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Case 1:05-cv-00533-MMS
Article 18-11

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Manual of the Medical Department

18-11

Determining Disability Evaluation Cases To Be Referred to the DON PEB

(1) General. The Navy DES derives from Title 10 USC 61 and is the mechanism by which retirement or separation for disability is effected for Navy and Marine Corps members. The DES provides for the removal from active duty of those members who can no longer perform the duties of their office, grade, rank, or rating owing to disability, and ensures that fair compensation is awarded to members whose military careers are cut short due to a service-incurred or service-aggravated disability. (2) Implementing Directive for DES. The directive used for DES in the Navy and Marine Corps is the current edition of the SECNAVINST 1850.4 , the Disability Evaluation Manual. Throughout this chapter, SECNAVINST 1850.4 series and Disability Evaluation Manual are used interchangeably and are synonymous. (3) Cases where a Navy or Marine Corps member's fitness for continued Naval service, owing to a condition that may constitute a disability, is called into question will be referred to the DON PEB for adjudication in accordance with the DON Disability Evaluation Manual. The PEB is in the organizational chain of command of the DIRSECNAVCORB, not of the Chief, BUMED. Some members may petition to waive their entitlement to PEB processing; these patients will predominantly be at the end of their obligated service and must be unwilling to be extended on active duty while their PEB case is being adjudicated. Waivers to PEB processing are submitted to the President, PEB for final approval. These voluntary waiver cases are to be contrasted with those Reserve Component (RC) patients who request to be released from active duty while their cases are being adjudicated (see article 18-23), and from those patients who have sufficient years to qualify for longevity retirement and wish to pursue this avenue rather than disability retirement or separation following a PEB determina-tion of unfitness for continued naval service (refer to SECNAVINST 1850.4, sections 3209, 3709, and enclosure (13)).

(4) Determining Fit or Unfit for Continued Naval Service. The determination that a member is fit (or unfit) for continued naval service (and if unfit, at what percentage of disability rating and which disability benefits apply) is solely and exclusively the responsibility of the PEB. Accordingly, MTFs do not determine fitness for continued service (this is not the same as determining "fit for duty" terminating a period of LIMDU, which MTFs do accomplish, as further explained in articles 18-1(2) and 18-10(11)). MTFs refer disability evaluation cases to the PEB for determination of fitness and of eligibility for disability benefits (refer to SECNAVINST 1850.4 series). As such, MTFs must be diligent in this regard to ensure that their staffs: (a) Refrain from conveying to patients opinions on the patients' fitness to continue naval service and/or opinions on disability percentage rating and potential disability benefits until findings are received from the DON PEB. (b) Refrain in their MEBRs from direct statements regarding whether patients are fit or unfit for continued naval service and/or opinions on disability percentage rating and potential disability benefits until findings are received from the PEB. (5) Line of Duty Determinations/Line of Duty Investigations (LODD/LODI). MTFs shall not unilaterally decline to process and forward to the PEB MEBRs in which parent command LODD/LODI indicate a member's condition was incurred outside the line of duty and due to the member's misconduct, as final decision-making authority of this decision also rests definitively with the PEB. Article 18-16 provides more detail on LODD cases. (6) Cases Involving Conditions Which May Have Existed Prior to Service (EPTS) merit special consideration. DOD Instruction 1332.38 (E3.P4. 5.2) and articles 3804m-3804p of the DON Disability Evaluation Manual delineate the following characteristics of EPTS considerations, but it is critical to note that exclusive and final authority for rendering EPTS determinations rests with the DON PEB, and MEBRs should accordingly refrain from presumptively labeling any condition "EPTS": (a) Except for medical defects and physical disabilities noted and recorded at the time of entrance, any injury or disease discovered after a

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Article 18-11

servicemember enters active duty, with the exception of congenital and hereditary conditions, is presumed to have been incurred in the line of duty. (b) Hereditary and genetic conditions shall be presumed to have been incurred prior to entry into active duty. They will be presumed service aggravated unless evidence clearly establishes that the condition is solely the time result of the condition's natural progression. (c) Generally recognized risks associated with treating preexisting conditions shall not be considered service aggravation. (d) Signs or symptoms of chronic disease identified so soon after the day of entry on military service (usually within 180 days) that the disease could not have originated in that short a period will be accepted as proof that the disease manifested prior to entrance into active military service (See DOD Instruction 1332.38 (E3.P4.5.4)). (e) Signs or symptoms of communicable disease within less than the medically recognized minimum incubation period after entry on active service will be accepted as evidence that the disease existed prior to military service (See DOD Instruction 1332.38 (E3.P4.5.4)). (f) Per service headquarters directives (e.g., MILPERSMAN 1910-130) the PEB is the final arbiter of EPTS disputes; any case which cannot be conclusively determined at the MTF level as to whether the condition actually EPTS or whether the condition was aggravated at any time after the member was enlisted or inducted will result in the convening of an MEB for referring the case to the PEB for final determination. (g) Per the SECNAVINST 1850.4 series, enclosure (10), "servicemembers found unfit for continued naval service whose medical conditions have not been permanently aggravated by military service, i.e., "Unfit-EPTS" are not eligible for disability severance pay or disability retirement if they have less than 8 years cumulative active service." Further details on this "8-year rule" are found at enclosure (10) of the DON Disability Evaluation Manual.

(7) Determining Which Cases Merit Referral to the PEB for Disability Evaluation. MANMED article 18-4 provides guidance on determining those patients for whom referral to the PEB may be appropriate. Moreover, dilemmas at the MTF level over whether a disabling condition exists that renders a member unfit for continued naval service will be resolved by referral of the case to the PEB. (8) Identifying Cases for Which PEB Referral May Not Be Appropriate. There are cases in which PEB referral is not appropriate; the following decision criteria will be helpful in allowing the MTF CA to determine whether an MEB for PEB referral will be convened. Additional guidance is available at article 3202 of the SECNAVINST 1850.4 series: (a) The mere presence of a diagnosis does not constitute a disability. As stipulated in the Navy Disability Evaluation Manual (article 2068), "a medical impairment or physical defect standing alone does not constitute a physical disability. To constitute a physical disability, the medical impairment or physical defect must be of such a nature and degree of severity as to interfere with the member's ability to adequately perform his or her duties." Article 2068 of the Navy Disability Evaluation Manual continues, "that the term "physical disability" includes mental disease, but not such inherent defects as behavioral disorders, adjustment disorders, personality disorders, and primary mental deficiencies." (b) Certain conditions and defects of a developmental nature are not ratable in the absence of an underlying ratable causative disorder and accordingly referral to the PEB is not appropriate. (Examples of these conditions appear in MANMED article 18-5 above, and in the SECNAVINST 1850.4 series, sections 2016, 3202, and attachment (b) to enclosure (8).) The PEB will reject all cases in which the sole diagnoses involve conditions not constituting a physical disability, as defined in article 2016 of the Navy Disability Evaluation Manual. (c) Lack of motivation for performance of duty does not justify referral to the PEB. (d) Request for referral to the PEB by the servicemember is not an independently sufficient reason for referral of a case to the PEB.

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(e) Physical disqualification from special duties, such as flying, serving on submarines, or in a medical specialty, does not necessarily imply unfitness for continued naval service. Referral to the PEB is appropriate only in cases where the member's ability to reasonably perform active military service is in doubt. (f) Inability to Meet Initial Enlistment/ Appointment Standards. Once enlisted or commissioned, the fact that a member may fall below initial entry or appointment standards, specified in MANMED chapter 15, does not require that an MEBR be referred for disability evaluation. Additional information on issues involving "Fitness to Separate" is found in article 18-25. (g) Physical Fitness and Overseas/Operational Suitability Situations Are Not in-and-of Themselves Sufficient Reasons to Forward a Case to the PEB. The inability to meet screening criteria for a specific assignment or administrative requirement (i.e., deployment, overseas or sea duty assignment, or participation in PRT/PFT/PFA cycle) does not alone justify referral to the PEB. Referral to the PEB is appropriate only in cases where the condition appears to be permanent in nature or of such a degree as to render the member unable to return to naval service within a reasonable period. MANMED, chapter 15 and BUMEDINST 1300.2 series provide amplifying information on fitness criteria. (h) Members Being Processed for Separation or Retirement for Reasons other than Physical Disability. Do not refer a member for disability evaluation who is being processed for separation or retirement for reasons other than physical disability, unless the member previously was found unfit but retained on active duty in a permanent limited duty (PLD) status, or the member's physical condition reasonably prompts doubt that he or she is fit to continue to perform the duties of office, grade, rank or rating/MOS. (i) Cases in Which Members Have Upcoming Surgical Procedures for Diagnosis(es) Relevant to the MEBR Being Considered by the PEB. These cases are discussed in more detail at MANMED article 18-25. As a general protocol, patients on whom an MEBR has been prepared and submitted to the PEB should not undergo surgery for any diagnosis unless that surgery is of an emergent nature.

Manual of the Medical Department
The PEB will be consulted immediately upon the MTF becoming aware of surgery planned for a patient for whom an MEBR has been submitted to the PEB. (j) Cases of Members Previously Evaluated by the PEB as Fit for Continued Naval Service Warrant Close Scrutiny by the MTF CA Prior to Any Proposed Resubmittal to the PEB. The President, PEB may reject any case (medical information submitted as a new MEBR, or addendum to a previous board) in which the date of the newly dictated medical information is within 6 months of the date of the PEB's notification of decision if, upon review by a medical officer assigned to the informal PEB, the medical officer advises: (1) The condition reported does not alter the subject member's previous findings. (2) The condition reported is not a significant deterioration of the previously reported condition. (3) The servicemember's treatment has not significantly changed. (4) The servicemember has required no significant outpatient treatment other than that required for maintenance. (9) The SECNAVINST 1850.4 current edition (as modified by PEB policy letters) is the definitive governing directive on cases being referred to the PEB. As such, in any situation where MANMED Chapter 18 and SECNAVINST 1850.4, DON Disability Evaluation Manual series appear in conflict concerning cases for the PEB, SECNAVINST 1850.4 will supersede MANMED chapter 18. CAs will ensure their personnel involved in any aspect of the disability evaluation process are thoroughly versed in the provisions of the DON Disability Evaluation Manual.
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Medical Evaluation Boards

Article 18-12

Section III PROCESSING MEDICAL EVALUATION BOARD REPORTS (MEBRs)
Article
18-12 Format of the MEBR for Referral to the DON Physical Evaluation Board (DON PEB) Format of the MEBR for Referral to the DON Physical Evaluation Board (DON PEB) Under Death Imminent Conditions Format of the MEBR Prepared for Placement on Limited Duty or for Referral to Service to Service Headquarters Requesting Limited Duty (Departmental Review) Non-Medical Assessment (NMA) Line of Duty/Misconduct (LOD/M) Determination The Abbreviated MEBR Format of the MEBR for Temporary Disability Retired List (TDRL) Reevaluation Definition of, and Processes for Complying With, Mandated Timeframes for Completion and Submission of MEBRs Transmission Methods, HIPAA, and Privacy Maintenance

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Format of the MEBR for Referral to the DON PEB

(1) Once a determination is made that an MEB will be convened referring a patient's case to the PEB for disability evaluation, the MEBR becomes of critical importance in ensuring appropriate clinical and administrative management of the patient.

(2) When developing an appropriate MEBR, the following criteria defined in the DON Disability Evaluation Manual (SECNAVINST 1850.4 series) must be satisfied. CAs shall ensure that this information is conveyed to their physicians comprising MEBs. Among the CA responsibilities surrounding medical boards is that all members of any MEB, as well as all MEB's staff involved with processing and administrative overview of MEBRs, must be thoroughly familiar with this MANMED article and chapter 8 of the DON Disability Evaluation Manual. The following depict criteria provided by the PEB

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for establishing a viable MEBR. A sample of an appropriate MEBR for submission to the PEB, developed in conjunction with the PEB, appears at the end of this article. (3) MEBR Documentation (a) Required Information (1) Member's name, rank or rate, grade, and social security number. (2) The specialty of the physicians comprising the MEB/signing off on the MEBR. (3) The clinical department and/or service authoring or sponsoring the document. (4) The MTF and its location. (5) Date the MEB was conducted and date the MEBR was dictated. (6) A legible, single-sided copy of the member's health record should accompany the MEBR. Any supplemental records should be submitted. (7) Copies of all narrative summaries of hospitalizations and all procedure reports are to be submitted with the MEBR. (8) Signatures of the MEB members on the NAVMED 6100/1 (Rev. 8-2004), cover sheet. Electronic signatures will not be accepted by the PEB as of this writing. (b) On Each Page (1) Member's last name, social security number, and date typed or transcribed in bottom margin. (2) Page number will be annotated at the bottom center of the page. (3) Document is marked "For Official Use Only ­ Privacy Act Protected." (c) Reason For Convening the MEB (e.g., physician-directed, command-directed) (1) The mere presence of a diagnosis is not synonymous with disability. It must be established that the medical disease or condition underlying the diagnosis actually interferes significantly with the member's ability to carry out the duties of his or her rank or rate.

Manual of the Medical Department
(2) When assessing the severity of symptoms, physicians must evaluate the subjective symptoms in light of objective findings and report discrepancies in addition to positive findings. (d) Eligibility for MEB (i.e., duty status). (e) Military Information (1) Date of first and most recent entry into service. (2) Estimated termination of service (i.e., EAOS/EAS). (3) Administrative actions ongoing, pending, or completed (e.g., LODI, courts-martial, selective early retirement, retirement, or separation dates). (f) Chief Complaint. Preferably stated in servicemember's own words as contained in the health record. (g) History of Present Illness. Exact details, including pertinent dates regarding illnesses or injuries, how injuries were incurred. Enclose and summarize any pertinent previous MEBRs. References to "interval history" are inappropriate as they assume that the PEB has access to the previous MEBRs which is not always the case. The author of the MEBR must give a complete history chronologically as well as simply event-based. (h) Past Medical History (1) Past injuries and illnesses. (2) Prior disability ratings (e.g., given by either the PEB or Department of Veterans Affairs). (3) Past hospitalizations and relevant outpatient treatment, including documentation of diagnosis and therapy, pertinent dates, and location should be listed. (4) Social information pertinent to the member's condition (e.g., activity level and sports activities engaged in would be pertinent to orthopedic evaluation; alcohol and drug usage rates must also be included in all cases) should be provided. (There is an inclusive list of applicable items under the specialty specific section for psychiatric disorders.) (5) Illnesses, conditions, and prodromal symptoms, existing prior to service (referred to as EPTS or existed prior to enlistment (EPTE) conditions).

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(i) Laboratory and Other Ancillary Studies. All studies that support and qualify the diagnosis(es) should be included as should any studies that conflict with the diagnosis(es). (j) Present Condition/Review of Systems and Current Functional Status (1) Current clinical condition(s) should be noted including all current complaints and review of systems; required medications and any nonmedication treatment regimens (e.g., physical therapy) in progress. (2) Functional status (a) The servicemember's functional status as to the ability to perform his or her required duty should be indicated. (b) If possible, a summation of the member's ability to perform the civilian equivalent of their assigned duties should be indicated. (3) A statement should be given regarding the prognosis for functional status after completion of treatment, if chronic treatment is not necessary. (4) A statement should be given regarding the prognosis for functional status in cases requiring chronic treatment. (5) The stability of the current clinical condition and functional status should be addressed. (6) Statement of compliance with treatment recommendations and reasonableness of any refusal of recommended treatment procedures, including surgery. NAVMED 6100/4 (Rev. 8-2004) must be submitted as a portion of the MEBR when refusal of surgery or treatment is considered "unreasonable." (7) Requirement for monitoring including frequency of indicated treatment and/or therapy visits and associated operational assignment limitations. (k) Conclusions (1) An informed opinion should be stated as to the servicemember's ability to meet current retention standards. (2) If a servicemember does not meet retention standards, the specific reasons why should be stated.

Article 18-12
(3) Treatment recommendations including medications, procedures, and behavior and/or lifestyle modifications must be depicted. Include a statement concerning the member's compliance. If non-compliant, indicate whether the patient's noncompliance is reasonable. (4) Under no circumstances is the narrative to indicate that the member is unfit, nor recommend a disability percentage rating. It is the PEB's responsibility to determine fitness and disability percentage ratings. The MEBR may state something to the effect, "the member is referred to the PEB because we are of the opinion that the member's condition may interfere with the performance of his or her duties because the member does not meet medical retention standards as described in..." (l) Drug Therapy. There may be certain instances where a specific drug therapy may in and of itself preclude the full performance of duties. This must be stated specifically if it is the reason for the board. (m) Limited Duty. The authoring physician should not only address previous periods of LIMDU (and what they were for) but also consider whether a member might obtain greater benefit by being referred to a LIMDU board for placement on LIMDU vice direct submission to the informal PEB. Reference to MANMED article 18-10 on LIMDU is recommended in such cases. (n) Surrebuttal. When the member submits a rebuttal to a medical board or an addendum, the authoring physician must address the member's specific issues. (o) Referral of Hospitalized Patients. Referral of such cases to PEB is appropriate only in the presence of significant extenuating circumstances. The MEBR will cite the reasons for continued retention in the hospital. For members who are hospitalized for an acute psychiatric emergency, the MEBR should include a mental status exam and statement of functional status within 30 days of submission of the MEBR to the PEB. (p) Competency Statements. Competency statements are required on all psychiatric diagnoses (except where the psychiatric condition has resolved).

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The statement of competency must be made by a psychiatrist, as the specific determination is to be made in accordance with the JAG Manual. Therefore, most cases that contain a psychiatric diagnosis should be referred to or evaluated by a psychiatrist. (q) Trauma. (i.e., severe trauma and acute clinical, fulminant presentations.) In clinical situations where the level of impairment is likely to change significantly within or over the following 2 months, submission of the MEBR should be delayed until this period of time has elapsed.
Note: MANMED article 18-19(2) addresses MTF timeliness for processing MEBRs; owing to the dynamic nature of trauma cases, MTFs should refrain from dictating and submitting MEBRs to the PEB if significant change in the patient's condition--which would have a material effect on the MEBR documentation--is anticipated within a 2-month period. Patients in this condition, however should be placed on a period of LIMDU (see article 18-10) pending the resolution of the case to a sufficient point that an appropriate MEBR dictation is possible.

Manual of the Medical Department
(t) TDRL Evaluations. Physicians performing TDRL evaluations are responsible for knowing the information contained in SECNAVINST 1850.4 series, part 6 of enclosure (3), that addresses TDRL reevaluations. (u) Physical Examination (PE). A complete PE must be recorded in the MEBR and must have been conducted within 6 months of the date of the MEBR. For all conditions, hand dominance must be stated. Height and weight must be documented in all MEBRs (in the narrative). (v) Selected Specialty-Related Considerations and Guidelines (1) Cardiology (a) Results of special studies to support and quantify the cardiac impairment should be noted, e.g., treadmill and thallium stress tests, angiography, and other special studies. (b) The functional therapeutic classification of the cardiac condition must be included. Either the New York or Canadian classification system may be used (see SECNAVINST 1850.4 series, enclosure (9), attachment (b), table 3, for assessment criteria). (c) General Information. Evaluation and reporting of cardiovascular function should be in terms of metabolic equivalents (METs) of energy expended to produce a certain level of symptoms. 1. Objective measurements of the level of physical activity, expressed as METs, at which cardiac symptoms develop is the main method of evaluating cardiovascular entities now. 2. Exercise capacity of skeletal muscle depends on the ability of the cardiovascular system to deliver oxygen to the muscle, and measuring exercise capacity can, therefore, also measure cardiovascular function. The most accurate measure of exercise capacity is the maximal oxygen uptake, which is the amount of oxygen, in liters per minute, transported from the lungs and skeletal muscle at peak effort. Because measurement of the maximal oxygen uptake is impractical, multiples of resting oxygen consumption (or METs) are used to calculate the energy cost of physical activity. One MET is the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters per kilogram of

(1) It is important that the MEBR be dictated at the latest possible time prior to submission. This is particularly important when the MEBR is done and then months pass while waiting for completion of the LODI. If the MEBR has previously been dictated, an addendum should be included stating current condition. Statements such as "There has been no change since the previous medical board was dictated" are generally insufficient. (2) Ensure that all of the member's complaints and conditions are addressed by the appropriate specialty in attached addenda. The authoring service, in conjunction with the MEBs department of the MTF, is responsible for ensuring that all required addenda and non-medical information are included in the original package. (r) Submission of Photographs. Current photographs are essential in burn cases, and very useful in cases with significantly disfiguring scars. Photographs submitted should be certified, by the medical photography department, to have been taken within 1 month of the date of dictation of the MEBR. (s) Organ Transplants. When the MTF has opted to retain the member to receive his or her transplant, the MTF will place the member on a LIMDU status pending the transplant. MEBR referral to the PEB should be delayed until the procedure has been done and the maximum therapeutic benefit of treatment has been achieved.

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body weight per minute. The calculation of work activities in multiples of METs is a useful measurement for assessing disability and standardizing the reporting of exercise workloads when different exercise protocols are used. 3. Alternative methods of evaluating function are provided for situations where treadmill stress testing is medically contraindicated: the examiner's estimation of the level of activity, expressed in METs and supported by examples of specific activities, such as slow stair climbing or shoveling snow that results in dyspnea, fatigue, angina, dizziness, or syncope is acceptable. (2) Gastroenterology. Servicemembers with fecal incontinence should have recorded findings of rectal examination, e.g., digital exam, manometric studies as indicated, and radiographic studies. The degree and frequency of the incontinence should be noted as well as the incapacitation caused by the condition. (3) Neurosurgery/Neurology (a) For vertebral disc problems, radicular findings on PE should be supported by laboratory studies such as computer-aided tomography (CT) scan, magnetic resonance imaging (MRI), electromyogram (EMG), or nerve conduction velocity (NCV). In cases where surgery has been performed, both pre- and post-operative deep-tendon reflexes should be documented. (b) General 1. Dementia and Head Trauma. Neuropsychiatric or neuropsychological assessment should be accomplished in all head injury cases. Results should be included. Neuropsychiatric or neuropsychological measurements should be performed as early as possible. Current tests (performed within 6 weeks of submission of the board) are also required. 2. Migraine Headaches. The number of incapacitating episodes (those that require the individual to stop the activity in which engaged and seek medical treatment) per week, month, or year should be noted and verified by a physician. 3. Seizure Disorder. The evaluation will be done by a neurologist. An electroencephalogram (EEG), MRI, or CT will be included in the

Article 18-12
initial examination. When subsequent seizure episodes occur while on medical therapy, blood levels of prescribed medication(s) will be determined. 4. Neuropathies. EMG and nerve conduction studies will be performed. 5. Multiple Sclerosis. Appropriate MRI(s) will be performed. 6. Industrial (and Industrially Related) Social Impairment. Estimate the degree of impairment that will be incurred by the servicemember. 7. Imaging Studies. For all neurological and neurosurgical conditions appropriate imaging studies should be obtained in concert with current standards of practice. (4) Ophthalmology (a) If retention standards are not met for reasons related to vision, visual fields must be included in the PE and verified by an ophthalmologist. Specialist examination should include uncorrected and corrected central visual acuity. Snellen's test or its equivalent will be used and if indicated measurements of the Goldmann perimeter chart will be included. (b) Visual field deficits must be documented on a Goldmann field chart using the III-4-e objective. Cases of diplopia must be documented using a Goldmann perimeter chart plotting the fields of diplopia. (5) Orthopaedics (a) Range of motion (ROM) measurements must be documented for injuries to the extremities. The results of the measurement should be validated and the method of measurement and validation should be stated. (b) In cases involving back pain, the use of Waddell's signs should be included in assessing the severity and character of the pain. (Refer to SECNAVINST 1850.4 series; also refer to Waddell G, McCulloch J.A., Kummel E, Venner R.M.. Nonorganic physical signs in low back pain. Spine. 1980; 5:117125. Waddell G. Somerville D., Henderson I., Newton M.. Objective clinical evaluation of physical impairment in chronic low back pain. Spine. 1992; 17:617-628.)

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(c) For vertebral disc problems, radicular findings on PE should be supported by laboratory studies such as CT scan, MRI, EMG, or NCV. In cases where surgery has been performed, both preand post-operative deep-tendon reflexes should be documented. (6) Otolaryngology. Audiograms must include speech discrimination scores. Current and entry level audiograms must also be included. (7) Psychiatry (a) Particular attention should be paid to documenting all prior psychiatric care. Supportive data should be obtained for verification of the patient's verbal history. (b) Psychiatric hospitalization is not prima facie evidence of an unfitting psychiatric disorder. It may, however, be evidence that the condition is administratively unsuiting. (c) Psychometric assessment should be carried out if such assessment will help quantify the severity of certain conditions and allow a reference point for future evaluation. (d) The Diagnostic and Statistical Manual of Mental Disorders (most recent edition) will be used for diagnostic terminology. The multiaxial system of assessment will be used to include axes I-V. The degree of industrial and industrially related social impairment must be individually determined and documented, for each axis I and axis II diagnosis, and correlated to the servicemember's clinical manifestations. Increased severity of symptoms due to transient stressors associated with the PEB and prospect of separation, retirement, relocation or re-employment will not be considered in determining the degree of impairment. The servicemember's total impairment for civilian industrial adaptability from all sources (axes I, II, III) should be determined and documented. The contribution of each condition to the total adaptability impairment should then be individually noted and correlated with the servicemember's clinical manifestations. (e) Every effort must be made to distinguish symptoms and impairment resulting from personality disorder, or maladaptive traits, from impairments based on other psychiatric conditions. The MEBR must specifically address the issues of

Manual of the Medical Department
relative contribution of noncompensable conditions (e.g., personality disorders, adjustment disorder, impulse control disorder, substance abuse, etc.). (f) Documentation shall be submitted addressing the following: 1. Living Arrangements (e.g., by oneself, with spouse and children, with parents and siblings). 2. Marital Status. Single, married, separated, divorced, and the type of relationship (harmony or strife). 3. Leisure Activity. Sports, hobbies, TV, or reading. 4. Acquaintances. Male, female, both sexes, many, few. 5. Substance Use or Abuse. Alcohol or drugs. 6. Police Encounters/Record. (8) Pulmonary. When the MEB is held for restrictive or obstructive pulmonary disease, rating is usually based upon pulmonary function tests measuring residual function. There must be a minimum of one set of PFTs. (a) Studies should be performed both before and after medication. 1. Pre-bronchodilator PFTs. When the results are normal, post-bronchodilator studies are not required. 2. In all other cases, postbronchodilator studies should be done unless contraindicated (because of allergy to medication, etc.) or if a patient was on bronchodilators before the test and had taken his or her medication within a few hours of the study. a. A physician who determines that a post-bronchodilator study should not be done in a given case should provide an explanation. b. The members of the informal PEB shall request either the explanation when not provided or a repeat of the studies.

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c. The post-bronchodilator results will be used in applying the evaluation criteria in the rating schedule. There is a small group of patients (5 percent or less) in whom there may be a paradoxical reaction to bronchodilators; i.e., the postbronchodilator results will be poorer than the prebronchodilator results. When there is a paradoxical response, the better (pre-bronchodilator) values will be used in the rating. d. When there is disparity between the results of different tests (FEV-1, FVC, etc.) so that the level of evaluation would differ depending on which test result is used, the test with the better (higher) values (i.e., that would give the lower evaluation) will be used. This is because such tests are effort-dependent, and such a difference is ordinarily due to a difference in effort from test to test. However, if there is a substantial disparity in the results, the MEB physician may be asked for an explanation and/or request that the test be repeated if there is no clear reason. e. When the FEV-1 is greater than 100 percent, an FEV-1/FVC ratio that is below normal should be considered a physiological variant rather than an abnormal value. (b) Where warranted, the member should have a methacholine challenge, especially when the original set of PFTs are "normal." (c) In cases of exercise-induced asthma, pulmonary function tests after exercise should be performed. (9) Urology (a) Cases involving neurogenic bladder must include studies that document the condition. (b) All cases involving incontinence must include studies that document the condition. (c) Cases involving incontinence and/ or neurogenic bladder should have documentation regarding severity as indicated by the number of times self catheterization is required, the number and type of pads required in a day, or the soilage frequency.

Article 18-12
(4) Format of the Dictated MEBR. As detailed in the DON Disability Evaluation Manual, enclosure (8), the following is an example of a well-prepared MEBR. MTFs will ensure compliance with this template in the preparation and forwarding of MEBRs to the PEB.

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Article 18-12

Manual of the Medical Department SAMPLE MEBR FOR REFERRING A CASE TO THE PEB
FOR OFFICIAL USE ONLY

NAME AND SSN: RATE: (To include rank and rating, e.g., Yeoman First Class) OR MILITARY OCCUPATIONAL SPECIALTY (MOS) AS INDICATED BY BRANCH OF SERVICE: UNIT/COMMAND: DATE: (DD/MM/YYYY) MILITARY HISTORY: Petty Officer______________________________ entered into active duty on ____________________________. She attended Recruit Training Command in Orlando, Florida. She then attended Yeoman A School in Meridian, Mississippi. She has been stationed at various locations and received awards for her exemplary service. She was twice named sailor of the quarter and once sailor of the year for the ____________________ area. She has received three consecutive good conduct medals and two Navy and Marine Corps achievement medals. CHIEF COMPLAINT: Back and Foot Pain HISTORY OF PRESENT ILLNESS: Petty Officer ____________________________ back pain began in 19______ after a motor vehicle accident. She developed worsening of her symptoms in __________ after a second motor vehicle accident. The back pain is constantly present with varying intensity. Exacerbating factors include walking or standing for greater than 2 minutes. Some palliation is noted with non-weight bearing rest. The symptoms have progressed insidiously to include plantar foot pain and arthralgias involving the hips, knees, and ankles. The plantar foot pain occurs daily and is exacerbated by any weight bearing activity. She has received a variety of health care evaluations with subsequent therapeutic recommendations. Unsuccessful treatments employed have included NSAIDS, muscle relaxants, tricyclic antidepressants to modify the pain threshold, orthotics, physical therapy, plantar and sacroiliac anesthetic injections, nighttime ankle splints, and local ultrasound treatment. A lumbosacral series revealed sacralization of the 5th lumbar vertebrae. She was evaluated by Physical Medicine and Rehabilitation at which time a bone scan was obtained that showed mild increased tracer uptake in both sacroiliac joints consistent with sacroiliitis. She was then referred to Rheumatology where she was initially evaluated in March 1997. Sacroiliac radiographs were suspicious for sacroiliac disease. An MRI subsequently revealed no evidence of sacroiliitis. Her symptoms have persisted despite maximal therapy and negatively impacted on her ability to perform her naval duties. She is therefore being referred to the Physical Evaluation Board for further review and disposition. ALLERGIES: None MEDICATIONS: Indomethacin SR 75mg bid, Norplant PAST MEDICAL HISTORY: Spina bifida occulta, childhood asthma, duplicated left renal collecting system without reflux or obstruction (urology evaluation completed in 1997), perivaginal cyst, tinea versicolor

For official use only Page ___ of ___ Pages

NavalHospital __________________________________ Patient Last Name and Last Four ___________________ Date Dictated __________ Date Typed __________

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PAST SURGICAL HISTORY: None. SOCIAL HISTORY: No tobacco or alcohol. REVIEW OF SYSTEMS:

Article 18-12

Musculoskeletal: Arthralgias involving hips, knees, and ankles, occurs with resting or ambulation, occasionally resolves with rest or spontaneously, chronicity 11 years, episodes last days to weeks; back pain of 11 years duration with symp-toms worsening since 1992, pain is worse with activity, palliation with resting and laying supine, prevents restorative sleep; plantar foot pain with radiation into achilles tendon and gastrocnemius, pain is constantly present and worse with weight bearing and ambulation, refractory to shoe inserts and nighttime splints. Neurologic: midline occipital headaches, occurs in the AM upon awakening, resolves with aspirin, chronicity 11 years; dizziness and fainting spells, episode duration approximately 2 minutes, chronicity 7 years, associated with gastro-intestinal symptoms, no known loss of consciousness. Gastrointestinal: "knot-like" sensation with pain in the epigastrium, associated nausea and increased bowel motility, associated salivary regurgitation without acid brash, no diarrhea or bloating, onset is spontaneous and without identifiable provocative factors, chronicity 7 years. PHYSICAL EXAMINATION: BP 123/77 P 75 T 98.9F Wt 123lbs HEENT - extraocular movements intact, Fundi normal, no oral ulcers, tympanic membranes clear NECK - normal range of motion, nontender, no lymphadenopathy, no thyroid enlargement or nodules LUNGS - clear HEART - regular rhythm, no murmurs or gallops ABDOMEN - no hepatosplenomegaly, nontender, bowel sounds present PELVIC - (Ob-Gyn) normal MUSCULOSKELETAL: Feet: plantar pain bilaterally at the calcaneus and metatarsal heads, callus formation overlying #1, 2, 5 bilaterally at the metatarsal heads. Back: focal area of palpable low pain overlying sacrum and lumbosacral junction, presacral fat pad, Schober's test reveals 2.5 cm lumbar distraction with back flexion, straight leg raise test negative, hyperextension hips without pain provocation, flattening appearance to lumbar spine, FABERE negative, no leg length discrepancy. Joints: no synovitis NEUROLOGIC - strength normal, deep tendon reflexes present and equal bilaterally, babinski absent, no sensory deficits elicited, muscle tone normal DERMATOLOGIC - scar at dorsum of left wrist, acneiform lesions on back. LABORATORY: Urinalysis - SG 1.026, trace protein, 1-2 RBC/HPF, 5-9 EPI/HPF Chemistries - normal complete blood count - normal erythrocyte sedimentation rate - 9 - <0.l HLA - B27 negative ELECTROCARDIOGRAM: sinus bradycardia.

For official use only Page ___ of ___ Pages

NavalHospital _________________________________ Patient Last Name and Last Four __________________ Date Dictated __________ Date Typed _________

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RADIOLOGY: (23 May 97) (4 April 97) (21 Mar 97) (6 Mar 97) (27 Feb 97)

Manual of the Medical Department

chest x-ray - normal MRI pelvis - normal ferguson pelvis - normal bone scan - increased uptake in the spinous processes of L4, 5; mild increased uptake in both sacroiliac joints lumber spine series - sacralization of L5 vertebrae

FINAL DIAGNOSES: (1) Plantar Fasciitis (2) Mechanical low back pain (3) Duplicated collecting system of left kidney without evidence of reflux or obstruction PRESENT CONDITION: Petty Officer _________________ is currently unable to successfully perform her military duties as reflected by the member and her direct supervisors. Her condition has placed an undue burden on coworkers in her office attempting to support those duties which Petty Officer _________________ is unable to perform. Her current medical problems have also significantly impacted her personal life by limiting her hobbies, interrupting normal sleep patterns, and making activities of daily living difficult. PROGNOSIS: Petty Officer _________________ is likely to require ongoing therapy and medical follow-up by clinicians interested in musculoskeletal ailments. RECOMMENDATIONS: 1. Petty Officer_______________ medical condition at this time precludes her from continuation on active duty. She is therefore being referred to the Physical Evaluation Board for further evaluation and disposition. 2. Continued use of proper shoe inserts and nighttime splints on a regular basis. 3. Daily stretching exercises targeting the plantar fascia and low back. 4. Daily strengthening exercises targeting the abdominal muscles and intrinsic muscles of the feet. 5. Regular use of NSAIDS at analgesic doses. 6. Periodic formal physical therapy evaluations to document proper self-directed rehabilitation routines and to monitor progress. 7. Evaluation every 3-4 months by a physician interested in the diagnosis and treatment of musculoskeletal problems. _______________________________ Signature and typed Name and Status (to include specialty) of MEB Member _______________________________ Signature and typed Name and Status (to include specialty) of MEB Member For official use only Page ___ of ___ Pages Naval Hospital _________________________________ Patient Last Name and Last Four ___________________ Date Dictated __________ Date Typed __________

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Article 18-14
(2) As developed in article 18-3(1) through 183(4), only CAs can effect an MEB, and an MEB must be convened for LIMDU cases. Commands must ensure that their providers and patients realize that a recommended period of LIMDU must be forwarded to service headquarters for adjudication does not commence until it has been approved by NAVPERSCOM or HQMC, as appropriate. Branch medical clinics and providers attached to ships and operational units do not--by definition--hold CA. Strict compliance with the criteria established in articles 18-3 and 18-10 regarding CA and LIMDU is mandatory for all MTFs and units with assigned medical personnel so that the most efficacious clinical and administrative case management activities are provided to our patients. (3) Appropriate clinical and administrative case management of patients in a LIMDU status is vital. This includes ensuring that cases requiring service headquarters approval for continuation on LIMDU are forwarded in ample time to enable the service headquarters to render timely decisions on either ordering LIMDU continuation or referral of cases to the DON PEB. MTFs must ensure close liaison with the LIMDU coordinators of the commands they serve to foster this timely referral of cases. MANMED article 18-10(11) addresses the reevaluation of patients in a LIMDU status. (4) Once a determination is made that an MEB will be convened to recommend a member to service headquarters for LIMDU, the MEBR becomes of critical importance in appropriate clinical and administrative management of the patient. (5) All MTFs will ensure compliance with the template (on the next page) in the preparation and forwarding of MEBRs to service headquarters for consideration of periods of LIMDU. (6) Procedures for returning members to "fit for duty" status from a period of LIMDU are contained in article 18-10(11).

18-13

Format of the MEBR for Referral to the DON PEB under Death Imminent Conditions

(1) Prior to December 2003, the Navy Disability Evaluation Manual allowed that in cases in which "competent medical authority determines that a service member's death is expected within 72 hours and it is determined to be in the best interests of his or her estate, the member may be referred expeditiously into the DES. To protect the interests of the Government and the service member, disposition shall be placement on the TDRL provided all requirements under statute, legal opinions, and regulation are met." (2) On 23 December 2003, the Principal Deputy to the Undersecretary of Defense for Personnel and Readiness rescinded the authority for the services to perform such "death imminent" PEB cases, predicated on Survivor Benefit Program (SBP) changes incorporated in the National Defense Authorization Act (NDAA) of 2004. (3) Accordingly, effective 30 December 2003, the DON PEB issued guidance that from that date forward there are no longer "death imminent" PEB procedures for the DON.

18-14

Format of the MEBR Prepared for Placement on Limited Duty or for Referral to Service Headquarters Requesting Limited Duty (Departmental Review)

(1) As discussed in MANMED article 18-10 regarding LIMDU, some LIMDU cases must be referred by MTFs to Navy or Marine Corps headquarters for approval.

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Article 18-14

Manual of the Medical Department

SAMPLE MEBR FOR SUBMITTING A CASE TO SERVICE HEADQUARTERS FOR LIMITED DUTY CONSIDERATION
FOR OFFICIAL USE ONLY NAME AND SSN: RATE: (To include rank and rating, e.g., Yeoman First Class) OR MILITARY OCCUPATIONAL SPECIALTY (MOS) AS INDICATED BY BRANCH OF SERVICE: UNIT/COMMAND: DATE: (DD/MM/YYYY) MILITARY HISTORY: Petty Officer ____________________________ entered into active duty on _____________________________________________. She attended Recruit Training Command in Orlando, Florida. She then attended Yeoman A School in Meridian, Mississippi. She has been stationed at various locations and received awards for her exemplary service. She was twice named sailor of the quarter and once sailor of the year for the____________________ area. She has received three consecutive good conduct medals and two Navy and Marine Corps achievement medals. CHIEF COMPLAINT: HISTORY OF PRESENT ILLNESS: PAST SIGNIFICANT MEDICAL HISTORY: PAST SURGICAL HISTORY: DATES OF AND DIAGNOSES CAUSING PAST LIMITED DUTY PERIODS: FINAL DIAGNOSES (LIST ALL PERTINENT DIAGNOSES): (1) (2) PRESENT CONDITION: Petty Officer ___________________ is currently unable to successfully perform her military duties as reflected by the member and her direct supervisors. Her condition has placed an undue burden on coworkers in her office attempting to support those duties which Petty Officer __________________ is unable to perform. Her current medical problems have also significantly impacted her personal life by limiting her hobbies, interrupting normal sleep patterns, and making activities of daily living difficult. PROGNOSIS, TO INCLUDE ESTIMATED PERIOD OF LIMITED DUTY: Petty Officer ___________________ is likely to require ongoing therapy and medical follow-up by clinicians interested in musculoskeletal ailments. PERIOD OF LIMITED DUTY RECOMMENDED BY THIS BOARD: COURSE OF CARE--INCLUDING SURGICAL PROCEDURES AND TIMEFRAMES--ANTICPATED DURING THIS RECOMMENDED PERIOD OF LIMITED DUTY: DISCUSSION OF LIKELIHOOD THAT PATIENT WILL RETURN TO MEDICALLY UNRESTRICTED DUTY DURING OR AT THE END OF THE RECOMMENDED PERIOD OF LIMITED DUTY: LIMITATIONS ON SERVICE DURING THE RECOMMENDED PERIOD OF LIMITED DUTY: ADDITIONAL FINDINGS AND/OR RECOMMENDATIONS: _______________________________ Signature and typed Name and Status (to include specialty) of MEB Member _______________________________ Signature and typed Name and Status (to include specialty) of MEB Member For official use only Page ___ of ___ Pages Naval Hospital _________________________________ Patient Last Name and Last Four ___________________ Date Dictated __________ Date Typed __________

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Article 18-15
(4) SECNAVINST 1850.4 series mandates that "commanders will ensure that NMAs are submitted to the requesting facility within 15 calendar days from the date of receipt of such request." For patients having transferred PCS from the previous parent command or having been sent TEMDU from the previous parent command to an MTF for treatment, the MTF is still obligated to obtain the NMA from the previous parent command. MTFs experiencing difficulty receiving NMAs from parent commands within the 15 calendar day timeframe are to judiciously direct requests for further assistance as deemed necessary to NAVPERSCOM (PERS-4821) or HQMC (MMSR-4). Obtaining NMAs often presents as one of the most time-consuming endeavors facing the MTFs in preparing complete MEBRs; MTF commanders shall ensure their respective MEBs staffs are diligent in pursuing NMAs to facilitate compliance with the "30-day window" for completing MEBRs as defined in article 18-19. To foster compliance with processing timeframes, parent commands should be encouraged to provide the NMA via naval message traffic or, as an alternative, to fax NMAs on their command letterhead to MTFs. (5) SECNAVINST 1850.4, enclosure (11), provides additional information on, and the format template for, the NMA, and pertinent sections thereof are reproduced here: (See sample command letter on next page.)

18-15

Non-Medical Assessment (NMA)

(1) Since December 1998, the PEB has required that each MEBR referring an ADSM into the DES in accordance with SECNAVINST 1850.4 series will contain an NMA. This tool, a CO's assessment of a service member's performance of duty relative to MEB considerations, has proven invaluable as an input to the deliberations of the PEB. (2) HQMC (MMSR-4) and NAVPERSCOM (PERS-4821) have also mandated an NMA will be included with selected MEBR sent by an MTF for "departmental review" to service headquarters relative to LIMDU requests (see articles 18-5 and 1814). (3) The NMA is to be completed by the servicemember's parent command, and to the maximum extent practicable be signed by the patient's CO. MTFs must request an NMA from a member's parent command immediately at the commencement of any MEB likely to refer a patient to the PEB for disability evaluation or to service headquarters for LIMDU consideration. MTFs should not presume that parent command's have ready access to the NMA format developed in SECNAVINST 1850.4 series, and should in their requests for NMA ensure that parent commands are provided reference locations where they can readily obtain the NMA format. These are to include: (a) Navy Directives online at http://neds. daps.dla.mil where the entire SECNAVINST 1850.4 series is available. (b) The Web site of the PEB at http://www. hq.navy.mil/ncpb, where a downloadable version of the NMA is available for parent comment use. (c) NMA templates embedded in messages from MTFs to parent commands advising of LIMDU recommendations and requirements for parent command NMA submittal. MTF requests for NMA should cite all these reference sources. MTFs should additionally ensure that their respective Web sites offer links to the PEB site, and should make this information available to parent commands as part of the NMA request documentation.

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Article 18-15

Manual of the Medical Department
COMMAND LETTERHEAD

Date: From: To: Subj: Commanding Officer Medical Treatment Facility NON-MEDICAL ASSESSMENT (NMA); CASE OF ________________________(name, SSN)

1. Questionnaire. The following assessment is submitted to assist the PEB in their determination of Fitness/Unfitness and/or service headquarters in determining appropriate limited duty: a. Service member's Rating/NEC/MOS/Specialty ___________ (Numerical designator and description; e.g., 031 I/Rifleman, A03/Aviation Ordnanceman). b. c. d. e. f. g. h. i. j. k. l. Is the member currently working out of his/her specialty because of the medical condition? Last date the member took PRT/PFT. Last date the member passed the PRT/PFT. Member's height and weight (inches/lbs) _______________. Is the member within weight and body fat standards? To your knowledge, is the member fully complying with the prescribed appointments and treatment for the therapy? How much time has the member's condition required him/her to be away from duties for treatment/evaluation/recuperation? Estimate the average number of hours per week the member is absent from command duties. How has this impacted member's performance? Is member pending disciplinary action or involuntary administrative separation for misconduct? If so, for what? Does the member have good potential for continued service in his/her present physical and mental condition?

m. Is member motivated for continued active duty? n. Is this member's performance worthy to remain on active duty in a Permanent Limited Duty status if found Unfit?

2. Commanding officer's comments: This paragraph is crucial to summarize member's situation in the perspective of the commanding officer. In a concise and succinct paragraph, statements are needed to assist in determining the fit/unfit potential of the member. Highlight the Sailor or Marine's ability to execute duties as required of his/her rating and the reality of their contribution. Discuss how their performance has been impacted. Discuss how the patient is attempting to work through his/her medical problem and meet daily goals to support the command's mission. The following guidelines should be followed in completing this paragraph: a. The NMA narrative summary is to be completed by the commanding officer. It captures his/her observations and those of other senior command personnel as to how the service member's medical impairments have or have not impacted upon the member's ability to function within the command. The NMA should describe how well the member performs military duties; i.e., MOS/rating duties, field duties or exercises, participation in the PRT/PFT, etc. Comment on what the member can or cannot do. Equally important is a description of the member's off-duty social and athletic activities. How have these activities been affected by the member's medical impairments? b. Commanding officers perform a vital role in assisting the PEB to make the proper Fit or Unfit determination. The commanding officer and senior command personnel are in the unique position to provide valuable information as to how the service member's physical and/or mental condition(s), as reported in the MEBR, affect the member's ability to function on a daily basis. The purpose of the NMA is to provide the PEB with those insights. c. The medical evaluation board has the responsibility to document the medical status of Sailors and Marines by describing the nature and severity of their medical conditions in the MEBR. The PEB function is to determine the servicemember's fitness to continue naval service. In the case of an unfitting condition, the PEB determines the required disability rating. Performance plays a large part in these decisions. d. For service members assigned to temporary holding units (TPUs), medical holding companies, or medical centers, commanding officers will complete those questions that pertain to the period of observation. If the TPU/medical center commanding officer has had sufficient observation of the member, then he or she will complete the questionnaire. If not, coordination with the previous command will be required to assist in answering questions covering the member's period of assignment to that command. 3. POC at this command is __________________ (name/rank/position) at Commercial _______________, DSN _______________, or e-mail ________________________________. ____________________________________ Commanding Officer

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Article 18-16
The legal standard of "clear and convincing evidence," not the less-demanding evidentiary standard of "beyond a reasonable doubt," is required to overcome the presumption of "in the line of duty" and "not the result of misconduct." (3) Intentional misconduct or willful neglect. Misconduct is wrongful conduct. However, simple or ordinary negligence or carelessness, standing alone, does not constitute misconduct. To support an opinion of misconduct, it must be established by clear and convincing evidence that the injury or disease either was intentionally incurred or the proximate result of such gross negligence as to demonstrate a reckless disregard of the consequences. If a resulting injury or disease is such that it could have been reasonably foreseen from the course of conduct, it is said to be a "proximate result." The fact that the conduct violates a law, regulation, or order, or the fact that the conduct is engaged in while the individual is intoxicated, does not, of itself, constitute a basis for a determination of misconduct. Such circumstances will however be considered along with all other facts and circumstances by the PEB in determining whether the conduct of the individual was grossly negligent, and whether the incurrence of injury or disease was reasonably foreseeable as a probable result of such conduct. (4) JAGINST 5800.7C (JAGMAN), chapter II, outlines policies and procedures for making LOD/ M determinations. If a member incurs a disease or injury that may result in a permanent disability or that results in the member's physical inability to perform duty for a period exceeding 24 hours (as distinguished from a period of hospitalization for evaluation or observation) then determination of whether the disease or injury was incurred in LOD or as a result of misconduct is required. At a minimum, in accordance with JAGMAN 0220d, a command must convene an investigation and make findings concerning misconduct and LOD when: (a) The injury was incurred under circumstances which suggest a finding of "misconduct" might result (for example, but not limited to, cases involving illegal drug use, intoxication, or bona fide suicide attempts). (b) The injury was incurred under circumstances that suggest a finding of "not in the line of duty" might result.

18-16

Line of Duty/Misconduct (LOD/M) Determination

(1) Under the laws (Title 10 USC, sections 12011204, 1206, and 1207) and regulations (SECNAVINST 1850.4 series) governing the Navy DES, members entitled to basic pay who incur or aggravate medical conditions which make them unfit to perform their military duties may be eligible to receive disability retirement or separation benefits. Members' eligibility to these benefits may be overcome however, if the physical disability resulted from the member's own intentional misconduct or willful neglect, was incurred while not in the LOD, or was incurred while the member was in an unauthorized absence status. (2) The SECNAVINST 1850.4 series details the LOD/M determination process, and critical attention should be paid to that section by MTFs determining whether to request LOD/M determination from parent commands. There is a legal presumption that any disease or injury discovered after a member enters active military service, with the exception of congenital and hereditary conditions, is presumed to have been incurred "in the line of duty" and "not the result of misconduct." While SECNAVINST 1850.4 series delineates several examples not considered in the line of duty, to include conditions incurred: (a) As a result of the member's own misconduct. (b) While avoiding duty by deserting the service. (c) During a period of unauthorized absence. (d) While confined under sentence of a courtmartial which included an unmerited dishonorable discharge. (e) While confined under sentence of a civil court following conviction for an offense which is defined as a felony by the law of the jurisdiction where convicted. (f) While on appellate leave.

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Article 18-16
(c) There is a reasonable chance of permanent disability and the CO considers the convening of an investigation essential to ensure an adequate record is made concerning the circumstances surrounding the incident. (d) The injured member is in the Naval or Marine Corps Reserve and the CO considers an investigation essential to an adequate official record made concerning the circumstances surrounding the incident. (5) JAGMAN section 0221details that each injury or disease requiring an LOD/M determination must be the subject of a preliminary inquiry. If, per JAGMAN 0221c, the preliminary inquiry shows in the opinion of the medical officer and with concurrence of the member's CO, that the injury or disease was incurred "in the line of duty" and "not as a result of the member's own misconduct" and appropriate medical record entries are made, no investigation need be convened. (6) JAGMAN sections 0230 and 0231 prescribe that commands record LOD/M determinations in the member's health or dental record. When a command investigation or written preliminary inquiry (as discussed in the preceding paragraph) has been prepared per JAGMAN, chapter II, commands will provide a copy of the inquiry or investigation with the General Court-Martial Convening Authority (GCMCA) endorsement, to the MEB convening authority for inclusion in the official records of the case which are forwarded with the MEBR for PEB consideration. The MEB will ensure the attending physician has made appropriate medical record entries concerning the preliminary inquiry, as detailed in the preceding paragraph. (7) As detailed in SECNAVINST 1850.4, section 3410, normally the PEB will accept the com