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 physical condition.
CASE DISCUSSION & POLICY ANALYSIS (INCLUDING SPECIFIC REFERENCES)
This 52- year old claimant is filing a DI claim alleging disability due to diabetes, a stroke, kidney pain, back pain, numbness in the fingers, joint discomfort, vision problems, and high blood pressure.
The evidence in file shows the claimant suffered a cerebrovascular accident (CVA) on 10/15/15, which resulted in left sided body weakness, slurred speech and gait ataxia. The brain MRI on 10/15/15 indicated a right pontine ischemic CVA and left cerebellar with suspected significant vertebral artery stenosis. The CT scan revealed documented hemodynamically significant lesion of the extracranial or intracranial circulation. At the follow up office visit with River City Neurology on 02/18/2016, claimant had improved, she no longer using a walker but was walking with a cane. On exam, her strength was reported 3-/5 in the left upper extremity and 4/5 in the left lower extremity. There was mildly increased tone on the left side. Although she was able to walk unassisted, she was unable to tandem walk and she had a left hemispheric gait. She …show more content…
There is insufficient documentation in file to assess claimant’s current condition. DI 22501.001.D indicates case evidence must be complete and detailed enough to permit an independent determination about whether the claimant is disabled. In this case, the claimant has significantly decreased strength and tone in the left log and walked with antalgic gait. There is insufficient evidence to assess claimant's ability of independent ambulation as suggested by the DDS RFC evaluation. ADLS show the claimant uses a cane daily and little ability to use the right
ISSUE
Additional evidence and documentation is needed to determine the degree of the severity imposed by the claimant’s physical condition.
CASE DISCUSSION & POLICY ANALYSIS (INCLUDING SPECIFIC REFERENCES)
This 52- year old claimant is filing a DI claim alleging disability due to diabetes, a stroke, kidney pain, back pain, numbness in the fingers, joint discomfort, vision problems, and high blood pressure.
The evidence in file shows the claimant suffered a cerebrovascular accident (CVA) on 10/15/15, which resulted in left sided body weakness, slurred speech and gait ataxia. The brain MRI on 10/15/15 indicated a right pontine ischemic CVA and left cerebellar with suspected significant vertebral artery stenosis. The CT scan revealed documented hemodynamically significant lesion of the extracranial or intracranial circulation. At the follow up office visit with River City Neurology on 02/18/2016, claimant had improved, she no longer using a walker but was walking with a cane. On exam, her strength was reported 3-/5 in the left upper extremity and 4/5 in the left lower extremity. There was mildly increased tone on the left side. Although she was able to walk unassisted, she was unable to tandem walk and she had a left hemispheric gait. She …show more content…
There is insufficient documentation in file to assess claimant’s current condition. DI 22501.001.D indicates case evidence must be complete and detailed enough to permit an independent determination about whether the claimant is disabled. In this case, the claimant has significantly decreased strength and tone in the left log and walked with antalgic gait. There is insufficient evidence to assess claimant's ability of independent ambulation as suggested by the DDS RFC evaluation. ADLS show the claimant uses a cane daily and little ability to use the right