Insufficient Medical Documentation to Determine Impairment Severity
ISSUE
Additional medical development is needed to assess the claimant’s physical and psychological impairment and complete the Sequential Evaluation of Disability.
CASE DISCUSSION AND POLICY ANALYSIS
This 55- year old claimant is filing a concurrent claim alleging disability due to asthma, SOB, knee disorders, knee pain, shoulder disorder, shoulder pain, feet disorder, back disorder, obesity, a hearing impairment, Bipolar disorder, depression, anxiety, and panic disorders as of 12/21/16.
The evidence in file shows the claimant has a history bipolar disorder, auditory hallucinations, and depression. Records note interrupted sleep, and mood swings. He was prescribed Lithium, which appeared to help but the claimant discontinued the medication due to the side effects. At the office visit on 5/2/17 he endorsed auditory …show more content…
The physical exam showed slightly decreased range of motion in the back and hips. X-rays of the lumbar spine showed minor degenerative changes. X-rays of the feet showed mild osteopenia.
The functional report shows the claimant is able to care for himself when he is not depressed. He is able to do light household chores with some encouragement. He shops in stores, goes out alone and drives.
The DDS determined listing 12.04 was met as of 6/12/17. A review of the file shows there is insufficient evidence to assess the claimant’s condition. At the claimant’s last visit, he inquired about a change of medication. It is unclear whether his medication was changed and his status after the change. Additionally, the claimant’s functional report do not appear severely limited. DI 24515.001B.3 states the evidence is sufficient when it contains all the information we need to make the determination. In this case, the evidence is insufficient to determine the claimant’s current psychological