Impairment Severity Case Study
Gr. I, Category 41
Insufficient Medical Documentation to Determine Impairment Severity
ISSUE: Additional medical and vocational development is needed to complete Sequential Evaluation.
CASE DISCUSSION AND POLICY ANALYSIS:
This 38-year-old claimant is filing a DIB claim alleging disability due to osteoarthritis, bursitis, impingement tear in hip, anxiety, depression, the inability to lift more than 20 pounds, lower back pain and sciatica, chronic pain, and morbid obesity as of 4/18/16.
The evidence in file shows the claimant has a history of near-super morbid obesity, anxiety and depression. She has moderate osteoarthritis of both hips. The evidence in file shows she was seen on 9/1/16 due to depression, she was upset that she was kicked off her spouses insurance. She is treated by a nurse practitioner who prescribes mild psychotropic medication. On 7/11/16, she complained of increased anxiety related to weight loss and marital issues. …show more content…
If an allowance is not possible based solely on physical impairments, additional development of the claimant’s mental impairment is necessary since the current mental medical evidence is insufficient per DI 22511.009. This policy states, evidence of a claimant's functional limitation is “sufficient” to permit an assessment of impairment severity when it is both consistent and complete enough to evaluate and assess function. In this case, there is no psychiatric MDI documented by an AMS.
Additionally, there is a vocational issue. On the SSA-3368, the claimant reported five jobs during the relevant period. The job at DSHS (job#1) was not performed at SGA level; therefore, not relevant. The rest of the jobs noted on the SSA-3368 were described on the SSA-3369. The walking/standing limitations would preclude the claimant's ability to meet the demands of the jobs documented on the SSA-3369 as actually
Insufficient Medical Documentation to Determine Impairment Severity
ISSUE: Additional medical and vocational development is needed to complete Sequential Evaluation.
CASE DISCUSSION AND POLICY ANALYSIS:
This 38-year-old claimant is filing a DIB claim alleging disability due to osteoarthritis, bursitis, impingement tear in hip, anxiety, depression, the inability to lift more than 20 pounds, lower back pain and sciatica, chronic pain, and morbid obesity as of 4/18/16.
The evidence in file shows the claimant has a history of near-super morbid obesity, anxiety and depression. She has moderate osteoarthritis of both hips. The evidence in file shows she was seen on 9/1/16 due to depression, she was upset that she was kicked off her spouses insurance. She is treated by a nurse practitioner who prescribes mild psychotropic medication. On 7/11/16, she complained of increased anxiety related to weight loss and marital issues. …show more content…
If an allowance is not possible based solely on physical impairments, additional development of the claimant’s mental impairment is necessary since the current mental medical evidence is insufficient per DI 22511.009. This policy states, evidence of a claimant's functional limitation is “sufficient” to permit an assessment of impairment severity when it is both consistent and complete enough to evaluate and assess function. In this case, there is no psychiatric MDI documented by an AMS.
Additionally, there is a vocational issue. On the SSA-3368, the claimant reported five jobs during the relevant period. The job at DSHS (job#1) was not performed at SGA level; therefore, not relevant. The rest of the jobs noted on the SSA-3368 were described on the SSA-3369. The walking/standing limitations would preclude the claimant's ability to meet the demands of the jobs documented on the SSA-3369 as actually