Impairment Severity Paper

Pt is a 84 year old Cascasion female living with her husband in their home. Husband reported the Pts Alzhemers has be pergresing for the last 8-9 years. Pt had open heart surgery in 2012, which contributed to the memory loss decline and increasing level of Alzhemer symtoms, husband verbalized. Husband reports they have been married for 19 years. Pt has a sister living Florda, two daughters living in Texas and Wyoming and one son in New York. The children stay in contact with them every other day. Pt reports she worked as a RN at the VA Hospital in New Mexico. Pt is not independent in the home without the husbands assistance. Pt does ambulate well in the home, but does have a walker in needed. Husband assists the Pt all her ADL's in the home and drives her to the store and for MD appointments. Husband currently suffers from Hemochromatosis (too much iron in one's body). Husband reports he manages well with his illness while taking care of Pt at the sametime. Husband reports the Pt's Alzehmers level appears to be stable at this time, but is quite forgetful at times and needs his assistance. Husband said they are managing

Zamudio, Human Resources Administrator and acting custodian of personnel records of the Domino Realty Management Company who allowed access, and copies in support of any relevant information pertaining to any injuries, had located a “Work/School Status Report” under the name of the “Talbert Medical Group.” The document had placed the claimant off from work from 2-5-01 through 2-5-01 for pain to the claimants left knee, and yet, according to Ms. Zamudio, the document did not state that a work related injury occurred as there were no other documentation in support of an injury. Furthermore, the witnesses had not cited any job related incidents where the claimants left knee from 2001 had been injured were the alleged 2001 left knee had been irritated or exacerbated in any

More significantly, the witnesses said they were knowledgeable that the claimant was involved in a recent automobile accident when he injured his “spinal cord” during the car crash where he was transported to a local emergency room for his injuries. They said the accident occurred in November

Ms. Almanza claimed she researched and provided the claimant’s entire personnel file for this investigation and stated she was not aware of any industrial-related injuries associated with the claimants said injuries, by noting that no treating physicians ever provided any causation or the implied injuries. She provided proof with the claimant’s personnel file taken into as evidence by stating there was no medical evidence, doctors note or request of modified work duties to suggest any medical

The patient is very independent in his home and is able to perform all ADLS within the home without any addtional assistance. MSW asked patient if he was interested in any addtional care giving support in the home, but patient declined addtional support at this time. Patinet stated he gets transportation from his neiabors to the store when needed. MSW offered the patient additional transportation services, but the patient declined needing any addtional transportation services at this time.Patient reported falling back in 2004 off the steps and was air lifted to the hospital. Patient reports having diffculty paying doctors and helicoter bills. Patinet's only income is through SS for $847. Patient reported that was the only time he was fallen in his life. Patinet has only been in the hospital two times during his lifetime. MSW offered life alert services, but the patient was not interested. Patient stated his only concern was being able to afford his doctor and helicotor transportion bills. MSW connected AHCCCS and spoke to represtative regarding getting patient signed up for the medicare savings program. Representative stated the patient has already applied for AHCCCS back in

This 66 year old is filing a DIB claim alleging disability due to stroke, fatigue, headache, mixed hyperlipidemia, hypertensive heart disease, benign heart failure, cerebrovascular left hemiparesis, allergic rhinitis, pollen induced, acid reflux disease, depression, benign hypotrophy, PTSD, elevated PSA, abnormal glucose, and a Vitamin D deficiency of 04/11/2014.

This 59- year old is filing a DIB claim alleging disability due to diabetes, high blood pressure, high cholesterol, arthritis, amnesia and right eye problems as of 06/01/2015.

The claimant alleges that her current claim to her bilateral wrists, elbows, arms, shoulders, neck, and upper and lower back, resulted from a CT claim from her former employer The View Corporation. The claimant alleges the CT claim she filed occurred during the early months of 2012 when she worked at The View Sonic Corporation. She could not recall the dates of when the CT claim were.

Allow as 99222, cc b/c the submitted record does not support the billed service of 99223 which requires the three following components: a comprehensive history, a comprehensive examination and a high medical decision making. The documentation scored as a 99222 with the following components: a comprehensive history, a comprehensive examination, and moderate medical decision making. For the next level of appeal, you will need to provide documentation to support a high medical decision making. The Centers for Medicare & Medicaid Services Manual, Publication 100-04, Chapter 12, Section 30.6.1 Selection of Level of Evaluation and Management Service, was utilized to make this determination.

3. The Claimant’s amount of the sequence of events relating to the treatment in question. Care should be taken to avoid importing text and phraseology from medical records or reports that the Claimant would not use in the normal course of discussing the case.

Borbely had physician appointment with his PCP Dr. Boggs and cardiac. Mr. Borbely declined surgery with cardiac physician. Medical records were requested from Henry Ford Hospital. Mr. Borbely had a neuropsychological testing and Dr. Kamoo is in the progress of contact his nephew for a review. Dr. Boggs felt Mr. Borbely had a dramatic cognitive changes compared to one year prior to the accident and is looking forward to the neuropsychological results. Dr. Boggs did feel Mr. Borbely had a head injury. I was contacted by claims adjuster confirming medical records status and informed that at this time to close his

REQUEST FOR CORRECTIVE ACTION: OQR has requested the FO to develop the last date that the claimant worked at the SGA level. After this determination has been made, the claim will be returned to

Client states “I accepted responsibility for the decision that I made that have led to legal conflicts.” Client appears to cope more effectively with his stress, and is in compliance with all his legal and treatment requirements. Client reported participation in self-help activities/ program, and his family is supportive of his recovery, as

Personal/Social History: The patient reports receiving her high school diploma and worked in the fast food industry as a cashier until her back injury and subsequently filing for disability.

At the most recent hearing in this case we took testimony from the claimant and Wayne Gervasi on the issue of a light duty job offers that had been made to the claimant and his refusal to respond to them or to provide medical evidence as to his restrictions. In the conclusion of the last