Impairment Rigidity Case Study
Gr. I, Category 41
Insufficient Medical Documentation to Determine Impairment Severity
ISSUE
Additional medical development is needed to assess the claimant’s physical impairment and complete the Sequential Evaluation of Disability.
CASE DISCUSSION AND POLICY ANALYSIS
This 56- year old claimant is filing a Concurrent Reconsideration claim alleging disability due to sciatica, nerve pain on both sides, inability to sit or stand for long periods, and back pain as of 03/27/2013.
The evidence in file shows the claimant has a history tremors, back pain and possible Parkinson’s. On 7/7/17, he was positive for resting tremors on the right arm and hand and cogwheel rigidity. He walked with a stooping posture and dragged his feet. The exam noted he had been started on Simemet 3 weeks earlier. The physical exam on 2/17/17 shows normal lower extremities. He …show more content…
was able to change positions without difficulty, pain or hesitation. He denied lower extremity weakness or numbness or tingling. On 2/22/17, he walked with a stooped posture and dragged his feet. He was seen 1/6/17 due to back pain. He was negative for muscle atrophy and he had a normal gait. He was scheduled for a spinal MRI for back pain but the exam had not been completed as of adjudication.
The DDS determined Listing 11.06 is equaled as of 2/23/17, when the claimant’s gait first became altered.
A review of the file indicates there is insufficient evidence to assess his condition. Per DI 34001.030, for this listing to be met the condition must persist for 3 months despite prescribed treatment. In this case, the claimant had only been on the Simemet 3 weeks, which is not long enough to determine whether there was an improvement in his condition. In addition, while an altered gait is noted, there is no mention of balance issues, or a description of his ability to use his upper extremities.
DI 24515.001B.3 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 the function. In this case, the evidence in file is not sufficient to fully assess the claimant’s condition. Additional information regarding his response to treatment, a detailed examination regarding balance, upper extremities and confirmation of whether he has completed the MRI exam is needed. REQUEST FOR CORRECTIVE
ACTION
Please contact the claimant for updated medical records, if no additional evidence exists, a consultative exam may be required.
After your action, please prepare a revised SSA-831 and notice if necessary and return the claim to OQR Chicago.
Insufficient Medical Documentation to Determine Impairment Severity
ISSUE
Additional medical development is needed to assess the claimant’s physical impairment and complete the Sequential Evaluation of Disability.
CASE DISCUSSION AND POLICY ANALYSIS
This 56- year old claimant is filing a Concurrent Reconsideration claim alleging disability due to sciatica, nerve pain on both sides, inability to sit or stand for long periods, and back pain as of 03/27/2013.
The evidence in file shows the claimant has a history tremors, back pain and possible Parkinson’s. On 7/7/17, he was positive for resting tremors on the right arm and hand and cogwheel rigidity. He walked with a stooping posture and dragged his feet. The exam noted he had been started on Simemet 3 weeks earlier. The physical exam on 2/17/17 shows normal lower extremities. He …show more content…
was able to change positions without difficulty, pain or hesitation. He denied lower extremity weakness or numbness or tingling. On 2/22/17, he walked with a stooped posture and dragged his feet. He was seen 1/6/17 due to back pain. He was negative for muscle atrophy and he had a normal gait. He was scheduled for a spinal MRI for back pain but the exam had not been completed as of adjudication.
The DDS determined Listing 11.06 is equaled as of 2/23/17, when the claimant’s gait first became altered.
A review of the file indicates there is insufficient evidence to assess his condition. Per DI 34001.030, for this listing to be met the condition must persist for 3 months despite prescribed treatment. In this case, the claimant had only been on the Simemet 3 weeks, which is not long enough to determine whether there was an improvement in his condition. In addition, while an altered gait is noted, there is no mention of balance issues, or a description of his ability to use his upper extremities.
DI 24515.001B.3 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 the function. In this case, the evidence in file is not sufficient to fully assess the claimant’s condition. Additional information regarding his response to treatment, a detailed examination regarding balance, upper extremities and confirmation of whether he has completed the MRI exam is needed. REQUEST FOR CORRECTIVE
ACTION
Please contact the claimant for updated medical records, if no additional evidence exists, a consultative exam may be required.
After your action, please prepare a revised SSA-831 and notice if necessary and return the claim to OQR Chicago.