RECORD OF PROCEEDINGS


      IN THE CASE OF:


      BOARD DATE:        5 December 2006
      DOCKET NUMBER:  AR20060002041


      I certify that hereinafter is recorded the true and complete record
of the proceedings of the Army Board for Correction of Military Records in
the case of the above-named individual.

|     |Mr. Carl W. S. Chun               |     |Director             |
|     |Ms. Joyce A. Wright               |     |Analyst              |


      The following members, a quorum, were present:

|     |Ms. Linda D. Simmons              |     |Chairperson          |
|     |Mr. Patrick H. McGann, Jr.        |     |Member               |
|     |Mr. Donald W. Steenfott           |     |Member               |

      The Board considered the following evidence:

      Exhibit A - Application for correction of military records.

      Exhibit B - Military Personnel Records (including advisory opinion,
if any).

THE APPLICANT'S REQUEST, STATEMENT, AND EVIDENCE:

1.  The applicant requests, in effect, reversal of his Physical Evaluation
Board (PEB) findings from EPTS (existed prior to service) without
aggravation to aggravated by service.

2.  The applicant states, in effect, that no accounting has been done to
obtain evidence from his primary physician nor has there been an accounting
of what was done in North Carolina by his commander despite knowing about
his heart condition.  There have been three surgeries for his heart and
each surgery has damaged something else.

3.  The applicant provides several copies of his PEBs and a copy of his DD
Form 214 (Certificate of Release or Discharge from Active Duty), in support
of his request.

COUNSEL'S REQUEST, STATEMENT AND EVIDENCE:

1.  The Disabled American Veterans (DAV), as counsel, provided a brief, in
support of the applicant's petition for relief.

2.  Counsel states that after a review of the applicant's application and
all of the evidence assembled for review, they continue to note the
contention of the applicant in his request for a discharge upgrade
reflecting his entitlement to a medical retirement, due to permanent
disability.  Counsel states the record reflects the applicant served in the
US Army for 13 years until he was discharged from active honorable service
due to a heart condition deemed by the PEB as EPTS.  The record reflects
the Medical Evaluation Board (MEB) evaluated the applicant on several
occasions while stationed with the Medical Hold Company at Walter Reed Army
Medical Center (WRAMC).  The applicant's treating cardiologist rendered the
medical opinion for the MEB/PEB that the applicant's current heart
disability was either caused or aggravated by military service.  

3.  Counsel states that it appears the MEB, although concerned about the
heart condition, forwarded the disability for consideration, to the PEB as
unfitting.  The PEB on several occasions rendered multiple decisions
starting with a 30 percent medical retirement, to a 0 percent and then
finally the EPTS finding.  There was no medical basis for any determination
other than a 30 percent medical retirement and placement of the applicant
on the Permanent Disability Retired List (PDRL). 


4.  Counsel states that the Board, upon review, would find no medical basis
for the EPTS determination, only the judgment of the President of the Board
without consideration to medical fact or medical specialist opinion.

5.  Counsel states, in effect, that although they understand that the
Department of Defense (DOD) and the Department of Veterans Affairs (VA) use
the same schedule for rating disabilities, their philosophy and application
are completely different.  Furthermore, they acknowledged the applicant
went through the Army's disability evaluation system never fully accepting
its findings, but with the understanding that the military was addressing
the disability(s) with his best interest in mind, when assigning the
30 percent disability to his condition.  All subsequent decisions had never
been accepted and were without factual basis.

6.  Counsel states he understands the local agencies' zeal to protect the
interest of the government, but believed the statutes were explicit with
regard to this matter, and as such, the board was not free to substitute
its own judgment as to whether or not a particular condition would be
considered, especially, when there was clear and convincing evidence of
record supporting the finding of PDRL.

7.  Counsel states that because of the importance of retirement benefits,
they believe the Board should exercise extreme caution in all aspects of
this review, to ensure that this administrative proceeding avoids arbitrary
action, and also the appearance of arbitrary action as well, and observes
the requirements established by law and implementation by regulation. 

8.  Therefore, counsel asks for the Board's careful and sympathetic
consideration of all evidence of record used in rendering a fair and
impartial decision, awarding at a minimum a 10 percent evaluation for each
of the disabilities, for a combined 50 percent evaluation, based on the
clinical evidence of record and the Schedule for Rating Disabilities, as
contained in Part Four of Title 38, Code of Federal Regulation, requiring
placement of the applicant on the PDRL. 

9.  Counsel provides no additional documentation in support of the
applicant's request.








CONSIDERATION OF EVIDENCE:

1.  The applicant's record contains a copy of his entrance examination, for
commission, dated 13 April 1992, which indicated that he was in good health
and was given a physical profile of 111111 for commission.

2.  The applicant was appointed as a Reserve commissioned officer of the
Puerto Rico Army National Guard (PRARNG), in the rank of first lieutenant
(1LT/O-2), on 28 January 1993, in the Chaplain’s Corp, with prior enlisted
service.

3.  On 21 January 2001, the applicant was administered a periodic physical,
at the age of 53.  He was found qualified for retention with a 112121
physical profile.  His summary of defects and diagnoses indicated that he
had "bilit" hearing loss and back problems.

4.  The applicant was promoted to major (MAJ/O-4), PRARNG, effective
23 January 2003.

5.  On 20 February 2003, orders were published, by the PR State Area
Command, ordering the applicant to active duty (AD) effective 21 February
2003, at Fort Bragg, North Carolina, in support of Operation Noble Eagle,
not to exceed 365 days.

6.  The applicant was ordered to AD on 15 February 2004, for a period of
90 days, with an end date of 14 May 2004.  He was attached to the WRAMC,
Medical Holding Company, for the purpose of an AD medical extension (ADME),
for medical treatment.  On 26 April 2004, his ADME was extended until
11 September 2004.

7.  On 23 July 2004, a cardiologist, WRAMC, prepared a medical summary
pertaining to the applicant.  The cardiologist stated that the applicant
was a 56 year old man who underwent single vessel bypass surgery of the
right coronary artery to treat an aberrant takeoff of his right coronary
artery on 20 April 2004.  This was done to attempt to reduce his risk for
sudden cardiac death and to treat his daily exertional chest tightness.
Objective data before the surgery showed no evidence of ischemia, and thus
he would not expect to see evidence of ischemia after the surgery either,
and had not.  However, he had become deconditioned through the process and
now had a lower exercise capacity than just 6 months ago.  This was to be
expected for the post-cardiac bypass period.


8.  The cardiologist diagnosed the applicant as having:  (a) aberrant right
coronary artery, surgically corrected; (b) status post cardiac bypass
surgery, single vessel, right coronary artery, 20 April 2004; and (c)
hypertension-easily treated with medication.  Other diagnoses were:  (a)
gastroesophageal reflux disease (GERD); (b) history of hepatitis B; and (c)
benign prostatic hypertrophy.

9.  The cardiologist's recommendations/prognosis was that as per Army
Regulation 40-501, given the applicant’s recent cardiac bypass surgery,
which was done for a "major cardiovascular anomaly," he should be referred
for an MEB.  The bypass was potentially curative of his additional risk.
Whether or not his exertional chest tightness resolved was less relevant
than the question of whether he could recover his physical condition to a
point that he could sustain over 6 minutes on a Full Bruce Protocol
Treadmill Test with no object evidence of ischemia.  The applicant was
currently ungergoing a trial of duty with a temporary P3 profile.  The
cardiologist referred him for an exercise rehabilitation program for
patients who had been through cardiac surgery.  In 6-8 weeks they would
repeat the stress test.  If the applicant's exercise tolerance improved and
there was still no evidence of cardiac ischemia, he would not need to be
sent to a PEB and should continue in his position as a chaplain.  In the
meantime, while undergoing the exercise training, he should be given duties
consistent with his training as a chaplain, if possible.

10.  On 26 August 2004, the applicant's ADME was extended until 10 December
2004.  On 19 November 2004, his ADME was extended until 10 March 2005.

11.  On 27 November 2004, the cardiologist, prepared an addendum and update
to the applicant's cardiology medical summary.  The cardiologist diagnosed
the applicant as having:  (a) aneurysmal coronary artery disease; (b)
aberrant take off of the right coronary artery; (c) mild ischemia in the
inferior region despite medical treatment; (d) hypertension; and (e) status
post cardiac bypass surgery, single vessel, 20 April 2004.  The graft was
occluded (seen by cardiac catheterization in October 2004).  Other
diagnoses were:  (a) epigastric hernia at site of bypass surgery scar, s/p
(status post) repair 24 November 2004; (b) GERD; (c) history of hepatitis
B; and (d) benign prostatic hypertrophy.

12.  The cardiologist's prognosis was that the applicant had cardiovascular
disease with Class II NYHA (New York Heart Association) symptoms.  These
were just as likely due to his aneurysmal coronary arteries as to his
aberrant right coronary artery.  The bypass surgery failed to correct this
problem.  In fact, the bypass graft itself failed, probably because the
flow through the native coronary artery was too great.  As per Army
Regulation 40-501, paragraph 3-21(e), due to ongoing Class II symptoms and
objective evidence of ischemia on stress echocardiogram, and paragraph 3-25
regarding a failed recovery period, the patient was referred for an MEB
with a permanent profile.  Paragraph 3-25 requires anyone who has symptoms
of Class II or worse to get a permanent P4 profile.

13.  The cardiologist continued that aneurysmal coronary artery disease
when not accompanied by obstructive coronary artery disease (as is the case
here) has a good prognosis.  The fact that the applicant was able to
complete 9 minutes on a Full Bruce protocol and had only mild inferior
ischemia also had a good prognosis.  However, the applicant also has an
aberrant take-off of his right coronary artery, which might add an
additional measure of risk.  His stress tests showed both continued
symptoms and objective evidence of ischemia.

14.  The cardiologist recommended that the applicant be placed on permanent
P4 profile restricting his exertion levels to a fast walk.  His cardiac and
non-cardiac medical issues taken together would likely prevent him from
being able to hold a full-time position.  The applicant would require
regular cardiology follow-up every 6-12 months and would need to remain on
medications as well as an anti-hypertensive regimen indefinitely.  Good
diet and exercise habits should continually be reinforced.

15.  On 28 February 2005, the Chief, PCCMS (Pulmonary and Critical Care
Medicine Services), WRAMC, prepared an addendum to the narrative summary.
The physician stated that the applicant had obstructive sleep apnea (OSA)
with an apnea hypopnea index-9/hr and treated with continuous positive
airway pressure (CPAP) at 10 cm H2O.  The applicant reported symptomatic
relief with CPAP with improved energy after and improved daytime alertness
with CPAP use.  The applicant was, at the time, being boarded for coronary
artery disease and he asked that his sleep pathology be factored into any
decisions by the MEB.  CPAP therapy is incompatible with worldwide
deployability.  CPAP therapy was not medically acceptable in accordance
with Army Regulation 40-501, chapter 3, paragraph 3-41c.

16.  On 1 March 2005, the applicant's case was considered by a MEB, at
WRAMC.  The MEB diagnosed the applicant as having:  (a) cardiovascular
disease Class II NYHA Functional Classification likely due to aneurysmal
coronary arteries with failed bypass graft surgery (medically
unacceptable);      (b) OSA (medically unacceptable); (c) epigastric hernia
at site of bypass surgery scar s/p repair; (d) GERD; (e) history of
hepatitis B; (f) benign prostatic hypertrophy; (g) left ankle pain and
plantar fasciitis; and (h) left kidney mass,  probable angiomyolipoma.
Diagnoses in item c to h were medically acceptable in accordance with AR 40-
501.  The applicant did not desire to continue on AD.
17.  The findings and recommendations of the board were approved and he was
referred to a PEB for further adjudication.  The applicant disagreed with
the MEB’s finding and recommendations.  He elected to appeal.

18.  On 4 March 2005, the applicant was retained on AD, by Orders A-03-
506635, to voluntarily participate in the RC (Reserve Component) medical
retention processing program for completion of medical care and treatment
with an end date of 28 August 2005.

19.  On 25 March 2005, the applicant submitted his appeal to the DCCS
(Deputy Commander for Clinical Services).  He states that in reference to
this MEB, he was in disagreement with the board’s findings that his OSA was
not permanently aggravated by service.  Prior to active service, he never
had a diagnosis of sleep apnea, nor had anyone known to him recommended any
studies that would provide such a diagnosis.  In reference to the Chief,
PCCMS, opinion that his sleep apnea be factored into any decision leading
to his case being forwarded to a PEB, there was no historical or clinical
documentation that on a factual basis would support a findings of EPTS for
this condition.

20.  He was also in disagreement with the MEB’s failure to fully develop an
accurate picture of his cardiovascular condition.  There was no
documentation included in his MEB from the Chief, of Cardiothoracic
Surgery, who performed his surgery.  He felt that input from the Chief
would be pertinent to his MEB findings.  He had spoken with him recently
and he had indicated to him that he would provide further written
documentation as to the specifics of the failed bypass surgery and
subsequent hernia.

21.  The manner he stated, in which his MEB was prepared failed to take
note of several other medical conditions that might be pertinent to the
MEB’s findings and recommendations.  Such conditions for which he was
currently undergoing therapy or treatment were:  (a) left ankle
instability; (b) plantar fasciitis; and          (c) peroneal tendon injury
subsequent to left venous graft.  The MEB also failed to take into
consideration his kidney condition, which was pending further studies to
include a CT scan scheduled for 16 April 2005.  His urologist had indicated
that he was unsure at this time whether or not he would require kidney
surgery.  Overall, he understood that his MEB was originated due to his
permanent cardiovascular condition, but it failed to provide the PEB with
the best picture of his overall medical condition.  He requested that a new
MEB be done taking into account all of his stated issues.


22.  On 13 April 2005, the applicant underwent a MEB medical examination.
He was diagnosed as having CAD (coronary artery disease) s/p, of plantar
fasciitis, and HTN (high blood pressure), OSA, and angiomyolipoma on serial
CT follow-up.  He was found not qualified for service. 

23.  On 26 April 2005, the applicant was issued a permanent physical
profile of 413311 for cardiac disease, sleep apnea, hearing loss, left
ankle pain, and bilateral foot pain.  His assignment limitations were, "no
exposure to noise levels in excess of 85 DBA (decibel, acoustic) or weapons
firing not to include PQR (sic POR [processing for overseas movement or
replacement]) or IWQ (Individual Weapons Qualification) with proper hearing
protection.  Annual hearing test required.  PT (Physical Training)  may be
limited by chest symptoms.  Low level weight lifting allowed to his own
tolerance.  No lifting more than 40 pounds.  Must have reliable access to
electricity during all sleeping periods.  Must be allowed to wear his left
ankle brace."

24.  On 26 April 2005, the RC Medical Board Advisor prepared a memorandum
for the applicant’s MEB appeal.  The advisor indicated that "sleep apnea
should not be EPTS" – it is listed as "incurred while entitled to base pay"
not EPTS.  The advisor’s opinion – he must have been confused because the
sleep apnea is not listed as EPTS.  The advisor indicated that the
applicant's assertion that, "it [the MEB] did not fully develop an accurate
picture of his cardiovascular condition because there was no documentation
from the cardiologist."  The NARSUM (narrative summary) the RC Medical
Board Advisor pointed out did discuss his bypass graft was occluded, that
he had aneurysmal coronary artery disease, and that he developed an
epigastric hernia that had to be repaired.  The advisor then opined that
the NARSUM from the cardiologist was not essential to the MEB as his CV
conditions were accurately reflected in the Cardiology NARSUM.

25.  On the same day, the RC Medical Board Advisor prepared a memorandum
for the PEBLO/PAD (PEB Liaison Officer/Patient Administration Division).
The advisor stated that what was provided by her was a clarification to the
NARSUM and an addendum the applicant prepared after reviewing the case with
the Orthopedic Surgeon and Cardiologist.

26.  The advisor indicated that left ankle pain and plantar fasciitis were
diagnosed after the NARSUM was completed.  The applicant was given the
diagnoses, with the ankle pain possibly due to a medial malleolus stress
fracture. The Orthopedic Surgeon reported, and this was noted on his 20
April 2005 clinic note, that the applicant’s symptoms were improving with
physical therapy and wearing a brace at night.  The Orthopedic Surgeon also
noted some
mild swelling not uncommon after GSV (greater saphenous vein) harvesting.
Of note, the applicant's claim that his peroneal tendon injury was related
to his vein harvest for his CABG  (coronary artery bypass graft) was
unsubstantiated, per Cardiology.  Treatment was ongoing but the condition
was medically acceptable even at his current state and even if a stress
fracture were discovered.  Limitations were reflected on his DA Form 3349.

27.  On an abnormal renal CT scan, the physician relayed that the applicant
had benign prostatic hyperplasia and a left renal mass most consistent with
an angiomyolipoma as seen on U/S and CT.  The only treatment required for
the angiomyolipoma was repeat CT in 3-6 months.  Both conditions were
medically acceptable.  The advisor stated that those diagnoses listed on
his NARSUM were unchanged but the following conditions were added:  (a)
left ankle pain and plantar faciitis; and (b) left kidney mass, probably
angiomyolipoma, both medically accepted.  The advisor recommended that the
applicant be referred to a PEB for further adjudication.

28.  On 12 May 2005, an MEB summary was prepared, by the Cardiothoracic
Surgery Service, pertaining to the applicant's original operation on
20 April 2004.  The applicant's chief complaint was anomalous coronary
circulation with chronic chest pain syndrome.  The physician indicated that
this summary was a re-dictation of their previous MEB proceedings.  The
physician recommended that the applicant be separated from the service with
full medical benefits to care for the anomalous coronary circulation.  The
applicant had a chronic atypical chest pain syndrome, which precluded him
from performing duties, such as deployment to an overseas area.

29.  On 23 May 2005, the Brigade Commander, PRARNG, prepared a memorandum
for the PEB.  The Brigade Commander, PRARNG, stated that the applicant was
a 57 year old serving in the Mobilization of the HHC (Headquarters and
Headquarters Company), 92nd SIB (Separate Infantry Brigade), a MTOE
(Modified Table of Organization and Equipment) as the Brigade Chaplain.
His current profile was 211111 having an assignment limitation of no sit-
ups for the Physical Fitness test given in June 1999.  However, while
mobilized at Fort Bragg and assigned to support a mission at Guantanamo
Base in 2003, he suffered a cardiac problem.  He underwent heart surgery
and was referred to a MEB to determine fitness for duty.  He was assigned
and was under the medical care of WRAMC Medical Hold.



30.  The commander stated that he was found with limitations to perform
cardiovascular activities and may not be able to perform his duties as
required of an officer in his grade.  The applicant could be exempt
without impacting mission accomplishment.  The bulk of this limitation
impacts the APFT (Army Physical Fitness Test).  The applicant had not
returned to his unit for the last year and was waiting for his MEB.  He
was not pending any adverse action.  His current ETS (expiration of term
of service) was 30 November 2007.  The Commander stated that he had been
his commander starting March 2004.  He was aware of his medical condition
causing prolonged profiles or missed performance of duty.  The Commander
concluded that the applicant’s performance of duty in all his ecclesiastic
areas had been exceptional.

31.  On 14 June 2005, the RC Medical Board Liaison, PEBLO, sent an email to
the Cardiologist informing him that the PEB returned the applicant’s case
for further medical information.  Specifically, they were requesting
additional information pertinent to the question, "Soldier has an anomalous
coronary circulation and an aberrant right coronary artery."  They were
trying to determine if this was an EPTS condition and to provide his
comment by email.

32.  On 15 June 2005, the Cardiologist sent an email to the RC Medical
Board Liaison, PEBLO.  The cardiologist listed the applicant’s diagnoses
and copied the following verbatim findings [paragraph following] from the
most recent medical summary for the applicant on 27 November 2004.

33.  The cardiologist stated that the first, aneurysmal coronary artery
disease, often develops with atherosclerosis and aging of an artery, and
may not have been present prior to service.  The second, an aberrant take
off of the right coronary artery, would be congenital and would have
existed prior to service.  The third, ischemia in the inferior region
despite medial treatment, is a direct result of a combination of the first
two problems.  The fourth, hypertension, develops later in life and is not
likely to have existed when the applicant was younger.  The last diagnosis
is a condition of being status post cardiac bypass surgery, which was done
in an attempt to resolve the symptoms that may be related to the first
three problems listed above.

34.  The cardiologist concluded by stating that, it was difficult to
classify the applicant’s disease as being EPTS or not, because the aberrant
artery existed prior to service, but the aneurysmal disease may not have.
It was most likely that the two in combination have led to the ischemia and
symptoms.


35.  On 22 June 2005, the applicant appeared before a PEB, at WRAMC. The
PEB concluded that the applicant’s medical condition prevented performance
of duty in his grade and specialty.  The membership of the PEB included a
voting member from the RC.  The PEB found the applicant unfit and
recommended a combined rating of 10 percent and that he be separated with
severance pay, if otherwise qualified.  The PEB indicated that his
separation was not based on a disability from injury or disease received in
the LOD as a direct result of armed conflict or caused by an
instrumentality of war and incurring in the LOD during a period of war as
defined by law.  The PEB also indicated that the applicant's disability did
not result from a combat related injury.  The Board adjourned on the same
day.  The applicant nonconcurred with the PEB recommendations and demanded
a formal hearing with counsel.

36.  On 29 June 2005, the applicant submitted his rebuttal.  He stated that
in reference to the PEB finding of 22 June 2005, the PEB did not consider
all appropriate medically ratable entities under Army Regulation 635-40.
Specifically, this case was not ripe for final board review in that the MEB
Summary of 27 November 2004, medically opined that:  "his cardiac and non-
cardiac medical issues taken together would likely prevent him from being
able to hold a full time position."  Medical findings included a hernia of
the chest, wherein the cardiac surgery took place.  Medical findings also
indicated that there was bilateral upper extremity radiating pain, non-
cardiac in origin.  Yet, no EMG (Electromyogram) had been accomplished to
ascertain the chronic residuals of the non-cardiac surgical intervention.

37.  He also stated that the addendum of 12 May 2005, also indicated that
he now had sub-acute thrombosis of the previously placed vein graft, with
excessive competitive flow.  Current diagnoses include the chronic chest
pain syndrome.  This was also not considered in the PEB finding and needed
to be afforded due process.  Chronic symptoms also included shortness of
breath, chest pain, dizziness, fatigue, and fainting.  Exercise stress test
report conducted on 30 June 2005 and reported by the cardiologist further
noted a conclusion of chest pain, dyspnea, and nausea in Stage 1 with METS
(Metabolic Equivalents [multiples of resting oxygen uptake]) of 5-7 at a
maximum.

38.  He stated as such, to indeed afford due process and allow an informed
decision to be rendered, the PEB was without a doubt, mandated to evaluate
all disabilities that precluded a Soldier from being able to perform the
duties of his rank, rating or military occupational skill as defined in
Army Regulation 635-40, in concert with the Department of the Army’s own
cardiologist’s findings of 27 November 2004, and 12 May 2005.  The
cardiologist had requested that he be allowed to attend his formal PEB
hearing and serve as a witness to such.  He further requested that a
representative from the DAV organization be assigned as his counsel for his
hearing.

39.  On 30 June 2005, the cardiologist prepared an MEB addendum.  He
diagnosed the applicant as having:  (a) aberrant right coronary artery;
          (b) atypical angina with objective ischemia on stress testing;
(c) failed coronary artery bypass graft; (d) hyptertension, controlled; (e)
obesity, body mass index=31; (f) GERD; and (g) repaired sternotomy
incisional hernia.  The cardiologist stated that after his reevaluation, he
was in agreement with the previously dictated disposition and
recommendation of both cardiologists.  The applicant did not meet retention
criteria based on Army Regulation 40-501, paragraph 3-21.  The applicant
would have continued symptoms and limitations to his functional activity
and military status.  The cardiologist recommended to the applicant that
they continue his current medical therapy, and they would together explore
treatments that could give him some improvement in his symptoms such as
novel stenting therapy or enhanced external counterpulsation treatment.
The cardiologist hoped that this summary provided clarification to the PEB
as to his current medical status.

40.  On 18 July 2005, the applicant appeared before an informal PEB.  His
findings were already discussed in his previous proceedings.  The PEB
proceeding indicated that since he had a service-connected medical
condition, he should contact a VA counselor to learn about available
benefits such as disability compensation, rehabilitation programs,
insurance, employment assistance, home loans and medical care benefits.
The PEB found the applicant unfit and recommended a combined rating of
30 percent and that he be placed on the Temporary Disability Retired List
(TDRL) with reexamination during December 2006.  The board adjourned the
same day.  The applicant concurred and waived a formal hearing of his case
on 1 August 2005.

41.  On 3 August 2005, the applicant's ADME was extended unit 24 February
2006.

42.  On 24 August 2005, the Chief, Operations Divisions, US Army Physical
Disability Agency (PDA), WRAMC prepared a memorandum for the President,
PEB, Subject:  Return of PEB proceedings [the applicant].  The case was
returned for reconsideration.  The PDA stated that the applicant had been
rated using the VASRD (VA Schedule for Rating Disabilities) Code 7005 for
ischemic heart disease due to aneurysmal coronary artery disease of the
right coronary artery.  The applicant’s history indicated that in 2003, he
presented to WRAMC with a "1.5 year course of almost daily exertional chest
tightness, sometime radiating to the neck or both arms, as well as 2-pillow
orthopnea and waking up feeling short of breathe as often as three times a
week."

43.  The memorandum continued, the following 15 June 2004, email from the
Soldier's cardiologist reads as follows:  "The first [cardiac diagnosis],
aneurismal coronary artery disease, often develops with atherosclerosis and
aging of an artery, and may not have been present prior to service.  The
second, an aberrant takeoff of the right coronary artery, would be
congenital and would have existed prior to service."  "It is difficult to
classify the applicant’s disease as being EPTS or not, because the aberrant
artery existed prior to service, but the aneurismal disease may not have.
It is most likely that the two in combination have lead to the ischemia and
symptoms."

44.  The cardiologist indicated that the applicant had (easily treated)
hypertension: however, the cardiologist did not specifically discuss the
relationship of the hypertension to the applicant’s cardiac status.  Also
noted is the applicant’s history of hyperlipidemia.  The cardiologist did
not specifically discuss the relationship of the applicant’s hyperlipidemia
to his atherosclerosis.  Given that the applicant had symptoms highly
suggestive of coronary artery disease of 1.5 years prior to the cardiology
visit in 2003, the applicant is apparently EPTS for hypertension and
hyperlipidemia, it is unclear how the PEB concluded the applicant’s
disability (i.e., VASRD 7005 coronary artery disease) was not due to
(entirely) EPTS conditions.  They also noted there was no evidence to
suggest that the applicant’s condition was aggravated while on active duty.

45.  They noted that one examiner references "ischemia by more sensitive
imaging test recently performed."  However, these were not included for
their review.  Based on the evidence of record, even if the applicant’s
condition could properly be rated, it appears that the correct rating would
be the 10 percent level. This was based on the following:  The applicant
was able to achieve 7-8 METS [metabolic equivalents] and there were no EKG
changes indicating ischemia.  They further noted the comment suggesting
that the applicant’s symptoms were due to lack of conditioning.

46.  On 8 September 2005, the cardiologist responded.  He stated that he
had reviewed the PDA memorandum dated 24 August 2005 and would respond to
the specific inquiries.  He states that with regard to numbered item 5
[item numbers correspond to paragraph numbers of the USAPDA's Memorandum],
hypertension and hyperlipidemia were known contributors to the development
of atherosclerosis and indeed were likely contributors in this case.  In
addition, atherosclerosis in turn contributed to the development of his
coronary artery aneurysms/ectasias and were a likely contributor, in this
case.

47.  With regard to numbered items 4 and 6 (aneurysmal coronary artery
disease), the time course of his symptoms as related in item number 3 match
his medical record, in particular a SF (Standard Form)-600, dated
28 January 2004, during a visit with the cardiologist.  The difficulty in
this case was determining the exact timing (preexisting or developing
during service) when a disease (namely atherosclerosis) is a progressive
disease.  The coronary artery anomaly clearly was an EPTS condition.  Given
that atherosclerosis and coronary aneurysms were usually progressive
diseases, it could not be established that they did not worsen during his
time in service.  In his opinion as a cardiologist, the applicant’s
symptoms and clinical situation were worse than when he entered service.
His most current stress test supported a decline in his functional status
compared to his initial stress test prior to bypass surgery.  He had been
admitted recently for angina (late August 2005) and he was treating his
symptoms as anginal symptoms.

48.  With regard to number item 7 (ischemia), the "more sensitive imaging
test" referred to were well documented both in his addendum dated 30 June
2005 and the medical summary dated 27 November 2004, by the cardiologist.
Specifically, this test was a stress echocardiogram performed 30 September
2004 after failure of his bypass graft where he developed ischemia in the
inferolateral wall on the stress echocardiography images.  Stress
echocardiography images were more sensitive to the development of ischemia
than routine electrocardiographic stress tests.  Accordingly, the applicant
met the definition of "objective evidence of myocardial ischemia" as
referenced in Army Regulation 40-501, paragraph 3-21, subparagraph a(4).
He stood by the determination of a NYHA Function Classification rating of
II as outlined by the criteria in Table 3-1, in Army Regulation 40-501.  He
disagreed with the applicant’s symptoms being dismissed as a lack of
conditioning.  His disagreement was evidenced by his ongoing  treatment of
angina and by the actions of other physicians in the past, namely referral
to and performance of coronary bypass surgery for these same symptoms.

49.  In summary, he has provided information based on both objective
testing and subjective medical opinion as requested in the applicant’s
case.  He respectfully deferred determination of his military disability
level to the appropriate authority.

50.  On 14 September 2005, the PEBLO returned the applicant’s case, with
the cardiologist's response attached.  The PEBLO informed the President, of
the PEB, she did not have the test results that were referred to by the
cardiologist in his response but that the documents should be in the
applicant’s medical records.

51.  On 22 September 2005, the President, PEB, prepared a memorandum for
the USAPDA, Subject:  Reply to a Request for Reconsideration [the
applicant].  The President, PEB, stated that based upon the USAPDA'S
request, the PEB reviewed his case file.  The review encompassed all
evidence submitted to the PEB for its use in prior deliberations as well as
additional evidence provided at their request.  The reviewing members of
the Board concluded that the evidence provided in this case was sufficient
to uphold their previous finding.  The PEB found that the addendum supplied
by the cardiologist, WRAMC, of 8 September 2005, stated that the applicant
had been admitted recently for angina (25 August 2005) and was treating his
anginal symptoms and was evidenced by the ongoing treatment of angina and
not lack of conditioning.  The PEB believed that this condition was an
independently unfitting condition, and the 30 percent disability rating was
warranted.

52.  On 22 September 2005, an administrative correction to the previously
issued DA Form 199 (PEB Proceeding), dated 18 July 2005, was prepared to
add to the addendum by the cardiologist, dated 8 September 2005, to the
disability description.

53.  On 17 October 2005, a DA Form 18 (Revised PEB Proceedings) was
prepared on the applicant.  The PDA had reviewed the medical evidence of
record and concluded that there was sufficient evidence to substantiate an
EPTS condition for which he was now unfit.  His condition had not been
permanently aggravated by service but was the result of natural
progression.  This natural progression of his EPTS condition was clarified
and concurred in by the cardiologist in an email exchange dated
29 September 2005 and 3 October 2005; revising his 8 September 2005
opinion.  The PDA modified his findings, rating, and disposition.  This
revision superseded his DA Form 199 pertaining to his 22 September 2005
informal PEB.  The PEB found the applicant unfit and recommended a combing
rating of 0 percent and that he be separated from the service without
disability benefits.

54.  On 24 October 2005, the applicant nonconcurred with the findings and
recommendations and demanded a formal hearing with representation by
counsel.


55.  On 17 November 2005, the applicant appeared before a formal PEB with
counsel.  The PEB found the applicant unfit due to an EPTS condition and
recommended separation from the service, without disability benefits.  The
PEB adjourned on the same day.

56.  On 17 November 2005, the applicant was informed by the President,
PEB, to complete an election statement and respond to the findings and
recommendations of the PEB within 10 days.  If he did not agree with the
recommended findings, he could prepare a statement of rebuttal to his
election.  His rebuttal must be based on one or more of the following
issues:  (a) the decision of the PEB was based upon fraud, collusion, or
mistake of law; (b) he did not receive a full and fair hearing; and (c)
substantial new evidence exists and is submitted, which, by due diligence,
could not have been presented before disposition of the case by the PEB.

57.  On 1 December 2005, the applicant submitted his rebuttal.  In his
rebuttal,  he believed that the formal PEB made a legal error in
determining that his condition existed prior to service.  Though he first
entered the military in 1992, his current term of service began in February
2003.  He developed issues with his heart in June 2003.  He would like the
board to consider the following:

      (a)  a great deal of weight was given to the opinion preferred by the
cardiologist particularly in email traffic referenced on the face of this
DA Form 18. Despite repeated requests, these emails were never provided to
him or his counsel to allow them to prepare for his hearing.  His counsel
was handed a copy of the email traffic, perhaps coincidentally, immediately
after a decision was reached in his formal PEB.  The formal PEB, then, did
not have any evidence before it that any of his treating physicians
believed that his condition was not permanently aggravated by service;

      (b)  while the cardiologist's opinion seemed to carry a great deal of
weight with both the PEB and the PDA, very little weight was given to the
medical opinion offered by his surgeon and primary treating physician;

      (c)  the PEB erred in failing to recognize that, even if he had a
preexisting heart condition, that condition was permanently aggravated by
service when his  chain of command at Fort Bragg, knowing he was having
cardiac issues, ordered him to Guantanamo Bay where no follow-up care was
available; and

      (d)  he has had numerous surgeries with virtually no lasting
improvement of his symptoms.  He is left with a hernia and instability in
his legs.  He has chronic angina requiring daily use of nitroglycerin in
both pill and inhaler form.  Not only is he no longer able to perform his
duties as a Catholic priest in the Army, but also he now has grave concerns
about his ability to return to his home parish in a meaningful way.

58.  The applicant concludes, in his rebuttal, that in light of the above,
he requests that the PEB rate his heart condition under VASRD Code "7005"
at 30 percent.  On 5 December 2005, he nonconcurred with the formal PEB’s
findings and recommendations.

59.  On 12 December 2005, the President, PEB, prepared a memorandum for the
applicant, Subject:  Appeal of PEB Formal Proceedings.  In this memorandum,
the President, PEB, informed the applicant that the PEB had received his
letter of rebuttal, dated 1 December 2005, to his formal PEB held on
17 November 2005.  The President stated that in his rebuttal he did not
provide information as to any new diagnosis or changes in his currently
rated disability, which existed prior to service.  The PEB affirmed the
decision of the formal hearing that found him unfit with conditions, which
existed prior to service (EPTS).  Although he presented no new objective
evidence, his case was carefully reviewed.  Based upon that review, the PEB
found no basis for a change in its action in his case and reaffirmed it
previous findings.

60.  The President, PEB, stated that the board appreciated the concerns
that he had expressed in reference to his post-Army future and the problems
he may face with employment and employability.  Although the recommendation
of EPTS was made, he was encouraged to open a file with VA to determine
what benefits could accrue to him from his active service. The President
concluded that the applicant’s entire case file, including his
rebuttal/addendum, had been forwarded to the USAPDA for review and that he
would be notified of any changes.

61.  The applicant was honorably discharged on 28 January 2006, under the
provisions of Army Regulation 635-40, paragraph 4-24b(4), disability, EPTS,
PEB, in the pay grade of O-4. 

62.  The applicant's Summary of Retirement Points shows he had completed
11 years, 11 months, and 3 days of qualifying service for retirement
purposes.  

63.  Army Regulation 635-40 provides the policy and procedure for
evaluation of the physical fitness of Soldiers who may be unfit to perform
their military duties because of physical disabilities.  It states that the
medical treatment facility commander with the primary care responsibility
will evaluate those referred to him and will, if it appears as though the
member is not medically qualified to perform duty or fails to meet
retention criteria, refer the member to a medical evaluation board.  Those
members who do not meet medical retention standards will be referred to a
physical evaluation board for a determination of whether they are able to
perform the duties of their grade and military specialty with the medically
disqualifying condition. 

64.  For example, a noncommissioned officer who receives above average
evaluation reports and passes Army Physical Fitness Tests (which have been
modified to comply with the individual’s physical profile limitations)
after the individual was diagnosed as having the medical disqualification
would probably be found to be fit for duty.  The fact that the individual
has a medically disqualifying condition does not mandate the person’s
separation from the service.  Fitness for duty, within the parameters of
the individual’s grade and military specialty, is the determining factor in
regards to separation.  If the PEB determines that an individual is
physically unfit, it recommends the percentage of disability to be awarded
which, in turn, determines whether an individual will be discharged with
severance pay or retired. 

65.  Paragraph 4-19b states that a PEB may decide that a Soldier’s physical
defect was EPTS, but must then determine whether the condition was
aggravated by military service.  If the PEB determines that a Soldier has
an unfitting EPTS condition which was service aggravated, the PEB must
determine the degree of disability that is in excess of the degree existing
at the time of entrance into the service.  The method of determining the
percentage of disability to be awarded in such cases is outlined in
appendix B, item B-10 of this regulation. 

66.  Paragraph 4-24 of Army Regulation 635-40 pertains to the disposition
of Soldiers by the Army Human Resources Command (AHRC) upon the final
decision of the Physical Disability Agency (PDA).  It states that AHRC will
dispose of the case by publishing orders or issuing proper instructions to
subordinate headquarters, or return any disability evaluation case to the
United States Army Physical Disability Agency (USADPA) for clarification or
reconsiderations when newly discovered evidence becomes available and is
not reflected in the findings and recommendations.  Subparagraph 4-24b(4)
applies to disability, Existed Prior to Service, EPTS, PEB.

67.  Army Regulation 600-8-4, chapter 4, paragraph 4-8(e) states, in
pertinent part, that if an EPTS condition was aggravated by military
service, the finding will be in line of duty.  If an EPTS condition is not
aggravated by military service, the finding will be not in line of duty,
EPTS.  Specific findings of natural progress of the pre-existing injury or
disease based on well established medical principles alone are enough to
overcome the presumption of service aggravation.
68.  Title 38, United States Code, permits the VA to award compensation for
disabilities which were incurred in or aggravated by active service.

DISCUSSION AND CONCLUSIONS:

1.  All of the applicant’s contentions to the ABCMR were considered by his
PEB, his formal PEB, and the PDA.  In the expert opinion of the individuals
providing those reviews, his physically disqualifying condition was EPTS.

2.  It is evident that the PDA properly applied Army Regulation 600-8-4,
chapter 4, paragraph 4-8(e), in determining that the applicant’s physically
unfitting condition was not aggravated by military service.  His
disqualifying condition was the result of the natural progress of the pre-
existing disease based on well established medical principles.

3.  As for the applicant’s contention that his surgeries aggravated his
EPTS condition, the evidence of record shows that while the surgeries
didn’t improve his condition, they did not worsen it either.  As such, the
applicant’s contention is not supported by the evidence of record.

BOARD VOTE:

________  ________  ________  GRANT FULL RELIEF

________  ________  ________  GRANT PARTIAL RELIEF

________  ________  ________  GRANT FORMAL HEARING

__LDS___  __PM___  _DWS __  DENY APPLICATION

BOARD DETERMINATION/RECOMMENDATION:

The evidence presented does not demonstrate the existence of a probable
error or injustice.  Therefore, the Board determined that the overall
merits of this case are insufficient as a basis for correction of the
records of the individual concerned.




                                  _____Linda D. Simmons_____
                                            CHAIRPERSON



                                    INDEX

|CASE ID                 |AR20060002041                           |
|SUFFIX                  |                                        |
|RECON                   |YYYYMMDD                                |
|DATE BOARDED            |20061205                                |
|TYPE OF DISCHARGE       |HD                                      |
|DATE OF DISCHARGE       |220060128                               |
|DISCHARGE AUTHORITY     |AR 635-40, para 4-24b(4)                |
|DISCHARGE REASON        |                                        |
|BOARD DECISION          |DENY                                    |
|REVIEW AUTHORITY        |                                        |
|ISSUES         1.       |                                        |
|2.                      |                                        |
|3.                      |                                        |
|4.                      |                                        |
|5.                      |                                        |
|6.                      |                                        |

-----------------------
[pic]