Disability Determination: Case Study

Group I, Category 30
Insufficient Documentation to Show Conformance to Procedural Requirements When A Disability Determination is Based on Unresolved Work Activity That Could Affect the Decision
ISSUE
Step 1 of Sequential Evaluation is not satisfied. The record does not reasonably document if, and when substantial gainful activity (SGA) ended.
CASE DISCUSSION & POLICY ANALYSIS (INCLUDING SPECIFIC REFERENCES)
This 50-year old claimant is filing a DIB claim alleging disability due to coronary atherosclerosis, atrioventricular block, hypothyroidism, dyspnea, ischemic dilated cardiomyopathy, ventricular fibrillation, sinus bradycardia, essential hypertension, cardiac arrest, and paroxysmal atrial fibrillation as of 08/06/2015.
The claimant has
The claim was denied J1 on 11/23/16. At the time of the determination the claimant was doing well status post placement of the pacemaker. However, current records show the claimant has continued to deteriorate despite prescribed treatment. His EF was 15-20 on 12/16 and the function report notes dyspnea with exertion, dizziness and fatigue. Therefore, the prior determine is incorrect and warrants re-opening. The claim is re-opened using the 1-year rule. DI 27505.001.A.1 indicates a final determination of a Title II claim may be reopened within 1 year from the date of notice of the initial determination “for any reason.” DI 27510.005B.1 indicates the DDS has the authority to re-open and revise the prior claim if the determination is below the ALJ level. In this case, the prior denial was incorrect and the claim should re-opened under the 1-year rule. There is no indication in file that DDS considered reopening of the prior claim. Absent re-opening, the EOD is limited to the day after the date the PDN is
On the SSA 3368, the claimant indicated he stopped working 8/26/15. However, records from Knoxville HMA Cardiology show the claimant informed his doctor on 11/20/16 he was going to start work at Home Depot delivering and setting up sheds. On 1/9/17, he states he was working at Home Depot and had started a kettle corn business. There is no mention of this work on a SSA 821/820 or elsewhere in the file. It is unclear if the claimant has returned to work at the SGA level. Therefore, additional information is required. DI 24001.005. A indicates that the DDS is responsible for recognizing work activity that is relevant to the disability decision that is not developed by the FO including unresolved questions and discrepancies on forms SSA 3368 and other evidence in