Citation Nr: 21072795 Decision Date: 12/06/21 Archive Date: 12/06/21 DOCKET NO. 17-28 744 DATE: December 6, 2021 ORDER An initial compensable rating for Dercum's disease, bilateral lower extremity ilio-inguinal nerve, is denied. An initial compensable rating for Dercum's disease, bilateral lower extremity obturator nerve, is denied. An initial compensable rating for Dercum's disease, bilateral lower extremity external cutaneous nerve, is denied. A rating higher than 10 percent for Dercum's disease, bilateral lower extremity femoral nerve, prior to June 4, 2018, is denied. A rating higher than 20 percent for Dercum's disease, bilateral lower extremity femoral nerve, from June 4, 2018 to the present, is denied. A rating higher than 10 percent for Dercum's disease, bilateral lower extremity sciatic nerve, prior to June 4, 2018, is denied. A rating higher than 20 percent for Dercum's disease, bilateral lower extremity sciatic nerve, from June 4, 2018 to the present, is denied. A rating higher than 20 percent for Dercum's disease, left upper extremity (minor), incomplete paralysis, prior to June 4, 2018, is denied. A rating higher than 30 percent for Dercum's disease, left upper extremity, incomplete paralysis, from June 4, 2018 to the present, is denied. A rating higher than 20 percent for Dercum's disease, right upper extremity (major), incomplete paralysis, prior to June 4, 2018, is denied. A 40 percent rating for Dercum's disease, right upper extremity, incomplete paralysis, from June 4, 2018 to the present, is granted. An initial rating higher than 10 percent for chronic sinusitis is denied. A rating higher than 30 percent for lipomatosis is denied. A total disability rating based on individual unemployability due to service-connected disabilities (TDIU), prior to June 4, 2018, is denied. The issue of an effective date earlier than March 3, 2014, for the grant of service connection for Dercum's disease, bilateral lower extremity ilio-inguinal nerve, is dismissed. The issue of an effective date earlier than March 3, 2014, for the grant of service connection for Dercum's disease, bilateral lower extremity obturator nerve, is dismissed. The issue of an effective date earlier than March 3, 2014, for the grant of service connection for Dercum's disease, bilateral lower extremity external cutaneous nerve, is dismissed. The issue of an effective date earlier than March 3, 2014, for the grant of service connection for Dercum's disease, bilateral lower extremity femoral nerve, is dismissed. The issue of an effective date earlier than March 3, 2014, for the grant of service connection for Dercum's disease, bilateral lower extremity sciatic nerve, is dismissed. The issue of an effective date earlier than March 3, 2014, for the grant of service connection for Dercum's disease, bilateral upper extremity, is dismissed. FINDINGS OF FACT 1. Throughout the period on appeal, the Veteran's Dercum's disease, bilateral lower extremity ilio-inguinal nerve, manifested by mild to moderate constant pain, moderate to severe intermittent pain, and mild to severe paresthesias or dysesthesias and numbness, resulting in mild to moderate incomplete paralysis. 2. Throughout the period on appeal, the Veteran's Dercum's disease, bilateral lower extremity obturator nerve, manifested by mild to moderate constant pain, moderate to severe intermittent pain, and mild to severe paresthesias or dysesthesias and numbness, resulting in mild to moderate incomplete paralysis. 3. Throughout the period on appeal, the Veteran's Dercum's disease, bilateral lower extremity external cutaneous nerve, manifested by mild to moderate constant pain, moderate to severe intermittent pain, mild to severe paresthesias or dysesthesias and numbness, resulting in mild to moderate incomplete paralysis. 4. Prior to June 4, 2018, the Veteran's Dercum's disease, bilateral lower extremity femoral nerve, manifested by moderate constant pain, and mild paresthesias or dysesthesias and numbness; resulting in mild incomplete paralysis. 5. From June 4, 2018 to the present, the Veteran's Dercum's disease, bilateral lower extremity femoral nerve, manifested by weakness, mild to moderate constant pain, severe intermittent pain, and moderate to severe paresthesias or dysesthesias and numbness, resulting in moderate incomplete paralysis. 6. Prior to June 4, 2018, the Veteran's Dercum's disease, bilateral lower extremity sciatic nerve, manifested by moderate constant pain, and mild paresthesias or dysesthesias and numbness; resulting in mild incomplete paralysis. 7. From June 4, 2018 to the present, the Veteran's Dercum's disease, bilateral lower extremity sciatic nerve, manifested by weakness, mild to moderate constant pain, severe intermittent pain, and moderate to severe paresthesias or dysesthesias and numbness, resulting in moderate incomplete paralysis. 8. Prior to June 4, 2018, the Veteran's Dercum's disease, left upper extremity, incomplete paralysis, manifested by moderate constant pain, and mild paresthesias or dysesthesias and numbness; resulting in mild incomplete paralysis. 9. From June 4, 2018 to the present, the Veteran's Dercum's disease, left upper extremity, incomplete paralysis, manifested by weakness, mild to severe constant and intermittent pain, and mild to moderate paresthesias or dysesthesias and numbness, resulting in, at worst, moderate incomplete paralysis. 10. Prior to June 4, 2018, the Veteran's Dercum's disease, right upper extremity, incomplete paralysis, manifested by moderate constant pain, and mild paresthesias or dysesthesias and numbness; resulting in mild incomplete paralysis. 11. From June 4, 2018 to the present, the Veteran's Dercum's disease, right upper extremity, incomplete paralysis, manifested by weakness, moderate to severe constant pain, severe intermittent pain, mild to moderate paresthesias or dysesthesias, and moderate numbness, resulting in moderate incomplete paralysis. 12. At no time during the appeal period is the Veteran's sinusitis shown to be productive of three or more incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or; more than six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. 13. Throughout the period on appeal, the Veteran has had up to 20 lipomas without 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; deep and nonlinear and an area or areas of at least 144 sq. in. or greater; more than 40 percent of the entire body, or more than 40 percent of exposed areas, or; requiring the use of constant or near constant systemic therapy such as corticosteroids or other immunosuppressive drugs. 14. For the period before June 4, 2018, the Veteran does not meet the schedular percentage threshold for a TDIU, and there is no evidence that he was unemployable due to his service-connected disabilities. 15. In a September 1999 decision, the Board denied the Veteran's appeal for a date earlier than January 1993 for a grant of service connection of a skin disorder, then characterized as lipomatosis; the Veteran did not appeal the Board's decision. CONCLUSIONS OF LAW 1. Throughout the period on appeal, the criteria for an initial compensable rating for Dercum's disease, bilateral lower extremity ilio-inguinal nerve, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.123, 4.124, 4.124a, Diagnostic Code (DC) 8530. 2. Throughout the period on appeal, the criteria for an initial compensable rating for Dercum's disease, bilateral lower extremity obturator nerve, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.123, 4.124, 4.124a, DC 8528. 3. Throughout the period on appeal, the criteria for an initial compensable rating for Dercum's disease, bilateral lower extremity external cutaneous nerve, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.123, 4.124, 4.124a, DC 8529. 4. The criteria for a rating higher than 10 percent for Dercum's disease, bilateral lower extremity femoral nerve, prior to June 4, 2018, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.123, 4.124, 4.124a, DC 8526. 5. The criteria for a rating higher than 20 percent for Dercum's disease, bilateral lower extremity femoral nerve, from June 4, 2018 to the present, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.123, 4.124, 4.124a, DC 8526. 6. The criteria for a rating higher than 10 percent for Dercum's disease, bilateral lower extremity sciatic nerve, prior to June 4, 2018, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.123, 4.124, 4.124a, DC 8520. 7. The criteria for a rating higher than 20 percent for Dercum's disease, bilateral lower extremity sciatic nerve, from June 4, 2018 to the present, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.123, 4.124, 4.124a, DC 8520. 8. The criteria for a rating higher than 20 percent for Dercum's disease, left upper extremity, incomplete paralysis, prior to June 4, 2018, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.123, 4.124, 4.124a, DC 8513. 9. The criteria for a rating higher than 30 percent for Dercum's disease, left upper extremity, incomplete paralysis, from June 4, 2018 to the present, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.123, 4.124, 4.124a, DC 8513. 10. The criteria for a rating higher than 20 percent for Dercum's disease, right upper extremity, incomplete paralysis, prior to June 4, 2018, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.123, 4.124, 4.124a, DC 8513. 11. The criteria for a 40 percent rating for Dercum's disease, right upper extremity, incomplete paralysis, from June 4, 2018 to the present, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.123, 4.124, 4.124a, DC 8513. 12. Throughout the period on appeal, the criteria for an initial rating higher than 10 percent for chronic sinusitis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.96, 4.97, DC 6512. 13. Throughout the period on appeal, the criteria for a rating higher than 30 percent for lipomatosis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.118, DCs 7819-7806. 14. For the period prior to June 4, 2018, the criteria for entitlement to a TDIU have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.314, 3.321, 3.340, 4.16. 15. The RO did not have jurisdiction to review the Veteran's assertion of a date earlier than January 1993 for a grant of service connection of a skin disorder, then characterized as lipomatosis. 38 U.S.C. §§ 5110(a), 7105(c); 38 C.F.R. §§ 3.105, 3.151, 3.155, 3.400. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from November 1978 to June 1979. This matter was previously before the Board of Veterans' Appeals (Board) in January 2020 when the issues were remanded for further development. After a review of the record, the Board has determined the following: Initial compensable ratings for the Veteran's Dercum's disease, bilateral lower extremity ilio-inguinal, obturator, and cutaneous nerves will be denied because, at worst, the Veteran had moderate incomplete paralysis of the nerves. Ratings higher than 10 percent, prior to June 4, 2018, and higher than 20 percent, from June 4, 2018 to the present, for the Veteran's bilateral lower extremity femoral nerve will be denied because, at worst, the Veteran had mild incomplete paralysis during the first period and moderate incomplete paralysis during the second period. Ratings higher than 10 percent, prior to June 4, 2018, and higher than 20 percent, from June 4, 2018 to the present, for the Veteran's bilateral lower extremity sciatic nerve will be denied because, at worst, the Veteran had mild incomplete paralysis during the first period and moderate incomplete paralysis during the second period. Ratings higher than 20 percent for the bilateral upper extremity, incomplete paralysis, prior to June 4, 2018, will be denied because, at worst, the Veteran had mild incomplete paralysis during the period. A 30 percent rating for left upper extremity (minor), incomplete paralysis, from June 4, 2018 to the present, will be denied because, at worst, the Veteran had moderate incomplete paralysis during the period. A 40 percent rating for right upper extremity (major), incomplete paralysis, from June 4, 2018 to the present, will be granted because, at worst, the Veteran had moderate incomplete paralysis during the period. A rating higher than 10 percent for chronic sinusitis will be denied because the evidence does not show that the Veteran's symptoms met the requirements for a higher rating during the period on appeal. A rating higher than 30 percent for lipomatosis will be denied because the evidence does not show that the Veteran's symptoms met the requirements for a higher rating during the period on appeal. A TDIU, for the period prior to June 4, 2018, will be denied because the Veteran does not meet the schedular percentage threshold, and there is no evidence that he was unemployable due to his service-connected disabilities. The issues of an earlier effective date of January 5, 1993 for the grant of service connection for Dercum's disease, bilateral lower extremity ilio-inguinal nerve, obturator nerve, external cutaneous nerve, femoral nerve, sciatic nerve, and incomplete paralysis of the bilateral upper extremity, will be dismissed. Increased Ratings Disability evaluations are determined by the application of a schedule of ratings which is based, as far as can practically be determined, on the average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Each service-connected disability is rated on the basis of specific criteria identified by diagnostic codes "DCs." 38 C.F.R. § 4.27. A claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). Regulations require that where there is a question as to which of two evaluations is to be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After the evidence has been assembled, it is the Board's responsibility to evaluate the entire record. 38 U.S.C. § 7104(a). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3. A VA claimant need only demonstrate that there is an approximate balance of positive and negative evidence in order to prevail. Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the preponderance of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert at 54. 1. An initial compensable rating for Dercum's disease, bilateral lower extremity ilio-inguinal nerve, is denied. 2. An initial compensable rating for Dercum's disease, bilateral lower extremity obturator nerve, is denied. 3. An initial compensable rating for Dercum's disease, bilateral lower extremity external cutaneous nerve, is denied. While each of the three nerves addressed here are rated under different DCs, the rating criteria for each of the different nerves and the applicable facts are essentially identical. For the following reasons, higher ratings are not warranted, and the claims are denied. The Veteran's bilateral lower extremity ilio-inguinal nerve is rated under DC 8530, the bilateral lower extremity obturator nerve is rated under DC 8528, and the bilateral lower extremity external cutaneous nerve is rated under DC 8529. While applicable to different nerves, DCs 8530, 8528, and 8529 all use the same rating criteria. Under each of the three DCs, mild or moderate paralysis of the nerve warrants a noncompensable rating. 38 C.F.R. § 4.124a, DCs 8528 to 8530. Severe to complete paralysis of the affected nerve warrants a 10 percent rating. Id. When the involvement is wholly sensory, the rating should be for the mild, or at most the moderate degree. 38 C.F.R. § 4.124a, Diseases of the Peripheral Nerves, Note. The terms "mild," "moderate," and "severe" are not defined in the rating schedule. Rather than applying a mechanical formula, the Board must evaluate all the evidence to arrive at a just and equitable decision. Additionally, the use of such terminology by VA examiners and others, although an element to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. Disability ratings for neurological conditions are ordinarily assigned based on impairment of motor, sensory, or mental function. See 38 C.F.R. § 4.124a. In evaluating peripheral nerve injuries, VA considers the site and character of the injury, the relative impairment in motor function, trophic (external) changes, or senses. VA gives special consideration to complete or partial loss of use of one or more extremities and disturbances of gait. Throughout the period on appeal, the Veteran has reported that he has pain associated with his peripheral neuropathy. He is competent to report such symptoms, and there is no evidence that his statements are not credible. Jandreau, 492 F.3d 1372. They are therefore entitled to probative weight as to the severity of his nerve disabilities during the period on appeal. During the July 2016 VA examination, the Veteran reported having severe neuropathic pain daily. The examiner noted that the Veteran experienced moderate constant pain, and mild paresthesias or dysesthesias and numbness, resulting in mild incomplete paralysis of the bilateral ilio-inguinal, obturator, and cutaneous nerves. The examiner stated that muscle strength was normal bilaterally with no evidence of atrophy. Reflexes were normal. However, sensation to light touch was decreased in the bilateral lower leg/ankle and foot/toes. No trophic changes were present. During the June 2018 VA examination, the examiner noted that the Veteran had weakness, and severe intermittent pain, paresthesias or dysesthesias, and numbness, resulting in moderate incomplete paralysis of the bilateral ilio-inguinal, obturator, and cutaneous nerves. The examiner stated that muscle strength was normal bilaterally with no evidence of atrophy. Reflexes were normal. However, sensation to light touch was decreased in the left lower extremity thigh/knee, lower leg/ankle, and foot/toes. Trophic changes in the form of shiny skin to the bilateral lower extremities was noted. During the July 2020 VA examination, the examiner noted that the Veteran had mild constant pain to the right lower extremity and moderate constant pain to the left lower extremity, severe intermittent pain bilaterally, and moderate paresthesias or dysesthesias and numbness bilaterally, resulting in moderate incomplete paralysis of the bilateral ilio-inguinal, obturator, and cutaneous nerves. The examiner stated that muscle strength was normal bilaterally with no evidence of atrophy. Reflexes were decreased in the bilateral knee and ankle. Sensation to light touch was decreased in the bilateral upper anterior thigh, thigh/knee, lower leg/ankle, and foot/toes. Trophic changes in the form of dry and scaley, hairless skin was noted. The Board finds that the VA examination reports are entitled to significant probative weight as to the severity of the Veteran's disability. Nieves-Rodriguez, 22 Vet. App. 295. The preponderance of the evidence is against a finding that compensable ratings are warranted for the Veteran's bilateral lower extremity ilio-inguinal, obturator, and external cutaneous nerves. Throughout the period on appeal, the evidence shows that the Veteran's muscle strength was normal, and without atrophy bilaterally. The July 2020 VA examination shows decreased reflexes in the bilateral knee and ankle, and decreased sensation to light touch in the bilateral upper anterior thigh, thigh/knee, lower leg/ankle, and foot/toes. However, the VA examinations show that the Veteran had, at worst, moderate incomplete paralysis of the nerves bilaterally. As such, the preponderance of the evidence is against a finding that initial compensable ratings for the Veteran's bilateral lower extremity ilio-inguinal, obturator, and external cutaneous nerves is warranted. 38 C.F.R. § 4.3, 4.7, 4.124a, DCs 8530, 8528, and 8529. Throughout the period on appeal, the preponderance of the evidence is against initial compensable ratings for the Veteran's bilateral lower extremity ilio-inguinal, obturator, and external cutaneous nerves. As such, the benefit-of-the-doubt doctrine is inapplicable. 38 C.F.R. § 4.3. For these reasons, the claims are denied. 4. A rating higher than 10 percent for Dercum's disease, bilateral lower extremity femoral nerve, prior to June 4, 2018, is denied. 5. A rating higher than 20 percent for Dercum's disease, bilateral lower extremity femoral nerve, from June 4, 2018 to the present, is denied. The Veteran's bilateral lower extremity femoral nerve has been rated as 10 percent disabling, prior to June 4, 2018, and as 20 percent disabling, from June 4, 2018 to the present, under DC 8526. For the following reasons, higher ratings are not warranted, and the claims are denied. DC 8526 provides ratings for paralysis of the femoral nerve. DC 8526 provides a 10 percent rating for mild incomplete paralysis; a 20 percent rating for moderate incomplete paralysis; and a 30 percent rating for severe incomplete paralysis. A 60 percent rating is warranted for complete paralysis of quadriceps extensor muscles. See 38 C.F.R. § 4.124a, DC 8526. As noted above, the terms "mild," "moderate," and "severe" are not defined in the rating schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to arrive at a just and equitable decision. Additionally, the use of such terminology by VA examiners and others, although an element to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. As noted above, the July 2016 VA examination shows that the Veteran reported having severe neuropathic pain daily. The examiner noted that the Veteran had moderate constant pain, and mild paresthesias or dysesthesias and numbness, resulting in mild incomplete paralysis of the femoral nerve bilaterally. The examiner stated that muscle strength was normal bilaterally with no evidence of atrophy. Reflexes were normal. However, sensation to light touch was decreased in the bilateral lower leg/ankle and foot/toes. No trophic changes were present. The June 2018 VA examination shows that the Veteran had weakness, and severe intermittent pain, paresthesias or dysesthesias, and numbness, resulting in moderate incomplete paralysis of the bilateral femoral nerve. The examiner stated that muscle strength was normal bilaterally with no evidence of atrophy. Reflexes were normal. However, sensation to light touch was decreased in the left lower extremity thigh/knee, lower leg ankle, and foot/toes. Trophic changes in the form of shiny skin to the bilateral lower extremities was noted. The July 2020 VA examination shows that the Veteran had mild constant pain to the right lower extremity and moderate constant pain to the left lower extremity, severe intermittent pain bilaterally, and moderate paresthesias or dysesthesias and numbness bilaterally, resulting in moderate incomplete paralysis of the bilateral femoral nerve. The examiner stated that muscle strength was normal bilaterally with no evidence of atrophy. Reflexes were decreased in the bilateral knee and ankle. Sensation to light touch was decreased in the bilateral upper anterior thigh, thigh/knee, lower leg/ankle, and foot/toes. Trophic changes in the form of dry and scaley, hairless skin was noted. For the period prior to June 4, 2018, the preponderance of the evidence is against a rating higher than 10 percent because the Veteran has not had moderate incomplete paralysis or complete paralysis of quadriceps extensor muscles of the right or left lower extremity. See 38 C.F.R. § 4.124a, DC 8526. For the period from June 4, 2018 to the present, the preponderance of the evidence is against a rating higher than 20 percent because the Veteran has not had severe incomplete paralysis or complete paralysis of quadriceps extensor muscles of the right or left lower extremity. Id. In conclusion, the preponderance of the evidence is against ratings higher than 10 percent, prior to June 4, 2018, and higher than 20 percent, from June 4, 2018 to the present, for the Veteran's bilateral lower extremity femoral nerve. The benefit-of-the-doubt doctrine is inapplicable. 38 C.F.R. § 4.3. For these reasons, the claims are denied. 6. A rating higher than 10 percent for Dercum's disease, bilateral lower extremity sciatic nerve, prior to June 4, 2018, is denied. 7. A rating higher than 20 percent for Dercum's disease, bilateral lower extremity sciatic nerve, from June 4, 2018 to the present, is denied. The Veteran's bilateral lower extremity sciatic nerve has been rated as 10 percent disabling, prior to June 4, 2018, and as 20 percent disabling, from June 4, 2018 to the present, under DC 8520. For the following reasons, higher ratings are not warranted, and the claims are denied. DC 8520 provides ratings for paralysis of the sciatic nerve. DC 8520 provides a 10 percent rating for mild incomplete paralysis; a 20 percent rating for moderate incomplete paralysis; and a 40 percent rating for moderately severe incomplete paralysis. A 60 percent rating is warranted for severe incomplete paralysis with marked muscular atrophy. An 80 percent rating is warranted for complete paralysis. See 38 C.F.R. § 4.124a, DC 8520. The July 2016 VA examination shows that the Veteran reported having severe neuropathic pain daily. The examiner noted that the Veteran had moderate constant pain, and mild paresthesias or dysesthesias and numbness, resulting in mild incomplete paralysis of the sciatic nerve bilaterally. The examiner stated that muscle strength was normal bilaterally with no evidence of atrophy. Reflexes were normal. However, sensation to light touch was decreased in the bilateral lower leg/ankle and foot/toes. No trophic changes were present. As noted above, the June 2018 VA examination shows that the Veteran had weakness, and severe intermittent pain, paresthesias or dysesthesias, and numbness, resulting in moderate incomplete paralysis of the bilateral sciatic nerve. The examiner stated that muscle strength was normal bilaterally with no evidence of atrophy. Reflexes were normal. However, sensation to light touch was decreased in the left lower extremity thigh/knee, lower leg ankle, and foot/toes. Trophic changes in the form of shiny skin to the bilateral lower extremities was noted. The July 2020 VA examination shows that the Veteran had mild constant pain to the right lower extremity and moderate constant pain to the left lower extremity, severe intermittent pain bilaterally, and moderate paresthesias or dysesthesias and numbness bilaterally, resulting in moderate incomplete paralysis bilaterally. The examiner stated that muscle strength was normal bilaterally with no evidence of atrophy. Reflexes were decreased in the bilateral knee and ankle. Sensation to light touch was decreased in the bilateral upper anterior thigh, thigh/knee, lower leg/ankle, and foot/toes. Trophic changes in the form of dry and scaley, hairless skin was noted. For the period prior to June 4, 2018, the preponderance of the evidence is against a rating higher than 10 percent because the Veteran has not had moderate incomplete paralysis, marked muscular atrophy, or complete paralysis of the right or left lower extremity. See 38 C.F.R. § 4.124a, DC 8520. For the period from June 4, 2018 to the present, the preponderance of the evidence is against a rating higher than 20 percent because the Veteran has not had moderately severe incomplete paralysis, marked muscular atrophy, or complete paralysis of the right or left lower extremity. Id. In conclusion, the preponderance of the evidence is against ratings higher than 10 percent, prior to June 4, 2018, and higher than 20 percent, from June 4, 2018 to the present, for the Veteran's bilateral lower extremity sciatic nerve. The benefit-of-the-doubt doctrine is inapplicable. 38 C.F.R. § 4.3. For these reasons, the claims are denied. 8. A rating higher than 20 percent for Dercum's disease, left upper extremity, incomplete paralysis, prior to June 4, 2018, is denied. 9. A rating higher than 30 percent for Dercum's disease, left upper extremity, incomplete paralysis, from June 4, 2018 to the present, is denied. 10. A rating higher than 20 percent for Dercum's disease, right upper extremity, incomplete paralysis, prior to June 4, 2018, is denied. 11. A 40 percent rating for Dercum's disease, right upper extremity, incomplete paralysis, from June 4, 2018 to the present, is granted. The Veteran's bilateral upper extremity, incomplete paralysis, has been rated as 20 percent disabling, prior to June 4, 2018, and as 30 percent disabling, from June 4, 2018 to the present, under DC 8513. For the following reasons, ratings higher than 20 percent for the bilateral upper extremity, incomplete paralysis, prior to June 4, 2018, and 30 percent for left upper extremity, incomplete paralysis, from June 4, 2018 to the present, will be denied. A 40 percent rating for right upper extremity, incomplete paralysis, from June 4, 2018 to the present, will be granted. DC 8513 provides ratings for paralysis of the sciatic nerve. DC 8513 provides a 20 percent rating for mild incomplete paralysis; a 30 percent rating for moderate incomplete paralysis of the minor extremity; a 40 percent rating for moderate incomplete paralysis of the major extremity; a 60 percent rating for severe incomplete paralysis of the minor extremity; and a 70 percent rating for severe incomplete paralysis of the major extremity. An 80 percent rating is warranted for complete paralysis of the minor extremity, and a 90 percent rating is warranted for complete paralysis of the major extremity. See 38 C.F.R. § 4.124a, DC 8513. As noted above, the terms "mild," "moderate," and "severe" are not defined in the rating schedule. Rather than applying a mechanical formula, the Board must evaluate all the evidence to arrive at a just and equitable decision. Additionally, the use of such terminology by VA examiners and others, although an element to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. The July 2016 VA examination shows that the Veteran reported having severe neuropathic pain daily. The examiner noted that the Veteran experienced moderate constant pain, and mild paresthesias or dysesthesias and numbness, resulting in mild incomplete paralysis of the bilateral median, ulnar, musculocutaneous, circumflex, and upper, middle, and lower radicular groups. The examiner stated that muscle strength was normal bilaterally with no evidence of atrophy. Reflexes and sensation to light touch were normal. No trophic changes were present. During the June 2018 VA examination, the examiner noted that the Veteran had weakness, severe constant and intermittent pain, and moderate paresthesias or dysesthesias and numbness, resulting in moderate incomplete paralysis of the median and musculocutaneous nerves of the left lower extremity. However, the examiner noted that the Veteran's right lower extremity was normal, even though his symptoms were identical bilaterally. The examiner stated that muscle strength was normal bilaterally with no evidence of atrophy. Reflexes were normal. Sensation to light touch was decreased to the left upper extremity in the shoulder area, inner/outer forearm, and hand/finger. Trophic changes were in the form of hair loss was noted. During the July 2020 VA examination, the examiner noted that the Veteran had moderate constant pain to the right upper extremity and mild constant pain to the left upper extremity, severe intermittent pain to the right upper extremity and mild intermittent pain to the left upper extremity, mild paresthesias or dysesthesias bilaterally, and moderate numbness to the right upper extremity and mild numbness to the left upper extremity, resulting in moderate incomplete paralysis of the right upper extremity radial and ulnar nerves, and mild incomplete paralysis of the left upper extremity radial and ulnar nerves. The examiner stated that muscle strength was normal bilaterally, but for wrist and grip strength, which was four out of five bilaterally. There was no evidence of atrophy. Reflexes were normal. Sensation to light touch was decreased in the right upper extremity in the shoulder area, inner/outer forearm, and hand/fingers. Trophic changes in the form of dry and scaley, hairless skin was noted. For the period prior to June 4, 2018, the preponderance of the evidence is against ratings higher than 20 percent for the bilateral upper extremity because the Veteran has not had moderate incomplete paralysis or complete paralysis of the right or left upper extremity. See 38 C.F.R. § 4.124a, DC 8513. For the period from June 4, 2018 to the present, the preponderance of the evidence is against a rating higher than 30 percent for the left upper extremity because the Veteran has not had severe incomplete paralysis or complete paralysis of the left upper extremity. Id. For the period from June 4, 2018 to the present, the evidence shows that a higher, 40 percent rating, for the right upper extremity is warranted, because the Veteran had moderate incomplete paralysis (major extremity). However, a rating higher than 40 percent is not warranted because the evidence does not show severe incomplete paralysis or complete paralysis of the right upper extremity. Id. In conclusion, the preponderance of the evidence is against ratings higher than 20 percent for the bilateral upper extremity, incomplete paralysis, prior to June 4, 2018, and higher than 30 percent for left upper extremity, incomplete paralysis, from June 4, 2018 to the present, and the claims are denied. A 40 percent rating for right upper extremity, incomplete paralysis, from June 4, 2018 to the present, is warranted, and the claim is granted to that extent only. To the extent that the claims are denied, the benefit-of-the-doubt doctrine is inapplicable. 38 C.F.R. § 4.3. 12. An initial rating higher than 10 percent for chronic sinusitis is denied. The Veteran contends that his chronic sinusitis is worse than that which is contemplated by his current 10 percent rating under DC 6510. For the following reasons, a rating higher than 10 percent is not warranted, and the claim is denied. Under the General Rating Formula for Sinusitis, governing DCs 6510 through 6514, a noncompensable rating is warranted when sinusitis is detected by X-ray only. A 10 percent rating is warranted when there are one or two incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or; three to six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. A 30 percent rating is warranted when there are three or more incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or; more than six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. A maximum 50 percent rating is warranted following radical surgery with chronic osteomyelitis, or; near constant sinusitis characterized by headaches, pain and tenderness of affected sinus, and purulent discharge or crusting after repeated surgeries. See 38 C.F.R. § 4.97, 6512. The note to that provision defines an "incapacitating episode" of sinusitis as one that requires bed rest and treatment by physician. Id. VA treatment records show reports of congestion and occasional sinus infection. During the July 2020 VA examination, the examiner noted a diagnosis of chronic sinusitis. The following findings, signs or symptoms were noted as attributable to the Veteran's condition: chronic sinusitis detected by imaging, episodes of sinusitis, headaches, tenderness of affected sinus, and purulent discharge. The examiner noted that the Veteran has had five non-incapacitating episodes of sinusitis characterized by headaches, pain and purulent discharge or crusting in the past 12 months. No incapacitating episodes of the same were indicated. The examiner noted that the Veteran has not had sinus surgery. The VA examination and treatment records, overall, provide evidence against the Veteran's claim for a rating higher than 10 percent for sinusitis. While they show a diagnosis of sinusitis, they do not show that at any time during the period on appeal did symptoms of the Veteran's sinusitis result in three or more incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or; more than six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting, to meet the criteria for the next higher, 30 percent rating. The evidence of record also does not show that the Veteran has underwent radical surgery for his disability followed by chronic osteomyelitis. The Veteran's sinusitis has not at any time under consideration been manifested by symptoms and impairment of a nature, frequency, and severity consistent with the criteria for the next higher, 30 percent rating (or approximating such a level of severity), and the record does not show that the Veteran underwent surgery for his disability followed by chronic osteomyelitis. Accordingly, the Board finds that a rating higher than 10 percent is not warranted, and the claim is denied. DC 6510. 38 U.S.C. § 5107(b); Gilbert, 1 Vet. App. at 49. 13. A rating higher than 30 percent for lipomatosis is denied. The Veteran contends that a rating higher 30 percent is warranted, throughout the entire period on appeal, for his lipomatosis under DCs 7819-7806. 38 C.F.R. § 4.118. For the following reasons, a rating higher than 30 percent is not warranted, and the claim is denied. In order to warrant a rating higher than 30 percent for lipomatosis, the evidence must show: 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 (50 percent under DC 7800); deep and nonlinear and an area or areas of at least 144 sq. in. (929 sq. cm) or greater (40 percent under DC7801); more than 40 percent of the entire body, or more than 40 percent of exposed areas, or; requires the use of constant or near constant systemic therapy such as corticosteroids or other immunosuppressive drugs (60 percent under DC 7806). See 38 C.F.R. § 4.118. During the April 2014 VA skin examination, the examiner noted multiple lipomatosis, on different areas, involving both upper and lower extremities and upper chest and abdomen, approximately 20 total areas. The examiner noted that size ranges from a very large 7x4cm on the back to 2x2cm in other areas. The Veteran reported that the nodules are sometimes painful. The examiner was unable to give and approximation of the total skin surface involvement since the lesions are scattered all over the body. No treatment was indicated over the preceding 12 months. During the July 2016 VA skin examination, the examiner noted a diagnosis of Dercum's disease. However, the examiner did not indicate the nature of the severity of the Veteran's condition, other than stating that the condition causes pain. During the June 2018 VA scars examination, the Veteran reported pain and itching at all surgical sites where lipomas have removed due to damage to nerves at surgical sites. The examiner noted three sites on the lower back, five on the right arm, and one on the left arm. All sites were noted to tender to palpation. The examiner recorded the following measurements for the five scars on the right arm: 1) 2cm x 3mm, 2) 3.5cm x 5mm, 3) 2.5cm x 5mm, 4) 3cm x 2mm, and 5) 3cm x 5mm. All scars were noted as linear and painful. The scar on the right arm was recorded as measuring 2.5cm x 2mm. The scar was noted as tender to palpation. The examiner recorded the following measurements for the three scars on the lower back: 1) 3cm x 3mm, 2) 7cm x 3mm, and 3) 4.5cm x 3mm. During the July 2020 VA scars examination, the examiner noted a diagnosis of Dercum's disease status-post excision of lipomas. The examiner recorded the following measurements for three scars on the right arm: 1) 3.5 x .3cm, 2) 3 x .2cm, and 3) 3 x .2cm. A scar to the low back measured 7 x .5cm. The approximate total area of the scars to the right arm were 2.25cm sq, and the approximate total area of the scar to the low back was 3.5cm sq. Throughout the entire period on appeal, a rating higher than 30 percent for lipomatosis is not warranted. The evidence does not show that the Veteran has scars with 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, as required for a higher, 50 percent rating, under DC 7800. The evidence does not show that the Veteran has scars that are deep and nonlinear and an area or areas of at least 144 sq. in. or greater, as required for a higher, 40 percent rating, under DC 7801. Finally, the evidence does not show that the Veteran's scars cover an area of more than 40 percent of the entire body, or more than 40 percent of exposed areas, or requires the use of constant or near constant systemic therapy such as corticosteroids or other immunosuppressive drugs, as required for a higher, 60 percent rating, under DC 7806. See 38 C.F.R. § 4.118. Accordingly, throughout the period on appeal, the Board finds that a rating higher than 30 percent is not warranted, and the claim is denied. DC 7819-7806. 38 U.S.C. § 5107(b); Gilbert, 1 Vet. App. at 49. 14. A TDIU, prior to June 4, 2018, is denied. The Veteran has been awarded a TDIU, from June 4, 2018 to the present. Therefore, consideration of a TDIU is limited to the period prior to June 4, 2018. Schedular TDIU may be assigned when the disabled person is determined to be unable to secure or follow a substantially gainful occupation as a result of service-connected disability or disabilities, provided that, if there is only one such disability, this disability shall be ratable at 60 percent or more, and that, if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. See 38 C.F.R. § 4.16(a). Disabilities resulting from common etiology or a single accident are considered one disability for the purpose of meeting the percentage thresholds for TDIU. Id. When determining whether the Veteran is unable to secure or follow a substantially gainful occupation due to his service-connected disability, consideration may be given to the Veteran's level of education, special training, and previous work experience, but it may not be given to his age or to any impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. Prior to June 4, 2018, the Veteran's service-connected lumbosacral strain was evaluated as 10 percent disabling, his lipomatosis was evaluated as 30 percent disabling, his bilateral upper extremity, incomplete paralysis, was evaluated as 20 percent disabling, his bilateral lower extremity sciatic nerve was evaluated as 10 percent disabling, his bilateral lower extremity femoral nerve was evaluated as 10 percent disabling, his chronic sinusitis was evaluated as 10 percent disabling, and he had various other disabilities rated as noncompensable. Prior to June 4, 2018, the Veteran's combined rating was 80 percent. Under 38 C.F.R. § 4.16(a), the Veteran does not meet the schedular requirement for a TDIU, prior to June 4, 2018. Total disability will be considered to exist when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340(a). A veteran's service-connected disabilities, employment history, educational and vocational attainment, and all other factors having a bearing on the issue must be addressed. Age may not be considered as a factor in evaluating service-connected disability; and unemployability, in service-connected claims, associated with advancing age or intercurrent disability, may not be used as a basis for a total disability rating. 38 C.F.R. § 4.19. As previously noted herein, the Veteran has not met the scheduler threshold criteria for the award of a TDIU, prior to June 4, 2018. Accordingly, a TDIU cannot be granted under the scheduler provisions of 38 C.F.R. § 4.16(a), prior to June 4, 2018. TDIU may be granted on an extra-schedular basis where a veteran who fails to meet the scheduler percentage requirements but is nonetheless unemployable by reason of service-connected disability. 38 C.F.R. § 4.16(b). The Board cannot assign an extra-schedular rating in the first instance, Bowling v. Principi, 15 Vet. App. 1, 10 (2001). However, "rating boards should submit to the Director, Compensation Service, for extra-schedular consideration all cases of veterans who are unemployable by reason of service-connected disabilities." 38 C.F.R. § 4.16(b). Consideration may be given to a Veteran's level of education, special training, and previous work experience, but it may not be given to his or her age or to any impairment caused by non-service-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. For the period prior to June 4, 2018, the evidence does not demonstrate that the Veteran's service-connected disabilities rendered him unable to secure and follow a substantially gainful occupation. The April 2014 and July 2016 VA examiners noted that the Veteran's skin conditions do not impact his ability to work. The July 2016 VA back examiner noted that the Veteran's back condition limits his ability to perform a physically demanding occupation. The July 2016 VA peripheral neuropathy examiner noted that the Veteran's peripheral nerve conditions does not impact his ability to work. Prior to June 4, 2018, there is no indication that the Veteran's service-connected disabilities caused him to be unable to secure or follow substantially gainful employment. Instead, the record indicates that, at worst, the Veteran was limited in his ability to perform a physically demanding occupation. Thus, for the period prior to June 4, 2018, the evidence does not demonstrate that the Veteran's service-connected disabilities rendered him unable to secure and follow a substantially gainful occupation. Therefore, as the Veteran is found to have been capable of substantially gainful employment, prior to June 4, 2018, entitlement to a TDIU cannot be granted for the period, referral to the Director of C&P for extraschedular consideration is not necessary. Earlier Effective Dates Residuals of Dercum's Disease 15. The issue of an effective date earlier than March 3, 2014, for the grant of service connection for Dercum's disease, bilateral lower extremity ilio-inguinal nerve, is dismissed. 16. The issue of an effective date earlier than March 3, 2014, for the grant of service connection for Dercum's disease, bilateral lower extremity obturator nerve, is dismissed. 17. The issue of an effective date earlier than March 3, 2014, for the grant of service connection for Dercum's disease, bilateral lower extremity external cutaneous nerve, is dismissed. 18. The issue of an effective date earlier than March 3, 2014, for the grant of service connection for Dercum's disease, bilateral lower extremity femoral nerve, is dismissed. 19. The issue of an effective date earlier than March 3, 2014, for the grant of service connection for Dercum's disease, bilateral lower extremity sciatic nerve, is dismissed. 20. The issue of an effective date earlier than March 3, 2014, for the grant of service connection for Dercum's disease, bilateral upper extremity, is dismissed. In November 1993, the RO denied reopening of a claim of service connection for a back disorder that had been previously denied in July 1979. The Veteran filed a notice of disagreement and after appellate proceedings, a March 1997 Board decision found that the Veteran had not submitted evidence sufficient to reopen the claim. However, the Board also found that the Veteran's claimed back symptoms consisted of both an asserted musculoskeletal back disorder and a skin disorder characterized as "growth" or lipomatosis. The Board granted service connection for the latter disorder. In May 1997, the RO effectuated the grant of connection for lipomatosis and assigned a 10 percent disability rating. The Veteran filed a notice of disagreement as to the assigned rating, and the RO assigned a 30 percent evaluation, effective January 1993. In September 1997, the RO issued a Statement of the Case as to the denial of an evaluation greater than 30 percent. The Veteran filed a substantive appeal which was received in October 1997. He also argued that the effective date of the service-connected disorder should be retroactive to the date of his original claim. In June 1998, the Veteran testified before a hearing officer at the RO in support of his contention of a date earlier than January 1993. A Supplemental Statement of the Case was issued in June 1998 as to both the lipomatosis rating and the earlier effective date. In a September 1999 decision, the Board denied the Veteran's appeal as to both issues. The Board's decision denying an earlier effective date was not appealed to the United States Court of Appeals for Veterans Claims and is final absent the showing of clear and unmistakable error ("CUE"). The Veteran's apparent theory of entitlement in support of an effective date earlier than January 5, 1993 for manifestations of Dercum's disease is that they are one and the same as the lipomas. He apparently asserts that he should therefore be granted earlier effective dates for the Dercum's manifestations. For earlier effective dates to be assigned for the Dercum's disease under this theory, he must show CUE in the Board's September 1999 decision. The Veteran's assertion of an earlier effective date before the RO was misplaced. As a lower adjudicator, the RO does not have the authority to revise or correct a Board decision as the latter is the appellate authority. Therefore, the issues of an earlier effective date of January 5, 1993 for the grant of service connection for Dercum's disease, bilateral lower extremity ilio-inguinal nerve, obturator nerve, external cutaneous nerve, femoral nerve, sciatic nerve, and incomplete paralysis of the bilateral upper extremity, are dismissed. If the Veteran desires to pursue an application for revision of the Board's September 1999 decision, he should file such a motion with the Board. His attention is called to the provisions of 38 C.F.R. §§ 20.1400 through 20.1411, addressing revision of decisions by the Board on grounds of CUE. The appeals as to earlier effective dates for the grants of service connection for Dercum's disease manifestations are accordingly dismissed. Vito A. Clementi Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Timothy T. Emmart The Board's action is binding only in this case. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.