Impairment Severity Case Study

Group I, Category 41 Insufficient Medical Documentation to Determine Impairment Severity

ISSUE

Additional evidence and documentation is needed to determine the degree of the severity imposed by the claimant’s psychological condition.

CASE DISCUSSION & POLICY ANALYSIS (INCLUDING SPECIFIC REFERENCES)

This 54- year old claimant is filing a DI claim alleging disability due to Cleidocranial dysplasia, scoliosis, and depression.

The evidence in file shows the claimant has a history of anxiety and depression. At the MSE on 11/13/15, she alleges a history of anxiety over the death of her mother and she was prescribed Xanax. During the exam, her thoughts were well organized and she appeared to be to functioning in at least the average intelligence

However, additional information is required (see the 416 in file for additional details). DI 22511.009 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, the claimant may have an eating disorder related to anxiety. She was scheduled to attend an appointment regarding the eating disorder. It is unclear whether she attended the appointment. DI 22505.006 indicates the DDS must develop evidence from all sources, including those discovered during development that have treated the claimant during the applicable 12-month

A SSA 3380 should also be requested in accordance with DI 22511.011.D1.

There is additional information regarding the claimant’s physical condition in file. The DDS assessed a RFC for 20/10/6/6. The evidence in file supports this determination.

If the additional development determines the claimant’s psychological condition is non-severe additional vocation development may still be required as the descriptions on the SSA 3369 are not detailed enough to complete a function-by-function comparison of the PRW as required by DI 25005.001A & B; SSR 82-62.

REQUEST FOR CORRECTIVE ACTION

Please contact the claimant for updated information regarding mental health treatment. If additional information exists these records should be requested. Contact the claimant for updated ADLs and if possible obtain a third party report regarding her mental capabilities.

After your action, please prepare a revised SSA-831 and notice if necessary and return the claim to OQP