unclassified 29 november 2010 col presenter/ office symbol / (210) xxx-xxx (dsn 471) /...
TRANSCRIPT
UNCLASSIFIED 29 November 2010COL Presenter/ Office Symbol / (210) XXX-XXX (DSN 471) / [email protected] April 19, 2023April 19, 2023UNCLASSIFIED
Overview of the Integrated Disability Evaluation System Narrative Summary
(IDES NARSUM)
Slide 1
UNCLASSIFIED 29 November 2010COL Presenter/ Office Symbol / (210) XXX-XXX (DSN 471) / [email protected] April 19, 2023April 19, 2023
Agenda
Background
Essential Requirements– Instructions– Purpose– Discussion– Comments– Examples
Way-Ahead
Summary & References
Questions & AnswersSlide 2
UNCLASSIFIED 29 November 2010COL Presenter/ Office Symbol / (210) XXX-XXX (DSN 471) / [email protected] April 19, 2023April 19, 2023UNCLASSIFIED
IDES NARSUM – Background In the Legacy MEB System, the traditional, inpatient H&P-
style NARSUM was the vehicle for presenting the entire case to the PEB so the PEB could make its fitness determination and disability rating.
In IDES, the VA provides the ratings and the PEB accepts the rating %’s for the diagnoses it finds UNFIT.
Army leadership saw the traditional NARSUM format as a major factor in MEB system delays and directed its revision.
In January 2011, the Revised Abbreviated NARSUM was developed to provide the PEB the information it needs to make its findings, focusing on the delta between the traditional NARSUM and the VA’s C&P exam.
Slide 3
UNCLASSIFIED 29 November 2010COL Presenter/ Office Symbol / (210) XXX-XXX (DSN 471) / [email protected] April 19, 2023April 19, 2023UNCLASSIFIED
IDES NARSUM – Background (Cont’d) The Revised Abbreviated NARSUM achieved many of its
goals:– Decreased processing time
– Reduction of unnecessary information
– Improved standardization across the AMEDD Feedback from the field has yielded several improvements,
resulting in the IDES NARSUM– Simplified outline format
– Reduced redundancy
– Better discussion of profile limitations
– Elimination of information previously required to support PEB rating % decisions
Slide 4
UNCLASSIFIED 29 November 2010COL Presenter/ Office Symbol / (210) XXX-XXX (DSN 471) / [email protected] April 19, 2023April 19, 2023UNCLASSIFIED
Section Requirement Purpose
1 Soldier Identification BLUF identification of Soldier and purpose for the MEB
2 Sources and References Lists specific medical evidence used in IDES NARSUM
3 Baseline Documentation Summarizes key military personnel information
4 DA 3947 Block 13a Diagnoses Lists all diagnoses upfront
5 MRDP Statement Explains how Soldier met MRDP
6 DA 3349 Review and Discussion Reviews, discusses, and updates (if necessary) the profile
7Diagnoses NOT Meeting Retention Standards
Discusses disqualifying diagnoses, WRT basis for Dx, onset, Tx course, impact to duty, and prognosis
8 Mental Competency Statement If applicable, standard statement WRT mental competency
9Diagnoses Meeting Retention Standards
Briefly addresses all non-disqualifying Dxs, indicating present status and why not considered disqualifying
10 Quality Assurance CheckAddresses apparent inconsistencies and timeliness of MEB
information
Summary of IDES NARSUM Requirements
Slide 5
UNCLASSIFIED 29 November 2010COL Presenter/ Office Symbol / (210) XXX-XXX (DSN 471) / [email protected] April 19, 2023April 19, 2023UNCLASSIFIED
1. Soldier Identification
Instructions Include Soldier’s name, rank, PMOS, and reason/s for referral into the IDES.
PurposeTo provide a location at the top of the document that quickly identifies the Soldier and the reason for the MEB.
DiscussionFeedback from the MEBs and PEBs indicated that an upfront one-liner identifying whose case this is and what is the nature of the MEB. Previously, the format of this information, if present at all, varied widely.
Comments
There is no other requirement to list the Soldier’s name and other identifying information in the document, except in the footer. In the IDES NARSUM TEMPLATE, the header and footer provide a standardized location for this information to be present on each page, IAW local MTF policy.
Slide 6
UNCLASSIFIED 29 November 2010COL Presenter/ Office Symbol / (210) XXX-XXX (DSN 471) / [email protected] April 19, 2023April 19, 2023UNCLASSIFIED
1. Soldier Identification – Examples
SGT John Smith is a 29 y/o infantryman (11B) referred to the MEB for back pain and PTSD.
SFC Robert Jones is a 20 y/o combat medic (68W) referred to the MEB for lower right leg amputation, mTBI and PTSD.
LTC Michael Ross is a 45 y/o nurse (66H) referred to the MEB for fibromyalgia and PTSD.
PVT Susie Snuffy is an 18 y/o Basic Trainee referred to the MEB for shin splints.
Slide 7
UNCLASSIFIED 29 November 2010COL Presenter/ Office Symbol / (210) XXX-XXX (DSN 471) / [email protected] April 19, 2023April 19, 2023UNCLASSIFIED
2. Sources and References
Instructions
At a minimum, review and reference: (a)relevant AHLTA notes; (b)DA 3349, Physical Profile; (c)DA Form 7652, Commander's Performance and Functional Statement; (d)Soldier’s VA Claim Form 21-0819, Section I, Medical Conditions to be Considered as the Basis of Fitness for Duty Determination; and Section II, Block 8, Additional Conditions; (e)relevant VA worksheet examinations and/or Disability Benefits Questionnaires (DBQ) presented in the VA Compensation & Pension Examination; (f)pertinent hardcopy clinical records; and (g)TSG findings, if Soldier’s case was referred for noncompliance or other reason.
Include and reference all written correspondence and (memorialized) oral communication considered.
Additional potentially useful documents may include the Pre/Post-Deployment Health Assessments, the initial entrance physical, operation reports, theater evacuation documents, previous VA decisions, and LOD paperwork.
Slide 8
UNCLASSIFIED 29 November 2010COL Presenter/ Office Symbol / (210) XXX-XXX (DSN 471) / [email protected] April 19, 2023April 19, 2023UNCLASSIFIED
2. Sources and References (Cont’d)
Purpose To list specific references used in the preparation of the NARSUM.
Discussion
This section provides the MEB and PEB specific references to key pieces of the record of medical evidence upon which it will base its decisions. Dates are important, as are consulting services, but individual doctors, facilities and clinics are not. Accounting for each and every visit the Soldier has ever made to an MTF is unnecessary—only include reference to the key visits that impacted the establishment of the diagnosis, the treatment decision points, and the MRDP. Including the PULHES and most recent profile revision date is important. Both the MEB and the PEB will have access to the entire record, but this brief section allows them to focus in on key requirements of the record that impact their respective decisions.
Comments
By referring to these documents, the MEB provider doesn’t need to cut & paste entire passages or test results into sections of the IDES NARSUM. When necessary, key pieces of information can be extracted and summarized, and the rest of the details can remain in the referred documents. This is especially helpful for lengthy consult reports, such as a BH ADDENDUM, or operative reports, for example.
Slide 9
UNCLASSIFIED 29 November 2010COL Presenter/ Office Symbol / (210) XXX-XXX (DSN 471) / [email protected] April 19, 2023April 19, 2023UNCLASSIFIED
2. Sources and References – Examples
a) AHLTA (PCM, 02FEB2011; ORTHO, 09FEB2011; BH, 03MAR2011; PT, 05MAR2011); b) DA 3349 Physical Profile (PULHES 113113, last revised 04MAR2011); c) Army Entrance Physical, 20JULY2001; d) VA C&P examination(s)e) PDHRA, 05JUN2010; and f) VA Claim Form 21-0819, Section I; and Section II, Block 8, Additional Conditions.
a) AHLTA Notes: Sick Call, dtd. 20090801; Orthopedics Consult, 20090910; Audiology Evaluation, 20091010; Physical Therapy Summary, 20091020; Orthopedics Post-Op Visit, 20100202; Pain Clinic Summary, 20100505; PCM re-eval, 20110309; Behavioral Health MEB Addendum, 20111112
b) DA 3349, Physical Profile, 20110801 (113111) (updated 20111225)c) DA Form 7652, Commander's Performance and Functional Statement, 20110701d) Soldier’s VA Claim Form 21-0819, Section I, Medical Conditions to be Considered as the Basis of Fitness for
Duty Determination; and Section II, Block 8, Additional Conditions, 20110715e) Disability Benefits Questionnaires (DBQ) and C&P Exam, 20110801f) Pertinent hardcopy clinical records: Orthopedic 2nd Opinion, 20091210g) TSG findings: N/Ah) Initial Entry Physical, 20080730i) Misc: Orthopedics OP Report (diagnostic knee arthroscopy), 20100113; PCM Appt (depression), 20090909;
Dental Treatment Record
Slide 10
UNCLASSIFIED 29 November 2010COL Presenter/ Office Symbol / (210) XXX-XXX (DSN 471) / [email protected] April 19, 2023April 19, 2023UNCLASSIFIED
3a. Baseline Documentation – Date of Entry into Service
Instructions Provide the Date of Entry into Service.
Purpose To indicate the Soldier’s Date of entry into Service.
DiscussionAlthough present in the Soldier’s military personnel records that are part of the MEB packet, feedback from the PEB indicated that it is helpful to have this information available in the IDES NARSUM.
Comments None
Slide 11
UNCLASSIFIED 29 November 2010COL Presenter/ Office Symbol / (210) XXX-XXX (DSN 471) / [email protected] April 19, 2023April 19, 2023UNCLASSIFIED
3a. Baseline Documentation – Date of Entry into Service – Examples
3.a. 20010911.
3.a. 05 April 2004.
3.a. DIEMS 19860723.
Slide 12
UNCLASSIFIED 29 November 2010COL Presenter/ Office Symbol / (210) XXX-XXX (DSN 471) / [email protected] April 19, 2023April 19, 2023UNCLASSIFIED
3b. Baseline Documentation – ETS Date
InstructionsProvide the Estimated Termination of Service (ETS) date, if known. If none, indicate, “indefinite.”
Purpose To indicate the Soldier’s Estimated Termination of Service date, if known.
DiscussionAlthough present in the Soldier’s military personnel records that are part of the MEB packet, feedback from the PEB indicated that it is helpful to have this information available in the IDES NARSUM.
Comments None
Slide 13
UNCLASSIFIED 29 November 2010COL Presenter/ Office Symbol / (210) XXX-XXX (DSN 471) / [email protected] April 19, 2023April 19, 2023UNCLASSIFIED
3b. Baseline Documentation – ETS Date – Examples
3.b. 20110911.
3.b. August 2012.
3.b. ETS 19860723.
3.b. Indefinite.
Slide 14
UNCLASSIFIED 29 November 2010COL Presenter/ Office Symbol / (210) XXX-XXX (DSN 471) / [email protected] April 19, 2023April 19, 2023UNCLASSIFIED
3.c. Baseline Documentation – Administrative Actions Ongoing, Pending or Completed
InstructionsList any significant personnel or administrative actions ongoing, pending, or completed (e.g., courts-martial, selective early retirement, bars, retirement or separation dates, etc.).
PurposeTo indicate any significant personnel or administrative actions ongoing, pending, or completed.
Discussion
Again, all of this information should be present in the administrative documents that accompany the MEB packet, but are provided here for the convenience of the MEB and PEB. Disposition options at the PEB level may be impacted by such actions.
Comments Refer all details to supporting documentation in Section 2.
Slide 15
UNCLASSIFIED 29 November 2010COL Presenter/ Office Symbol / (210) XXX-XXX (DSN 471) / [email protected] April 19, 2023April 19, 2023UNCLASSIFIED
3.c. Baseline Documentation – Administrative Actions Ongoing, Pending or Completed – Examples
3.c. None.
3.c. ETS scheduled, April 2012.
3.c. Retirement request submitted, September 2011, pending approval.
3.c. Pending Chapter for misconduct.
3.c. ART 15 (2009).
Slide 16
UNCLASSIFIED 29 November 2010COL Presenter/ Office Symbol / (210) XXX-XXX (DSN 471) / [email protected] April 19, 2023April 19, 2023UNCLASSIFIED
3.c. Baseline Documentation – Line of Duty Information
InstructionsList any significant personnel or administrative actions ongoing, pending, or completed (e.g., courts-martial, selective early retirement, bars, retirement or separation dates, etc.).
Purpose To indicate Line of Duty (LOD) information, if necessary.
Discussion
LOD information is not necessary for the MEB to determine if the primary condition/s fail retention standards, nor for the PEB to determine fitness. If found unfit by the PEB, however, eligibility for benefits depends on duty status, and this is especially important when adjudicating non-duty or non-LOD conditions.
CommentsLOD documentation should be included as attachments to the IDES NARSUM, and referenced to in Section 2.
Slide 17
UNCLASSIFIED 29 November 2010COL Presenter/ Office Symbol / (210) XXX-XXX (DSN 471) / [email protected] April 19, 2023April 19, 2023UNCLASSIFIED
3d. Baseline Documentation – LOD Information – Examples
3.d. Not Applicable.
3.d. LOD for shoulder instability, dtd. 20100430.
3.d. No LOD available for diagnosis of low back pain due to lumbar strain.
3.d. LOD available for disqualifying Dx of PTSD, but no LOD available for non-disqualifying Dx of knee injury.
Slide 18
UNCLASSIFIED 29 November 2010COL Presenter/ Office Symbol / (210) XXX-XXX (DSN 471) / [email protected] April 19, 2023April 19, 2023UNCLASSIFIED
4. DA 3947 Block 13a Diagnoses (Pending Final Signature)
Instructions List all disqualifying and non-disqualifying diagnoses.
Purpose To provide an upfront list of all medical diagnoses relevant to the MEB.
Discussion
Feedback from the PEBs indicated that it is helpful to have a single list of all known medical diagnoses in the IDES NARSUM. Discussion of each of the diagnoses is found elsewhere in the IDES NARSUM, but the individual diagnoses are provided here for the convenience of the MEB and PEB. List all diagnoses using standard medical terminology, and be as specific as possible to best reflect the actual diagnoses. Indicate in parentheses the conclusion of the MEB regarding retention standards, and/or if the diagnosis was identified as a result of the VA Claim. See examples. The final DA 3947, once signed, will reflect the complete list of diagnoses, following appeals.
CommentsIt is important to list the actual diagnoses that will appear on the DA 3947. Do not list symptoms that are not diagnoses, such as “pain.” ICD-10 coding is not necessary to include in the IDES NARSUM, but will be entered on the DA 3947.
Slide 19
UNCLASSIFIED 29 November 2010COL Presenter/ Office Symbol / (210) XXX-XXX (DSN 471) / [email protected] April 19, 2023April 19, 2023UNCLASSIFIED
4. DA 3947 Block 13a Diagnoses – Examples
4. Asthma, moderate-persistent, disqualifying
4. Chronic Right Hip Arthritis, not medically disqualifying
4. Rotator Cuff Tendonitis, Left Shoulder, not medically disqualifying
4. Snoring due to Obstructive Sleep Apnea (VA Dx), not medically disqualifying
4. (a) Degenerative Disc Disease, Lumbar Spine, disqualifying (b) Tinnitus (VA Dx), not medically disqualifying (c) GERD, not medically disqualifying (d) PTSD, not medically disqualifying
Slide 20
UNCLASSIFIED 29 November 2010COL Presenter/ Office Symbol / (210) XXX-XXX (DSN 471) / [email protected] April 19, 2023April 19, 2023UNCLASSIFIED
5. MRDP Statement
Instructions
Indicate which diagnosis(es) cause the Soldier to meet MRDP, and, on what basis: e.g., 12 months have passed; optimal medical benefit has been provided, return to duty (RTD) is unlikely based on the nature of the condition (due to the diagnosis), etc.
PurposeTo explain the basis for the Soldier meeting his or her Medical Retention Determination Point (MRDP).
Discussion
This section is a brief statement that explains how the Soldier has met his or her MRDP due to at least one condition. IAW MEDCOM Policy, conditions that appear stabilized and are unlikely to yield RTD within one year of onset or diagnosis must be referred to the MEB. Other conditions may or may not also be at MRDP, however, referral must continue for the primary condition regardless of whether or not the other conditions have met MRDP individually.
CommentsThis statement is most helpful to the MEB that must ensure that the Soldier has been afforded the maximum opportunity for treatment and RTD of his or her primary condition/s.
Slide 21
UNCLASSIFIED 29 November 2010COL Presenter/ Office Symbol / (210) XXX-XXX (DSN 471) / [email protected] April 19, 2023April 19, 2023UNCLASSIFIED
5. MRDP Statement – Examples
5. Soldier has reached MRDP due to lumbar spine arthritis because he has undergone 12 months of conservative management and his condition has not improved to allow him to return to duty. His back has improved, but he states that when he tries to perform activities that would be required in PMOS, his pain recurs. The neurosurgeon has indicated that surgery is not indicated because it is not likely to improve his condition.
5. Soldier has reached MRDP due to PTSD because she has had this diagnosis for 4 years, and despite ongoing treatment since first diagnosed, including individual and group therapy for the last 4 years and medication for the past 3 years, she has not improved significantly enough to permit return to duty.
5. Soldier has reached MRDP due to his unstable angina because he has failed his cardiac trial of duty because of recurring chest pain and shortness of breath, despite medication, during minimal activities, following his myocardial infarction three months ago in JAN 2011.
5. Soldier has reached MRDP due to recurrent left shoulder dislocation because he has not improved to the point of normal functioning despite multiple reconstructive surgeries and physical therapy over the past 20 months. Although additional surgeries are recommended to improve his pain level and range of motion long-term, his orthopedists do not expect that he will regain enough stability and function to allow full return to duty.
5. SGT Snuffy has met MRDP for his knee pain due to patellar tendonitis, based on his inability to return to full duty as an 11B following 12 months of treatment, profiling and optimal medical benefit.
Slide 22
UNCLASSIFIED 29 November 2010COL Presenter/ Office Symbol / (210) XXX-XXX (DSN 471) / [email protected] April 19, 2023April 19, 2023UNCLASSIFIED
6. DA 3349, Physical Profile: Review (Update) and Discussion
Instructions
Review latest DA 3349, Physical Profile, for accuracy and completeness. Consider each diagnosis individually and in combination with all others. Verify the DA 3349 (a) includes each diagnosis (in lay terminology) causing profile limitations; (b) aligns the PULHES and profiled activities with the listed disqualifying (P3/4) diagnoses and non-disqualifying (P2) diagnoses; and (c) accurately portrays ability or inability to perform each of the ten functional activities. See AR 40-501, Chapter 8-20b (4d) (defining an austere environment as an area that regularly experiences significant environmental hazards with limited access to a reliable source of electricity and where force protection levels mandate prolonged use of body armor and/or chemical protection equipment). Update DA 3349 if it is incomplete or inaccurate. Discuss each diagnosis explaining the medical basis for concluding it precludes the Soldier from performing one or more functional activities checked “no.”
Slide 23
UNCLASSIFIED 29 November 2010COL Presenter/ Office Symbol / (210) XXX-XXX (DSN 471) / [email protected] April 19, 2023April 19, 2023UNCLASSIFIED
6. DA 3349, Physical Profile Discussion (Cont’d)
Purpose To explain the clinical basis for the limitations on the P3/4 profile.
Discussion
Feedback from the PEB indicated that previous NARSUMs lacked sufficient discussion regarding the clinical basis for the limitations on the DA 3349 physical profile. In addition, discussion of the DA 3349 was spread across multiple sections, thus creating redundancy and conflicting information. Section 6 provides a single location to fully explain the DA 3349 so that the PEB understands the impact of the Soldier’s diagnosis on the performance of functional activities. This discussion should also address minor limitations resulting from non-disqualifying conditions, such as P2 diagnoses and temporary conditions that have not yet stabilized. The DA 3349 must also be updated to reflect the most current condition of the Soldier, which may be better known after completion of the MEB evaluation.
Comments
Simply listing the limitations is not sufficient, and is unnecessary since the PEB has the profile as part of the MEB packet. The most important part of this section is to make the connection between the diagnoses and the limitations on the profile, so that the PEB understands the impact the diagnoses have on the Soldier’s functional activities.
Slide 24
UNCLASSIFIED 29 November 2010COL Presenter/ Office Symbol / (210) XXX-XXX (DSN 471) / [email protected] April 19, 2023April 19, 2023UNCLASSIFIED
6. DA 3349, Physical Profile Discussion – Examples
6. DA 3349 indicates “knee pain” which limits safe and effective performance of duty in his MOS, which requires significant running, lifting and other physical activities. His inability to run at own pace or in formation, per Block 8, precludes use of P2, as does his inability to comfortably perform functional activities 5f and 5i, due to aggravation of pain and weakness in his right knee with such activities. While he is able to complete an alternate APFT, his inability to run in formations is incompatible with the physical requirements expected from an 11B. Additionally, the DA 3349 physical profile has been updated to reflect his H2 hearing profile, and the resulting DA 3349 is PULHES (113211), dtd. 20111225.
6. SGT Smith’s back pain renders him unable to safely or comfortably perform the duties of his MOS, which require heavy lifting, frequent running and ruck marching, and other soldier skills required of an 11B, as per DA 3349, Section 5.
6. SGT Smith’s PTSD renders him unable to function satisfactorily in stressful environments, to include field settings and austere deployed areas. This is because his anxiousness interferes with his ability to complete assignments. He has also been advised to not fire or carry his assigned weapon due to his history of suicidal attempts requiring inpatient treatment. There are no other physical limitations on his profile due to his primary psychiatric condition, and no other medical issues requiring limitation, so the PULHES of 111113 is valid and current.
Slide 25
UNCLASSIFIED 29 November 2010COL Presenter/ Office Symbol / (210) XXX-XXX (DSN 471) / [email protected] April 19, 2023April 19, 2023UNCLASSIFIED
7. Diagnosis/es NOT Meeting Medical Retention Standards
Instructions
Complete this section for each diagnosis that is cause for profile limitations (even if temporary); or, when the diagnosis as currently manifesting in this Soldier (a) significantly limits or interferes with performance of duties; (b) would compromise or aggravate the Soldier’s health or well-being if they were to remain in the military. (This may involve dependence on certain medications, appliances, severe dietary restrictions, or frequent special treatments, or include a requirement for frequent clinical monitoring); (c) may compromise the health of well-being of other Soldiers; and/or; (d) may prejudice the best interests of the Government if the Soldier were to remain in the military.
Slide 26
UNCLASSIFIED 29 November 2010COL Presenter/ Office Symbol / (210) XXX-XXX (DSN 471) / [email protected] April 19, 2023April 19, 2023UNCLASSIFIED
7.a. Diagnosis/es NOT Meeting Medical Retention Standards – Medical Basis for Diagnosis
InstructionsIndicate the medical basis for the diagnosis (e.g., X-ray confirmation of osteoarthritis; meeting requisite DSM-IV criteria; endoscopy findings, etc.).
Purpose To explain the medical basis for concluding that a disqualifying diagnosis exists.
Discussion
Though it may seem obvious, the medical basis for concluding that a diagnosis was made is often missing from the NARSUM. This is a common cause for returns, so this section is added to prevent unnecessary returns for additional information. Briefly explaining how the disqualifying diagnoses were made assures the PEB that appropriate evaluation was taken to support the diagnoses that are being adjudicated for fitness.
Comments
Explaining how a diagnosis was made is easy for most conditions. However, for some diagnoses, the Soldier may have presented with symptoms for a long time before a diagnosis could be made. Note that discussion regarding the onset and treatment summary are not needed in this section, as they are presented later on in the IDES NARSUM.
Slide 27
UNCLASSIFIED 29 November 2010COL Presenter/ Office Symbol / (210) XXX-XXX (DSN 471) / [email protected] April 19, 2023April 19, 2023UNCLASSIFIED
7.a. Diagnosis/es NOT Meeting Medical Retention Standards – Medical Basis for Diagnosis – Examples
7.a. The disqualifying diagnosis of asthma was made based on the results of a PFT on 20090425 indicating a 20% improvement in FEV1/FVC after bronchodilator administration.
7.a. The disqualifying diagnosis of degenerative disc disease involving the lumbar spine was based on plain film radiography on 20101220 showing signs of vertebral body degeneration.
7.a. The disqualifying diagnosis of PTSD was made based on the results of a psychiatric consultation on 20111324 concluding that all but two criteria for PTSD were met in this Soldier per DSM-IV standards.
7.a. The disqualifying diagnosis of retropatellar pain syndrome was made based on the clinical findings of tenderness to palpation on exam on 20111119, along with descriptive accounts from the Soldier’s chain of command regarding his inability to ambulate effectively in the course of his duties because of repeated complaints of pain in his knees.
Slide 28
UNCLASSIFIED 29 November 2010COL Presenter/ Office Symbol / (210) XXX-XXX (DSN 471) / [email protected] April 19, 2023April 19, 2023UNCLASSIFIED
7.b. Diagnosis/es NOT Meeting Medical Retention Standards – Onset
Instructions
Indicate Soldier’s duty status at point of injury or diagnosis (e.g., Active Duty; Mobilized Reserve; or Troop Program Unit), and, any relevant surrounding circumstances (e.g., in Iraq, in garrison, during training, combat-related, non-combat-related, insidious onset, etc.). Reference contemporaneous AHLTA notes or other relevant documents relating to onset. Discuss evidence (if any) indicating the condition (even if not diagnosed until the Soldier was in the military) existed prior to military (e.g., initial entrance exam; previous VA records; and/or general medical principles (with citation to the medical literature)). Where there is evidence the condition existed prior to service, indicate any evidence to support military activities permanently worsened the Soldier’s condition.
Slide 29
UNCLASSIFIED 29 November 2010COL Presenter/ Office Symbol / (210) XXX-XXX (DSN 471) / [email protected] April 19, 2023April 19, 2023UNCLASSIFIED
7.b. Diagnosis/es NOT Meeting Medical Retention Standards – Onset (Cont’d)
PurposeTo indicate the date of onset of the disqualifying diagnosis, and address EPTS, if applicable.
Discussion
For injuries, the date of onset is easy to find. Even if symptoms did not develop immediately, or the diagnosis was not established until later on, the date when the injury occurred is relatively easy to determine. For disease processes, the initial date of symptoms attributable to the diagnosis might not be as clear, but the date when it is likely that the diagnosis was present should be indicated. The Soldier’s duty status at the onset of the diagnosis is very important, because if found unfit, benefits may be impacted by the Soldier’s duty status at the point of injury or when the diagnosis of disease was made. In addition, for EPTS diagnoses, indicate the basis for concluding the diagnosis existed prior to service, such as reference to an initial physical exam or waiver, and discuss whether the diagnosis was aggravated by military service or worsened as a result of the natural course of disease.
Comments
Explaining when a diagnosis was made is easy for most conditions. However, for some diagnoses, the Soldier may have presented with symptoms for a long time before a diagnosis could be made. Note that discussion regarding treatment summary is not needed in this section, as it is presented in the next IDES NARSUM section.
Slide 30
UNCLASSIFIED 29 November 2010COL Presenter/ Office Symbol / (210) XXX-XXX (DSN 471) / [email protected] April 19, 2023April 19, 2023UNCLASSIFIED
7.b. Diagnosis/es NOT Meeting Medical Retention Standards – Onset – Examples
7.b. Initial onset of the back injury in March 2009 at Ft. XYZ is consistent with AHLTA records showing a clinic visit for backache on 09MAR2009. Soldier states he was also seen in theater for a flare-up of back pain after fall during an IED explosion he states he was involved in.
7.b. According to the AHLTA record on 14APR2003 and unit LOD documentation from 16APR2003, the Soldier twisted her right ankle getting off the bus upon initial arrival at the MOB site prior to her unit’s deployment, which she did not participate in due to the subsequent 7 years of therapy, rest and rehabilitation in the WTU for her ankle injury.
7.b. SGT Snuffy enlisted into Active Duty in 2008 and completed BCT and AIT without difficulty. While on AD status assigned to his first unit at Ft. Swampy, he reported the acute onset of right knee pain while running with his unit during morning PT on 20090801. There is no evidence that he had any prior knee problems prior to service, per his initial entry physical and review of AHLTA records prior to the point of injury.
7.b. SGT Snuffy enlisted into Active Duty in 2008 and completed BCT and AIT without difficulty. While on AD status assigned to his first unit at Ft. Swampy, he reported the acute onset of right knee pain while running with his unit during morning PT on 20090801. The Soldier’s entrance examination on 28JUN2008 reveals a waiver was requested and approved for a right knee injury sustained in High School gymnastics . Soldier had surgery of his right ACL. Thus, this diagnosis is considered to have EPTS and is aggravated by military service.
7.b. Initial report of PTSD symptoms noted during PDHRA in 2010, reflecting onset of symptoms since returning from deployment.
Slide 31
UNCLASSIFIED 29 November 2010COL Presenter/ Office Symbol / (210) XXX-XXX (DSN 471) / [email protected] April 19, 2023April 19, 2023UNCLASSIFIED
7.c. Diagnosis/es NOT Meeting Medical Retention Standards – Treatment Summary
Instructions
Summarize treatments, consultations, and surgeries, with approximate dates. Indicate to what extent specific treatments have improved, worsened, or have had no impact. Indicate any complications of treatment. When the medical retention standards require a Soldier to have undergone specific treatment; to have be seen by a specialist; etc., prior to the MEB finding the Soldier does not meet retention standards, include details supporting Soldier has, in fact, undergone specific treatment; been seen by the required specialist; etc.
Slide 32
UNCLASSIFIED 29 November 2010COL Presenter/ Office Symbol / (210) XXX-XXX (DSN 471) / [email protected] April 19, 2023April 19, 2023UNCLASSIFIED
7.c. Diagnosis/es NOT Meeting Medical Retention Standards – Treatment Summary (Cont’d)
Purpose To summarize the treatment course relevant to the disqualifying diagnosis.
Discussion
It is important to document in the IDES NARSUM the evidence from the record that demonstrates that the appropriate work-up has been completed, and that the required tests, consultations and/or medical opinions have been considered. Per AR 40-501, certain types of treatment are necessary to have been tried in order to determine that a condition fails retention standards if the treatment isn’t effective. For example, a Soldier with asthma is required to be evaluated by a Pulmonologist or Allergist. A Soldier with a cardiac condition should have had a cardiac trial of duty. These consultations and treatments should be well-documented in the AHLTA record. Indicate those key pieces of evidence that describe the treatment course and refer to those documents in Section 2.
Comments
This section should simply be a list of relevant milestones in the Soldier’s course of treatment, from onset to MRDP. Note that Section 7.a., above, is there to summarize how the diagnosis was established. So, while this section is the closest thing to a traditional “HPI,” you only need to list or briefly summarize the key dates, treatments, and consults along the way.
Slide 33
UNCLASSIFIED 29 November 2010COL Presenter/ Office Symbol / (210) XXX-XXX (DSN 471) / [email protected] April 19, 2023April 19, 2023UNCLASSIFIED
7.c. Diagnosis/es NOT Meeting Medical Retention Standards – Treatment Summary – Examples
7.c. SGT Snuffy went to Sick Call immediately following the injury in 08/2009. Evaluation revealed a strain of the infrapatellar tendon, and this was re-confirmed during subsequent clinic visits, which also included normal X-rays (20090803) and MRI (20110912). Conservative treatment, to include rest, ice, NSAIDs, and stretching were recommended. Orthopedics was consulted in 09/2009, and Physical Therapy was recommended. Three months’ of PT did not improve his pain, so Orthopedics was re-consulted, and a diagnostic arthroscopy was recommended. Surgery on 20100113 was uncomplicated and revealed no further diagnosis. Continued conservative management was offered, as was Pain Clinic management in 05/2010, which continued for six months. While his resting pain and leg strength have improved with medication and PT, he remains unable to comfortably perform more strenuous activities, such as running, rucking, and bearing heavy loads.
7.c. See also VA C&P examination dated 10MAR2009. Per AHLTA records, Initial ER evaluation of ankle fracture following parachute injury at Ft. Bragg on 10JAN2008, Orthopedic Consultations through 28MAY2008, Surgery #1 in June 2008, Surgery #2 on 02SEP2008, Pain Management Clinic evaluations in December 2008, and final Physical Therapy assessment on 19FEB2009.
Slide 34
UNCLASSIFIED 29 November 2010COL Presenter/ Office Symbol / (210) XXX-XXX (DSN 471) / [email protected] April 19, 2023April 19, 2023UNCLASSIFIED
7.c. Diagnosis/es NOT Meeting Medical Retention Standards – Treatment Summary – Examples (Cont’d)
7.c. Per AHLTA records, Initial ER evaluation for shortness of breath at Ft. Sill on 10JAN2008, Initial PFTs done on 28MAY2008, Pulmonary Clinic consultations from May – December 2008, Allergy Consult on 02SEP2008, and most recent PFTs completed on 19FEB2009. Improvement of symptoms is documented with inhaled bronchodilator therapy and intermittent use of inhaled corticosteroids. SGT Black’s asthma has not improved sufficiently over time to allow RTD, despite optimal medical treatment. He continues to smoke cigarettes, up to 1 pack per day. It is likely that smoking cession, if successful, would have improved his functional capacity to the point of being able to meet retention standards. See also VA C&P Examination, dated 10MAR2009.
Slide 35
UNCLASSIFIED 29 November 2010COL Presenter/ Office Symbol / (210) XXX-XXX (DSN 471) / [email protected] April 19, 2023April 19, 2023UNCLASSIFIED
7.d. Diagnosis/es NOT Meeting Medical Retention Standards – Noncompliance Statement
Instructions
If the MEB indicates the Soldier has been “noncompliant” with treatment or recommendations, the MEB must refer the Soldier’s case to TSG for review. The TSG findings are to be included within the MEB. If TSG finds the Soldier’s refusal of treatment for this diagnosis is unreasonable, the MEB should discuss the anticipated impact of treatment on the Soldier’s symptoms and physical manifestations, and whether, with treatment, the Soldier’s condition due to this diagnosis would meet medical retention standards. See AR 600-20 Army Command Policy 5-4 Command Aspects of Medical Care.
Slide 36
UNCLASSIFIED 29 November 2010COL Presenter/ Office Symbol / (210) XXX-XXX (DSN 471) / [email protected] April 19, 2023April 19, 2023UNCLASSIFIED
7.d. Diagnosis/es NOT Meeting Medical Retention Standards – Noncompliance Statement (Cont’d)
PurposeTo summarize the opinion from OTSG regarding non-compliance issues, if needed.
Discussion
Where the Surgeon General (TSG) finds the Soldier’s refusal of treatment for this diagnosis is unreasonable, the MEB should discuss 1) the anticipated impact of treatment on the Soldier’s symptoms and physical manifestations; and 2) whether, with treatment, the Soldier’s condition due to this diagnosis would meet medical retention standards. See AR 600-20 Army Command Policy 5-4 Command Aspects of Medical Care. This is one area where the PEB may award a lesser rating than the VA’s, because the condition could have been made less severe had medical treatment been accepted. Include reference to the OTSG Memo in Section 2.
Comments
This does NOT refer to medical non-compliance, such as an asthmatic who won’t quit smoking, or a diabetic that won’t lose weight, or a back pain case who won’t stop powerlifting, for example. This non-compliance, if felt to be relevant, can be discussed in the Section 7.d, above, “Treatment Summary.”
Slide 37
UNCLASSIFIED 29 November 2010COL Presenter/ Office Symbol / (210) XXX-XXX (DSN 471) / [email protected] April 19, 2023April 19, 2023UNCLASSIFIED
7.d. Diagnosis/es NOT Meeting Medical Retention Standards – Noncompliance Statement – Examples
7.d. N/A.
7.d. SGT Smith’s rotator cuff injury was evaluated by three orthopedic surgeons who all agreed, on independent evaluation of his case, that surgical repair using arthroscopy would have a high success rate, and that he would be expected to be RTD following his rehabilitation of 2-4 months. Both his level of pain and range of motion would be expected to improve after surgery, and his orthopedists consider his recommended surgery to be a low risk for medical complications. SGT Smith has refused operative treatment. OTSG has determined that Soldier’s refusal of surgery is reasonable. Thus, he must continue on a P3 profile and meets MRDP for the purposes of MEB processing.
Slide 38
UNCLASSIFIED 29 November 2010COL Presenter/ Office Symbol / (210) XXX-XXX (DSN 471) / [email protected] April 19, 2023April 19, 2023UNCLASSIFIED
7.e. Diagnosis/es NOT Meeting Medical Retention Standards – Prognosis Statement
Instructions
Explain how Soldier’s condition (due to the diagnosis) is likely to change over the next five years in terms of symptom manifestations, required treatment, future surgeries, etc. Indicate whether condition is likely to improve enough to permit Soldier to RTD (for the specific diagnosis). Indicate when it is not possible to provide this information without resort to mere speculation.
Slide 39
UNCLASSIFIED 29 November 2010COL Presenter/ Office Symbol / (210) XXX-XXX (DSN 471) / [email protected] April 19, 2023April 19, 2023UNCLASSIFIED
7.e. Diagnosis/es NOT Meeting Medical Retention Standards – Prognosis Statement (Cont’d)
Purpose To provide an opinion regarding prognosis.
Discussion
If it finds a Soldier unfit for a given condition, the PEB must decide if the Soldier should be permanently separated or retired, or if he should be placed onto the Temporary Retired Disabled List (TDRL). Soldiers placed on the TDRL are re-evaluated and considered for fitness at 18 months, up to 5 years. If an unfitting condition has the potential to improve to the point where it is possible that the Soldier could RTD, then the PEB needs to know that when deciding the initial disposition. Similarly, if eventual RTD or any clinical improvement is unlikely, this also needs to be explained to the PEB in the IDES NARSUM.
Comments
Prior to IDES, the prognosis statement was essential to determine disability rating at the PEB, because, unlike the VA ratings which can change over time, the Army rating is permanent. Thus, knowing if the diagnosis was likely to worsen or improve over time could help the PEB make its rating and disposition determination. In IDES, the rating aspect is not an issue, but the disposition aspect still is, which is why a general statement regarding the 5-year prognosis is still considered helpful.
Slide 40
UNCLASSIFIED 29 November 2010COL Presenter/ Office Symbol / (210) XXX-XXX (DSN 471) / [email protected] April 19, 2023April 19, 2023UNCLASSIFIED
7.e. Diagnosis/es NOT Meeting Medical Retention Standards – Prognosis Statement – Examples
7.e. Continued conservative management without subjecting the Soldier to arduous physical training is likely to alleviate his knee pain symptoms over time. Whether his condition is likely to improve enough to permit his eventual RTD in the next 5 years is not possible to provide without resort to mere speculation.
7.e. Low back pain due to lumbar area degenerative disk disease. This Soldier is not currently a candidate for surgery. With return to civilian life away from the rigors of the military, the Soldier back pain is likely to improve. The Soldier’s range of motion might improve as the pain improves. However, I would need to resort to mere speculation to say to what extent. It is unlikely that back condition will resolve to the point where he could safely return to the military.
7.e. PTSD symptoms (such as inability to form effective work relationships) are likely to continue to improve once Soldier is separated from the military environment. Soldier’s level of functioning appears to have improved since originally diagnosed and since starting on treatment. PTSD symptoms may resolve over the next five years such that the condition should have little impact on his career. My opinion is based on his response to treatment (medications and counseling); and the Soldier’s eagerness to return to his supportive family and his prior place of employment. (He was able to get a desk job at the local Sherriff’s office).
Slide 41
UNCLASSIFIED 29 November 2010COL Presenter/ Office Symbol / (210) XXX-XXX (DSN 471) / [email protected] April 19, 2023April 19, 2023UNCLASSIFIED
7.f. Diagnosis/es NOT Meeting Medical Retention Standards – Impact on Duty Performance
Instructions
Independent of profile limitations (discussed in 5, above), describe impact of diagnosis (and manifestations) on PMOS or AOC duty performance. Specific symptoms; physical findings; or comments by Unit leadership (through the DA Form 7652, Commander's Performance and Functional Statement) may provide information indicating whether the condition (due to the diagnosis) interferes with safe, reliable and/or effective duty. If the Soldier is not working in their PMOS, discuss whether Soldier is performing in civilian job closely related to their PMOS or AOC.
Slide 42
UNCLASSIFIED 29 November 2010COL Presenter/ Office Symbol / (210) XXX-XXX (DSN 471) / [email protected] April 19, 2023April 19, 2023UNCLASSIFIED
7.f. Diagnosis/es NOT Meeting Medical Retention Standards – Impact on Duty Performance (Cont’d)
Purpose To list each disqualifying diagnosis and its application to AR 40-501, Chapter 3.
Discussion
This section lists each diagnosis and discusses how the criteria in the applicable AR 40-501, Ch. 3 paragraph apply, if there is a corresponding Chapter 3 sub-paragraph for that diagnosis. For diagnoses that mail retention standards but do not have a specific corresponding Chapter 3 sub-paragraph, the MEB examiner must explain why retention standards are not met using the Ch.3-1 criteria: Does the diagnosis (1) significantly limit or interfere with Soldier’s performance of duty; (2) compromise or aggravate Soldier’s health or well-being if they were to remain in the military; (3) compromise the health of well-being of other Soldiers; and/or (4) prejudice the best interests of the Government if the Soldier were to remain in the military? If Ch. 3-41e(1) is cited, ensure that credible evidence is provided that demonstrates an inability to safely or effectively perform duties. Specific examples provide more accurate understanding of the impact to this Soldier, his or her unit and the interests of the military, if the Soldier were to remain in the military.
Comments
Using as much of the language in the corresponding Chapter 3 sub-paragraphs as possible is helpful to demonstrate that the appropriate criteria in AR 40-501 have been considered. For “miscellaneous” diagnoses, use 3-41e(1), but be sure to fully explain the rationale for concluding that retention standards are not met.
Slide 43
UNCLASSIFIED 29 November 2010COL Presenter/ Office Symbol / (210) XXX-XXX (DSN 471) / [email protected] April 19, 2023April 19, 2023UNCLASSIFIED
7.f. Diagnosis/es NOT Meeting Medical Retention Standards – Impact on Duty Performance – Examples
7.f. Per his DA 7652, SGT Snuffy’s commander states that he is unable to effectively participate in arduous physical training, such as going to the range and conducting patrols, while wearing equipment required in his MOS. In addition, lost duty time due to frequent sick call visits and therapy appointments has caused SGT Snuffy to fall behind his peers in necessary MOS training. As a result, he has been reassigned to less physical duties outside his MOS. While SGT Snuffy has been able to perform very well as a supply clerk, his commander feels that his physical limitations prevent him from achieving any success as an 11B in the future.
7.f. MAJ (Dr.) Getwell’s chain of command indicates that she has been unable to see patients as a credentialed medical provider since her head injury. Per her DA 7652, she is unable to work greater than 4 hours per day, and she cannot participate in her department’s rotational call schedule. Her ongoing medical appointments, as well as incapacitating headaches at least 4-6 times per month requiring bed rest, preclude her from attending clinic on a regular basis, and as a result, she is no longer being required to manage a panel of patients in her clinic. MAJ Getwell has undergone a 12-month rehabilitation to try and transition her back to normal clinical practice; however, despite some improvements, she is unable to meet even the minimum of demands of a physician in the military.
Slide 44
UNCLASSIFIED 29 November 2010COL Presenter/ Office Symbol / (210) XXX-XXX (DSN 471) / [email protected] April 19, 2023April 19, 2023UNCLASSIFIED
7.g. Diagnosis/es NOT Meeting Medical Retention Standards – Selection of AR 40-501, Ch. 3, provisions
Instructions
For each diagnosis list specific applicable AR 40-501, Ch. 3 provision. Summarize reason/s supporting selected provision. When referencing 3-41e, identify the specific subparagraph(s) that apply. Explain/discuss whether, as presenting in this Soldier, the condition (diagnosis): (1) significantly limits or interferes with Soldier’s performance of their duties; (2) would compromise or aggravate Soldier’s health or well-being if they were to remain in the military. (This may involve dependence on certain medications, appliances, severe dietary restrictions, or frequent special treatments, or include a requirement for frequent clinical monitoring); (3) may compromise the health of well-being of other Soldiers; and/or; (4) may prejudice the best interests of the Government if the Soldier were to remain in the military.
Slide 45
UNCLASSIFIED 29 November 2010COL Presenter/ Office Symbol / (210) XXX-XXX (DSN 471) / [email protected] April 19, 2023April 19, 2023UNCLASSIFIED
7.g. Diagnosis/es NOT Meeting Medical Retention Standards – Selection of AR 40-501, Ch. 3, provisions (Cont’d)
Purpose To list each disqualifying diagnosis and its application to AR 40-501, Chapter 3.
Discussion
This section lists each diagnosis and discusses how the criteria in the applicable AR 40-501, Ch. 3 paragraph apply, if there is a corresponding Chapter 3 sub-paragraph for that diagnosis. For diagnoses that mail retention standards but do not have a specific corresponding Chapter 3 sub-paragraph, the MEB examiner must explain why retention standards are not met using the Ch.3-1 criteria: Does the diagnosis (1) significantly limit or interfere with Soldier’s performance of duty; (2) compromise or aggravate Soldier’s health or well-being if they were to remain in the military; (3) compromise the health of well-being of other Soldiers; and/or (4) prejudice the best interests of the Government if the Soldier were to remain in the military? If Ch. 3-41e(1) is cited, ensure that credible evidence is provided that demonstrates an inability to safely or effectively perform duties. Specific examples provide more accurate understanding of the impact to this Soldier, his or her unit and the interests of the military, if the Soldier were to remain in the military.
Comments
Using as much of the language in the corresponding Chapter 3 sub-paragraphs as possible is helpful to demonstrate that the appropriate criteria in AR 40-501 have been considered. For “miscellaneous” diagnoses, use 3-41e(1), but be sure to fully explain the rationale for concluding that retention standards are not met.
Slide 46
UNCLASSIFIED 29 November 2010COL Presenter/ Office Symbol / (210) XXX-XXX (DSN 471) / [email protected] April 19, 2023April 19, 2023UNCLASSIFIED
7.g. Diagnosis/es NOT Meeting Medical Retention Standards – Selection of AR 40-501, Ch. 3, provisions – Examples
7.g. Right knee pain due to chronic patellar tendonitis, disqualifying per AR 40-501, Ch. 3-14n. His inability to comfortably and effectively perform certain physical requirements of his MOS duties is unlikely to improve with continued military service.
7.g. Major depression, disqualifying per AR 40-501, Ch. 3-32. His inability to comfortably and effectively perform his MOS duties due to persistence of significant symptoms requiring frequent hospitalizations is unlikely to improve with continued military service.
7.g. Epilepsy, disqualifying per AR 40-501, Ch. 3-30i(4). His inability to control breakthrough seizures despite medication use for > 6 months is cause for MEB referral.
7.g. Asthma, disqualifying per AR 40-501, Ch. 3-27a(1). His inability to comfortably and effectively perform certain physical requirements of his MOS duties, including passing the 2-mile aerobic event of the APFT, due to continued wheezing, despite medication management, is unlikely to improve with continued military service.
Slide 47
UNCLASSIFIED 29 November 2010COL Presenter/ Office Symbol / (210) XXX-XXX (DSN 471) / [email protected] April 19, 2023April 19, 2023UNCLASSIFIED
8. Mental Competency Statement, when applicable
Instructions
Whether or not any behavioral health diagnosis is disqualifying, provide a mental competency statement. Indicate whether the Soldier is (a) mentally competent for pay purposes, (b) capable of understanding the nature of, and cooperating in, PEB proceedings, and/or (c) dangerous to themselves or others.
Purpose To verify mental competency when a behavioral health diagnosis is present.
Discussion
For each Soldier with a mental disorder (of any etiology, and whether or not the diagnosis is disqualifying) indicate whether the Soldier is (1) Mentally competent for pay purposes, (2) Capable of understanding the nature of, and cooperating in, PEB proceedings, and/or (3) Dangerous to themselves or others. The psychiatrist or other BH provider reviewing or contributing to this MEB will usually provide this statement in his or her most recent clinical note. This statement is a legal requirement for the PEB, and the specific criteria upon which these statements are based is within the purview of the psychiatrist and Soldier’s Counsel.
CommentsSome diagnoses are considered to be BH-related and require a Mental Competency Statement, such as Sleep Apnea, Headaches, and Erectile Dysfunction. When in doubt, provide this statement.
Slide 48
UNCLASSIFIED 29 November 2010COL Presenter/ Office Symbol / (210) XXX-XXX (DSN 471) / [email protected] April 19, 2023April 19, 2023UNCLASSIFIED
8. Mental Competency Statement – Examples
8. N/A.
8. Per the attached Behavioral Health MEB Addendum, requested due to his history of depression, the Soldier is deemed mentally competent for pay purposes, is capable of understanding the nature of, and cooperating in, PEB proceedings, and is not considered dangerous to himself or others.
8. Regarding SGT Smith’s mTBI, per the clinical psychiatrist’s note on 11APR2011, SGT Smith is considered mentally competent for pay purposes, and is not dangerous to himself or others. Based on his neuropsychiatric testing results, however, he is not considered to be capable of understanding the nature of, and cooperating in, PEB proceedings, due to his severe memory deficits since the injury.
Slide 49
UNCLASSIFIED 29 November 2010COL Presenter/ Office Symbol / (210) XXX-XXX (DSN 471) / [email protected] April 19, 2023April 19, 2023UNCLASSIFIED
9. Diagnosis/es Meeting Medical Retention Standards
Instructions
For each diagnosis that meets retention standards, discuss in enough detail to demonstrate the MEB has considered whether the diagnosis (individually and in combination with the Soldier’s other diagnoses) is cause for referral to the MEB. See Section 6.a., above. If it cannot be determined whether the condition meets retention standards because the Soldier has not been fully treated (vs. evaluated), describe the condition in this section if it is cause for significant profile limitations (e.g., inability to perform one or more functional activities, etc.); or, would not meet retention standards if the condition remained as it is today even after treatment.
Slide 50
UNCLASSIFIED 29 November 2010COL Presenter/ Office Symbol / (210) XXX-XXX (DSN 471) / [email protected] April 19, 2023April 19, 2023UNCLASSIFIED
9. Diagnosis/es Meeting Medical Retention Standards (Cont’d)
Purpose To address all other medical diagnoses that do not fail retention standards.
Discussion
The PEB requires that all conditions be addressed, including those that do NOT fail retention criteria in AR 40-501, Chapter 3. In the past, simply listing the conditions as not-disqualifying was acceptable, but this is no longer the case. For EACH condition not failing retention standards per AR 40-501, provides specific reason(s) why condition is not cause for referral. Consider AR 40-501, Ch 3-41.e(1) (providing conditions are cause for referral when they individually or in combination result in interference with satisfactory performance of duty; or, prevent performing functional activities listed under item 5 on DA Form 3349 (Physical Profile)). The MEB examiner needs to be able to briefly, and authoritatively state the reason/s why a condition does not fail retention standards, using evidence in the VA C&P examinations, language in AR 40-501, the AHLTA record, previous profiles, Commanders’ Statements, and any other evidence that supports this position. Every claimed condition must have a corresponding statement in this section, although combining diagnoses with a common explanation is acceptable.
Comments
It is insufficient to state that a diagnosis does not fail retention standards simply because it has not met MRDP. It does not explain why. Reasons such as (1) has never been seen for symptoms relating to that diagnosis; (2) has never been on significant profile for that diagnosis; (3) has no evidence of duty limitation from that diagnosis; etc., provide better evidence supporting that the diagnosis, even if present, has not materially impacted the safe or effective performance of duty while in service.
Slide 51
UNCLASSIFIED 29 November 2010COL Presenter/ Office Symbol / (210) XXX-XXX (DSN 471) / [email protected] April 19, 2023April 19, 2023UNCLASSIFIED
9. Diagnosis/es Meeting Medical Retention Standards – Examples
9. Sensorineural Hearing Loss, not disqualifying, per AR 40-501, Chapter 3-10. Audiology evaluation reveals decline in hearing following duty as a range safety NCOIC in 2009. H2 profile accurately reflects his current limitations which do not impact duty performance.
9. Depression, not disqualifying, per AR 40-501, Chapter 3-32. Brief episode of situational depression in 2009 following his ART 15 was treated and has resolved, as documented in his BH MEB Addendum.
9. Lumbar strain (VA Dx), not disqualifying, per AR 40-501, Chapter 3-39. Records indicate evidence that he sought care for low back pain several times over the years, and he has received treatment for it. However, there is no evidence that this has materially impacted his ability to perform his duty over time.
9. PTSD (VA Dx), Sleep Apnea (VA Dx), Erectile Dysfunction (VA Dx), Tinnitus (VA Dx), TMJ Syndrome (VA Dx) – all not disqualifying, per AR 40-501, Chapter 3. Records do not reveal any evidence that these diagnoses have ever been made prior to the MEB process, nor has the Soldier ever sought evaluation or treatment while in the service. After discussion with the Soldier, and in consideration of all available records, there is no evidence supporting that these conditions, individually or in combination, impact the his ability to perform DA 3349 functional activities, significantly limit or interfere with his performance of duties, would compromise or aggravate his health or well-being if he was to remain in the military, may compromise the health or well-being of other Soldiers, or may prejudice the best interests of the Government if he were to remain in the military.
Slide 52
UNCLASSIFIED 29 November 2010COL Presenter/ Office Symbol / (210) XXX-XXX (DSN 471) / [email protected] April 19, 2023April 19, 2023UNCLASSIFIED
9. Diagnosis/es Meeting Medical Retention Standards – Examples (Cont’d)
9. Pes Planus. Not disqualifying. With reference to AR 40-501, Chapters 3-13b(2), there is no evidence to support that the condition has materially impacted the performance of his duty. There is documentation in the health record that supports the diagnosis of mild-to-moderate flat feet, and the soldier has been treated with orthotics. However, there is no evidence that the condition causes pronation on weight-bearing, prevents the wearing of military footwear, or is associated with vascular changes.
9. GERD (per VA C&P Claim Form). Not disqualifying. With reference to AR 40-501, Chapters 3-5e, 3-5l, and 3-29e(2), there is no evidence to support this condition materially impacts the performance of duty. Health records indicate no endoscopic evidence of gastritis, ulceration or other complications, and treatment with medication has provided satisfactory symptom relief over time.
9. Degenerative Disc Disease, Lumbar Spine. Not disqualifying. With reference to AR 40-501, Chapters 3-39h, there is radiographic evidence supporting the condition exists, and it has been significant enough at times to warrant treatment for pain and limited duty. An L2 permanent profile, dated 28JAN2009, has been provided to reflect the limitations caused by this condition, and the Soldier has been able to pass an alternate APFT. The condition, however, has not been so severe to cause an inability to perform common Soldier skills as reflected in Block 5 of the DA 3349 Physical Profile, nor has there been a significant impact to the overall duty performance.
9. Scars (VA Dx), not disqualifying, per AR 40-501, Chapter 3-38y. Minor scars from his right knee arthroscopy are not extensive or adherent, nor is there evidence that they interfere with the function of his leg.
Slide 53
UNCLASSIFIED 29 November 2010COL Presenter/ Office Symbol / (210) XXX-XXX (DSN 471) / [email protected] April 19, 2023April 19, 2023UNCLASSIFIED
9. Diagnosis/es Meeting Medical Retention Standards – Examples (Cont’d)
9. Fracture, Distal Radius. Not disqualifying. SM is currently being treated for a right wrist fracture that occurred about two weeks ago while playing ice hockey on 20111210, approximately 4 months after his MEB for intractable low back pain was begun. Records indicate that healing is proceeding uneventfully, and full, unlimited function is expected once his cast is removed and physical therapy is completed over the next 3-6 months.
9. Fracture, Pelvis. Unable to determine if disqualifying. SM is currently being treated for a pelvis fracture that occurred about two weeks ago as a result of MVA on 20111210, approximately 4 months after his MEB for shoulder pain was begun. Records indicate that a determination of long-term functional limitations may not be possible for at least 6 months, and further surgery may be required. During this treatment phase, however, the SM is unable to participate in any physical activities due to required rest, and side effects from narcotic pain medication impairs his ability to operate heavy equipment and drive a vehicle. Thus, he has a temporary profile with PULHES 113111, in addition to his P3 profile for his primary disqualifying medical diagnosis.
Slide 54
UNCLASSIFIED 29 November 2010COL Presenter/ Office Symbol / (210) XXX-XXX (DSN 471) / [email protected] April 19, 2023April 19, 2023UNCLASSIFIED
10.a. Quality Assurance Check – Apparent Inconsistencies
Instructions
Identify important inconsistencies relating to onset, diagnosis, severity, impact on duty, etc. When relevant to MEB findings, address each diagnostic variance, and where possible, reconcile the inconsistency using evidence available in the record. Note: other sources of inconsistency may arise from information within military treatment records and the Commander's Statement.
Slide 55
UNCLASSIFIED 29 November 2010COL Presenter/ Office Symbol / (210) XXX-XXX (DSN 471) / [email protected] April 19, 2023April 19, 2023UNCLASSIFIED
10.a. QA Check – Apparent Inconsistencies (Cont’d)
Purpose To address apparent inconsistencies that have potential impact to the MEB.
Discussion
In cases where there is an inconsistency between the MTF and the VA with regard to any aspect of the case that may lead to an unfair or inaccurate adjudication, or potential appeal, the MEB examiner must provide a brief analysis and opinion that addresses the inconsistency. The MEB examiner must address conflicting MEB information, when viewed in its entirety, that appears inconsistent, such as: (1) history (duty status; location and surrounding circumstances); (2) diagnoses; (3) interpretation of test results; and (4) impact of condition(s) on duty performance; etc. A reasonable, brief explanation or resolution to the discrepancy must be provided, with focus on those aspects that have potential impact to a fair and complete adjudication. Most commonly, this can be a difference of opinion with respect to a diagnosis, such as PTSD versus Adjustment Disorder. Whether or not a newly-identified diagnosis represents a potentially unfitting condition based on the level of severity described to the VA examiner versus the documented treatment record in the service is another common area of inconsistency. But also common are inconsistencies in the time, location, and or circumstances surrounding the initial onset or diagnosis of a given condition, such as whether or not it occurred during a combat operation. The key to success is the MEB examiner reviewing the VA C&P exams carefully and being able to spot inconsistencies. Often times, the inconsistency cannot be explained, so the MEB examiner must at least provide what factual evidence is available at the time.
CommentsThis section is designed to be used in lieu of the “Diagnostic Variance Memo,” however, if a DVM is used, it can be summarized here and referred to as an attachment in Section 2.
Slide 56
UNCLASSIFIED 29 November 2010COL Presenter/ Office Symbol / (210) XXX-XXX (DSN 471) / [email protected] April 19, 2023April 19, 2023UNCLASSIFIED
10.a. QA Check – Apparent Inconsistencies – Examples
10.a. Lumbar strain. Previous physical examinations by at least ten credentialed providers document no complaints of back pain or neurologic symptoms, and reveal normal back and neurologic examinations with full ROM. Observations of the MEB examiner at the initial IDES referral appointment are consistent with this evidence. The VA DBQ documents excruciating back pain, leg numbness and significant decrement in ROM as demonstrated on exam. When presented with this evidence, SGT Snuffy states that his right knee causes his back to hurt, and he happened to be having a “bad day” on the day of his VA appointment. His lawyer alleges that the lumbar strain is directly related to his disqualifying condition must also be considered disqualifying as a result. It is the opinion of this examiner that the lumbar strain, if present, meets retention standards, as is supported by the documentation in the STR.
10.a. TMJ Syndrome. The VA examiner documents the Soldier reports constant, debilitating bilateral jaw pain that limits his ability to open his mouth. Review of SGT Snuffy’s Dental Treatment Record over the past 3 years reveals no mention of symptoms suggesting TMJ syndrome, nor any abnormal examination suggesting any other oral pathology. It is my opinion that this Dx does not exist, and even if it does, per VA standards, there is no evidence it has limited the Soldier’s military duty and therefore would meet retention standards.
10.a. PTSD (VA Dx). The VA DBQ reveals that the Soldier reports disabling symptoms of PTSD which began following an IED explosion in Iraq. Discussion with SGT Snuffy and review of his medical and personnel records do not reveal any evidence that he was ever deployed, nor has he ever been evaluated for, or been diagnosed with PTSD. It is my opinion that this Dx does not exist, and even if it does, per VA standards, there is no evidence it has limited the Soldier’s military duty and therefore meets retention standards.
Slide 57
UNCLASSIFIED 29 November 2010COL Presenter/ Office Symbol / (210) XXX-XXX (DSN 471) / [email protected] April 19, 2023April 19, 2023UNCLASSIFIED
10.a. QA Check – Apparent Inconsistencies – Examples (Cont’d)
10.a. Migraine Headaches (VA Dx). The VA has labeled the Soldier’s headaches as migraine. In my opinion and based on the AHLTA notes, the Soldier’s headaches are muscle tension headaches because he does not have an aura or other features of migraine, notwithstanding the one episode of nausea with one headache, which may have been medication-related.
10.a. Anxiety Disorder. The VA has indicated the Soldier does not meet the criteria for PSTD and that the Soldier has anxiety disorder, NOS. The VA has indicated that the Soldier does not have persistent symptoms of increased arousal in two or more areas. Soldier’s treating behavioral health providers indicate the Soldier continues to meet the diagnostic criteria for PTSD. Given that the VA exam was based on a moment of time vs. the Soldier’s treating physician's observation of this Soldier through the years, and the Army’s current endorsement of PTSD, PTSD is the mental disorder for which this Soldier falls below medical retention standards.
10.a. Lumbar strain without radiculopathy. Previous physical examinations in the AHLTA record related to the SM’s low back pain indicate normal ROM, posture and neurologic examination in the lower extremities, to include 5/5 strength and 2+/2+ patellar DTRs. The VA examination, however, documents an inability to walk due to pain, <5% ROM of the lumbar spine, 1/5 strength in the right leg and 2/5 strength in the left leg, and complete absence of patellar reflexes. I requested the SM return for re-examination. I personally observed him ride and park his motorcycle at our clinic without visible difficulty, and walk into the exam room without alteration of gait or painful grimace. On exam, my previous findings were confirmed, revealing no deficits in strength, sensation or reflexes. I therefore conclude that the SM’s diagnosis of lumbago due to lumbar muscle strain is without radiculopathy, and does not fail retention standards.
Slide 58
UNCLASSIFIED 29 November 2010COL Presenter/ Office Symbol / (210) XXX-XXX (DSN 471) / [email protected] April 19, 2023April 19, 2023UNCLASSIFIED
10.b. QA Check – Timeliness of MEB Information
Instructions
Generally, information should be no older than 6 months. Where information is older than 6 months, the MEB may need to (1) update the information; (2) complete re-examination/re-testing, as appropriate; or (3) otherwise address the Soldier’s concerns regarding the accuracy of the description of the Soldier’s condition due to the diagnosis. Information may be older than 6 months provided the MEB specifically explains why reevaluation or testing is unlikely to change issues relating to MRDP and/or is otherwise clinically unnecessary, whether or not the diagnosis meets medical retention standards. The MEB examiner must indicate that indicate that the reason/s for not repeating tests or consults has been explained to the Soldier. If the MEB information is up to date, so state.
Slide 59
UNCLASSIFIED 29 November 2010COL Presenter/ Office Symbol / (210) XXX-XXX (DSN 471) / [email protected] April 19, 2023April 19, 2023UNCLASSIFIED
10.b. QA Check – Timeliness of MEB Information (Cont’d)
Purpose To address timeliness of MEB information.
Discussion
This section is a brief statement that attests to the currency of the pertinent exams, consults, and tests used in the preparation of the NARSUM. Previous rules stated that all evidence must be no older than 6 months. New rules, as depicted in USAPDA Memo dated 10 Dec 2010, state that evidence older than 6 months can be considered current if the examiner determines that updating the test or consult is not clinically warranted, is unsafe, or is unlikely to change the likelihood of RTD based on the stability of the Soldier’s symptoms and/or condition. When making this statement, the MEB examiner must indicate that the reason/s for not repeating tests or consults has been explained to the Soldier. Although the Soldier does not have to grant concurrence with the examiner’s decision in order for the case to move forward, failure to adequately explain the reasons for not repeating tests or obtaining additional consults may potentially lead to unnecessary appeals and complaints.
CommentsExplaining that there has been no clinical change in the condition and the diagnosis remains unchanged is usually adequate.
Slide 60
UNCLASSIFIED 29 November 2010COL Presenter/ Office Symbol / (210) XXX-XXX (DSN 471) / [email protected] April 19, 2023April 19, 2023UNCLASSIFIED
10.b. QA Check – Timeliness of MEB Information – Examples
10.b. As discussed with the Soldier, repeat MRI of the lumbar spine is not clinically indicated because there has been no significant change in his condition. (Pain is sometimes aggravated by activity but remains localized with no clinical evidence of radiculopathy). All other supporting clinical information is from within the last 6 months.
10.b. All evaluations and testing has been completed within the past 4 months. The descriptions of the Soldier’s conditions reflects their current severity. This has been explained to the Soldier.
10.b. MRI of the right knee, performed on 20110912 as part of his pre-operative evaluation prior to surgery, is older than six months. The results are considered current and valid, since there are no new symptoms since that time suggesting a different diagnosis, and his symptoms have actually improved over time. This has been explained to the Soldier. All other MEB information is up to date.
10.b. EKG performed as part of a routine physical exam three years ago was normal. However, the SM reported palpitations, similar to that which he experienced several years ago and was evaluated by a cardiologist, so a new EKG was obtained. EKG on 20111120 is unchanged compared to prior, revealing a normal sinus rhythm and no evidence of ischemia or dysrhythmia. Re-consultation with cardiology is not indicated at this time, and he is advised to follow-up with his primary care manager for further evaluation should his symptoms persist or worsen. This has been explained to the Soldier. All other MEB information is up to date.
Slide 61
UNCLASSIFIED 29 November 2010COL Presenter/ Office Symbol / (210) XXX-XXX (DSN 471) / [email protected] April 19, 2023April 19, 2023UNCLASSIFIED
Way Ahead AR 40-400 is currently being updated to reflect the design
and requirements of the IDES NARSUM The U.S. Army Physical Disability Agency continues to
provide timely feedback to MEBs regarding deficiencies in MEB packets. The monthly “Why Code” report references reasons for returns to the numbered sections of the IDES NARSUM.
Metrics will continue to be monitored to measure effective-ness of the IDES NARSUM in meeting its intended goals– Return Rates, Appeals Rates– Preparation Time, overall MEB Processing Time– Patient Satisfaction– MEB Clinic, PEBLO, and PEB Satisfaction
Slide 62
UNCLASSIFIED 29 November 2010COL Presenter/ Office Symbol / (210) XXX-XXX (DSN 471) / [email protected] April 19, 2023April 19, 2023UNCLASSIFIED
Summary By focusing on essential requirements unique to processing
MEB cases in IDES, the revised IDES NARSUM format continues to standardize and simplify the information relevant to the MEB and PEB.
Adopting this standard across the AMEDD will reduce MTF variability and facilitate training new MEB examiners.
The resulting improvement in MEB quality (to include reducing inconsistencies) will decrease appeals and reduce processing time and PEB returns.
Reducing duplicative work will significantly decrease administrative burden.
Slide 63
UNCLASSIFIED 29 November 2010COL Presenter/ Office Symbol / (210) XXX-XXX (DSN 471) / [email protected] April 19, 2023April 19, 2023
AR 40-400 – http://www.apd.army.mil/pdffiles/r40_400.pdf AR 635-40 – http://www.apd.army.mil/pdffiles/r635_40.pdf AR 600-60 – http://www.apd.army.mil/pdffiles/r600_60.pdf AR 40-501 – http://www.apd.army.mil/pdffiles/r40_501.pdf
Websites U.S. Army Physical Disability Agency –
https://www.hrc.army.mil/SITE/Active/TAGD/Pda/pdapage.htm Deployment Health Clinical Center –
http://www.pdhealth.mil/hss/des.asp U.S. Army Human Resources Command –
https://www.hrc.army.mil/site/Active/tagd/Pda/ArmyPDES.html
References
Slide 64