Free Supplemental Brief - District Court of Federal Claims - federal

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Chapter 18

Medical Evaluation Boards

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Manual of the Medical Department

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Contents

Chapter 18 CURRENT VS. REVISED CONTENTS
Old Article
18-1

Title
Purpose

New Article
18-1

Title
Overview, and Definition of MEBs and MEBRs MTF Convening Authority Definition and Responsibilities MTF Convening Authority Definition and Responsibilities Medical Evaluation Board (MEB) Composition Conditions and Circumstances Requiring the Convening of an MEB and Medical Conditions Not Meriting an MEB Being Convened; Administrative Redress; and Cases Involving Legal and/or Administrative Action Health Record Entries, Record Keeping Requirements, and TMU Inspections Various Sections, regarding MEBR preparation to PEB, for LIMDU, and under Death Imminent conditions Gathering Patient Data and Completing the Patient Information Sheet MTF Convening Authority Definition and Responsibilities Notifying and Counseling the Patient of the Decision to Convene an MEB. (Also see article 18-28)

18-2

Convening Authority

18-3

18-3

Responsibilities of the Convening Authority Composition

18-3

18-4

18-6

18-5

Convening of a Medical Board

18-4 and 18-5

18-6

Health Record Entity

18-8

18-7

Medical Board Report Preparations

18-12 through 18-14 18-9

18-8

Medical Board Report Cover Sheet (NAVMED 6100/1) Convening Authority Actions

18-9

18-3

18-10

Counseling the Member and Subsequent Processing

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Old Article
18-11

Title
Notification of Parent Command

New Article
18-10 and 18-15 through 18-17 and 18-28 18-10 through 18-18

Title
Multiple Sections, discussing various types of MEBRs including LIMDU and PEB cases, Non-Medical Assessments, and Cancellation of Cases at PEB Multiple Sections, discussing various types of MEBRs including LIMDU and PEB Cases, Non-Medical Assessments, and Cancellation of Cases at PEB. (Also see article 18-3) Definition of, and Processes for Complying With, Mandated Timeframes for Completion and Submission of MEBRs The Medical Board OnLine Triservice Tracking (MedBOLTT) System Format of the MEBR prepared for Placement on Limited Duty or for Referral to Service Headquarters Requesting Limited Duty (i.e., "Departmental Review") Multiple Sections, discussing LIMDU and PEB Cases, and special consideration in Flag, General, and Medical Corps Officers Recruits: Removal from "Full Duty" Status; MEBs on Recruits and Members Within First 180 Days of Service Recruits: Removal from "Full Duty" Status; MEBs on Recruits and Members Within First 180 Days of Service Recruits: Removal from "Full Duty" Status; MEBs on Recruits and Members Within First 180 Days of Service

18-12

Report Routing and Disposition

18-13

Processing Time

18-19

18-14

Automatic Data

18-27

18-15

Departmental Review

18-14

18-16

Medical Boards on Officers

18-10 through 18-14 and 18-24 18-21

18-17

Recruit Evaluation Unit

18-18

Determination of Fitness for Recruits for Service

18-21

18-19

Medical Boards on Recruits

18-21

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Contents

Old Article
18-20

Title
Medical Boards on Reservists

New Article
18-23

Title
Reservists: Physical Disqualification and Referral to the PEB Overview and Definition of MEBs and MEBRs and Limited Duty

18-21

Return to Duty-Aviation, Submarine, and Other Special Duty Personnel Members Who Refuse Medical, Dental, or Surgical Treatment Board With Disciplinary or Punitive/Misconduct Administrative Action

18-1 and 18-10

18-22

18-11

Determining Disability Cases to be Referred to the DON PEB Medical Conditions Not Meriting an MEB Being Convened; Administrative Redress; and Cases Involving Legal and/or Administrative Action Recruits: Removal from "Full Duty" Status; MEBs on Recruits and Members Within First 180 Days of Service Medical Conditions Not Meriting an MEB Being Convened; Administrative Redress; and Cases Involving Legal and/or Administrative Action Medical Conditions Not Meriting an MEB Being Convened; Administrative Redress; and Cases Involving Legal and/or Administrative Action Recruits: Removal from "Full Duty" Status; MEBs on Recruits and Members Within First 180 Days of Service MEB Composition and Notifying and Counseling the Patient of the Decision to Convene an MEB Limited Duty

18-23

18-5

18-24

Medical Boards Involving Waivers of Entry Standards

18-21

18-25

Conditions Not Considered A Physical Disability

18-5

18-26

Medical Boards for Members Medically Waived from the Physical Readiness Test

18-5

18-27

EPTE Physical Defects

18-21

18-28

Mental Competency and Incapacitation

18-6 and 18-7

18-29

Temporary Limited Duty (TLD) Medical Boards

18-10

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Old Article
18-30

Title
Light Duty

New Article
18-2

Title
Removal from Duty for Medical Reasons: Sick in Quarters (SIQ), Convalescent Leave, Light Duty, Limited Duty MTF Convening Authority Definition and Responsibilities MTF Convening Authority Definition Responsibilities Non-Medical Assessment (NMA); and Line of Duty/Misconduct (LOD/M) Determination Care at the End of Active Duty, Medical Care Subsequent to Submission of a Case to the PEB, and Fitness to Separate Rejection, Suspension, or Termination of Cases at PEB Checklist Elements for MEBR Being Submitted to the PEB MTF Convening Authority Definition and Responsibilities Incorporated in the body of the chapter

18-31

Triservice Medical Boards

18-3

18-32

Medical Boards from Other than DOD Sources Providing Additional Medical Information and Line of Duty and Misconduct Investigation Surgical Procedures on Member in the Disability Evaluation System

18-3

18-33

18-15 and 18-16

18-34

18-25

18-35

Withdrawing a Medical Board from the DES Medical Board Quality Control Checklist Cognizant MTFs for Triservice Medical Boards Acronyms

18-28

18-36

18-26

18-37

18-3

18-38

N/A

NEW ARTICLES 18-20 Transmission Methods, HIPAA, and Privacy Maintenance Students and Midshipmen Training for MTF Staff, Patient Counseling, and the Role of the PEBLOs Reference Listing N/A New Article

18-22 18-29

N/A N/A

New Article New Article

18-30

N/A

New Article

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Medical Evaluation Boards

Contents

Chapter 18 TABLE OF CONTENTS
Article
18-1 18-2

Title
Overview and Definition of MEBs and MEBRs Removal from Duty for Medical Reasons: Sick In Quarters (SIQ), Convalescent Leave, Light Duty, or Limited Duty MTF Convening Authority Definition and Responsibilities Conditions and Circumstances Requiring the Convening of an MEB Medical Conditions Not Meriting an MEB Being Convened; Administrative Redress; and Cases Involving Legal and/or Administrative Action Medical Evaluation Board (MEB) Composition Notifying and Counseling the Patient of the Decision to Convene An MEB Health Record Entries, Record Keeping Requirements, and TMU Inspections Gathering Patient Data and Completing the Patient Information Sheet Limited Duty Determining Disability Evaluation Cases To Be Referred to the DON PEB Format of the MEBR for Referral to the DON PEB Format of the MEBR for Referral to the DON PEB under Death Imminent Conditions Format of the MEBR Prepared for Placement on Limited Duty or for Referral to Service Headquarters Requesting Limited Duty (Departmental Review)

Page
18-9

18-12 18-16 18-19

18-3 18-4 18-5

18-22 18-24 18-25

18-6 18-7 18-8

18-25 18-26 18-33

18-9 18-10 18-11

18-38 18-41

18-12 18-13

18-51

18-14

18-51

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Manual of the Medical Department

Article
18-15 18-16 18-17 18-18 18-19

Title
Non-Medical Assessment (NMA) Line of Duty/Misconduct (LOD/M) Determination The Abbreviated MEBR Format of the MEBR for TDRL Reevaluation Definition of, and Processes for Complying With, Mandated Timeframes for Completion and Submission of MEBRs Transmission Methods, HIPAA, and Privacy Maintenance Recruits: Removal from "Full Duty" Status; MEBs on Recruits and Members Within First 180 Days of Service Students and Midshipmen Reservists: Physical Disqualification and Referral to the PEB Flag, General, and Medical Corps Officers: PEB Requirements Care at the End of Active Duty, Medical Care Subsequent to Submission of a Case to the PEB, and Fitness to Separate Checklist Elements for MEBR Being Submitted to the PEB The Medical Board OnLine Triservice Tracking (MedBOLTT) System Rejection, Suspension, or Termination of Cases at PEB Training for MTF Staff, Patient Counseling, and the Role of the PEBLOs Reference Listing

Page
18-53 18-55 18-57 18-59

18-60 18-62

18-20 18-21

18-64 18-68 18-68 18-69

18-22 18-23 18-24 18-25

18-70 18-72 18-73 18-74 18-75 18-77

18-26 18-27 18-28 18-29 18-30

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Medical Evaluation Boards

Article 18-1

Section I OVERVIEW
Article
18-1 Overview and Definition of Medical Evaluation Boards (MEBs) and Medical Evaluation Board Reports (MEBRs) Removal from Duty for Medical Reasons: Sick In Quarters (SIQ), Convalescent Leave, Light Duty, or Limited Duty

Page
18-9

18-2

18-12

18-1

Overview and Definition of Medical Evaluation Boards (MEBs) and Medical Evaluation Board Reports (MEBRs)

(e) Provides processes for referral of MEB cases into the Navy Disability Evaluation System (DES), including MTF processing responsibilities, and conditions not meriting referral to the DES. (f) Provides key references for additional research. (2) Overview and Definition. Navy Medicine will evaluate each instance in the career of a Navy and Marine Corps active duty service member (ADSM) in which a medical condition will be responsible for the member's inability to operate in a medically unrestricted duty status. Periods of "light duty" (as defined in article 18-2(4)) may be sufficient to allow a return to duty status; failing this, Navy Medicine will conduct MEBs to determine whether the member will be placed on temporary LIMDU and/or referred into the DES. For the purpose of determining cases to be referred to MEBs, "medically unrestricted duty status" signifies that there is no medical condition prohibiting the member's ability to fully execute the duties and responsibilities of their rank, rate, specialty, or office including operational/worldwide assignability. (Pregnancy does not, by governing directive definition, automatically equate to "medically restricted duty status" for purposes of MEB referral; directives issued by the respective Service headquarters on the management of pregnant servicewomen (see OPNAVINST 6000.1 series and Marine Corps Order (MCO) P3000.13 series) should be consulted for the appropriate protocols for those patients.)

(1) This chapter of the MANMED (a) Reiterates that MEB and MEBR operations are significant and vital components of appropriate patient care, as well as compelling readiness issues whose appropriate execution serves as a tangible force multiplier. (b) Defines the processes by which Navy and Marine Corps members are removed from full duty for medical reasons, including "light duty" and "limited duty (LIMDU)." (c) Delineates the operations, responsibilities, and composition of MEBs. (d) Identifies unique parameters of MEB evaluation of cases of recruits, reservists, and students in certain programs leading to a commission, Midshipmen, Flag and general officers, physicians, and personnel facing high year tenure or other mandatory separation or retirement proceedings.

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Article 18-1
(3) Medical Evaluation Board (MEB). An MEB is a panel of providers attached to one of the medical treatment facilities (MTFs) whose commander or commanding officer (CO) has been expressly designated to hold "convening authority" (CA) for MEBs. (MANMED article 18-3 describes CA in detail; article 18-6 details MEB composition.) (4) Medical Evaluation Board Report (MEBR). The deliberations of an MEB will result in a document of findings known as the MEBR. The MEBR will either: (a) Recommend placement of an active duty service member on a period of temporary LIMDU. (b) Verify that the member is "fit for duty," after being cleared from LIMDU, and should be able to execute the duties of their respective office. (c) Refer the case to the Department of the Navy (DON) Physical Evaluation Board (PEB) for disability adjudication and determination of fitness for continued service, in accordance with SECNAVINST 1850.4 series, "Department of the Navy Disability Evaluation Manual." (5) Distinguishing "Fit for Duty" from "Fitness for Continued Naval Service" (a) "Fit for Duty" refers to a pronouncement by a physician or by an MEB that a patient previously on light or LIMDU has healed from the injury or illness that necessitated the member's serving in a medically restricted duty status. (b) "Fitness for Continued Naval Service" is a finding made exclusively by the DON PEB in determining an ADSM's ability to continue serving in the Navy or Marine Corps. This topic is explained in detail in this chapter in article 18-10 regarding LIMDU and in article 18-11 regarding referral of cases to the DON PEB. (6) Distinguishing MEBs from MEBRs. There has historically been imprecision as to the meaning of the term "medical board." To remove the ambiguity inherent in this term, it will be superceded by the terms "Medical Evaluation Board " and "Medical Evaluation Board Report." It is imperative to distinguish between an MEB-the providers evaluating a patient, and an MEBR-the MEB's product.

Manual of the Medical Department
"Medical boards" are most appropriately referred to as MEBs, and will be identified as such throughout the remainder of this chapter and in the operations of Navy Medicine. (7) Coordination. This chapter has been coordinated by the Bureau of Medicine and Surgery (BUMED) through the Office of the Chief of Naval Operations (OPNAV) (particularly N-1) and Headquarters, United States Marine Corps (USMC). This chapter is maintained by the BUMED Patient Administration and TRICARE Operations Branch; 2300 E Street, NW, Washington DC 20372-5300. All inquiries on, or proposed changes to, the content of this chapter should be directed to that branch. Additionally, information on "best practices" that MTF officials and other stakeholders wish to share with others to enhance the efficacy of the enterprisewide MEB operation are actively solicited by the BUMED Patient Administration and TRICARE Operations Branch for distribution to the field.
Note: The optimal use of this chapter will be derived by reading it in its entirety, and by comprehensively reading the resources referenced within. However, owing to the complexity of the subject matter, topics have been presented in sufficient detail that the articles of the chapter can "stand alone" for those requiring rapid information on a specific topic. Accordingly, much of the information in the chapter is repeated, intentionally, in a number of the articles, and information from the references is liberally imported, so that readers can still derive benefit by reference to particular articles (as depicted in the Table of Contents) if a comprehensive read of the chapter and additional references is not possible.

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Medical Evaluation Boards

Article 18-2

REMOVAL FROM DUTY FOR MEDICAL REASONS: SICK IN QUARTERS (SIQ), CONVALESCENT LEAVE, LIGHT DUTY, LIMITED DUTY

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Article 18-2

Manual of the Medical Department
the facilities to accommodate the patient's condition, and the availability of any necessary auxiliary caregivers at the member's "quarters," are entirely clinically compatible with the condition for which the member is being placed SIQ. (b) Providers are also responsible for ensuring the patient in an SIQ status fully understands any follow-on evaluation and care requirements during and following the SIQ period. (c) Appropriate clinical judgment is critical in successfully evaluating a patient for SIQ status, and any doubt as to the appropriateness of an SIQ placement will be resolved by foregoing SIQ status in lieu of a more comprehensive treatment protocol. (d) The recommendation to place a member on SIQ must be communicated by the senior medical department representative or MTF to the appropriate level of the member's parent command for concurrence. MTF commanders and senior medical department representatives shall ensure an appropriate notification process exists for timely notification to an ADSM's parent command of any SIQ recommendation; a critical component of this process is verifying the timely receipt of information by the parent command. MTF business practices in this regard must carefully balance the undeniable need to provide information to the parent command with the need to protect the patient against further aggravation or discomfort from the condition that has resulted in the SIQ recommendation. In some cases, requiring the patient to physically return to his or her parent command to present an "SIQ chit" for approval may be clinically contraindicated. Here, the provider and MTF leadership need to rely on other appropriate communication methods that satisfy both the health care needs of the patient and the operational and administrative control needs of the parent command (e.g., if the patient's return to the parent command is contraindicated, the provider or another appropriate MTF official might call the patient's division officer for official notification; this would be followed by the patient's delivering the SIQ paperwork to the division officer upon the patient's return to duty). (1) In the event of a conflict between the MTF's SIQ recommendation and the parent command's willingness to grant SIQ status, the matter should be elevated to such a level in the chain of command of the respective MTF and the parent command that an appropriate compromise is achieved

18-2

Removal from Duty for Medical Reasons: Sick In Quarters (SIQ), Convalescent Leave, Light Duty, or Limited Duty

(1) MTF Responsibilities. Navy MTFs will recommend Navy and Marine Corps members for periods of medically restricted duty when this is deemed clinically appropriate by properly credentialled Department of Defense (DOD) health care providers. MTF leadership will ensure an appropriate mechanism exists within their respective MTFs to notify the patient, the patient's parent command, and when possible, the patient's personnel support detachment (PSD) or administrative office, of the timeframe of this medically restricted duty period, and of the restrictions from duty recommended for the service member in each case. The following paragraphs present the categories of potential "medically restricted duty" status for Navy and Marine Corps members. (2) Sick In Quarters (SIQ). A properly credentialled DOD health care provider may recommend a member for SIQ status following medical treatment or for the purpose of "medically directed self treatment." "SIQ," as implied in the name, is a status in which the military member is relieved of all military duties with the expectation that the member will be in his or her residence recuperating until the expiration of the SIQ period. Providers recommending members for SIQ do so in full anticipation that the member will return to a medically unrestricted duty status at the conclusion of the SIQ period. SIQ status should usually not exceed 72 hours. (MILPERSMAN articles in the 1050 series and MCO P1900.16 series may be consulted for additional information in those rare instances in which extensions of SIQ status (potentially up to 14 days) emerge as medically indicated. Respective Service headquarters instructions on the management of pregnant servicewomen should be consulted for special categories of SIQ, e.g., "OB Quarters," that may be appropriate in caring for these patients.) (a) Health care providers recommending a service member for SIQ are responsible for ensuring, in concert with the ADSM's parent command, that

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Medical Evaluation Boards
that preserves both the parent command's mission readiness posture and the patient's well-being. As in all endeavors, the member's CO bears overall and final responsibility for the well-being of the member; Navy Medicine must ensure that appropriate information is conveyed that allows COs to exactingly carry out this responsibility in medical matters. (2) Placing a member on SIQ does not require the convening of an MEB. (3) Convalescent Leave. A properly credentialed DOD health care provider may recommend a member be placed in convalescent leave (often referred to as "con leave") status following significant medical treatment and/or a period of inpatient hospitalization. "Convalescent leave" is a period when the member is relieved of all military duties and is in a leave status until the expiration of the leave period. (Convalescent leave is not charged as regular leave; if given medical clearance members may travel, usually at their own expense, to a location other than their residence during a convalescent leave period. Some convalescent leave travel for members medically evacuated (MEDEVAC'd) from a war zone may qualify for reimbursement.) Every health care provider recommending convalescent leave on any patient will be familiar with the provisions of, and have ready access through their patient administration officer to, MILPERSMAN article 1050-180, MCO P1900.16 series, and NAVMEDCOMINST 6320.3B, section A-4d (as modified by BUMED Notice 1300 of 3 May 1991) which detail convalescent leave policies. Providers must pay particular attention to factors such as length of convalescent leave periods and requirements for medical evaluation during and at the conclusion of convalescent leave.
Note: Convalescent leave periods are not to exceed 30 days (with the exception of post-delivery maternity cases in which 42 days of convalescent leave may be recommended). Questions on any aspect of the convalescent leave program are to be referred to the MTF's patient administration officer.

Article 18-2
(b) Appropriate clinical judgment is critical in successfully evaluating a patient for convalescent leave status, and any doubt as to the appropriateness of a convalescent leave recommendation will be resolved by foregoing the leave in lieu of a more comprehensive treatment protocol. (c) The decision to place a member on convalescent leave generally requires concurrence of the member's parent command. (In instances where the member's parent command is geographically removed from the MTF recommending convalescent leave, the MTF CO or their designee can approve the convalescent leave without approval of the parent command.) Parent command concurrence on a convalescent leave recommendation is often obtained by having the member deliver the convalescent leave request, after medical endorsement from the provider, to the parent command. There may be cases however, in which directing the patient back to the parent command is logistically difficult or clinically contraindicated based on the condition that resulted in the convalescent leave recommendation. In these instances, MTF business practices must carefully balance the undeniable need to provide information to the parent command with the need to protect the patient against further aggravation or discomfort from the condition that has resulted in the convalescent leave recommendation. In such cases, the provider and MTF leadership need to rely on other appropriate communication methods that satisfy both the health care needs of the patient and the operational and administrative control needs of the parent command (e.g., if the patient's return to the parent command prior to starting convalescent leave is clinically contraindicated, the provider or another appropriate MTF official might call the patient's division officer for official notification; this would be followed by the patient's delivering to the division officer the convalescent leave paperwork upon the patient's return to duty. Moreover, the convalescent leave notification can be conveyed in the message traffic sent by MTFs to parent commands advising them when command members are discharged from an inpatient hospitalization.). (d) In the event of a conflict between the MTF's convalescent leave recommendation and the parent command's granting convalescent leave, the matter should be elevated to such a level in the chain of command of the respective MTF and parent command that an appropriate compromise is achieved

(a) Health care providers recommending convalescent leave are responsible for ascertaining from the patient that the facilities to accommodate the patient's condition, and the availability of any necessary auxiliary caregivers at the member's proposed convalescent leave site, are entirely clinically compatible with the patient's condition.

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Article 18-2
that preserves both the parent command's mission readiness posture and the patient's well-being. As in all endeavors, the member's CO bears overall and final responsibility for the well-being of the member; Navy Medicine must ensure that appropriate information is conveyed that allows COs to exactingly carry out this responsibility in medical matters. (e) Placing a member on convalescent leave does not of itself require the convening of an MEB. (4) Light Duty. A properly credentialed DOD health care provider may recommend a Navy or Marine Corps member for light duty to evaluate the affect that an illness, injury, or disease process has on the member's ability to be in a medically unrestricted duty status. "Light duty" is a period when the member reports to their work space, but during the period the member is excused from the performance of certain aspects of military duties, as defined in their individual light duty write-up. The goal of light duty is to allow for appropriate clinical evaluation without causing further damage to the patient during the evaluation period. A provider placing a member on light duty does so only with the expectation that the member will be able to return to medically unrestricted duty status at the end of the light duty period; care must be exercised to ensure that light duty is not abused or used as an inappropriate substitute for MEB overview of a case. Accordingly, when a diagnosis is initially made of a new condition for which the provider feels light duty is appropriate, light duty is permitted. (This criterion of a "new condition" does not preclude multiple "light duty" periods over the course of a member's career; it does however preclude excessive periods of light duty consecutively for the same condition.) Light duty presumes frequent provider and patient interaction to determine whether return to medically unrestricted duty status or more intensive therapeutic intervention is appropriate in any given case. Therefore, light duty will be ordered in periods not to exceed 30 days to ensure appropriate patient clinical oversight. Consecutive light duty for any "new condition" up to 90 days may be ordered by the provider (in maximum 30-day periods), but in no case will light duty exceed 90 consecutive days, inclusive of any convalescent leave periods. At the end of the light duty period, the member will either be immediately returned to medically unrestricted duty or will be referred to an MEB.

Manual of the Medical Department
(a) The MEB will prepare an MEBR for placing the member on temporary LIMDU and/or referring the member to the PEB for DES processing. In no case will a member reach the 90th day of light duty without the MTF having submitted an MEBR either placing the ADSM on LIMDU or referring the patient to the PEB for DES adjudication. (b) A provider recommending a member for a light duty status will complete NAVMED 6310/1 (11-2004), Individual Sick Slip. The provider will clearly annotate the restrictions and limitations imposed upon the member's duty, as well as the time period required in a light duty status. The provider will ensure that the NAVMED 6310/1 is placed in the member's health record and that copies are provided to the member for the member to deliver to the parent command. (c) If there is a question that the medical condition necessitating light duty is due to an injury, thereby requiring line of duty/misconduct (LOD/M) determination, the provider will ensure the member is directed to the MTF's patient administration department immediately following the determination that light duty is clinically indicated. The patient administration or medical boards office will launch (via naval message traffic) the request to the parent command for a line of duty determination/investigation (LODD/I). LOD/M determinations are discussed in more detail in article 18-16. (d) The decision to place a member on light duty requires concurrence of the member's parent command. As light duty placement, by definition, will usually return the patient to the parent command throughout the light duty period, parent command concurrence for a light duty recommendation is most often obtained by having the member deliver the light duty recommendation to the parent command. MTF commanders shall ensure an appropriate notification process exists by which the MTF makes timely notification to the parent command of any Navy or Marine member recommended for light duty; a critical component of this process is a mechanism for positively verifying the timely receipt of information by the parent command. (e) MTF providers and patient administration officers must maintain close liaison with parent commands of members placed on light duty, and remain mindful of the burdens placed on a command when

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Medical Evaluation Boards
its members are medically restricted from performing aspects of their duty. In the event of a conflict between the MTF's light duty recommendation and the parent command's granting light duty, the matter should be elevated to such a level in the chain of command, of the respective MTF and parent command, that an appropriate compromise is achieved that preserves both the parent command's mission readiness posture and the patient's well-being. However, if a parent command indicates that it is incapable of accommodating a proposed light duty placement for a member, and the provider has conclusive clinical indications that denial of light duty will cause further harm to the patient, the provider should immediately initiate MEB proceedings for an MEBR leading to the patient's placement on temporary LIMDU. As in all endeavors, the member's CO bears overall and final responsibility for the well-being of the member; Navy Medicine must ensure that appropriate information is conveyed that allows COs to exactingly carry out this responsibility in medical matters. (f) Placing a member on light duty does not require the convening of an MEB. (5) Limited Duty. A properly convened MEB at an MTF may recommend that a member be placed on a documented period of medically restricted duty as a result of illness, injury, or disease process. LIMDU is a period when the member reports to their work space, but during the period the member is excused from the performance of certain aspects of military duties as defined in their individual LIMDU write-up. For this chapter, and in the actions of all MEBs throughout Navy Medicine, "limited duty" will refer to temporary limited duty (as opposed to permanent limited duty). Temporary limited duty is also known as LIMDU and or TLD; these terms are used interchangeably throughout this chapter. (a) LIMDU is similar in many respects to light duty; major differences between the two are that, in comparison to light duty, LIMDU periods: (1) Last longer than light duty periods. (2) Require notification to not only the parent command, but to respective service headquarters and the servicing PSD of the member's status. (3) May necessitate the transfer of the member from the parent command if it is a deployable unit.

Article 18-2
(4) Do not necessarily require the consent of the member's parent command, or of the respective service headquarters. MTF commanders possessing "Convening Authority" allowing them to empanel MEBs must ensure appropriate business practices to alleviate undue burden on both the patient and the patient's parent command, and must include in all LIMDU cases appropriate notification to the patient's parent command servicing personnel/administrative office, and the respective service headquarters personnel office. (b) Continuing care, recovery, and rehabilitation are conducted during LIMDU in an effort to return the member to medically unrestricted duty status. (c) LIMDU may only be provided to a patient as the result of the actions of an MEB. LIMDU MEBs are addressed in detail in article 18-10. (d) A patient whose case is referred to the PEB for DES adjudication, if the patient is not already in a LIMDU status, will be concurrently placed on LIMDU pending the PEB outcome. The Abbreviated Limited Duty Medical Evaluation Board Report detailed in article 18-17 may be used for this purpose.

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Section II CONVENING MEDICAL EVALUATION BOARDS (MEBs)
Article
18-3 18-4 MTF Convening Authority Definition and Responsibilities Conditions and Circumstances Requiring the Convening of a Medical Evaluation Board (MEB) Medical Conditions Not Meriting an MEB Being Convened; Administrative Redress; and Cases Involving Legal and/or Administrative Action Medical Evaluation Board (MEB) Composition Notifying and Counseling the Patient of the Decision to Convene An MEB Health Record Entries, Record Keeping Requirements, and TMU Inspections Gathering Patient Data and Completing the Patient Information Sheet Limited Duty Determining Disability Evaluation Cases To Be Referred to the Department of the Navy Physical Evaluation Board (DON PEB)

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18-22 18-24 18-25 18-25 18-26 18-33

18-6 18-7 18-8 18-9 18-10 18-11

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MTF Convening Authority Definition and Responsibilities

(1) Convening Authority. Authority in Navy Medicine to convene MEBs is granted exclusively to the COs of naval medical centers, naval hospitals, naval medical clinics, and the naval ambulatory care centers. As such, these officers may order an MEB

comprising providers under their respective command to evaluate any member of the Armed Forces. Only MTFs whose COs have "CA" can conduct MEBs. (This "authority" is not to be confused with court-martial CA pursuant to the Uniform Code of Military Justice (UCMJ).) Officers in charge (OICs) of branch medical clinics do not hold CA; neither do operational unit surgeons or ship medical officers. Within DON, other than the MTF commanders identified in this paragraph, and those officers identified in article 18-3(2) below, no other command or officer may convene an MEB, or take unilateral action to place a member on LIMDU, or refer a member's case to the DON PEB.

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(2) Additional Officers Authorized to Order MEBs. The Chief of Naval Operations (CNO), the Commandant of the Marine Corps (CMC), the Fleet Commanders, the Chief of Naval Personnel (CHNAVPERS), the Commander, Naval Reserve Force (COMNAVRESFOR), the Chief, Bureau of Medicine and Surgery (BUMED), and the OIC, Military Medical Support Office (MMSO) may also initiate MEBs by ordering one of the CA officers identified in article 18-3(1) to convene an MEB. (3) Delegation of CA Signatory Responsibility for Approving MEBRs. The COs defined as CAs in article 18-3(1) may delegate, in writing, signatory responsibility for acting in their behalf to approve or disapprove the findings and recommendations of an MEB convened at their respective MTFs. This delegation does not confer CA status; it allows appropriate senior clinical leaders at the MTFs to assist their MTF CA in the execution of his or her myriad responsibilities by reviewing and processing MEBRs. Deciding whether to delegate this signatory responsibility is entirely at the discretion of each MTF commander for his or her respective command. If the CA does award signatory responsibility, the following hierarchy will be followed: at Naval medical centers and naval hospitals, this signatory responsibility delegation may be granted to appropriate directors and clinical department heads; at naval medical clinics and naval ambulatory care centers, this delegation will not be granted below the level of the chief of clinical services. (4) Branch Medical Clinics and Operational Units (a) In no circumstance will CA signatory responsibility be delegated to branch medical clinics. (b) MTF commanders, may, however consider authorizing their respective branch clinic's clinical staffs to serve as MEB members and to initiate MEBRs which then must be forwarded to the MTF for processing and CA approval and signature before the MEBR findings or recommendations become effective. This initiative to "move paper, not patients" affords the opportunity to rapidly assess members, to assist in compliance with TRICARE access standards, and to potentially reduce travel difficulties and time away from the command for members whose conditions merit MEB referral. Evaluation of a

Article 18-3
branch medical clinic's capability to initiate MEBRs must be predicated on the availability (either internally or in conjunction with TRICARE partners) of clinically appropriate diagnostic resources and appropriate medical specialists. MTF commanders will personally render the decision on which of their respective branch clinics are authorized to initiate MEBRs, will communicate this policy in writing throughout their respective commands, and will ensure an appropriate evaluation process exists to monitor the efficacy of this program. This initiative is only available to branch medical clinics under the auspices of an MTF whose commander has CA. (1) Shipboard and operational unit medical department representatives who are not under the direct chain of command of an MTF commander with CA, as defined in article 18-3(1) above, are not eligible to participate in this initiative and are prohibited from independently executing MEB actions and MEBRs. (2) Similar prohibitions exist on providers who are permanently assigned under the direct chain of command of an MTF commander with CA, but who are temporarily rendering care at an operational unit (e.g., on temporary additional duty (TAD) or "circuit riding" to provide specialty care). Cases these providers determine to require consideration for LIMDU or for referral to the PEB must be referred for action to an MTF whose commander or CO holds CA. (As delineated in article 18-3(4)(b) above, MTF commanders may consider authorizing these providers to serve as MEB members and initiate MEBRs which then must be forwarded to the MTF for processing and CA approval and signature before their findings and/or recommendations become effective.) Accordingly, no provider can unilaterally place a member on LIMDU or otherwise execute MEB actions in the absence of deliberation by other MEB members and the approval of an MTF CA. For shipboard/operational personnel, it is likely that a condition significant enough to merit referral to an MEB is not compatible with continued shipboard/operational unit service; providers and patient administration officers must ensure close liaison with the parent command of members in this situation to effect appropriate transfer (e.g., temporary duty (TEMDU) orders on enlisted members or permanent change of station (PCS) orders on officer members) for treatment.

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(5) Other Service and TRICARE Provider Involvement in Navy and Marine MEBs (a) Paperwork on the cases of all Navy and Marine members undergoing any MEB action must be processed through a Navy MTF, even if an MTF of another branch of the Armed Forces initiated the MEB or if TRICARE network providers were engaged in the preparation of the MEBR. (b) Previous editions of this chapter provided detailed listings of which U.S. Army and U.S.Air Force MTFs should receive and send MEB cases to Navy MTFs. In this iteration, MTF commanders are allowed discretion in determining which MTFs they will work with regarding MEB actions. Of paramount importance is the establishment of positive working relationships between respective MTF medical board services, as significant aspects of this performance of MEBs (e.g., "profiles" in other services) differ among the branches of the Armed Forces. Navy MTFs receiving MEBs from other service MTFs on Navy and Marine personnel shall ensure that the patient administration department reviews all work being forwarded from the other services' MTF; at the conclusion of this verification, the patient administration/MEB officer shall append a Navy cover sheet, bearing all signatures and designations as required for processing any board originating within a Navy MTF, to the MEBR before forwarding it to the CA. (6) Responsibilities of the CA (a) Ensuring that patients being evaluated by an MEB are thoroughly and appropriately counseled on the process. The CA will ensure as well that patients are, as appropriate, made thoroughly familiar with LIMDU, medical holding company operations, DES processing, and the role of the PEB liaison officers (PEBLOs). A critical part of this requirement for counseling is the provision of appropriate physical plant spaces in which patients meet with providers, MTF medical boards staff, and PEBLOs such that patient privacy is protected and confidential counseling can occur. (b) Ensuring that patients being evaluated by an MEB are made thoroughly aware of the findings of the MEB, are provided a copy of the MEBR, are afforded the opportunity to discuss opinions and recommendations with each member of the MEB, and are afforded the opportunity to submit a statement

Manual of the Medical Department
on any portion of the MEBR, which then becomes a part of the official documentation of the MEBR. If the CA determines that revealing any of the information contained in the MEBR to the patient will be harmful, deleterious, or have adverse affect on the mental and physical health of the patient, or if the patient has been determined mentally incompetent or incapacitated to handle his or her own affairs, the CA will instead ensure that the legally appropriate next of kin (or legally appointed trustee) representing the patient is provided all information and afforded all rights described in this article (see SECNAVINST 1850.4 series, Navy Disability Evaluation Manual, that offers additional information on this topic). (c) Ensuring that only appropriately trained providers are appointed to MEBs. In addition to requisite clinical training, appropriate training, at a minimum, consists of thorough familiarity with this document and with the SECNAVINST 1850.4 series. The CA will ensure that defined criteria for MEB membership are published for their respective commands, and will ensure development of verification methods to ensure that only fully trained providers are allowed to comprise MEBs. (d) Ensuring that MEBs are comprised of the correct number and specialties (board certified or board eligible) of providers, appointed based on the condition and status of the patient being evaluated (e.g., psychiatrists on a mental incapacitation board, or reserve representation when a reservist is being evaluated by an MEB). Article 18-6 details MEB composition. (e) Ensuring that MEB office and patient administration staff members are appropriately trained in supporting MEBs, including the compilation and processing of MEBRs. This training, at a minimum, consists of thorough familiarity with this document and with the SECNAVINST 1850.4 series, Navy Disability Evaluation Manual. Training must also be implemented at the MTF level to ensure that the patient administration staff who will be serving and counseling patients are adequately prepared for their vital roles. Article 18-29 details MEB training requirements. (f) Ensuring inclusion of all indicated medical tests and examinations, including a complete physical examination (PE), conducted in accordance with the Manual of the Medical Department (MANMED)

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chapter 15 and as required by the SECNAVINST 1850.4 series (attachment A to enclosure (8)) for those cases being referred to the PEB, with each MEBR, and ensuring that all appropriate annotations of MEB activity are incorporated into the patient's medical record. (g) Ensuring compliance with processing timeframes stipulated in the SECNAVINST 1850.4 series, Navy Disability Evaluation Manual, and ensuring proper entry of MEBR information in the Medical Board OnLine Triservice Tracking (MedBOLTT) System, or systems that replace it, as installed in MTFs and operated under the aegis of Naval Medical Information Management Center (NMIMC). (h) Ensuring that appropriate liaison is maintained with the Responsible Line Commander, parent commands, and servicing personnel support activities and detachments of patients undergoing MEB processing, as well as with the NAVPERS Transient Monitoring Unit (TMU). Critical among this liaison function is ensuring that monthly meetings held by the MTF for "LIMDU coordinators" representing all commands with patients on LIMDU occur as required by the MILPERSMAN. MTFs can significantly enhance their performance in this regard by ensuring appropriate interoperability exists between their MEB offices and their Operational Forces Medical Liaison Services Office. (i) Ensuring, in conjunction with the PEB, that indicated cases are brought to the attention of the Chief, BUMED (BUMED Risk Management) for review and possible reporting to the National Practitioner Data Bank (DPDB) as delineated in section 5.2.9. of DOD Directive 6025.13 of 4 May 2004, Medical Quality Assurance (MQA) in the Military Health System.

Article 18-4

18-4

Conditions and Circumstances Requiring the Convening of an MEB

(1) Proposals of MEBs. An MEB evaluates a patient and produces an MEBR on that patient's condition. MTF CAs may convene an MEB to evaluate and prepare an MEBR on any member of the military. MEBRs are used for two purposes: (a) Placing a patient on temporary limited duty (TLD or LIMDU). (b) Referring a patient to the PEB for a determination of the patient's fitness for continued service. The DON PEB is not under the aegis of Navy Medicine, and reports directly to the Director, Secretary of the Navy Council of Review Boards (DIRSECNAVCORB) formerly DIRNCPB. Delegated by the Secretary of the Navy (SECNAV), the PEB, under DIRSECNAVCORB, has sole authority within the DON to determine a Navy or Marine member's fitness for continued Naval service for a condition which may constitute disability. (2) Circumstances Indicating Need for an MEB. An MEB shall be initiated when a physician trained and certified for MEB membership by the MTF CA (as defined in articles 18-3(5) and 18-6) determines that: (a) A member has a condition that appears to significantly interfere with performance of duties appropriate to the member's office, grade, rank, or rating. (b) A member has a condition that will prohibit returning the patient to his or her parent command in a medically unrestricted duty status following appropriate light duty as defined in article 182(4). Special consideration must be exercised in cases involving members assigned to operational commands which may be unable to sustain the unplanned loss of ADSMs for significant light duty periods. For these ADSMs, placement of the member on LIMDU or in a medical holding company status

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Article 18-4
may be indicated to ensure the most appropriate personnel status of the unit and allow for the parent command to effect an "unplanned loss" replacement most expeditiously; MTF staff must be in close liaison with the patient's commands in these cases to determine appropriate actions. (c) A member has a condition that may seriously compromise the member's health or well-being if the member were to remain in the military service (e.g., continued service would likely result in extended hospitalization(s), requirements for close medical supervision, or potential aggravations of the existing condition). (d) A member has a condition that may prejudice the best interests of the Government if the member were to remain in the military service. (e) A member has a condition that requires assignment limitations (e.g., geographic restraints or assignment near a particular MTF with specialty services, etc.). (f) An inactive reservist incurs or aggravates an injury or illness during a period of active service and the period of required treatment, rehabilitation, or convalescence is expected to exceed 12 weeks or require retention beyond authorized active duty service orders. (g) A member refuses reasonable medical or dental treatment (including surgery) and the member's ability to perform medically unrestricted duty is suspect. In these cases, the CA will determine the "reasonableness" of the member's refusal to accept indicated care, predicated on appropriate clinical standards of practice, availability of reliable care, (e.g., in an outside of the Continental United States (OCONUS) setting where care is not available at an MTF and MEDEVAC is clinically contraindicated), and other factors the CA deems appropriate. (h) A member who has "self-referred" for elective care outside the direct Military Health System (MHS) (e.g., for organ donation or corrective laser eye surgery) who sustains an untoward outcome that calls into question the member's continued fitness for service as a result of that care will be referred by an MEB to the DON PEB. The PEB will determine the member's fitness for continued Naval service and concurrently will determine whether the

Manual of the Medical Department
patient is eligible for disability benefits. Parent commands and MTFs must perform specific counseling requirements; refer to SECNAVINST 1850.4, BUMEDINST 6320.72, and BUMEDINST 6300.8 series instructions. (i) A member whose condition indicates the need to receive an organ transplant merits referral to an MEB; close coordination between the MTF and the PEB must occur in these cases, particularly if the member is being retained in an active duty status until the completion of the transplant; refer to SECNAVINST 1850.4 series, enclosure (8), attachment A, paragraph 2s. (3) Conditions Indicating Need for an MEB. SECNAVINST 1850.4 series, enclosure (8), provides a listing of "Medical Conditions and Physical Defects Which Normally are Cause for Referral to the Physical Evaluation Board." While the primary consideration in determining whether an MEB should be convened is the professional judgment of the attending physician, this list should be consulted frequently by providers and patient administration staff. (4) Referral of Patients to an MEB. Uniformity throughout Navy Medicine in referring patients to MEBs is a critical issue for our MTFs, our patients, and their parent commands. Issues beyond those implicit in the care of an individual patient, such as total force personnel strengths and the maintenance of a fit force, are key and vital considerations that must be addressed concurrently with the delivery of exactingly efficacious medical care. Accordingly, the criteria for convening MEBs and preparing MEBRs must be diligently applied throughout Navy Medicine. While each unique patient's case merits scrutiny for extenuating circumstances, the operating parameter for the overwhelming majority of our patients is that if an ADSM has a medical condition which will be responsible for their inability to operate in a medically unrestricted duty status for 90 days or greater duration, the patient must be referred to an MEB for placement in a TLD/LIMDU status and/or for referral to the DON PEB. (5) Guidelines for Convening MEBs. The following provides guidelines for convening MEBs to place patients on TLD/LIMDU and/or refer patients to the PEB: (See next page for guidelines.)

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(a) Enuresis.

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Medical Conditions Not Meriting an MEB Being Convened; Administrative Redress; and Cases Involving Legal and/or Administrative Action

(b) Sleepwalking and/or somnambulism. (c) Dyslexia and other learning disorders. (d) Attention deficit hyperactivity disorder. (e) Stammering or stuttering. (f) Incapacitating fear of flying confirmed by psychiatric evaluation.

(1) MEBs convene to evaluate patients and produce MEBRs that either place a member on temporary LIMDU and/or refer a member to the PEB for disability evaluation. The Navy Disability Evaluation Manual, SECNAVINST 1850.4 series defines "disability" as "any impairment due to disease or injury, regardless of degree, that reduces or prevents an individual's actual or presumed ability to engage in gainful employment or normal activity." (2) As stipulated in the Navy Disability Evaluation Manual 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." 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." (3) Conditions not meriting an MEB. Accordingly, the mere presence of a physical or mental condition does not constitute a "disability" and therefore there are conditions and situations in which convening an MEB is neither appropriate nor desired. Certain conditions and defects of a developmental nature are not ratable in the absence of an underlying ratable causative disorder. These conditions, while not appropriate for MEB referral, may be referred for appropriate administrative action (for Navy, MILPERSMAN article 1900 series applies and for USMC, the Marine Corps Separation and Retirement Manual (MARCORSEPMAN), chapter 6, applies) and include, but are not limited to, the following, which are detailed in SECNAVINST 1840.4 series (in sections 2016 and 3202, and in attachment B to enclosure (8)):

(g) Airsickness, motion sickness, and/or travel sickness. (h) Phobic fear of air, sea, and submarine modes of transportation. (i) Uncomplicated alcoholism or other substance use disorder. (j) Personality disorders. (k) Mental retardation. (l) Adjustment disorders. (m) Impulse control disorders. (n) Homosexuality. (o) Sexual gender and identity disorders paraphilias. (p) Sexual dysfunction. (q) Factitious disorder. (r) Obesity. (s) Overheight. (t) Psuedofolliculitis barbae of the face and/ or neck. (u) Medical contraindication to the administration of required immunizations. (v) Significant allergic reaction to stinging insect venom. (w) Unsanitary habits. (x) Certain anemias, in the absence of unfitting sequelae, including G6PD deficiency, other inherited anemia trait, and Von Willebrand's Disease. (y) Allergy to uniform clothing or wool.

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(z) Long sleeper syndrome. (aa) Hyperlipidemia. (4) Circumstances Not Meriting an MEB for Referral to the PEB. In addition to the medical conditions listed above, the following circumstances also contraindicate evaluation by an MEB for referring the matter to the PEB (refer to SECNAVINST 1850.4 series, section 3202): (a) Lack of motivation to perform duty. (b) Request by member for referral to an MEB or PEB in the absence of appropriate diagnosis(es) meriting an MEB. (c) Inability of member to meet initial enlistment/appointment standards. (d) Physical disqualification for special duties. (e) Inability to meet physical standards for specific assignment or administrative requirement. (This includes participation in physical readiness test (PRT), physical fitness tests (PFT), and physical fitness assessment (PFA) cycle. Referral to the PEB merely due to an inability to participate in PRT, PFT, and PFA is inappropriate; however, if the inability to participate in the PRT, PFT, and PFA is due to an illness or injury that is a potential disability as defined elsewhere in this chapter and in the SECNAVINST 1850.4 series, then referral to the PEB is appropriate. Close coordination with respective service headquarters and respective Service PRT, PFT, and PFA instructions is encouraged in these cases.) (f) Members being processed for separation or retirement for reasons other than physical disability (unless the member was previously found unfit by the PEB and is in a permanent LIMDU status, or unless the member's physical condition reasonably prompts doubt that he or she is fit to continue to perform their duties pending the separation or retirement). (5) Pregnancy. An MEB is not mandatory in cases of servicemembers temporarily unable to perform aspects of their duty due to pregnancy or complications from pregnancy; service directives (i.e., OPNAVINST 6000.1 series and MCO P3000.13 series) provide reporting requirements and amplifying information particularly related to protocols that

Article 18-5
"some servicewomen may require a significant alteration in work assignment which may adversely impact the command." Referral for administrative separation is not routinely appropriate in cases of pregnant servicewomen; the sole exception to this is recruits found to be pregnant upon reporting to their respective recruit training commands for basic training. In these cases, as conveyed for instance for Navy personnel in MILPERSMAN article 1910-112 "Separation by Reason of Convenience of the Government - Pregnancy:" "Members who are pregnant, and medical authorities certify in writing that the pregnancy existed prior to entry into the service, will be separated following MILPERSMAN article 1910-130, "Separation By Reason of Defective Enlistments and Inductions and Erroneous Inductions - Erroneous Enlistment," and shall be separated without medical benefits." OPNAVINST 6000.1 series provides guidance on the administrative management of pregnant servicewomen. (6) Legal and Administrative Considerations. In cases in which the member is facing legal and/or involuntary administrative separation issues that may result in separation, these processes and their outcomes, as mandated by service headquarter directives, supercede MEB action, including referral to the PEB for DES processing. For this reason, it is critical that MTFs contemplating convening an MEB on a patient ascertain whether the patient is pending any legal or administrative proceeding or involuntary administrative separation (as indicated in the patient information sheet, see article 18-9). Any cases in which a legal or involuntary administrative separation concern emerges should immediately be referred to the appropriate service headquarters (PERS-4821 or HQMC MMSR-4) for LIMDU cases, or the PEB in cases submitted to the PEB, for determination on the appropriateness of continuing MEB action. MEB action in these cases should be suspended pending the resolution of the legal and/or administrative separation issues; moreover, cases should not be referred to the PEB for disability evaluation if legal or involuntary administrative separation issues are pending (SECNAVINST 1850.4 series, article 3403, provides amplifying information.). It is incumbent upon MTFs processing MEBs on patients to diligently determine, through patient interviews, non-medical assessment (NMA) review, contact with parent commands, and other appropriate avenues, whether legal or involuntary administrative separation issues are pending in any case.

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Article 18-6

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(4) CA Not to Serve as an MEB Member. To maintain the requisite impartiality required of the final reviewer of MEBRs prepared in the MTF, the CA (i.e., CO) will not serve as an actual member of MEBs. Likewise, officers to whom the CA has provided signatory responsibility as final command review will not, on any case, serve as both a member of the MEB and the command's final reviewer of the MEBR produced by that MEB. (5) Boards Convened to Evaluate Dental Conditions. When the basis for the board is a dental treatment matter, the senior member should be a dentist properly credentialled and actively engaged in clinical practice on the staff of a DOD MTF or dental treatment facility (DTF). Other members must be physicians as detailed in article 18-6(2). An MEB prepared on a Navy or Marine Corps active duty dental patient to determine the patient's fitness for continued Naval service will be processed through a Navy MTF for further routing as indicated to the Navy PEB. (6) Boards Convened on Reservists. When an MEB is convened to evaluate an active or inactive Naval or Marine Corps Reserve member, the CA will direct that the MEB membership reflects the Reserve status of the patient being evaluated. The CA will expressly annotate the Reserve representation on the MEB in the MEBR; this annotation will include a distinct citation in the forwarding endorsement to the MEBR if appropriate Reserve representation was not practicable. (7) Clinical Specialty Representation on MEBs. Specialist involvement in the preparation of MEBRs is the standard which will be achieved throughout Navy Medicine. Commanders and COs holding CA for MEBs shall ensure that, preferably all MEB members but, at a minimum, the senior member of any MEB shall be trained and either board-certified or board-eligible in the specialty most relevant to diagnosing and treating that condition which is most responsible for the patient being referred to an MEB. In cases where any of the MEB members are not specialists engaged in the active practice of that area of medicine most relevant to the diagnosis primarily responsible for referral to an MEB, the CA will ensure that the MEBR expressly indicates that key clinical information in the MEBR is predicated on specialty consultation by providers other than those comprising the MEB. The CA will also ensure in these cases that the patient is thoroughly instructed on the process

18-6

Medical Evaluation Board (MEB) Composition

(1) CA Responsibility in Appointing Medical Board Members. The prime consideration in the composition of an MEB is ensuring that the physicians comprising the Board have sufficient professional training, specialization, and experience, and have been appropriately trained in the operations of DON LIMDU and disability evaluation processes. (At a minimum, this training should consist of a thorough understanding of this chapter, SECNAVINST 1850.4 series, and of all pertinent MTF-specific governing directives.) (2) Number of Physicians Comprising an MEB. There are a minimum of two members required on an MEB, a junior member and a senior member; the CA may name a third member to an MEB as deemed appropriate. (A mandatory exception to this is that all MEBs convened in cases adjudicating mental incapacitation require three physician members,