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Impairment Severity Paper

Satisfactory Essays
Group I, Category 41 Insufficient Medical Documentation to Determine Impairment Severity
ISSUE
Additional evidence is needed to determine the degree of the severity imposed by the claimant’s physical condition.
CASE DISCUSSION & POLICY ANALYSIS (INCLUDING SPECIFIC REFERENCES)
This 49-year-old claimant is filing a DI claim alleging disability due to Willebrand's disease, hereditary hemorraghic telangiectases, COPD, chronic depression, anxiety, PTSD, high blood pressure, high cholesterol, and hypolipidemia.
The evidence in file shows the claimant has a history of advanced COPD requiring oxygen (O2) and moderate obesity with a BMI as high as 36. At an office visit on 12/11/14 the claimant’s O2 saturation level was 95% and down to 88% with exercise on RA. The physical exam on 2/10/15 shows 93% oxygen saturation. The lungs were clear to auscultation. At the exam on 5/14/14 the claimant had intentionally lost 25 pounds. She was
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The evidence in file indicated the claimant is capable of performing and sustaining simple, routine and/or repetitive tasks and should be able to do so over the course of a normal workday and workweek.
ADLs show the claimant as no difficulty with personal care. She is able to prepare simple meals, do household chores and laundry. She has anxiety and panic attacks when going out alone. She can walk 20-30 feet before needing to rest and lift 10 pounds. The claimant has a history of COPD and poor oxygen. She has also been treated for mental disorders that could produce symptoms as alleged but with treating sources records indicating they are under fair control with medication management and counseling. Her allegations are deemed partially credible.
REQUEST FOR CORRECTIVE ACTION
Please obtain updated oxygenation levels on room air while resting and while ambulating.
After your action, please prepare a revised SSA-831 and notice if necessary and return the claim to OQR
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