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AF | PDBR | CY2013 | PD2013 00349
Original file (PD2013 00349.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX         CASE: PD1300349
BRANCH OF SERVICE: Army  BOARD DATE: 20140314
SEPARATION DATE: 20041213


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was a mobilized National Guard Reserve SPC/E-4 (31B/Military Police) medically separated for left eye pain secondary to post herpetic trigeminal neuralgia and major depressive disorder (MDD). The applicant was mobilized in February 2003 and reported pain in his left eye in April 2003 and was diagnosed with left eye herpetic keratitis. The ocular problem resolved, but he continued to complain of pain and was referred to Neurology and diagnosed with post herpetic neuralgia. During this time the applicant began to suffer from depressive symptoms and was referred to psychiatry. His left eye pain (secondary to post herpetic trigeminal neuralgia) and MDD could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS) or satisfy physical fitness standards (profile allowed for alternate aerobic event). He was issued a permanent P3/S3 profile and referred for a Medical Evaluation Board (MEB). The left eye pain and MDD conditions were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. No other conditions were submitted by the MEB. The Informal PEB adjudicated the left eye condition and MDD as unfitting, rated 10% and 10% respectively, with application of the VA Schedule for Rating Disabilities (VASRD). The CI made no appeals and was released from active duty due to medical disability and transferred to the Retired Reserve with entitlement to apply for retirement benefits at age 60, pursuant to his request.


CI CONTENTION: The applicant wrote “I was initially granted 60%-and finally granted 40%” in block 3 of his application, with no specific contention in his application.


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. In addition, the CI was notified by the Army that his case may eligible for review of the military disability evaluation of his mental health (MH) condition in accordance with Secretary of Defense directive for a comprehensive review of Service members who were referred to a disability evaluation process between 11 September 2001 and 30 April 2012 and whose MH diagnoses were changed during that process. In accordance with Secretary of Defense directive for a comprehensive review of the MH diagnoses that were changed during the Disability Evaluation System (DES) process, the applicant’s case file was reviewed regarding diagnosis change, fitness determination, and rating of unfitting mental health diagnoses in accordance with the VASRD §4.129 and §4.130. The ratings for the unfitting left eye and MDD are addressed below; and, no additional conditions are within the DoDI 6040.44 defined purview of the Board. Any conditions 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 20040723
 VA - (3 Mos. Post-Separation)
Condition
 Code Rating Condition Code Rating Exam
Left Eye Pain secondary to post herpetic trigeminal neuralgia 8405 10% Residual Neuralgia s/p herpetic keratitis 8405 30% 20050301
Major Depressive Disorder 9434 10% Dysthymia 9433 10% 20050308
No Additional MEB/PEB Entries
 Other x 3 20050301
Combined Rating: 20%
 Combined: 40%
Derived from VA Rating Decision (VA RD ) dated 200 50404 ( most proximate to date of separation [ DOS ] ).


ANALYSIS SUMMARY: The DES is responsible for maintaining a fit and vital fighting force. While the DES considers all of the service member's medical conditions, compensation can only be offered for those medical conditions that cut short a member’s career, and then only to the degree of severity present at the time of final disposition. The DES has neither the role nor the authority to compensate members for anticipated future severity or potential complications of conditions resulting in medical separation nor for conditions determined to be service-connected by the Department of Veterans Affairs (DVA) but not determined to be unfitting by the PEB. However the DVA, operating under a different set of laws (Title 38, United States Code), is empowered to compensate all service-connected conditions and to periodically re-evaluate said conditions for the purpose of adjusting the Veteran’s disability rating should his degree of impairment vary over time. The Board’s role is confined to the review of medical records and all evidence at hand to assess the fairness of PEB rating determinations, compared to VASRD standards, based on severity at the time of separation.

Left Eye Pain Secondary to Post Herpetic Trigeminal Neuralgia. In April 2003, the CI was diagnosed and treated for left eye herpetic keratitis, an infection of the cornea of the eye (the outermost clear covering). The ocular infection and inflammation resolved with treatment. There was a small residual scar in the center of the cornea that did not affect vision (CI had mild near sightedness and wore glasses for several years). He continued to complain of left eye pain that did not improve with medications. He was evaluated with a computerized tomography scan on 20 May 2003, which demonstrated no abnormalities which would cause the pain. Evaluation by a neurologist in June 2003 concluded with a diagnosis of post-herpetic neuralgia of the trigeminal nerve (5th cranial nerve). Magnetic resonance imaging on 11 July 2003, was normal showing no abnormality of nerves or other structures consistent with the diagnosis. The CI was treated with medications for the neuralgia pain. On 1 July 2003, a primary care clinic note for medication refills noted the corneal ulcer and recorded a pain report of 0 on a 10 scale. On 2 March 2004, at a primary care clinic follow-up, the CI rated his pain as 2 on a 10 scale. On 14 April 2004, at an ophthalmology appointment, pain was reported as 4 out of 10. The cornea was now reported to be clear (no scar or inflammation) and visual acuity 20/40 without glasses, the same as prior to the onset of the problem. At the MEB physical examination completed on 23 May 2004, and cited in the narrative summary (NARSUM), the CI was described to be in “no acute distress.” His post-herpetic trigeminal neuralgia was determined to be stable and not worsening. The examining physician noted that the neuralgia caused significant pain with physical exertion. The CI was reported to also have pain with exposure to sunlight. The CI averred that sensitivity to bright lights required him to wear sunglasses indoors. The MEB NARSUM on 25 May 2004 noted that due to his neuralgia pain he was rendered unable to perform the duties of his MOS and basic military functional activities. His prognosis at that time was considered reserved considering that his pain was not improving despite multiple trials of medications. Despite the pain caused by his neuralgia, the NARSUM noted that from a functional point of view, he did not have any limitations and he was totally independent. Furthermore, he did not have any geographic assignment limitations. The psychiatrist in the MEB psychiatric addendum finalized on 17 June 2004 noted that the CI did work at night because he was able to perform duties when not in direct sunlight. On 25 August 2004, ophthalmology evaluation recorded a normal exam. The CI reported since beginning a new medication he felt much better from the pain. The ophthalmologist advised the CI his symptoms would likely continue to improve over time. The ophthalmologist on 1 December 2004 12 days prior to separation noted that the CI had pain at a level of six on a ten point scale (ten being the worst pain ever experienced). The ophthalmologist further recorded the CI as much improved with minimal side effects on the latest medication regimen. The VA Compensation and Pension (C&P) examination completed on 10 March 2005, 3 months after separation, noted that the CI was described as having intermittent pain behind his left eye ball of 8 to 9 in level on a 10-point scale. The pain was described as worsening with sunlight and relieved with medication. The decreased visual acuity was consistent with his near sightedness and was corrected by prescription glasses. A VA examination on 8 March 2005 described that the CI had resumed his employment of 16 years. There were no reports of days of work missed or decrease in work performance.

The Board directs attention to its rating recommendation based on the above evidence. The Informal PEB adjudicated the left eye pain secondary to post-herpetic trigeminal neuralgia with chronic photophobia rated as incomplete and moderate assigning a rating of 10% using the code 8405 neuralgia fifth (trigeminal) cranial nerve. The VA rated the condition 30% (also coded 8405) for severe incomplete paralysis citing the C&P examination. The VA subsequently reduced the rating to 0% based on a 2006 C&P examination, 2 years after separation. This Board must correlate the above clinical data with the 2004 rating schedule code 8405 neuralgia fifth (trigeminal) nerve. All members agreed the symptoms of the CI at the time of separation did not rise to the level of complete paralysis for a 50% rating under this code. The deliberations centered on whether the symptoms more nearly approximated severe incomplete paralysis for a 30% rating versus moderate incomplete paralysis for a 10% rating. The Board considered the functional impact reported at the MEB NARSUM as well as the improvement in symptoms noted in the August 2004 and 1 December 2004 ophthalmology evaluations prior to separation. All members agreed that the evidence of the treatment records does not support a finding of a condition at the level of severe to establish a rating of 30% as of separation. In consideration of these factors and the severity of symptoms and disability in evidence, members agreed that the impairment did not exceed moderate incomplete paralysis. 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 trigeminal neuralgia condition.

Major Depressive Disorder. The CI was mobilized in February 2003 and went for training with his unit. As noted above he developed trigeminal neuralgia beginning in April 2003 and was unable to train with his unit and was assigned indoor duties. He subsequently experienced depressed mood following the development of the trigeminal neuralgia condition and was seen in the MH clinic at the training base from September 2003 to December 2003 and diagnosed with adjustment disorder with depressed mood. He returned to his home base with his unit and was placed on medical hold for continuing treatment and MEB. A MEB examination (DD Form 2807 and DD Form 2808) dated 13 February 2004, noted depression “well controlled on meds,” with the last evaluation in December 2003. He was referred to a civilian psychologist who evaluated him on 12 April 2004 and diagnosed major depression. A 15 April 2004 MH clinic (military treatment facility) noted the CI had stopped taking his medications. He was advised to resume medication treatment. The MEB examination was updated 25 May 2004 and no changes were noted. The general medical MEB NARSUM on 25 May 2004 noted depression to be medically acceptable. His medication was subsequently changed to a different medication in June 2004. The MEB psychiatry NARSUM on 14 June 2004, diagnosed the CI with MDD manifested by decreased interest in activities, feeling sad, isolating from people and being less communicative. He expressed concerns about his ability to resume his civilian job due to the photophobia from his trigeminal neuralgia as his job required work outside. The mental status examination (MSE) noted full range of affect, with normal speech and thought processes without suicidal ideation, delusional or hallucinatory symptoms, speech disturbance, cognitive impairment or other abnormalities. The psychiatrist concluded the CI did not meet retention standards and assigned a S3 profile. Subsequent treatment notes reflect report of less pain and improved mood with medication treatment, with some transient increases in symptoms associated with marital and work stressors. The 24 August 2004 MH appointment noted fuller range of effect and plans for the future. The 22 September 2004 mental health clinic appointment notes “feels better – happier;” “improved mood - coping well; stable.” The 6 October 2004 MH clinic appointment, 2 months prior to separation, notes, “affect full, not depressed, increased energy,” and having a good relationship with his children. The 9 November 2004 MH clinic appointment and a 14 November 2004 psychiatry appointment record that the CI had stopped taking his medications a month prior to the appointment because he was feeling well, but experienced return of symptoms. He was advised to resume the effective medications. The VA C&P mental disorders exam dated 8 March 2005, 3 months after separation, described that the CI had resumed his employment of 16 years. There were no reports of days of work missed or decrease in work performance. He was on medication for his depressed mood and had alimony problems. His MSE at that time demonstrated an anxious and depressed mood, restricted affect and fair memory. The C&P MH examiner seeking to describe reported symptoms that could have affected employment and social functioning noted no inappropriate behavior, other than irritability and verbal aggressiveness. The examiner also noted CI’s complaint of awakening very early and getting sleepy in the daytime. The VA examiner diagnosed the CI with dysthymia and assigned a Global Assessment of Functioning of 75, meaning if symptoms were present, they were transient and expectable reactions to psychosocial stressors. The Board first considered if there were any changes in diagnoses in accordance with the special MH review project. The diagnosis of depression was unchanged throughout the DES process. The Board concluded that there was no elimination or change in mental health diagnosis. Therefore, the case does not meet the inclusion criteria in the Terms of Reference of the MH Review Project.

The Board directs attention to its rating recommendation based on the above evidence. The PEB rated the MDD 10% citing requirement for medication. The VA rated the depression condition diagnosed as dysthymia 10% based on the VA C&P examination 3 months after separation. All Board members agreed that the provisions of §4.129 were not applicable in this case. The Board discussion centered on a 30% versus the 10% rating. The Board noted the CI’s symptoms were controlled with medication in the months just prior to separation, and that he returned to employment following separation. The commander’s comments on 3 May 2003 did not provide information indicating that his depressed mood interfered with satisfactory duty performance. The Board concluded that the preponderance of evidence indicates that the impairment from the depressive disorder at the time of separation was mild which would decrease work efficiency and ability to perform occupational tasks only during periods of significant stress. After due deliberation, considering the preponderance of the evidence the Board failed, on balance, to find adequate reasonable doubt favoring the CI in support of a recommendation for the higher rating than the 10% adjudicated by the PEB at the time of separation.
BOARD FINDINGS: 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 left eye pain secondary to post herpetic trigeminal neuralgia condition and IAW VASRD §4.124a, the Board unanimously recommends no change in the PEB adjudication. In the matter of the MDD condition and IAW VASRD §4.130, 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 recharacterization of the CI’s disability and separation determination, as follows:

UNFITTING CONDITION VASRD CODE RATING
Left Eye Pain Secondary to Post Herpetic Trigeminal Neuralgia 8405 10%
Major Depressive Disorder 9434 10%
COMBINED 20%


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20130506, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record








                 
XXXXXXXXXXXXXXXXXX, DAF
President
Physical Disability Board of Review


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MEMORANDUM FOR Commander, US Army Physical Disability Agency
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557


 invalid font number 31502 SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXX invalid font number 31502 , AR20140011032 (PD201300349)
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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 and hereby deny the individual’s application.
This decision is final. The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail.

BY ORDER OF THE SECRETARY OF THE ARMY:


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Encl                                                  XXXXXXXXXXXXXXXXXX invalid font number 31502
                                                      Deputy Assistant Secretary
                                                      (Army Review Boards)

CF:
( ) DoD PDBR
( ) DVA

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