Group I, Category 44 Insufficient Medical Documentation to Determine Impairment Severity
ISSUE
There is insufficient evidence regarding the claimant’s physical condition to complete the Sequential Evaluation of Disability.
CASE DISCUSSION & POLICY ANALYSIS (INCLUDING SPECIFIC REFERENCES)
This 59- year old claimant is filing a concurrent claim alleging disability due to arthritis in the knees, a herniated disc, scoliosis, and arthritis in the back, tendonitis in left foot, urinary leakage, and high cholesterol. The evidence in file shows the claimant has a history of chronic lumbar pain. She is mildly obese with a body mass index as high as 33. X-rays of the lumbar spine (LS) taken 7/9/13 show multilevel degenerative changes with spurring and mild anterolisthesis of L4-L5. Degenerative joint disease in the left hip was also noted. The LS MRI taken 3/25/16 shows multilevel degenerative changes. The physical exam on 10/14/16 indicated the claimant’s spinal exam was essentially normal, although an antalgic gait was noted. Evidence from John Fetzer shows the claimant has a history of heel pain. The exam on 8/30/16 shows a gait disturbance. She opted to undergo a below knee rigid cast to treat the achilles tenosynovitis. On 9/30/16, the physical exam showed full …show more content…
The evidence in file does not support this assessment. The left Achilles tendonitis has resolved and no longer pose an impairment. The evidence in file supports a RFC for 20/10/6/6 with postural restrictions of stooping to occasional. DI 24510.006 indicates the RFC must be based on all of the available medical evidence, including medical history, medical signs and laboratory findings and effects of symptoms including pain that are reasonably attributed to a medically determinable impairment. In this case, the evidence supports a RFC for 20/10/6/6. However, the evidence in file is insufficient to establish a detailed
ISSUE
There is insufficient evidence regarding the claimant’s physical condition to complete the Sequential Evaluation of Disability.
CASE DISCUSSION & POLICY ANALYSIS (INCLUDING SPECIFIC REFERENCES)
This 59- year old claimant is filing a concurrent claim alleging disability due to arthritis in the knees, a herniated disc, scoliosis, and arthritis in the back, tendonitis in left foot, urinary leakage, and high cholesterol. The evidence in file shows the claimant has a history of chronic lumbar pain. She is mildly obese with a body mass index as high as 33. X-rays of the lumbar spine (LS) taken 7/9/13 show multilevel degenerative changes with spurring and mild anterolisthesis of L4-L5. Degenerative joint disease in the left hip was also noted. The LS MRI taken 3/25/16 shows multilevel degenerative changes. The physical exam on 10/14/16 indicated the claimant’s spinal exam was essentially normal, although an antalgic gait was noted. Evidence from John Fetzer shows the claimant has a history of heel pain. The exam on 8/30/16 shows a gait disturbance. She opted to undergo a below knee rigid cast to treat the achilles tenosynovitis. On 9/30/16, the physical exam showed full …show more content…
The evidence in file does not support this assessment. The left Achilles tendonitis has resolved and no longer pose an impairment. The evidence in file supports a RFC for 20/10/6/6 with postural restrictions of stooping to occasional. DI 24510.006 indicates the RFC must be based on all of the available medical evidence, including medical history, medical signs and laboratory findings and effects of symptoms including pain that are reasonably attributed to a medically determinable impairment. In this case, the evidence supports a RFC for 20/10/6/6. However, the evidence in file is insufficient to establish a detailed