Physical Diagnoses That May Preclude Redeployment in DBA Claims

In prior posts, I addressed the psychological diagnoses and medications which may preclude redeployment to CENTCOM following a Defense Base Act injury. This post addresses the physical injuries which may preclude deployment or redeployment.

In short, the military wants contractors who have the physical capability of performing their work and completing their mission. The Code of Federal Regulations says as much. See 32 C.F.R. 158.7(k). While it is true that medical waivers may be granted, those waivers are few and far between. In fact, waivers “are unlikely for contractor personnel.” Id. If a contractor wants an waiver for a particular employee, then “an explanation should be given as to why other persons who meet the medical standards could not be identified to fulfill the deployed duties.” Id.

So, what are the physical conditions which may preclude deployment? Actually, the Department of Defense has prepared non-exhaustive lists that identify those conditions. The newest version of the list is the Amplification of the Minimal Standards of Fitness for Deployment to the CENTCOM AOR, which states in pertinent part:

Documented medical conditions precluding medical clearance. A list of all possible diagnoses and their severity that may cause an individual to be non-deployable would be too expansive. The medical evaluator must carefully consider whether the climate, altitude, nature of available food and housing, availability of medical, behavioral health, dental, surgical, and laboratory services, or whether other environmental and operational factors may be hazardous to the deploying person’s health. The following list of conditions should not be considered exhaustive. Other conditions may render an individual medically non-deployable (see paragraph 6). Medical clearance to deploy with any of the following documented medical conditions may be granted, except where otherwise noted, IAW MOD THIRTEEN Section 15.C. If an individual is found deployed with a pre-existing non-deployable condition and without a waiver for that condition, a waiver request to remain deployed should be submitted to the respective Component Surgeon. If the waiver request is denied, the individual will be redeployed out of the CENTCOM AOR. Individuals with the following conditions will not deploy without an approved waiver:

A.   Specific Medical Conditions / Restrictions: 

1. Asthma or other respiratory conditions that have a Forced Expiratory Volume-1 < 50% of predicted despite appropriate therapy, that have required hospitalization in the past 12 months, or that requires daily systemic (not inhaled) steroids. Respiratory conditions that have been well controlled for 6 months and are evaluated to pose no risk of deterioration in the deployed environment may be considered for
2. Seizure disorder, either within the last year or currently on anticonvulsant medication for prior seizure disorder/activity. Persons on a stable anticonvulsant regimen, who have been seizure-free for one year, may be considered for
3. Diabetes mellitus, type 1 or 2, on pharmacotherapy or with HgA₁C > 0.
   1. Type 1 diabetes or insulin-requiring type 2
   2. Type 2 diabetes, on oral agents only, with no change in medication within the last 90 days and HgA1C ≤ 7.0 does not require a waiver if a calculated 10-year coronary heart disease risk percentage (see paragraph 7.B.7) is less than 15%. If the calculated 10-year risk is 15% or greater, further evaluation is required prior to waiver submission. See B.8. for more detailed
   3. Newly diagnosed diabetics will require 90 days of stability, either on oral medications or with lifestyle changes, before a waiver will be considered. They should also have documentation of a complete initial diabetic evaluation (eye exam, foot exam, nutrition counseling, etc.).

4. History of heat Those with no multiple episodes, persistent sequelae, or organ damage, and no episode within the last 24 months, may be considered for waiver.
5. Meniere’s disease or other vertiginous/motion sickness disorder, unless well controlled on medications available in
6. Recurrent syncope for any reason. Waiver request should include the etiology and diagnosis of the
7. Endocrine conditions requiring replacement or adjustment therapies must be stable, require no laboratory monitoring or specialty consultation, and require only routine follow- up which must be available in the deployed location or by specific arrangement. Hormonal preparations must be administered by oral or transdermal routes, be within clinically appropriate dose parameters, have no special storage requirements, and not produce side effects which interfere with the normal performance of duties or require additional medications to
8. Any musculoskeletal condition that significantly impairs performance of duties in a deployed environment. If there are concerns, an official functional capacity exam (FCE) should be performed and results included with the waiver
9. Migraine headache, when frequent or severe enough to disrupt normal performance of duties. Waiver submission should note history, frequency, severity, and functional impact of headaches, as well previous and current treatment regimens. Neurology evaluation and endorsement
10. Nephrolithiasis, recurrent or currently symptomatic.
11. Pregnancy.
12. Obstructive sleep apnea (OSA). The OSA is diagnosed with an attended, in- laboratory polysomnography (PSG) with a minimum of 2 hours of total sleep time, that yields an apnea-hypopnea index (AHI), and/or respiratory disturbance index (RDI), of greater than 5 / Unattended, home PSG is not acceptable for deployment purposes. For individuals previously diagnosed with OSA, updated or repeat PSG is not required unless clinically indicated (i.e. significant change in body habitus, corrective surgery or return of OSA symptoms). Individuals treated with an oral appliance require PSG documentation that OSA is controlled with its use. Individuals who are treated with automatic positive airway pressure (APAP), continuous positive airway pressure (CPAP) and bi-level positive airway pressure (BPAP) are acceptable as long as the condition being treated is OSA and not a more complex respiratory disorder.  Complex OSA, central sleep apnea or OSA that requires advanced modes of ventilation such as adaptive servo-ventilation (ASV) or average volume assured pressure support (AVAPS) is generally non-deployable. Individuals using PAP therapy should deploy with a machine that has rechargeable battery back-up and sufficient supplies (air filters, tubing and interfaces/masks) for the duration of the deployment. Individuals deploying with PAP therapy to a location where the sleep environment has unfiltered air will typically not be granted waivers if a waiver is otherwise required per the guidance below. The following guidelines are designed to ensure that individuals with OSA are adequately treated and that their condition is not of the severity that would pose a safety risk should they be required to go without their PAP therapy for a significant length of time.
    1. Symptomatic OSA (i.e. excessive daytime sleepiness) of any severity, with or without any treatment.
    2. Asymptomatic mild OSA (diagnostic AHI and RDI < 15/hr): Deployable with or without treatment (PAP or otherwise). No waiver
13. History of clinically diagnosed traumatic brain injury (mTBI/TBI) of any severity, including mild. Waiver may not be required, but pre-deployment evaluation, which may include both neurological and psychological components, is needed per ref
    1. Individuals who have a history of a single mild Traumatic Brain Injury may deploy once released by a medical provider after 24-hours symptom
    2. Individuals who have sustained a second mTBI within a 12-month period, may deploy after seven days symptom free and release by a medical
    3. Individuals who have had three clinically diagnosed TBIs (of any severity, including mild) since their last full neurological and psychological evaluation are required to have such an evaluation completed prior to deployability determination.
14. BMI > 35 with or without any significant Military personnel in compliance with Service body fat guidelines do not require a waiver. Morbid obesity (BMI > 40 or weight greater than 300 pounds) can generally not be supported. Civilians and contractors should submit a body fat worksheet with the waiver request. A BMI calculator is located at http://www.nhlbi.nih.gov/guidelines/obesity/BMI/bmicalc.htm.
15. Any medical conditions (except OSA-see 10 above) that require certain durable medical equipment or appliances (e.g., nebulizers, catheters, spinal cord stimulators) or that requires periodic evaluation/treatment by medical specialists not readily available in theater.

B.   Cardiovascular Conditions:

1. Symptomatic coronary artery disease. Also, see 8.
2. Myocardial infarction within one year of deployment. Also, see 8.
3. Coronary artery bypass graft, coronary artery angioplasty, carotid endarterectomy, other arterial stenting, or aneurysm repair within one year of deployment. Also, see 8.
4. Cardiac dysrhythmias or arrhythmias, either symptomatic or requiring medication, electro-physiologic control, or automatic implantable cardiac defibrillator or other implantable cardiac devices.
5. Hypertension if controlled with a medication or lifestyle regimen that has been stable for 90 days and requires no changes does not require a Single episode hypertension found on predeployment physical should be accompanied by serial blood pressure checks (3 day BP checks) to ensure hypertension is not persistent.
6. Heart failure or history of heart failure.
7. Civilian personnel who are 40 years of age or older must have a 10-year CHD risk percentage calculated (online calculator is available at http://tools.acc.org/ASCVD-Risk- Estimator/). If the individual’s calculated 10-year CHD risk is 15% or greater, the individual should be referred for further cardiology work-up and evaluation, to include at least one of the following: graded exercise stress test with a myocardial perfusion scintigraphy (SPECT scan) or stress echocardiography as determined by the evaluating cardiologist. Results of the evaluation (physical exam, Framingham results, etc.) and testing, along with the evaluating cardiologist’s recommendation regarding suitability for deployment, should be included in a waiver request to deploy.
8. Uncontrolled hyperlipidemia. Lipid screening should be accomplished IAW Service specific guidelines for lipid assessment. All others (e.g. civilians, contractors) ≥35 years old should have a lipid screening profile performed prior to deployment. While hyperlipidemia should be addressed IAW clinical treatment guidelines, hyperlipidemia values that are outside any of the following (Total Cholesterol > 260, LDL > 190, Triglycerides > 500), either treated or untreated, requires a waiver to be submitted.

C.   Infectious Disease:

1. Blood-borne diseases (Hepatitis B, Hepatitis C, HTLV) that may be transmitted to others in a deployed environment. Waiver requests for persons testing positive for a blood borne disease should include a full test panel for the disease, including all antigens, antibodies, viral load, and appropriate tests for affected organ systems.
2. Confirmed HIV infection is disqualifying for deployment, IAW References I and T, service specific policies, and agreements with host nations. Note that some nations within the CENTCOM AOR have legal prohibitions against entering their country(ies) with this
3. Latent tuberculosis (LTBI). Individuals who are newly diagnosed with LTBI by either TST or IGRA testing will be evaluated for TB disease with at least a symptom screen and chest x-ray, and will have documented LTBI evaluation and counseling for consideration of treatment. Those with untreated or incompletely treated LTBI, including those with newly diagnosed LTBI, previously diagnosed LTBI, and those currently under treatment for LTBI will be provided information regarding the risks and benefits of LTBI treatment during deployment (see paragraph G.6.C). Individuals meeting the above criteria do not require a waiver for deployment. Active duty TST convertors who have documented completion of public health nursing evaluation for TB disease and counseling for LTBI treatment described above may deploy without a waiver as long as all Service specific requirements are met.
4. History of active tuberculosis (TB). Must have documented completion of full treatment course prior to deployment. Those currently on treatment for TB disease may not
5. A CENTCOM waiver cannot override host or transit nation infectious disease or immunization restrictions. Active duty must comply with status of forces agreements; civilian deployers should contact the nation’s embassy for up-to-date information.

D.    Eye, Ear, Nose, Throat, Dental Conditions:

1. Vision loss. Best corrected visual acuity which does not meet minimum occupational requirements to safely perform duties. Bilateral blindness or visual acuity that is unsafe for the combat environment per the examining
2. Refractive eye Personnel who have had laser refractive surgery must have a satisfactory period for post-surgical recovery before deployment. There is a large degree of patient variability which prevents establishing a set timeframe for full recovery. The attending ophthalmologist or optometrist will determine when recovery is complete.
   1. Personnel are non-deployable while still using ophthalmic steroid drops post-procedure.
   2. Personnel are non-deployable for three months following uncomplicated photorefractive keratectomy (PRK) or laser epithelial keratomileusis (LASEK), or one month for laser-assisted in situ keratomileusis (LASIK) unless a waiver is granted.
   3. Waiver request should include clearance from treating ophthalmologist or optometrist.
3. Hearing loss. Service members must meet all Service-specific requirements. Individuals must have sufficient unaided hearing to perform duties safely, hear and wake up to emergency alarms unaided, and hear instructions in the absence of visual cues such as lip reading. If there is any safety question, Speech Recognition In Noise Test (SPRINT) or equivalent is a recommended
4. Tracheostomy or
5. Patients without a dental exam within 12 months of deployment, or those who are likely to require evaluation or treatment during the period of deployment for oral conditions that are likely to result in a dental
   1. Individuals being evaluated by a non-DoD civilian dentist should use a DD Form 2813, or equivalent, as proof of dental examination.
   2. Individuals with orthodontic equipment require a waiver to deploy. Waiver requests to deploy should include a current evaluation by their treating orthodontic provider and include a statement that wires with neutral force are in place.

E.   Cancer:

1. Cancer for which the individual is receiving continuing treatment or which requires frequent subspecialist examination and/or laboratory testing during the anticipated duration of the
2. Precancerous lesions that have not been treated and/or evaluated and that require treatment/evaluation during the anticipated duration of the
3. All cancers should be in complete remission for at least a year before a waiver is submitted.

F.  Surgery:

1. Any medical condition that requires surgery (e.g., unrepaired hernia) or for which surgery has been performed and the patient requires ongoing treatment, rehabilitation or additional surgery to remove devices (e.g., external fixator placement).
2. Individuals who have had surgery requiring follow up during the deployment period or who have not been cleared/released by their surgeon (excludes minor procedures).
3. Individuals who have had surgery (open or laparoscopic) within 6 weeks of deployment.
4. Cosmetic, bariatric, or gender reassignment procedures are disqualifying until fully recovered with all follow-up and revisions complete, to include adjuvant counselling, medical treatment, and Service requirements. Special dietary and hygienic requirements cannot be reliably accommodated and may be independently

Keep in mind that these specific diagnoses are not the end-all-be-all of the medical exclusions. There are some general, overarching guidelines that should be considered when gauging an injured employee’s ability to return to work in the CENTCOM AOR. In short, can the injured worker “perform all essential functions of the position in the deployed environment, with or without reasonable accommodation, without causing undue hardship.” If not, then re-deployment is not realistic.