 9 Jun 15 ICO XXXXXXXXXXXXXXXXXX
1. Pursuant to reference (a) I approve the recommendations of the Physical Disability Board of Review set forth in references (b) through (e).

2. The official records of the following individuals are to be corrected to reflect the stated disposition:

a.       XXXXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability severance pay with a disability rating of 20 percent (increased from 10 percent) effective date of discharge.
b. XXXXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability severance pay with a disability rating of 20 percent (increased from 10 percent) effective date of discharge.

c. XXXXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 30 percent disability rating (increased from 20 percent) effective date of discharge.

d. XXXXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability severance pay with a disability rating of 10 percent (increased from 0 (zero) percent) effective date of discharge.

3. Please ensure all necessary actions are taken to implement these decisions, including the recoupment of disability severance pay, if warranted, and notification to the subject members once those actions are complete.



 XXXXXXXXXXXXXXXXXXXX
Assistant General Counsel
(Manpower & Reserve Affairs)

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