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.
The DDS assessed a RFC for the ability to lift/carry less than 10 pounds frequently and occasionally and standing less than 2 hours in an 8-hour day. The evidence in file supports this determination. Additionally, the claimant can occasionally climb ramps/stairs, but should never climb ladder/ropes/scaffolds. All other postural activities are limited to occasionally. She should not work at unprotected heights, or around dangerous machinery. She should avoid walking on wet, slippery or uneven surfaces.
There is insufficient evidence in file to assess the claimant’s mental condition. The claimant’s psychiatric treating sources are non acceptable medical sources (AMS). DI 22505.003.3.a indicates non-AMS medical sources include medical personnel who are not AMSs but, are legally permitted to provide health care, such as nurse practitioners, and therapists. DI 22505.003.3.B.2 indicates we require evidence from an AMS to establish that an individual has an MDI at step 2 of sequential evaluation. In this case, there is no psychiatric MDI from an AMS.
The DDS did not address the claimant’s mental impairment as the claimant was allowed based on her physical impairments alone.
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
performed.
The prior SSA-3368 notes that the claimant worked as a caregiver from 2006 to 2009 and from 2009 to 2010. According to the current SSA-3369, during this period, the claimant worked as a program manager. It remains unclear if the claimant fulfilled multiple capacities in the same setting or if the program manager is a composite job. Prior to making a decision, DDS needs to clarify the number of jobs performed from 2006 to 2010. If the claimant performed more than the one job listed on the SSA-3369, DDS would need to obtain a detailed description of the missing job(s).
OQR realizes that there is a severely restrictive; however, a complete detailed description of all past work is required nonetheless. A decision must be made on how the claimant actually performed this work. There is no need to discuss the ability to meet the demands of his past work as generally performed or the ability to transfer skills because all occupational bases are significantly eroded. The work should be described sufficiently to perform a function-by-function analysis and detailed enough to locate its counterpart in the DOT in accordance with DI 25005.025A.Therefore additional development is required.
DI 25005.020.A indicates that the claimant's past work must be detailed enough to compare the requirements of the work with the RFC on a function-by-function basis. DI 22515.001.B.4 notes that a complete detailed description is needed for each job held during the relevant period in order to complete a sequential evaluation. The descriptions should include job titles, dates of employment, hours/days worked, rate of pay, physical/mental demands, job duties, nature and extent of supervision, types of tools/machinery/equipment used, and knowledge required.
If additional vocational development reveals that the claimant is unable to meet the demands of her past work, Vocational Rule 201.28 would provide the framework for a decision of disabled. If additional vocational development reveals that the claimant meets the physical demands of her past work, DDS would need to assess the potential mental MDIs.