Citation Nr: 1801957 Decision Date: 01/10/18 Archive Date: 01/23/18 DOCKET NO. 13-34 243A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to an initial compensable rating for multiple lipomas, right upper extremity. 2. Entitlement to an initial rating in excess of 20 percent for multiple lipomas, left upper extremity. 3. Entitlement to an initial rating in excess of 10 percent for multiple lipomas, anterior trunk. 4. Entitlement to an initial compensable rating for multiple lipomas, posterior trunk. 5. Entitlement to an initial rating in excess of 10 percent for multiple lipomas, posterior neck. 6. Entitlement to an initial compensable rating for painful lipomas, upper body, prior to December 3, 2013, and for an initial rating in excess of 20 percent for the period from December 3, 2013. 7. Entitlement to an initial compensable rating for residual scars, right forearm, status post lipoma removal. 8. Entitlement to a total disability rating based on individual unemployability (TDIU) prior to July 31, 2012, and to a TDIU based upon the service-connected lipomas alone from July 31, 2012, to September 11, 2015. REPRESENTATION Veteran represented by: Texas Veterans Commission ATTORNEY FOR THE BOARD Rachel E. Jensen, Associate Counsel INTRODUCTION The Veteran served on active duty in the United States Navy from April 1958 to May 1971. These matters come to the Board of Veterans' Appeals (Board) on appeal from June 2012 and June 2015 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. In the June 2012 decision, service connection was granted for lipomas of the upper body at a noncompensable rate and residual scars of the right forearm at a noncompensable rate, effective June 17, 2010. The Veteran submitted a timely appeal. In the June 2015 decision, the evaluation of upper body lipomas was increased to 20 percent, effective December 3, 2013. Service connection was also granted for lipomas of the left upper extremity (LUE) at 20 percent disabling, of the right upper extremity (RUE) at a noncompensable rate, of the posterior trunk at a noncompensable rate, and of the anterior trunk at 10 percent disabling, all effective October 20, 2014. The Veteran submitted a timely appeal and these claims came before the Board in November 2015 where they were denied, along with a service connection claim for a dental disorder for dental treatment purposes. The November 2015 Board decision also granted service connection for multiple lipomas of the posterior neck at 10 percent disabling, effective October 20, 2014. The Veteran subsequently appealed the decision to the Court of Appeals for Veterans Claims (Court). In an August 2017 Joint Motion for Partial Remand (JMPR), the Court vacated the portion of the Board decision regarding the increased rating claims. The dental disorder claim was dismissed This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2017). 38 U.S.C. § 7107(a)(2) (2012). FINDINGS OF FACT 1. As of October 31, 2013, the Veteran's RUE lipomas measured 10.5 sq. cm in size, and as of October 20, 2014, they measured 40.5 sq. cm in size, and have not resulted in appreciable limitation of function. 2. As of October 31, 2013, the Veteran's LUE lipomas measured 21 sq. cm in size, and as of October 20, 2014, they measured 123 sq. cm in size, and have not resulted in appreciable limitation of function. 3. The Veteran's anterior trunk lipomas were observed measuring 50 sq. cm on October 31, 2013, and have not resulted in limitation of function. 4. The Veteran's posterior trunk lipomas were observed measuring 26 cm on October 31, 2013, and have not resulted in a limitation of function. 5. The Veteran's posterior neck lipomas were observable on October 31, 2013, but no characteristics of disfigurement were reported. 6. The October 2014 private examination report indicated that the Veteran has soft tissue masses on his posterior neck that are neither painful nor unstable, but have surface contour that is elevated on palpation. 7. Medical evidence revealed three painful lipomas on the Veteran's trunk and extremities. 8. Giving the Veteran all benefit of the doubt, he has experienced approximately three painful lipomas throughout the appeal period. 9. The evidence fails to show that the Veteran's residual scars, right forearm, status post lipoma removal, cover an area of at least 929 sq. cm, limit function, are painful, or are unstable. 10. The Veteran's service-connected disabilities did not meet the schedular requirements for a TDIU and there is no evidence of record that he was unable to establish and maintain substantially gainful employment due to his service-connected disabilities prior to July 31, 2012. 11. From July 31, 2012, to September 11, 2015, the Veteran's lipoma ratings were insufficient to warrant entitlement to a TDIU on the basis of one service-connected disability. CONCLUSIONS OF LAW 1. The criteria for an initial noncompensable rating from October 31, 2013, and a rating of 10 percent but no higher from October 20, 2014, for RUE multiple lipomas have been met. 38 U.S.C. § 1155, 5103, 5103A, 5107(b) (2012); 38 C.F.R. 3.102, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.118, Diagnostic Code (DC) 7800-7819 (2017). 2. The criteria for an initial noncompensable rating from October 31, 2013, and a rating of 20 percent but no higher from October 20, 2014, for LUE multiple lipomas have been met. 38 U.S.C. § 1155, 5103, 5103A, 5107(b); 38 C.F.R. 3.102, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.118, DC 7800-7819. 3. The criteria for an initial rating of 10 percent, but no higher, from October 31, 2013, for multiple lipomas of the anterior trunk have been met. 38 U.S.C. § 1155, 5103, 5103A, 5107(b); 38 C.F.R. 3.102, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.118, DC 7800-7819. 4. The criteria for an initial noncompensable rating from October 31, 2013, for multiple lipomas of the posterior trunk have been met. 38 U.S.C. § 1155, 5103, 5103A, 5107(b); 38 C.F.R. 3.102, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.118, DC 7800-7819. 5. The criteria for an initial noncompensable rating from October 31, 2013, and a 10 percent rating, but no higher, from October 20, 2014, for multiple lipomas of the posterior neck have been met. 38 U.S.C. § 1155, 5103, 5103A, 5107(b); 38 C.F.R. 3.102, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.118, DC 7800-7819. 6. The criteria for an initial 20 percent rating from June 17, 2010, for painful lipomas of the upper body have been met. 38 U.S.C. § 1155, 5103, 5103A, 5107(b); 38 C.F.R. 3.102, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.118, DC 7800-7819. 7. The criteria for an initial compensable rating for residual scars, right forearm, status post lipoma removal, have not been met. 38 U.S.C. § 1155, 5103, 5103A, 5107(b); 38 C.F.R. 3.102, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.118, DC 7800-7819. 8. The criteria for a TDIU prior to July 31, 2012, have not been met. 38 U.S.C. § 1155, 5103, 5103A, 5107(b); 38 C.F.R. §§ 3.102, 4.16 (2017). 9. The criteria for a TDIU based solely on the Veteran's service-connected lipomas have not been met. 38 U.S.C. § 1114(s), 1155, 5103, 5103A, 5107(b) (2012); 38 C.F.R. §§ 3.102, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4 (2017). The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of, or incident to, military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7. After consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The evaluation of the same disability under various diagnoses, and the evaluation of the same manifestation under different diagnoses, are to be avoided. 38 C.F.R. § 4.14 (2017). The Veteran's entire history is reviewed when making disability evaluations. 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where the question for consideration is the propriety of the initial evaluation assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of a "staged rating" (assignment of different ratings for distinct periods of time, based on the facts found) is required. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Veteran's service-connected lipomas and residual scars are rated as benign skin neoplasms under 38 C.F.R. § 4.118, Diagnostic Code 7819. DC 7819 requires benign skin neoplasms to be rated as disfigurement of the head, face, or neck under DC 7800, as scars under DCs 7801, 7802, 7803, 7804, or 7805, or as impairment of function. Accordingly, the Veteran's disabilities have been rated under the following diagnostic codes: upper body lipomas under DC 7804; right forearm residual scars under DC 7805; LUE lipomas under DC 7801; RUE lipomas under DC 7801; posterior trunk lipomas under DC 7800; and anterior trunk lipomas under DC 7801. Under DC 7800, a 10 percent rating is warranted for scars that are located on the head, face, or neck when there is one characteristic of disfigurement. A 30 percent rating is warranted when there is visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, or lips), or; with two or three characteristics of disfigurement. A 50 percent rating is warranted when there is visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features, or; with four or five characteristics of disfigurement. An 80 percent rating is warranted when there is visible or palpable tissue loss and either gross distortion or asymmetry of three or more features or paired sets of features, or; with six or more characteristics of disfigurement. 38 C.F.R. § 4.118, DC 7800. For purposes of evaluation of under 38 C.F.R. § 4.118, the eight characteristics of disfigurement are: a scar that is 5 or more inches (13 cm), in length; a scar that is at least one-quarter inch (0.6 cm) wide at the widest part; surface contour of the scar that is elevated or depressed on palpation; a scar that is adherent to underlying tissue; skin that is hypo- or hyper-pigmented in an area exceeding 6 sq. inches (39 sq. cm); skin texture that is abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding 6 sq. inches (39 sq. cm); underlying soft tissue that is missing in an area exceeding six square inches (39 sq. cm); and skin that is indurated and inflexible in an area exceeding 6 sq. inches (39 sq. cm). 38 C.F.R. § 4.118, DC 7800, Note 1. VA is to consider unretouched color photographs when evaluating under these criteria. Id., at Note 3. Additionally, VA is to separately evaluate disabling effects other than disfigurement that are associated with individual scars of the head, face, or neck, such as pain, instability, and residuals of associated muscle or nerve injury, under the appropriate diagnostic code(s) and apply 38 C.F.R. § 4.25 to combine the evaluation(s) with the evaluation assigned under DC 7800. Id., at Note 4. Finally, the characteristics of disfigurement may be caused by one scar or by multiple scars; the characteristics that are required to assign a particular evaluation need not be caused by a single scar in order to assign that evaluation. Id., at Note 5. Under DC 7801, a 10 percent evaluation when the area(s) is at least 6 sq. inches (39 sq. cm) but less than 12 sq. inches (77 sq. cm). A 20 percent evaluation is assigned when the area(s) is at least 12 sq. inches (77 sq. cm) but less than 72 sq. inches (465 sq. cm). A 30 percent evaluation is assigned when the area(s) is at least 72 sq. inches (465 sq. cm) but less than 144 sq. inches (929 sq. cm). A 40 percent evaluation is assigned when the area(s) exceeds 144 sq. inches (929 sq. cm). Note 1 provides that a deep scar is one associated with underlying soft tissue damage. 38 C.F.R. § 4.118, DC 7801. Under DC 7802, a maximum schedular evaluation of 10 percent is warranted for scars with an area(s) of 144 sq. inches (929 sq. cm) or greater. Note 1 provides that a superficial scar is one not associated with underlying soft tissue damage. 38 C.F.R. § 4.118, DC 7802. Under DC 7804, which applies to scars that are unstable or painful, a 10 percent evaluation is warranted for one or two scars that are unstable or painful. A 20 percent evaluation is warranted for three or four scars that are unstable or painful. A 30 percent evaluation is warranted for five or more scars that are unstable or painful. Note 1 provides that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Note 2 provides that if one or more scars are both unstable and painful, 10 percent should be added to the evaluation that is based on the total number of unstable or painful scars. Note 3 provides that scars evaluated under DC 7800, 7801, 7802, and 7805 may also receive an evaluation under this diagnostic code, when applicable. 38 C.F.R. § 4.118, DC 7804. DC 7805 applies to other scars (including linear scars) and other effects of scars evaluated under DC 7800, 7801, 7802 and 7804. Any disabling effects not considered in a rating provided under DC 7800 through 7804 should be evaluated under an appropriate diagnostic code. 38 C.F.R. § 4.118, DC 7805. A private medical treatment record from December 2009 stated that the Veteran had multiple lipomas with one under his chin causing dysphagia. In September 2010, the Veteran submitted a statement that his lipomas produced a dull throb and growth in his forearms. He witnessed continued growth of multiple lipomas, especially in his arms, chest, back, and chin. He felt they could be causing a circulatory problem in his upper left arm which he noticed when driving long distances where he had to change position and shake his arm to recover circulation. He also reported increase in pain in his left forearm. The Veteran underwent a VA examination to determine eligibility for aid and attendance benefits in June 2011. An examination of the skin revealed multiple soft tissue swelling in the bilateral upper extremities, chest and abdomen, upper and lower back, and the neck inframandibular region. The examiner noted that they varied in size from 1 inch to 2 inches in diameter, and were soft with free mobility. No tenderness, redness, or discharge was observed. One-inch horizontal, oblique, superficial scar marks on the right forearm from lipoma removal were witnessed with no attachment to underlying soft tissue. They were light brown to white in color and no inflammation, discharge, or keloid formation was found. The examiner characterized the lipomas as asymptomatic. In February 2012, the Veteran's private doctor excised a 10 cm left lumbar subfascial mass consistent with lipoma. In March 2012, he excised eight soft tissue masses from the left arm and two soft tissue tumors from the sublingual area. The Veteran submitted a statement in September 2012 that described the onset of his lipomas in service, accompanied by a dull, throbbing pain. He reported that after service, the lipomas continued to grow and cover his arms, back, chest, and neck. A large lipoma on his back and several on his arms began to be very painful. One lipoma under his neck caused pain, affected his swallowing, and caused coughing. He stated that he continued to have lipomas in his arms, back, and shoulders, making him unable to work and restricting activities such as yard work, car servicing, cooking, and playing with his grandchildren. The Veteran's private doctor completed a diagram of the Veteran's front and back in October 2013 that detailed fifteen total lipomas, with lipomas on his anterior trunk measuring 5 by 6 cm, 4 cm, and 4 by 5 cm; lipomas on his RUE measuring 2.5 cm, 2 cm, 3 cm, and 3 cm; lipomas on his LUE measuring 9 cm, 7 cm, and 5 cm; and lipomas on his back measuring 5 cm, 4 cm, 7 cm, 5 cm, and 5 cm. Additionally, two lipomas were indicated on the posterior neck, but no measurements were provided. The same doctor completed a Disability Benefits Questionnaire (DBQ) in December 2013 which noted that the Veteran had painful scars but did not identify how many were painful. He reported deep soft tissue masses on the RUE measuring 2.5 cm, 2 cm, 5 cm, 3 cm, and 2 cm; deep soft tissue masses of the LUE measuring 9 cm and 5 cm; and soft tissue masses of the posterior trunk measuring 7 cm, 5 cm, and 5 cm. The doctor stated that as the Veteran's soft tissue masses increase in size, they become painful and can limit range of motion. In the Veteran's December 2013 Substantive Appeal, he reiterated that he experienced pain from lipomas since service that has continued to the present day. The same doctor completed another DBQ in October 2014. He observed three painful scars on the Veteran's trunk and extremities, multiple soft tissue tumors over the anterior chest and posterior thorax, and soft tissue masses on the posterior neck. He noted that the surface contour of the neck lipomas was elevated on palpation. He reported again that if the soft tissue masses increase in size or volume, as they have done, they can become very painful and can limit range of motion of the extremities. He also stated that the Veteran had chronic joint pain associated with his scars. He updated the diagram of scars he had previously completed, noting that an additional lipoma on his RUE measuring 6 by 5 cm, and lipomas on his LUE that had previously measured 9 cm and 7 cm now measured 11.5 by 6 cm and 9 by 6 cm, respectively. I. RUE Lipomas The Veteran's RUE lipomas are currently noncompensable, effective October 20, 2014, under DC 7801. At the June 2011 VA examination, multiple soft tissue swelling in the bilateral upper extremities, varying in size from 1 inch to 2 inches in diameter, were observed. The October 2013 diagram completed by the Veteran's private doctor noted lipomas on his right arm measuring 2.5 cm, 2 cm, 3 cm, and 3 cm., totaling 10.5 cm. The December 2013 DBQ documented deep soft tissue masses on the RUE measuring 2.5 cm, 2 cm, 5 cm, 3 cm, and 2 cm, totaling 14.5 cm. In the October 2014 updated diagram, the clinician observed lipomas measuring 2.5 cm, 2 cm, 3 cm, and 3 cm, and an additional 30 sq. cm lipoma, bringing the entire area covered by his lipomas to 40.5 cm. It is clear that the Veteran's RUE lipomas were observable and documented as early as October 31, 2013, the date of the private doctor's diagram. However, the combined size of the lipomas merits a noncompensable rating under DC 7801. As demonstrated in the October 2014 updated diagram, the Veteran's RUE lipomas are deep, nonlinear scars of at least 39 sq. cm but less than 77 sq. cm. Accordingly, they merit a 10 percent rating under DC 7801, effective October 20, 2014. At no time have they measured greater than 77 sq. cm, therefore, a higher rating under DC 7801 is not warranted. Thus, the Veteran's RUE lipomas are granted a noncompensable rating from October 31, 2013, and a rating of 10 percent, but no higher, from October 20, 2014. The Veteran has consistently reported symptoms of pain associated with his lipomas. His private doctor has also documented painful lipomas. He stated in the October 2014 DBQ that the Veteran also experienced chronic joint pain associated with his lipomas. However, because the Veteran is separately service-connected for painful lipomas of the upper body under DC 7804, any painful symptoms associated with the RUE lipomas will be considered in conjunction with that rating, discussed below. In both the December 2013 and October 2014 DBQs, the examiner indicated that as the Veteran's lipomas increase in size or volume, they become very painful and can limit range of motion of the extremities. The Veteran has also reported that he cannot work due to the lipomas and is restricted in his activities, such as yard work and playing with his grandchildren. Although it is certainly possible that the Veteran's range of motion could be affected by extremely large masses on his RUE, there has been no indication of how his functionality is affected by the lipomas. The private doctor noted that as they increased in size, they became very painful and that can limit his range of motion. However, as discussed below, the Veteran is separately service-connected for the pain in his RUE lipomas under his upper body painful lipomas disability. The doctor has indicated that limitation of motion from pain can happen, but limited range of motion due to the lipomas has not been shown to have occurred to an appreciable degree upon examination. Accordingly, a separate rating under 38 C.F.R. § 4.118, DC 7805, is not warranted. II. LUE Lipomas The Veteran's LUE lipomas are currently 20 percent disabling, effective October 20, 2014, under DC 7801. At the June 2011 VA examination, multiple soft tissue swelling in the bilateral upper extremities, varying in size from 1 inch to 2 inches in diameter, were observed. In March 2012, the Veteran had eight soft tissue masses excised from his left arm. In the October 2013 diagram, the Veteran's private doctor identified lipomas on his left arm measuring 9 cm, 7 cm, and 5 cm, totaling 21 cm. At the December 2013 DBQ, deep soft tissue masses of the LUE measuring 9 cm and 5 cm were observed, totaling 14 cm. In the October 2014 DBQ and updated diagram, the private doctor noted that the lipomas on his left arm that had previously measured 9 cm and 7 cm now measured 11.5 by 6 cm and 9 by 6 cm, respectively, for a total of 123 sq. cm. It is clear that the Veteran's LUE lipomas were observable and documented as early as October 31, 2013, the date of the private doctor's diagram. However, the combined size of the lipomas merits a noncompensable rating under DC 7801. As demonstrated in the October 2014 updated diagram, the Veteran's LUE lipomas are deep, nonlinear scars of at least 77 sq. cm but not more than 465 sq. cm. Thus, a 20 percent rating is appropriate under DC 7801. Because the LUE lipomas have at no point in the record been observed measuring 465 sq. cm, a higher rating under DC 7801 is not warranted. Therefore, the Veteran's LUE lipomas are granted a noncompensable rating from October 31, 2013, and a rating of 20 percent but no higher from October 20, 2014. Again, any painful symptoms from the Veteran's LUE lipomas will be discussed below in conjunction with his upper body painful lipomas separate rating. In both the December 2013 and October 2014 DBQs, the examiner indicated that as the Veteran's lipomas increase in size or volume, they become very painful and can limit range of motion of the extremities. The Veteran has also reported that he cannot work due to the lipomas and is restricted in his activities, such as yard work and playing with his grandchildren. Although it is certainly possible that the Veteran's range of motion could be affected by extremely large masses on his LUE, there has been no indication of how his functionality is affected by the lipomas. The private doctor noted that as they increased in size, they became very painful and that can limit his range of motion. However, as discussed below, the Veteran is separately service-connected for the pain in his LUE lipomas under his upper body painful lipomas disability. The doctor has indicated that limitation of motion from pain can happen, but limited range of motion due to the lipomas has not been shown to have occurred to an appreciable degree upon examination. Accordingly, a separate rating under 38 C.F.R. § 4.118, DC 7805, is not warranted. III. Anterior Trunk Lipomas As noted above, the Veteran was awarded service connection for the multiple lipomas on his anterior trunk at 10 percent disabling, effective October 20, 2014, based upon the results of the private doctor's October 2014 DBQ. However, the diagram created by that same doctor in October 2013 indicates that the Veteran had lipomas on his anterior trunk measuring 5 by 6 cm, 4 cm, and 4 by 5 cm, totaling 50 sq. cm. As the lipomas affect an area of at least 39 sq. cm but less than 77 sq. cm, a 10 percent rating is warranted under DC 7801 as of the date of the diagram, October 31, 2013. Similarly sized lipomas were documented in the October 2014 diagram. As they have at no time been observed measuring an area more than 77 sq. cm, a higher rating under DC 7801 is not warranted. Therefore, the Veteran's anterior trunk lipomas are granted a 10 percent rating from October 31, 2013. Again, any painful symptoms from the Veteran's anterior trunk lipomas will be discussed below in conjunction with his upper body painful lipomas separate rating. The only limitation of function that has been raised in the record was the examiner's statement in the December 2013 and October 2014 DBQs regarding limited range of motion of the extremities. Because the notation was limited to the Veteran's extremities, and there is no additional indication in the record that there is limitation of function in the Veteran's anterior trunk due to his lipomas, no additional rating under DC 7805 is warranted. Accordingly, a 10 percent rating for the anterior trunk lipomas is warranted from October 31, 2013. IV. Posterior Trunk Lipomas As noted above, the Veteran was awarded service connection for the multiple lipomas on his posterior trunk at a noncompensable rate, effective October 20, 2014. The diagram created by the private doctor in October 2013 indicates lipomas of the back measuring 5 cm, 4 cm, 7 cm, 5 cm, and 5 cm, totaling 26 cm. The December 2013 DBQ reported soft tissue masses of the posterior trunk measuring 7 cm, 5 cm, and 5 cm, totaling 17 cm. The October 2014 DBQ and updated diagram indicated results similar to the October 2013 diagram. It is clear that the Veteran's posterior trunk lipomas were observable and documented as early as October 31, 2013, the date of the private doctor's diagram. However, the combined size of the lipomas merits a noncompensable rating under DC 7801. At no point in the record have lipomas totaling 39 sq. cm been observed on the posterior trunk. Therefore, a compensable rating is not warranted under DC 7801. Accordingly, the Veteran's posterior trunk lipomas warrant a noncompensable rating from October 31, 2013. Again, any painful symptoms from the Veteran's posterior trunk lipomas will be discussed below in conjunction with his upper body painful lipomas separate rating. The only limitation of function that has been raised in the record was the examiner's statement in the December 2013 and October 2014 DBQs regarding limited range of motion of the extremities. Because the notation was limited to the Veteran's extremities, and there is no additional indication in the record that there is limitation of function in the Veteran's posterior trunk due to his lipomas, no additional rating under DC 7805 is warranted. Based on the foregoing, the Veteran's posterior trunk lipomas warrant a noncompensable rating from October 31, 2013. V. Posterior Neck Lipomas Service connection for lipomas of the posterior neck was awarded in the November 2015 Board decision, at 10 percent disabling, effective October 20, 2014, under DC 7800. Service connection was granted because of the October 2014 DBQ which identified "soft tissue masses - posterior neck" with elevated surface contour, and the October 2014 updated diagram showing two masses on the back of the Veteran's neck. The October 2013 diagram also indicated two masses on the posterior neck. In addition, masses were observed on other areas of the Veteran's neck throughout the appeal period. A 3 cm lipoma was first noted under the Veteran's chin in December 2009. A lipoma in the neck "inframandibular region" was found on the June 2011 VA examination. In February 2012, the Veteran sought removal of a lipoma observed in the "submental area" of the neck, and two lipomas were ultimately excised from that area in March 2012. Although there have been some indications of lipomas in the anterior neck, those observed appear to have been surgically removed. There are no indications in the October 2013 diagram, December 2013 DBQ, or October 2014 DBQ and updated diagram that the Veteran has had any further anterior lipomas. Giving the Veteran all benefit of the doubt, the indications on the October 2013 diagram of the two masses on the posterior neck, later supported by the October 2014 diagram and the doctor's notations on the DBQ, suggest his posterior neck lipomas were observable as early as the date of the October 2013 diagram. However, there is no indication in the December 2013 DBQ or other medical records prior to October 2014 of elevated surface contour on palpation or any other characteristics of disfigurement under DC 7800. As such, a compensable rating is not warranted, but these facts provide a basis for a noncompensable rating from October 31, 2013, to October 20, 2014. The October 2014 DBQ indicated that there was elevated surface contour on palpation of the posterior neck lipomas, but no further characteristics of disfigurement were reported. Accordingly, a rating in excess of 10 percent disabling from October 20, 2014, is not merited under DC 7800. Again, any painful symptoms from the Veteran's posterior neck lipomas will be discussed below in conjunction with his upper body painful lipomas separate rating. The only limitation of function that has been raised in the record was the examiner's statement in the December 2013 and October 2014 DBQs regarding limited range of motion of the extremities. Because the notation was limited to the Veteran's extremities, and there is no additional indication in the record that there is limitation of function in the Veteran's posterior neck due to his lipomas, no additional rating under DC 7805 is warranted. VI. Painful Lipomas, Upper Body As noted above, the Veteran was service connected for painful lipomas of the upper body at a noncompensable rate, effective June 17, 2010. That rating was increased to 20 percent disabling, effective December 3, 2013. The Veteran has repeatedly contended that his lipomas were painful in service and that his post-service lipomas have continued to cause him pain. He even indicated to his private doctors that he wanted several of them excised due to pain. Medical records indicate his lipomas caused him pain. As it happened, the December 2013 DBQ did not indicate the number of lipomas the Veteran had that were painful. No clarification from the Veteran's private doctor was sought. The first quantification of painful lipomas was in the October 2014 DBQ, where three were noted. The Board finds that the Veteran's consistent description of painful lipomas since service is competent, credible, and probative. Because the only objective medical evidence of painful lipomas is the three indicated upon examination in the October 2014 DBQ, it is the most probative quantification of painful lipomas for purposes of DC 7804. Giving the Veteran all benefit of the doubt due to his lay statements and actions consistent with painful lipomas, his upper body painful lipomas are therefore granted a 20 percent rating throughout the entire appeal period. There has been no objective quantification of five or more painful or unstable lipomas throughout the appeal period; therefore, an increased rating under DC 7804 is not warranted. In the October 2014 DBQ, the private doctor indicated that the Veteran had chronic joint pain associated with his lipomas. However, the Veteran has never contended this, and without any rationale or explanation, there is no evidence of a connection between such a skin disorder and a musculoskeletal condition. Further, the Veteran has other diagnoses in his medical records that could account for joint pain (i.e., severe degenerative joint disease). Thus, without further evidence to the contrary, the Board concludes that any potential joint pain the Veteran may be experiencing due to his lipomas is captured by the 20 percent rating under DC 7804 for painful or unstable scars. Therefore, an initial 20 percent rating, but no higher, is warranted for painful lipomas, upper body, throughout the entire appeal period. VII. Residual Scars, Right Forearm As noted above, the Veteran was awarded service connection for residual scars, right forearm, status post lipoma removal, and assigned a noncompensable rating, effective June 17, 2010. At the June 2011 VA examination, one-inch horizontal, oblique, superficial scar marks on the right forearm from lipoma removal were witnessed with no attachment to underlying soft tissue. They were light brown to white in color and no inflammation, discharge, or keloid formation was found. No scars of the right forearm were discussed in the October 2013 diagram, December 2013 DBQ, or October 2014 DBQ and updated diagram. Because the right forearm scars have not been found to be of an area 929 sq. cm or greater, a compensable rating under DC 7802 is not warranted. Although the Veteran has reported pain in his lipomas, he has not indicated that he experiences pain in the residual scars of the right forearm. Therefore, an additional rating under DC 7804 is not merited. Similarly, there has been no indication that the residual scars from the lipoma excision have caused any limitation of function or any other disabling effect. Thus, an increased rating under DC 7805 has not been demonstrated. Based on the foregoing, the Board finds that the preponderance of the evidence is against the claim for a compensable rating for the Veteran's residual right forearm scars and the appeal must be denied. There is no doubt to be resolved as to this matter. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert, 1 Vet. App. at 49. VIII. TDIU The Veteran was granted a TDIU based on all of his service-connected disabilities in a May 2013 rating decision, effective July 31, 2012, which is the date his combined disability ratings met the schedular requirements for a TDIU. 38 C.F.R. § 4.16(a). The entitlement to TDIU was discontinued September 11, 2015, the date that he was granted a 100 percent schedular evaluation due to all of his service-connected disabilities. Due to the decisions herein on the claims on appeal, it must be considered whether the Veteran may have met the schedular requirements for a TDIU prior to July 31, 2012. A total disability rating for compensation purposes may be assigned where the schedular rating is less than total and where it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of a service-connected disability ratable at 60 percent or more or as a result of two or more disabilities, provided at least one disability is ratable at 40 percent or more, and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). Consideration may be given to the Veteran's level of education, special training, and previous work experience in arriving at a conclusion, but not to his or her age or to the impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 4.16, 4.19 (2017); see also Van Hoose v. Brown, 4 Vet. App. 361 (1993). To meet the requirement of "one 60 percent disability" or "one 40 percent disability," the following will be considered as one disability: (1) disability of one or both lower extremities, including the bilateral factor, if applicable; (2) disabilities resulting from one common etiology; (3) disabilities affecting a single body system; (4) multiple injuries incurred in action; and (5) multiple disabilities incurred as a prisoner of war. Id. Substantially gainful employment is defined as work which is more than marginal and which permits the individual to earn a living wage. Moore v. Derwinski, 1 Vet. App. 356 (1991). Marginal employment may also be held to exist, on a facts-found basis (including, but not limited to, employment in a protected environment such as a family business or sheltered workshop), when earned annual income exceeds the poverty threshold. 38 C.F.R. § 4.16. Prior to July 31, 2012, the Veteran had a noncompensable rating for painful lipomas of the upper body, a 10 percent rating for tinnitus, and a noncompensable rating for residual scars of the right forearm, combining to a 10 percent disability rating. The painful lipomas have been granted a 20 percent rating effective June 17, 2010, per this decision. Therefore, the Veteran's pre-July 31, 2012, combined disability rating is 30 percent. 38 C.F.R. § 4.25 (2017). This does not meet the schedular threshold for a TDIU. Additionally, there is no indication prior to the Veteran's lay statements in September 2012 that he was unemployable due to the painful lipomas, tinnitus, and residual forearm scars. In a January 2011 Income-Net Worth and Employment Statement VA Form 21-527, he stated that his age and back disability prevented him from working. The only examinations of record prior to July 31, 2012, did not address employability. As such, there is insufficient evidence that the Veteran was unable to maintain substantially gainful employment prior to July 31, 2012, due to his service-connected painful upper body lipomas, tinnitus, and residual scar of the right forearm such as to warrant extraschedular TDIU consideration. 38 C.F.R. § 4.16; Roberson v. Principi, 251 F.3d 1378 (2001), Rice v. Shinseki, supra. The Board notes that the Veteran was granted a TDIU based on all of his service-connected disabilities. However, if a Veteran can be awarded a TDIU based upon one service-connected disability, he is eligible for special monthly compensation, if there is additional service-connected disability or disabilities independently ratable at 60 percent or more. 38 U.S.C. § 1114(s). The JPMR directed the Board to consider whether the Veteran's lipomas alone met the criteria for TDIU from July 2012 to September 2015. As of July 31, 2012, the Veteran continued to only have two conditions service-connected due to his lipomas - painful lipomas of the upper body at 20 percent disabling and residual scars of the right forearm at 0 percent disabling, combining to 20 percent. As of October 31, 2013, the Veteran had seven conditions service-connected due to his lipomas (per this decision): painful lipomas of the upper body at 20 percent disabling; multiple lipomas of the anterior trunk at 10 percent disabling; noncompensable ratings for RUE, LUE, posterior trunk, and posterior neck multiple lipomas; and a noncompensable rating for residual scars of the right forearm, resulting in a combined rate for the lipomas of 30 percent disabling. As of October 20, 2014, the Veteran had seven conditions service-connected due to his lipomas at the following rates (per this decision): painful lipomas of the upper body at 20 percent disabling; LUE multiple lipomas at 20 percent disabling; RUE multiple lipomas at 10 percent disabling; anterior trunk multiple lipomas at 10 percent disabling, posterior neck lipomas at 10 percent disabling, and noncompensable ratings for lipomas of the posterior trunk and residual scars of the right forearm, resulting in a 50 percent combined rate for the lipomas only. The Veteran's lipomas have not met the schedular requirements for a TDIU based upon one service-connected disability. The Veteran has contended that the lipomas in his arms, back, and shoulder rendered him unable to work and restricted his leisure activities. See September 2012 statement. However, both the December 2013 and October 2014 DBQs did not address whether the lipomas affected his ability to work, while the September 2014 and August 2015 Parkinson's disease private DBQs specified that his Parkinson's disease affected his ability to work due to tremors in his hands, difficulty working with faces, and difficulty walking. Given the foregoing, the Board finds that there is insufficient evidence that the Veteran's inability to maintain substantially gainful employment was due solely to his service-connected lipomas, sufficient to warrant extraschedular consideration. As such, the Veteran cannot be awarded a TDIU from July 31, 2012, to September 11, 2015, on the basis of only his service-connected lipomas. ORDER An initial noncompensable rating from October 31, 2013, and a rating of 10 percent but no higher from October 20, 2014, for RUE multiple lipomas is granted. An initial noncompensable rating from October 31, 2013, and a rating of 20 percent but no higher from October 20, 2014, for LUE multiple lipomas is granted. An initial rating of 10 percent, but no higher, from October 31, 2013, for multiple lipomas of the anterior trunk is granted. An initial noncompensable rating from October 31, 2013, for multiple lipomas of the posterior trunk is granted. An initial noncompensable rating from October 31, 2013, and a 10 percent rating, but no higher, from October 20, 2014, for multiple lipomas of the posterior neck is granted. An initial 20 percent rating from June 17, 2010, for painful lipomas of the upper body is granted. An initial compensable rating for residual scars, right forearm, status post lipoma removal is denied. Entitlement to a TDIU prior to July 31, 2012, is denied. Entitlement to a TDIU based solely on the Veteran's service-connected lipomas is denied. ____________________________________________ MICHAEL KILCOYNE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs