Disability Discharge

Department of Defense

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DoD Instruction 1332.18 Disability Evaluation System (10 November 2022)
DOD Manual 1332.18 Vol. 1 Disability Evaluation System (DES) Manual: Processes (24 FEB 2023)
DOD INSTRUCTION 6130.03, Volume 2 Medical Standards for Military Service: Retention (4 September 2020, incorporating Change 1, 6 June 2022)
View related fact sheet

DoD Instruction 1332.18 Disability Evaluation System (10 November 2022)

Source: DoD Instruction 1332.18 Disability Evaluation System (10 November 2022) (703 KB)

Comments: To view or download the complete regulation, click on the link to it in the box above these comments.

DOD Manual 1332.18 Vol. 1 Disability Evaluation System (DES) Manual: Processes (24 FEB 2023)

Source: DOD Manual 1332.18 Vol. 1 Disability Evaluation System (DES) Manual: Processes (24 FEB 2023) (800 KB)

Comments: To view or download the complete regulation, click on the link to it in the box above these comments.

This manual implements policy, assigns responsibilities, and provides procedures for the Disability Evaluation System (DES) pursuant to DoD Instruction (DoDI) 1332.18.

DOD INSTRUCTION 6130.03, Volume 2 Medical Standards for Military Service: Retention (4 September 2020, incorporating Change 1, 6 June 2022)

Source: DOD INSTRUCTION 6130.03, Volume 2 Medical Standards for Military Service: Retention (4 September 2020, incorporating Change 1, 6 June 2022) (562 KB)

Comments: To view or download the complete regulation, click on the link to it in the box above these comments.

SECTION 1: GENERAL I SSUANCE I NFORMATION

1.1. APPLICABILITY.

a. This volume applies to OSD, the Military Departments (including the Coast Guard at all times, including when it is a Service in the Department of Homeland Security by agreement with

that Department), the Office of the Chairman of the Joint Chiefs of Staff and the Joint Staff, the Combatant Commands, the Office of the Inspector General of the Department of Defense, the

Defense Agencies, the DoD Field Activities, and all other organizational entities within the DoD (referred to collectively in this volume as the “DoD Components”).

b. Gender dysphoria-related standards in this volume do not apply to Service members considered exempt pursuant to DoDI 1300.28.

1.2. POLICY.

It is DoD policy that:

a. Service members meet DoD medical standards established in this volume to be retained in the Military Services.

b. Service members who are unable to successfully complete their assigned duties while deployed, stationed with only operational healthcare unit support, or while in garrison conditions, be referred to:

(1) The Disability Evaluation System (DES), on a case-by-case basis, in accordance with DoD Instruction (DoDI) 1332.18 and DoDI 1332.45; or

(2) For conditions not constituting a disability, the responsible Military Department for possible administrative action, in accordance with DoDI 1332.14 or DoDI 1332.30.

c. DoD medical standards for military retention are consistent with:

(1) The criteria for DES referral, in accordance with DoDI 1332.18 and other military requirements, as further defined in Paragraph 3.2 of this volume.

(2) Deployment requirements, as defined in DoDI 6490.07, and a broader definition of deployability, as defined in DoDI 1332.18.

(3) Retention determinations for certain non-deployable Service members in accordance with DoDI 1332.45.

(4) Military Health System (MHS) efforts to improve performance, economy, and efficiency.

d. Additional, more selective medical standards for military retention may be established by the Secretaries of the Military Departments based on the Service member’s office, grade, rank, or

rating, as long as such standards are objectively applied and are not inconsistent with applicable laws or DoD policies.

1.3. SUMMARY OF CHANGE 1.

In accordance with the June 6, 2022 Secretary of Defense memorandum, the changes to this issuance update DoD policy with respect to individuals who have been identified as HIV-

positive. Individuals who have been identified as HIV-positive, are asymptomatic, and who have a clinically confirmed undetectable viral load will have no restrictions applied to their

deployability or to their ability to commission while a Service member solely on the basis of their HIV-positive status. Nor will such individuals be discharged or separated solely on the

basis of their HIV-positive status.

…

3.2. APPLICATION OF CRITERIA USED TO DEVELOP STANDARDS.

The standards in Section 5 will be applied on a case-by-case basis considering the following criteria:

a. The affected Service member’s ability to safely complete common military tasks at a general duty level. Tasks may include, but are not limited to:

(1) Climbing and going down structures such as stairs, a ladder, ladderwells, or a cargo net.

(2) Wearing personal protective gear.

(3) Running 100 yards.

(4) Standing in formation.

(5) Carrying personal equipment.

(6) Operating a vehicle.

(7) Operating an assigned weapons system, to include safe operation of an individual firearm.

(8) Subsisting on field rations.

(9) Working in extreme environments or confined spaces.

(10) Operating for extended work periods.

(11) Communicating effectively.

b. Limitations or requirements due to medical condition(s) or objections to recommended medical interventions that:

(1) Impose unreasonable medical requirements on the Military Services to maintain or protect the Service member.

(2) Require diagnostic(s), treatment(s), or surveillance for longer than 12 months that is not anticipated to be routinely available in operational locations, unless approved by the Service

member’s unit commander in accordance with DoDI 1332.45.

(3) Present an obvious risk to the health or safety of the member, other Service members, or other personnel serving with or accompanying an armed force in the field.

(4) Are of such a nature or duration that progressive worsening or effects of external stressors are reasonably expected to result in a grave medical outcome or an unacceptable

negative impact on mission execution.

(5) Are incompatible with the physical and psychological demands required for deployment and the Service member’s office, grade, rank, or rating.

…

SECTION 5: DISQUALIFYING CONDITIONS

5.1. GENERAL.

The medical standards for military retention are classified into general systems in this section. Unless otherwise stipulated, these are the conditions that do not meet the retention standard. These conditions must persist despite appropriate treatment and impair function to preclude satisfactory performance of required military duties of the Service member’s office, grade, rank, or rating.

5.2. HEAD.

Defects of the skull, face, or mandible to a degree that prevents the member from properly wearing required protective equipment (e.g., military headgear) are not compatible with retention. The condition must persist despite appropriate treatment and impair function so as to preclude satisfactory performance of required military duties of the Service member’s office, grade, rank, or rating.

5.3. EYES.

c. Corneal degeneration, when contact lenses or other special corrective devices (e.g., telescopic lenses, electronic magnifiers) are required to prevent progression or to meet the standards in Paragraph 5.4. d. Aphakia, bilateral if not a surgical candidate. This condition is not compatible with retention and the Service should initiate appropriate medical and personnel actions upon diagnosis. Paragraph 5.3.a does not apply.

e. Binocular diplopia, not correctable by surgery, that is severe, constant, and in a zone less than 20 degrees from the primary position.

f. Bilateral concentric constriction to less than 40 degrees interfering with the ability to safely perform duty.

g. Absence of an eye or enucleation. This condition is not compatible with retention and the Services should initiate appropriate medical and personnel actions upon diagnosis. Paragraph 5.3.a. does not apply.

h. Night blindness requiring assistance to travel at night or resulting in duty limitations due to an inability to perform night missions.

i. Any chronic eye diseases requiring treatment with systemic immuno suppressant medication.

5.4. VISION.

When considering the conditions listed in this paragraph, the condition must persist despite appropriate treatment and impair function to preclude satisfactory performance of required military duties of the Service member’s office, grade, rank, or rating. Vision standards must be met with the unaided eye or clear glasses without specialized optical aids including, but not limited to, telescopic, magnifying, or tinted lenses (excluding sunglasses for routine wear). Color vision standards will be set by the individual DoD Components.

a. With both eyes open, best corrected for both distant and near vision of at least 20/40.

b. Any condition that specifically requires contact lenses for correction of vision.

c. Anisometropia worse than 3.5 diopters (spherical equivalent difference).

d. Any scotoma large enough to impair duty performance including, but not limited to, permanent hemianopsia.

5.5. EARS.

a. Persistent defect that prevents the proper wearing of required military equipment (e.g., hearing protection).

b. Ménière’s disease and other disorders of balance or sensorium with frequent and severe attacks that interfere with satisfactory performance of duty.

c. Any conditions of the ear that persist despite appropriate treatment and necessitate frequent and prolonged medical care or hospitalization (e.g., cholesteatoma, chronicotitis infections, and associated secondary changes).

5.6. HEARING.

Hearing loss that prohibits safe performance of duty, with or without hearing aids or other assistive devices is not compatible with retention. The condition must persist despite appropriate treatment and impair function to preclude satisfactory performance of required military duties of the Service member’s office, grade, rank, or rating.

5.7. NOSE, SINUSES, MOUTH, AND LARYNX.

a. Vocal cord dysfunction characterized by bilateral vocal cord paralysis or dysfunction significant enough to interfere with speech or cause respiratory compromise upon exertion.

b. Any persistent condition of the sinuses or nasal cavity that requires ongoing medical care beyond operationally available maintenance medications to maintain sinonasal function.

c. Conditions or defects of the mouth, tongue, palate, throat, pharynx, larynx, and nose that interfere with chewing, swallowing, speech, or breathing.

5.8. DENTAL.

Diseases and abnormalities of the jaw or associated tissues that prevent normal mastication, speech, or proper wear of required protective equipment are not compatible with retention. The condition must persist despite appropriate treatment and impair function to preclude satisfactory performance of required military duties of the Service member’s office, grade, rank, or rating.

5.9. NECK.

Limited range of motion of the neck that impairs normal function is not compatible with retention. The condition must persist despite appropriate treatment and impair function to preclude satisfactory performance of required military duties of the Service member’s office, grade, rank, or rating.

5.10. LUNGS, CHEST WALL, PLEURA, AND MEDIASTINUM.

When considering the conditions listed in this paragraph, the condition must persist despite appropriate treatment and impair function to preclude satisfactory performance of required military duties of the Service member’s office, grade, rank, or rating. Conditions in this paragraph do not meet the standards if the Service member cannot meet Service-specific pulmonary functional assessment (e.g., trial of duty or established standard) or if medical clearance cannot be given for safe participation in Service-specific physical fitness testing.

a. Asthma or airway hyper responsiveness with:

(1) Persistent symptoms;

(2) Forced expiratory volume in one second (FEV1) persistently below 70 percent despite treatment with inhaled corticosteroids; or

(3) More than once required oral steroid or emergent asthma treatment in the previous 12 months.

b. Chronic obstructive pulmonary disease with:

(1) Persistent symptoms;

(2) FEV1 between 50 percent and 79 percent of predicted FEV1 that cannot pass Service-determined functional assessments;

(3) FEV1 of less than 50 percent of predicted FEV1, despite treatment with inhaled corticosteroids; or

(4) More than one required hospitalization in the previous 12 months.

c. Bronchiectasis, if severe or symptomatic.

d. Thoracic cavity malformation or dysfunction, including pectus excavatum, pectus carinatum, or diaphragmagtic defect, if it is symptomatic or interferes with the wearing of military equipment or the performance of military duty.

e. Chronic or recurrent pulmonary disease or symptoms including, but not limited to:

(1) Pulmonary fibrosis;

(2) Emphysema;

(3) Interstitial lung disease;

(4) Pulmonary sarcoidosis;

(5) Pleurisy; or

(6) Residuals of surgery that prevent satisfactory performance of duty.

f. Recurrent spontaneous pneumothorax, when the underlying defect is not correctable by surgery.

g. Tuberculosis, pulmonary or extra pulmonary, with clinically significant sequelae following treatment, if resistant to treatment or if the condition is of such severity that the individual is not expected to return to full duty despite appropriate treatment.

h. Pulmonary embolism, recurrent or a single episode, if anticoagulation medications, other than aspirin, are clinically indicated for longer than 12 months.

i. Cystic fibrosis.

j. Any condition for which chronic use of supplemental oxygen is indicated.

5.11. HEART.

a. When considering the conditions listed in this paragraph, the condition must persist despite appropriate treatment and impair function to preclude satisfactory performance of required military duties of the Service member’s office, grade, rank, or rating. Conditions in this paragraph do not meet the standards if the Service member cannot meet Service-specific cardiac functional assessment (e.g., a Service-defined trial of duty period) or if medical clearance cannot be given for safe participation in Service-specific physical fitness testing due to risk of disease progression or adverse cardiac event.

b. Heart valve disease; including:

(1) Any valve replacement. This condition is not compatible with retention and the Service should initiate appropriate medical and personnel actions after post-operative recovery (or a period of Limited Duty). Paragraph 5.11.a does not apply.

(2) Moderate or worse valvular insufficiency or regurgitation if a cardiologist determines that the Service member has physical activity or duty restrictions to reduce the risk of disease progression or an adverse cardiac event.

(3) Mild or worse valvular stenosis if a cardiologist determines the Service member has physical activity or duty restrictions to reduce the risk of disease progression or adverse cardiac event.

c. Cardiomyopathy or heart failure; including:

(1) Persistent cardiomyopathy or heart failure related to a potentially reversible condition when a cardiologist determines that the underlying etiology is uncorrectable.

(2) Cardiomyopathy or heart failure, upon diagnosis, when secondary to an underlying permanent condition including, but not limited to: hypertrophic cardiomyopathy, amyloidosis, sarcoidosis, ventricular non-compaction syndrome, and arrhythmogenic right ventricular cardiomyopathy. This condition is not compatible with retention and the Service should initiate appropriate medical and personnel actions upon diagnosis. Paragraph 5.11.a does not apply.

d. Clinical indication or presence of pacemaker or implantable cardioverter-defibrillator. This condition is not compatible with retention and the Service should initiate appropriate medical and personnel actions upon diagnosis. Paragraph 5.11.a does not apply.

e. Atrial and ventricular arrhythmias, other than isolated Premature Ventricular Contractions and Premature Atrial Contractions, unless successfully ablated (if indicated) and cleared by a cardiologist for unrestricted exercise.

f. Channelopathies reliably diagnosed by a cardiologist that predisposes to sudden cardiac death and syncope including, but not limited to:

(1) Brugada pattern;

(2) Acquired or Congenital Long QT syndrome; or

(3) Catecholiminergic Polymorphic Ventricular Tachycardia. This condition is not compatible with retention and the Service should initiate appropriate medical and personnel actions upon diagnosis. Paragraph 5.11.a does not apply.

g. Pre-excitation pattern (e.g., Wolff-Parkinson-White pattern) unless it is asymptomatic and associated with low-risk accessory pathway by appropriate diagnostic testing, or successfully treated with ablation.

h. Conduction disorders associated with potentially fatal or severely symptomatic events including, but not limited to:

(1) Disorders of sinus arrest;

(2) Asystole;

(3) Mobitz type II second-degree atrioventricular block;

(4) Third-degree atrioventricular block; or

(5) Sudden cardiac death unless associated with recognizable temporary precipitating conditions (e.g., perioperative period, hypoxia, electrolyte disturbance, drug toxicity, infection, or acute illness). This condition is not compatible with retention and the Service should initiate appropriate medical and personnel actions upon diagnosis. Paragraph 5.11.a does not apply.

i. Coronary artery disease; including:

(1) Acute Coronary Syndrome (ST-elevation myocardial infarction or Non-ST elevation myocardial infarction):

(a) That required intervention including, but not limited to:

1. Percutaneous coronary intervention;

2. Coronary artery bypass grafting; or

3. Thrombolytic medication.

(b) For which anti-platelet therapy, other than aspirin, occurs for longer than 12 months.

(2) Stable coronary disease, unless there is no evidence of ischemia and the Service member can achieve 10 metabolic equivalents while on optimal medical therapy.

j. Chronic pericardial disease, reliably diagnosed by a cardiologist.

k. Complex congenital heart disease including, but not limited to: tetrology of Fallot, coarctation of the aorta, and Ebstein’s anomaly, unless successfully treated by surgical or percutaneous correction.

l. Symptomatic or hemodynamically significant anatomic intracardiac shunts including, but not limited to: patent foramen ovale, atrial septal defect, and ventricular septal defect, if persistent despite surgical or percutaneous correction (as indicated).

m. Recurrent syncope or near syncope (including postural orthostatic tachycardia syndrome) that interferes with duty, if no treatable cause is identified or it persists despite conservative therapy.

n. Rheumatic heart disease, if sequelae present.

o. History of spontaneous coronary artery dissection.

p. Surgery of the heart or pericardium with persistent duty limitations.

5.12. ABDOMINAL ORGANS AND GASTROINTESTINAL SYSTEM.

When considering the conditions listed in this paragraph, the condition must persist despite appropriate treatment and impair function to preclude satisfactory performance of required military duties of the member’s office, grade, rank, or rating. Conditions in this paragraph do not meet retention standards if associated with the inability to maintain normal weight or nutrition, require repeated procedures or surgery, or if the condition requires immunomodulating or immunosuppressant medications.

a. Esophageal stricture, including manifestations of eosinophilic esophagitis, that requires a restricted diet or frequent dilatation.

b. Persistent esophageal disease (e.g., dysmotility disorders, achalasia, esophagitis, esophageal spasm) that is severe, or results in dysphagia.

c. Gastritis, if severe, with recurring symptoms not relieved by medication, surgery, or endoscopic intervention.

d. Non-ulcerative or functional dyspepsia not controlled by medications.

e. Recurrent gastric or duodenal ulcer, with or without obstruction or perforation confirmed by laboratory, imaging, or endoscopy.

f. Inflammatory bowel disease including, but not limited to:

(1) Crohn’s disease;

(2) Ulcerative colitis;

(3) Ulcerative proctitis;.

5.15. URINARY SYSTEM.

b. Chronic or interstitial cystitis.

c. Chronic incontinence, dysfunction, or urinary retention requiring catheterization.

d. Cystoplasty, if reconstruction is unsatisfactory or if refractory symptomatic infections persist.

e. Ureterointestinal or direct cutaneous urinary diversion.

f. Urethral abnormalities, if they:

(1) Result in chronic incontinence;

(2) Result in the persistent need for catheterization; or

(3) Require a urethrostomy, if a satisfactory urethra cannot be restored.

g. Ureteral abnormalities, including ureterocystostomy, if both ureters are markedly dilated with irreversible changes, or if they result in:

(1) Recurrent obstruction;

(2) Kidney infection; or

(3) Other chronic kidney dysfunction.

h. Kidney transplant recipient(s). This condition is not compatible with retention and the Service should initiate appropriate medical and personnel actions upon diagnosis. Paragraph 5.15.a. does not apply.

i. Chronic or recurrent pyelonephritis with secondary hypertension or hypertensive end-organ damage.

j. Kidney abnormalities, including:

(1) Polycystic kidney disease;

(2) Horseshoe kidney;

(3) Hypoplasia of the kidney; or

(4) Residuals of perirenal abscess when renal function is:

(a) Impaired;

(b) Associated with secondary hypertension or hypertensive end-organ damage; or

k. Hydronephrosis associated with significant systemic effects, renal impairment, secondary hypertension, hypertensive end-organ damage, or frequent infections.

l. Chronic kidney disease, stage 3A or worse, according to the Kidney Disease Improving Global Outcomes Guidelines Standard, as reliably diagnosed by a nephrologist. Any level of chronic kidney disease for which chronic immunosuppressant medications (e.g., medication for steroid relapsing glomerulonephritis) are required. This condition is not compatible with retention and the Service should initiate appropriate medical and personnel actions upon diagnosis. Paragraph 5.15.a does not apply.

m. Chronic nephritis or nephrotic syndrome. Service-specific criteria for proteinuria may apply.

n. Recurrent calculi that:

(1) Result in recurring infections;

(2) Result in obstructive uropathy unresponsive to medical or surgical treatment; or

(3) Are symptomatic and occur with a frequency that prevents satisfactory performance of duty.

5.16. SPINE AND SACROILIAC JOINT CONDITIONS.

When considering the conditions listed in this paragraph, the condition must persist despite appropriate treatment and impair function to preclude satisfactory performance of required military duties of the Service member’s office, grade, rank, or rating. Conditions in this paragraph do not meet retention standards if medical clearance cannot be given for safe participation in Service-specific physical fitness testing.

a. Spondyloarthritis. Chronic or recurring episodes of axial or peripheral arthritis that may include extra-articular involvement that:

(1) Causes functional impairment interfering with successful performance of duty supported by objective, subjective, and radiographic findings; or

(2) Requires medication for control that needs frequent monitoring by a physician due to debilitating or serious side effects including, but not limited to:

(a) Ankylosing spondylitis;

(b) Reactive arthritis;

(d) Arthritis associated with inflammatory bowel disease.

b. Radicular or non-radicular pain involving the cervical, thoracic, lumbosacral, or coccygeal spine, whether idiopathic or secondary to degenerative disc or joint disease.

c. Kyphosis:

(1) Resulting in greater than 50 degrees of curvature, if symptomatic, so as to limit the wearing of military equipment; or

(2) If recurrently symptomatic, regardless of the degree of curvature.

d. Scoliosis:

(1) Resulting in severe deformity—greater than 30 degrees of curvature—if symptomatic, so as to limit the wearing of military equipment; or

(2) If recurrently symptomatic, regardless of the degree of curvature.

e. Congenital or surgical fusion or disc replacement.

f. Vertebral fractures after radiographic evidence of complete healing and experiencing moderate or severe symptoms that result in repeated acute medical visits.

g. Spina bifida with demonstrable signs and moderate symptoms of root or cord involvement.

h. Spondylolysis or spondylolisthesis with moderate or severe symptoms resulting in repeated acute medical visits.

5.17. UPPER EXTREMITY CONDITIONS.

When considering the conditions listed in this paragraph, the condition must persist despite appropriate treatment and impair function to preclude satisfactory performance of required military duties of the Service member’s office, grade, rank, or rating. Conditions in this paragraph do not meet retention standards if medical clearance cannot be given for safe participation in Service-specific physical fitness testing.

a. Limitation of joint motion.

b. Amputation of any part of hand and fingers.

c. Intrinsic paralysis or weakness of upper limbs when symptoms are severe and persistent.

5.18. LOWER EXTREMITY CONDITIONS.

a. Limitation of joint motion.

b. Foot and ankle conditions that include:

(1) Amputation of any part of the foot or toes.

(2) Conditions of the foot or toes that prevent the satisfactory performance of required military duty or the wearing of required military footwear, such as:

(a) Deformity of the toes;

(b) Clubfoot;

(d) Recurrent plantar fasciitis; or

(e) Symptomatic neuroma.

c. Chronic foot, leg, knee, thigh, and hip conditions, such as:

(1) Chronic anterior knee pain;

(2) Instability after knee ligament reconstruction; or

(3) Recurrent stress fracture.

d. Coxa vara to such a degree that it results in chronic pain.

5.19. GENERALIZED CONDITIONS OF THE MUSCULOSKELETAL SYSTEM.

a. Persistent symptoms after any dislocation, subluxation, or instability of the hip, knee, ankle, subtalar joint, foot, shoulder, hand, wrist, or elbow.

b. Osteoarthritis or infectious arthritis with severe symptoms or traumatic arthritis.

c. Malunion, non-union, or hypertrophic ossification with persistent severe deformity or loss of function.

d. Prosthetic replacement of any joints, if there is resultant loss of function or persistent pain.

e. History of neuromuscular paralysis, weakness, contracture, or atrophy that is not

completely resolved.

f. Osteopenia, osteoporosis, or osteomalacia resulting in fracture with residual symptoms after therapy.

g. Recurrent episodes of chronic osteomyelitis that:

(1) Are not responsive to treatment; or

(2) Involve the bone to a degree that interferes with stability and function.

h. Osteonecrosis, to include avascular necrosis of bone.

i. Chronic tendonitis, tenosynovitis, or tendinopathy.

j. Osteitis deformans (i.e., Paget’s disease) that involve single or multiple bones and result in deformities or symptoms that severely interfere with function.

k. Chronic mechanical low back pain.

5.20. VASCULAR SYSTEM.

a. Abnormalities of the arteries including, but not limited to, aneurysms, arteriovenous malformations, or arteritis.

b. Peripheral artery disease including claudication and renal artery stenosis.

c. Hypertensive cardiovascular disease and hypertensive vascular disease.

(1) Essential hypertension that:

(a) Is not controlled despite an adequate period of therapy in an ambulatory status;

(b) Is associated with end organ damage; or

(2) Secondary hypertension, unless the underlying cause has been treated with subsequent control of blood pressure.

d. Persistent peripheral vascular disease.

e. Venous disease that, despite appropriate treatment, results in:

(1) Persistent duty limitations.

(2) Limitations in the wearing of the military uniform.

f. Deep vein thrombosis (recurrent or a single episode), if anticoagulation medications, other than aspirin, are clinically indicated for longer than 12 months.

g. Surgery of the vascular system with persistent duty limitations.

h. Thoracic Outlet Syndrome including:

(1) Thoracic Outlet Syndrome—either neurogenic, arterial, or venous:

(a) With symptoms that are not controlled, despite an adequate period of therapy and

surgery;

(b) That is associated with end organ damage, or

(2) Venous Thoracic Outlet Syndrome that required venous reconstruction with a stent or open surgery.

(3) Arterial Thoracic Outlet Syndrome that required arterial reconstruction with a bypass or interposition graft.

i. Popliteal Entrapment Syndrome:

(1) With symptoms that are not controlled despite an adequate period of therapy and surgery, is associated with end organ damage, or requires anticoagulation medication other than aspirin.

(2) That required arterial reconstruction with a bypass or interposition graft.

5.21. SKIN AND SOFT TISSUE CONDITIONS.

a. Skin or soft tissue conditions, such as:

(1) Severe nodulocystic acne;

(2) Hidradenitis suppurativa;

(3) Inflammatory or scarring scalp disorders;

(4) Bullous dermatoses (including, but not limited to, dermatitis herpetiformis, emphigus, and epidermolysis bullosa);

(5) Lichen planus; or

(6) Panniculitis that prevents the proper wearing required military uniform or equipment.

b. Severe atopic dermatitis that prevents the proper wearing of required military uniform or equipment.

c. Any dermatitis, including eczematous or exfoliative, that prevents the proper wearing of required military uniform or equipment.

d. Persistent or recurrent symptomatic cysts, including pilonidal cysts or furunculosis, that prevent the proper wearing of required military uniform or equipment.

e. Chronic or current lymphedema.

f. Severe hyperhidrosis.

g. Scars or keloids that:

(1) Prevent the proper wearing of required military uniform or equipment; or

(2) Interfere with the function of an extremity or body area, including by limiting range of motion or causing chronic pain.

h. Neurofibromatosis, other than cutaneous neurofibromas.

i. Psoriasis or parapsoriasis that is uncontrolled or requires:

(1) Systemic immunomodulating;

(2) Immunosuppressant medications; or

(3) Ultraviolet light therapy.

j. Scleroderma that seriously interferes with the function of an extremity or body area.

k. Chronic urticaria or angioedema that is not responsive to treatment or requires duty limitations despite appropriate treatment.

l. Intractable symptomatic plantar keratosis.

m. Intractable superficial or deep fungal infections.

n. Malignant neoplasms (refer to Paragraph 5.29 for malignancies):

(1) Including melanoma, melanoma in situ, and cutaneous lymphoma (mycosis fungoides).

(2) Not including basal cell and squamous cell carcinomas.

o. Any photosensitive dermatosis, including, but not limited to:

(1) Cutaneous lupus erythematosus;

(2) Dermatomyositis;

(3) Polymorphous light eruption; or

(4) Solar urticaria.

p. Severe or chronic erythema multiforme.

q. Chronic, non-healing ulcers of the skin.

5.22. BLOOD AND BLOOD FORMING CONDITIONS.

a. Anemia, hereditary or acquired, when

(1) Response to therapy is unsatisfactory; or

(2) Therapy requires prolonged, intensive, medical supervision or intervention.

b. Hypercoagulable disease associated with vascular thrombosis when anticoagulation medication of any type (except aspirin) is clinically indicated for longer than 12 months.

c. Bleeding disorders including, but not limited to:

(1) Hemophilia or other clinically significant factor deficiencies;

(2) Thrombocytopenia with persistent platelet count less than 50,000;

(3) Clinically significant Von Willebrand disease; or

(4) Platelet function disorders.

d. Chronic leukopenia:

(1) If therapy is clinically indicated due to a malignant process; or

(2) Where therapy is indicated for longer than 12 months.

e. Primary Polycythemia Vera, Essential Thrombocytosis, or Chronic Myelogenous Leukemia, if therapy beyond aspirin is clinically indicated.

f. Chronic and clinically significant splenomegaly.

g. Chronic or recurrent symptomatic hemolytic crisis.

5.23. SYSTEMIC CONDITIONS.

a. When considering the conditions listed in this paragraph, the condition must persist despite appropriate treatment and impair function so as to preclude satisfactory performance of required military duties of the member’s office, grade, rank, or rating. Conditions listed in this paragraph do not meet medical retention standards if they require medication for control with frequent monitoring by a medical provider due to potential debilitating or serious side effects.

b. Disorders involving the immune system, including immunodeficiencies with progressive clinical illness.

(1) A Service member with laboratory evidence of Human Immunodeficiency Virus infection will be referred for appropriate treatment and a medical evaluation of fitness for continued service in the same manner as a Service member with other chronic or progressive illnesses, including evaluation on a case-by-case basis. Covered personnel will not be discharged or separated solely on the basis of their HIV-positive status.

(2) Primary immunodeficiencies—including, but not limited to, hypogammaglobulinemia, common variable immune deficiency, or complement deficiency—with objective evidence of function deficiency and severe symptoms that are not controlled with treatment, or when injectable medications are clinically indicated.

c. Tuberculosis (pulmonary or extra pulmonary) with clinically significant sequelae following treatment, if:

(1) Resistant to treatment; or

(2) The condition is of such severity that the individual is not expected to return to full duty despite appropriate treatment.

d. Severe chronic complications of sexually transmitted diseases including neurosyphilis.

e. Recurrent anaphylaxis, if:

(1) Immunotherapy is not sufficient in reducing the risk;

(2) Avoidance of the trigger results in long-term duty limitations; or

(3) The individual is not expected to return to duty.

f. Chronic, severe, urticarial, or histaminergic angioedema.

g. Hereditary angioedema. This condition is not compatible with retention and the Service should initiate appropriate medical and personnel actions upon diagnosis. Paragraph 5.23.a does not apply.

h. Recurrent rhabdomyolysis, a single episode of idiopathic rhabdomyolysis, or a single episode of rhabdomyolysis that is associated with underlying metabolic or endocrine abnormalities.

i. Severe motion sickness. If due to an underlying disorder, process via the relevant standard. Otherwise, it may require processing through Service specific separation guidance.

j. Sarcoidosis, eosinophilic granuloma, or amyloidosis progressive with severe or multiple organ involvement.

k. Infections (superficial, local, or systemic) that are not responsive to appropriate treatment.

5.24. ENDOCRINE AND METABOLIC CONDITIONS.

a. Adrenal dysfunction, including Addison’s disease or Cushing’s disease.

b. Diabetes mellitus, unless hemoglobin A1c can be maintained at less than eight percent using only lifestyle modifications (e.g., diet and exercise) or with the following medications (alone or in combination):

(1) Metformin;

(2) Dipeptidyl peptidase 4 inhibitors; or

(3) Glucagon-like peptide-1 receptor agonists.

c. Pituitary dysfunction or mass effect from pituitary tumor.

d. Diabetes insipidus, after treatment and resolution of an underlying etiology.

e. Hyperparathyroidism, when residuals or complications are present.

f. Hypoparathyroidism, when severe, persistent, and difficult to manage.

g. Goiter, if mass effect.

h. Persistent, symptomatic, hypothyroidism or hyperthyroidism that is not responsive to therapy.

i. Persistent metabolic bone disease—including, but not limited to, osteoporosis, Paget’s disease, and osteomalacia—if:

(1) Associated with pathological fractures; or

(2) The condition prevents the wearing of military equipment.

j. Osteogenesis imperfecta.

k. Hypogonadism with medically required injectable hormone replacement.

l. Hypoglycemia when caused by an insulinoma or other hypoglycemia-inducing tumor.

m. Gout with frequent acute exacerbations or severe bone, joint, or kidney damage.

n. Endocrine hyperfunctioning syndromes including, but not limited to:

(1) Multiple endocrine neoplasia;

(2) Pheochromocytoma;

(3) Salt-wasting congenital adrenal hyperplasia;

(4) Carcinoid syndrome; or

(5) Endocrine tumors of the gastrointestinal tract.

5.25. RHEUMATOLOGIC CONDITIONS.

When considering the conditions listed in this paragraph, the condition must persist despite appropriate treatment and impair function so as to preclude satisfactory performance of required military duties of the member’s office, grade, rank, or rating. Conditions listed in this paragraph do not meet medical retention standards if the condition requires geographic limitations to protect the individual from infectious disease risk or due to limited monitoring capabilities, is associated with adverse effects from medication, or if medical clearance cannot be given for safe participation in Service-specific physical fitness testing.

a. Systemic lupus erythematosus.

b. Mixed connective tissue disease.

c. Progressive systemic sclerosis, including:

(1) Calcinosis;

(2) Raynaud’s phenomenon;

(3) Esophageal dysmotility;

(4) Scleroderma; or

(5) Telangiectasia syndrome.

d. Rheumatoid arthritis.

e. Sjögren’s syndrome.

f. Chronic autoimmune vasculitides or autoimmune diseases including, but not limited to:

(1) Polyarteritis nodosa.

(2) Behçet’s disease.

(3) Takayasu’s arteritis.

(4) Giant cell arteritis.

(5) Anti-neutrophil cytoplasmic antibody associated vasculitis.

(6) IgG-4 disease.

(7) Henoch-Schonlein Purpura.

g. Myopathy or polymyositis.

h. Fibromyalgia or myofascial pain syndrome.

i. Connective tissue disorders if associated with cardiac manifestations or limitations from recurrent musculoskeletal dysfunction.

5.26. NEUROLOGIC CONDITIONS.

b. Cerebrovascular conditions including, but not limited to:

(1) Subarachnoid or intracerebral hemorrhage;

(2) Vascular stenosis;

(3) Stroke;

(4) Aneurysm;

(5) Arteriovenous malformation; or

(6) Recurrent transient ischemic attack unless underlying etiology is identified and definitively treated.

c. Anomalies of the central nervous system or meninges with persistent sequelae including, but not limited to:

(1) Pain.

(2) Significant sensory or motor impairment.

(3) Severe headaches.

(4) Seizures.

(5) Alteration of consciousness, personality, or mental function.

d. Permanent or progressive cognitive impairment due to Alzheimer’s disease or other dementias. This condition is not compatible with retention and the Service should initiate appropriate medical and personnel actions upon diagnosis. Paragraph 5.26.a does not apply.

e. Neuromuscular disorders and muscular dystrophy including, but not limited to:

(1) Facioscapulohumeral muscular dystrophy.

(2) Limb girdle dystrophy.

(3) Myotonic dystrophy.

f. Chronic or recurrent demyelinating processes (e.g., multiple sclerosis, transverse myelitis, or recurrent optic myelitis).

g. Migraine, tension, or cluster headaches, when manifested by frequent incapacitating attacks.

h. Traumatic brain injury associated with persistent sequelae including, but not limited to:

(1) Pain.

(2) Significant sensory, cognitive, or motor impairment.

(3) Severe headaches.

(4) Seizures.

(5) Alteration of consciousness, personality, or mental function.

i. Peripheral neuropathy or paralytic disorders resulting in permanent functional impairment.

j. Provoked seizures, if recurrent more than 6 months after the Service member begins treatment and the effects of medication:

(1) Prohibit satisfactory performance of duty;

(2) Require significant follow-up; or

(3) Require modifications to reduce psychological stressors or enhance safety.

k. Epilepsy. This condition is not compatible with retention and the Service should initiate appropriate medical and personnel actions upon diagnosis. Paragraph 5.26.a does not apply.

l. Myasthenia gravis, unless only involving extraocular muscles.

m. Tremor, tic disorders, or dystonia (e.g., Tourette’s Syndrome) with significant functional impairment.

n. Recurrent, neurogenic, or unexplained syncope or near syncope that interferes with duty.

5.27. SLEEP DISORDERS.

a. Clinical sleep disorders—including circadian rhythm disorders, insomnia, narcolepsy, cataplexy, or other hypersomnia disorders—that cause sleep disruption resulting in excessive daytime somnolence or other impacts on duty such as:

(1) Mood disturbance;

(2) Irritability; or

(3) Chronic use of prescription medication to promote sleep or maintain daytime wakefulness.

b. Obstructive sleep apnea, of any severity:

(1) With continued symptoms despite treatment with positive airway pressure machines or oral positional devices; or

(2) That requires supplemental oxygen or any chronic medication to maintain wakefulness.

c. Sleep-related movement disorder that causes sleep disruption resulting in excessive daytime somnolence or other impacts on duty, such as:

(1) Mood disturbance;

(2) Irritability; or

(3) Chronic use of prescription medication to promote sleep or maintain daytime

wakefulness.

5.28. BEHAVIORAL HEALTH.

The following conditions, defined using the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, unless otherwise stated, are not compatible with retention and the Service should initiate appropriate medical and personnel actions upon diagnosis.

a. Schizophrenia, delusional disorder, schizophreniform disorder, schizoaffective disorder, and brief psychotic disorder. Substance- or medication–induced psychotic disorder and psychotic disorder(s) due to another medical condition should be considered on a case-by-case basis.

b. Bipolar I disorder.

c. Other bipolar spectrum disorders—including bipolar II disorder, cyclothymic disorder, substance- or medication–induced bipolar disorder—will be considered on a case-by-case basis if, despite appropriate treatment, they:

(1) Require persistent duty modifications to reduce psychological stressors or enhance safety; or

(2) Impair function so as to preclude satisfactory performance of required military duties of the member’s office, grade, rank, or rating.

d. Other behavioral health conditions, defined using the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders—including, but not limited to, anxiety disorders, depressive disorders, or eating or feeding disorders—will be considered on a case-by-case basis if, despite appropriate treatment, they:

(1) Require persistent duty modifications to reduce psychological stressors or enhance safety; or

(2) Impair function so as to preclude satisfactory performance of required military duties of the member’s office, grade, rank, or rating.

e. Per Paragraph 3.3, disqualifying behavioral health conditions should either be referred to the DES or processed for administrative separation, based on whichever is appropriate for that condition.

5.29. TUMORS AND MALIGNANCIES.

a. All malignancies will be evaluated for potential recurrence and need for medical surveillance that could require permanent duty limitations, in accordance with Military Department regulations.

b. Malignant neoplasms that are not responsive to therapy or have residuals of treatment that limit satisfactory performance of duty.

c. Benign tumors with mass effect or that interfere with the wearing of military equipment.

5.30. MISCELLANEOUS CONDITIONS.

Conditions listed in this paragraph do not meet medical retention standards if they require medication for control with frequent monitoring by a medical provider due to potentialdebilitating or serious side effects or geographic limitations to protect the individual from infectious disease risk.

a. Porphyria.

b. Cold-related disorders or injuries with sequelae.

c. Organ or tissue transplantation for which long-term immunosuppressant therapy is clinically indicated.

d. History of heatstroke or heat injury.

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Contents

DoD Instruction 1332.18 Disability Evaluation System (10 November 2022)

DOD Manual 1332.18 Vol. 1 Disability Evaluation System (DES) Manual: Processes (24 FEB 2023)

DOD INSTRUCTION 6130.03, Volume 2 Medical Standards for Military Service: Retention (4 September 2020, incorporating Change 1, 6 June 2022)