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Impairment Compliance

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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 55- year old claimant is filing a DIB claim alleging disability due to migraines without aura, typical aura with migraines, migraines with basilar type aura, sporadic hemiplegic migraines, bell’s palsy, atypical chest pain, silent myocardial infarction, sleep apnea and seizure like activity. The evidence in file shows the claimant has a history of migraines since 2009. An office note on 06/24/16 states that claimant has multiple type of migraine headaches including typical migraine with and without aura; migraine with basilar-type aura; and occasional hemiplegic migraine. The claimant’s EEG shows bitemporal slowing, which may…show more content…
However, it is unclear whether the headaches have persisted at the noted on the office visit on 1/14/14. A more complete longitudinal record is needed to determine whether the claimant’s headache frequency remained at listing-level for at least 12 months despite treatment. If the headache frequency described in the 06/24/16 progress note can be confirmed back to the AOD, the intent of listing 11.03 would be satisfied. DI 24505.015.B2. indicates if the claimant has an impairment not described in the listing of impairments we will compare their findings with those for closely analogous listed impairments. If the findings related to the claimant’s impairment are at least of equal medical significance to those of a listed impairment, we determine their impairment is medically equivalent to the most closely analogous listing. In this case, the findings of the claimant’s impairment are very similar to those of 11.03. However, at this time duration is
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