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AF | PDBR | CY2014 | PD-2014-01395

Original file (PD-2014-01395.rtf) Auto-classification: Denied

RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXX CASE: PD-2014-01395
BRANCH OF SERVICE: Army BOARD DATE: 20150312

SEPARATION DATE: 20081230

SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Human Resources Specialist) medically separated for neurocardiogenic syncope and postural orthostatic tachycardia syndrome (POTS). The condition could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty or satisfy physical fitness standards. She was issued a permanent P3/L2 profile and referred for a Medical Evaluation Board (MEB). The “severe vasovagal syncope, s/p pacemaker placement” condition was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. The MEB also identified and forwarded 13 other conditions, all listed as meeting retention standards, (mild mitral valve prolapse (MVP), history (Hx) of non-cardiac chest pain, anxiety/mild depression, 6mm non-calcified density posterior-lateral and upper aspect of the left lung, Hx of migraine headaches, mild hypokalemia, Hx of ovarian cyst, Hx of H. pylori, Hx of Achilles tendonitis, Hx of sinusitis, and Hx of nasal fracture) for PEB adjudication. The Informal PEB (IPEB) adjudicated the neurocardiogenic syncope and POTS as unfitting, rated 10%. The CI appealed and requested a Formal PEB (FPEB). The FPEB affirmed the IPEB adjudication with l ikely application of Veterans Affairs Schedule for Rating Disabilities (VASRD) . The remaining condition s were determined to be not unfitting . The CI made no further appeals and was medically separated.

CI CONTENTION: “Conditions of MVP with tricuspid, mitral and pulmonic regurgitation and neurocardiogenic syncope treated with dual chamber pacemaker were rated together. The MVP with the three regurgitations and the neurocardiogenic syncope are two separate diagnoses. The neurocardiogenic syncope is treated with the pacemaker, not the MVP.”

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 :

FPEB – Dated 20080812	VA - (~14 Mos. Post-Separation)
Condition	Code	Rating	Condition	Code	Rating	Exam
Neurocardiogenic Syncope and POTS	8299-8210	10%	Neurocardiogenic Syncope; Orthostatic Hypotension; Mild MVP; Mitral Tricuspid and Pulmonic Regurgitation	7018-7011	10%	20100222
Mild MVP	Not Unfitting
Other x12 (Not In Scope)	Other x2
RATING: 10%	RATING: 10%

Derived from VA Rating Decision (VA RD ) dated 20 1 0 0719 (most proximate to date of separation ( DOS ) )

ANALYSIS SUMMARY:

Neurocardiogenic Syncope and Postural Orthostatic Tachycardia Syndrome. The evidence supported that the CI experienced increasingly frequent syncopal events in September 2007, though certainly she reported having syncopal events previously (usually attributed to dehydration, etc). After the recurrent syncopal events increased significantly, she underwent workups by neurology and cardiology that included a tilt table test which demonstrated a 5 to 7 second asystolic (no heart beat) pause. She had a stress test with imaging that documented good exercise tolerance at 10.1 METS with no evidence of ischemic heart disease. Concerning the remainder of her evaluation, the evidence contained the following except from one of her physicians:

“I obtained a copy of her echocardiogram, the myocardial perfusion imaging and the exercise stress test from Dr. [physician’s name] office. They were all normal. I discussed this with the patient to calm her anxiety and showed her that the mitral prolapse is mild and that the regurgitation she was concerned about, which is a trace of mitral, tricuspid and pulmonary regurgitation. I told her that this needs to be followed up and is most likely not involved in the symptoms she is having now.”

She had a pacemaker placed to prevent the syncopal episodes (10 months prior to separation). The commander’s note prepared eight months prior to separation stated, “Since the installation of the pace maker she has not suffered from the fainting or dizzy spells.” Additionally, her cardiologist made the following statement:

“She is feeling better and has not had syncope since her pacemaker placement. She has started exercising and doing scuba diving. Patient denied having chest pain, shortness of breath, palpitations, edema, lightheadedness, hematuria, melena, fever, cough or fatigue.”

The narrative summary prepared almost 6 months prior to separation noted that the CI’s recurrent syncope was most likely secondary to severe vasovagal syncope. She had not had any recurrent syncopal episodes since her pacemaker placement. The physical exam revealed a scar over the pacemaker insertion site but was otherwise normal. Her medication at that time included Midodrine (a medication that increased vessel tone) twice daily.

At the VA Compensation and Pension (C&P) exam performed 14 months after separation, the CI reported she initially had 2-3 syncopal episodes a month prior to pacemaker placement. After pacemaker placement and with taking the medication Midodrine, the CI denied any further syncopal episodes. Physical exam revealed a normal pulse and blood pressure. Her cardiopulmonary exam was normal.

The Board directed its attention to its rating recommendation based on the above evidence. The PEB applied the analogous VASRD code 8299-8210 (incomplete paralysis of the vagus nerve) and rated it 10% citing “moderate.” The Board reviewed the VASRD rating criteria for code 8210 which is copied below for the reader’s convenience:

Tenth (pneumogastric, vagus) cranial nerve.

8210 Paralysis of:
Complete .............................................................. 50
Incomplete, severe ............................................... 30
Incomplete, moderate ........................................... 10

NOTE: Dependent upon extent of sensory and motor loss to organs of voice, respiration, pharynx, stomach and heart.

The CI exhibited only intermittent impairment of the vagus nerve and none of the other potential impairments as noted in the “note” section of the rating criteria and therefore Board members agreed that the moderate, 10% rating applied by the PEB was appropriate. The Board considered the VA’s coding and rating scheme of the combination code of 7018 (implantable cardiac pacemakers) with code 7011 (sustained ventricular arrhythmias) and also rated it 10%. Rating under code 7011 requires a determination of the CI’s cardiac symptoms along with the workload documented by cardiac stress testing. The CI had an exercise stress test 14 months prior to separation that documented a workload of 10.1 METS without any abnormal cardiac symptoms. That result along with documentation contained in the evidence that pacemaker placement resulted in resolution of her syncopal episodes met the 10% VASRD rating criteria of “workload of greater than 7 METs but not greater than 10 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; continuous medication required.” Under VASRD code 7018, the minimum rating after pacemaker placement under is 10%. All evidence agrees that the CI’s neurocardiogenic syncope resolved after pacemaker placement and there is no appropriate coding/rating scheme that would result in a higher rating. Considering the totality of the evidence and mindful of VASRD §4.3 (reasonable doubt), members agreed that a disability rating of 10% for the neurocardiogenic syncope and POTS condition was appropriately recommended in this case.

Contended Mild MVP Condition. The Board’s main charge is to assess the fairness of the PEB’s determination that the mild MVP condition was not unfitting. The Board’s threshold for countering fitness determinations requires a preponderance of evidence, but remains adherent to the DoDI 6040.44 “fair and equitable” standard. The mild MVP condition was not profiled or implicated in the commander’s statement and was not judged to fail retention standards. All entries were reviewed and considered by the Board. There was no performance based evidence from the record that the mild MVP condition significantly interfered with satisfactory duty performance. 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 for the mild MVP contended condition and so no additional disability rating is recommended.

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 neurocardiogenic syncope and POTS condition and IAW VASRD §4.124a, the Board unanimously recommends no change in the PEB adjudication. In the matter of the contended mild MVP 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, 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 20140318, 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, AR20150013446 (PD201401395)

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:

Encl              XXXXXXXXXXXXXXX
                           Deputy Assistant Secretary of the Army
                           (Review Boards)

CF:
( ) DoD PDBR
( ) DVA

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AF | PDBR | CY2014 | PD-2014-01395

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