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Social Security Case Example One
In this sample, we have prepared a hypothetical case study to familiarize you with the process of Case Evaluation. This lesson has three main objectives. The first is to offer you practical experience in case analysis. The second is to show you how to organize case information into a usable form and finally to demonstrate an effective method of presenting case information to the Social Security Administration. In this case study, all the medical and vocational information is presented in the synopsis in order to save time. You are to assume that the information given in these case examples are part of the claimant’s disability case file. You will be told from what source the medical information was extracted in order to avoid confusion. You are entering case one on the reconsideration level.
SSA form 4268 PDN: Mr. Shane is a forty-year-old individual with sixteen years of education and eleven years of work experience as an accountant. He has alleged disability due to osteopenia, hypertension, and an inability to stand, sit or walk for extended periods due to pain. The medical evidence as previously reviewed by SSA shows that Mr. Shane does suffer from osteopenia and hypertension that has reduced his ability to perform work of a light RFC (according to SSA), with limitations in bending, stooping and walking. Also, according to SSA, the claimant remains capable of returning to his past work as an accountant as this job is generally performed. For this reason, the claimant has been found not disabled with the ability to return to his past work as an accountant. Note: The 4268 has supplied a lot of valuable information about this case right from the start. Using 4268 PDN information, you now know the claimant’s age, education, past work, SSA’s RFC for the claimant, why a case was denied (can do past work), and at what step in the SA process, the denial occurred. In this case, the denial occurred at step five of the SA process. You may also realize that given the claimant’s age and educational level, we will have to further reduce his RFC to less than sedentary in order to argue for an allowance decision. WHY? Because this claimant is a younger individual (49 years old or less), with a high school or higher educational level and with no doubt transferable skills to other sedentary jobs given the professional level of his past work as an accountant.
The phone interview is just another method of acquiring information in a case. Mr. Shane states in his interview that he is a forty-year-old accountant with sixteen years of education and a three-year history of hypertension and osteopenia. He states that in January of 2014 he began to experience severe pain in his back that forced him to quit work one year later. He states that he was x-rayed by Dr. Mann who discovered small fractures in his spine in June of 2014. This was not the first time these fractures have been seen. He suffered similar fractures before in January of 2010 and recovered. Claimant also states that he has had this problem since at least January of 2010 and that the fractures are slow to heal. The claimant now feels that his condition has worsened and that he is no longer able to engage in work. Even in a sitting position, the claimant states that he is unable to tolerate the severe back pain. He feels that he has been treated unfairly by SSA for giving him a denial decision on his initial application and as a result, he is now also experiencing increased psychological distress. Note: Given what the claimant has told you during the phone interview, you should immediately get information from both the claimant and his family members describing his activities of daily living (ADLs). Due to recent successful lawsuits against the SSA, Social Security must now consider any and all restrictions claimed by an applicant. This includes restrictions caused by pain or fatigue. These restrictions, if verified, must be considered in the claimant’s final RFC.
Claimant Activities of Daily Living (ADLs) The claimant tells you that he gets up in the morning and eats his first meal prepared by his wife. He then gets his newspaper and sits to read it. He can only sit for about fifteen minutes without getting back pain, so he takes a few hours to get through the paper. When seated and as the back pain starts, the claimant gets up and walks for about ten minutes before sitting again. He feels he is unable to walk more than a half-hour without aggravating his back pain. He does very few chores around the house. He feels incapable of lifting more than fifteen to twenty pounds without causing further damage to his back. The claimant often experiences back stiffness and says he says that he is in pain most of the day and night._ He does describe problems with sleeping due to pain. He takes Tylenol with codeine for pain, but this only relieves the pain for an hour or two. He is unable to bend, stoop, crawl, sit or walk for more than thirty minutes at a time without pain. He is also having financial problems as a result of being out of work, and he is now feeling depressed.
Collateral ADL interview Now you are ready to take ADL information from the claimant’s family members or close friends. This information should describe what the claimant is able to do during an average day. What the collateral source tells you must coincide with the limitations described by the claimant. Mr. Shane’s main collateral source, his wife, adds that he can no longer make love due to his back pain. A wise representative would organize the above ADL information into two separate documents. One completed by the claimant and the other by the collateral source. ADL information should always be presented in written form. You can use an SSA ADL form or a narrative report prepared as a letter. You would then SSA. Note: That the claimant’s alleged limitations are reasonable given his condition. If the limitations are further supported by the medical evidence, this will give credibility to all ADL statements, encouraging SSA to give greater consideration to the alleged restrictions prior to making another decision. Now we are ready to begin reviewing the medical evidence.
Source: University of Kansas Medical Center The patient was admitted to the Kansas Medical Center on 2-5-14 due to complaints of extreme back pain. Physical examination was remarkable for the decreased range of motion of the lumbar spine and tenderness on palpation of the upper and lower back. The neurological exam was normal. The patient was able to walk without assistance with some obvious discomfort. X-rays showed multiple hairline fractures of the thoracic and lumbar spine. All lab data were within normal limits (WNL). The patient was placed in a removable body cast and was told not to perform any type of physical activity. He was discharged with pain medication and a diagnosis of osteopenia of unknown etiology.
Mr. Shane is a forty-year-old gentleman whom I have followed for the past year. He has a history of osteopenia of unknown cause. He was first evaluated by me in February of 2004 for complaints of severe back discomfort. X-rays taken at that time showed multiple fractures of the thoracic and lumbar spine. In the last year, Mr. Shane has experienced progressive osteopenia with four or five documented vertebral compression fractures. He has shown a loss of three to four inches in height due to the degeneration of bones in the thoracic and lumbar spine. The fractures suffered by this patient are pathological and are not associated with a traumatic event. The patient is in great discomfort and is unable to stand, sit, bend, or walk for more than an hour without great discomfort. It is recommended that he restrict his activities to avoid more spinal fractures. At the present time, he has a diagnosis of severe progressive osteopenia of unknown etiology, hypertension (controlled), and multiple vertebral fractures secondary to osteopenia. It is my medical opinion that this patient would be unable to engage in any type of sustained work activity at the present time, due to the pain and physical limitations associated with his disorder.
Date 2-6-04 from the UKMC. X-ray shows multiple hairline fractures of both the thoracic and lumbar spinal areas starting at T10-L4. There is also evidence of degenerative changes at the L2-4 spinal levels with osteophytic changes noted. Note: If you are confused about this claimant’s medical condition, this is the time to exercise step three of the case evaluation process and learn more about the claimant’s conditions. You can do this by turning to your Merck Manual or any other medical impairment text. This action would constitute step three in Flow Chart A from lesson six. Try to get a general picture of the claimant’s condition and how it might keep him from performing work.
3369 Vocational Form: Step four in the case evaluation process directs us to acquire and review all available vocational information. The 3369 shows that Mr. Shane has worked as an accountant for about eleven years. Prior to his accounting position, he worked as a clinical (medical or psychiatric) social worker for the State of Kansas for about three years. He has also held a series of unskilled labor jobs requiring heavy lifting (75-100 lb.) in his younger years. His accounting job was described as being sedentary. He worked as an accountant in a sitting position and was not required to lift anything weighing more than ten pounds. There was occasional bending with frequent reaching above his head for manuals. The claimant used adding machines, calculators, computers, etc., and wrote highly technical reports._ He stood and walked three hours of an eight hour day, and sat five hours of an eight hour day. Note: At this point, we have all the basic information we need to begin processing this case. (See numbers five and six of the case evaluation Flow Chart A.) In this case, the claimant was denied at step five in the sequential analysis process, so we must begin our argument at this same step. At this point, we must attempt to prove that Mr. Shane cannot return to his past work as an accountant or social worker. Once we have shown that the claimant is incapable of performing his past work, we are ready to argue that he is also incapable of performing other types of work as well. By comparing the demands of his past work to his current physical limitations, it is clear that he cannot return to his past work. We rule out other work in the same manner. First, it appears that the claimant has a severe impairment that has resulted in significant physical limitations. We must argue that the limitation should be for less than sedentary work. In this case, the evidence supports such a limitation. All you need do is point this out to SSA in your argument. Citing the supporting evidence will assure that SSA takes your recommendation for a less than sedentary RFC seriously.
The claimant is a forty-year-old accountant with sixteen years of education who has alleged disability due to osteopenia, hypertension, and an inability to stand, sit, and walk for extended periods of time. The medical evidence clearly supports a severe impairment that does not meet or equal the listings. The evidence indicates that claimant could not realistically perform even a sedentary job due to restrictions in his ability to sit, stand and walk for extended periods, In this case, there is no need for you to address any of the claimant’s labor jobs because it is obvious he is not physically capable of doing work on that level as indicated by his light RFC given in the first case denial. If you wish, you can look up the claimant’s past work in the DOT & SCO as instructed in the Special Subjects section. The SCO describes an accounting job as sedentary work that physically requires that a person be able to reach, handle finger, feel, and see. Although not specifically addressed in the SCO, a person must also be able to sit for extended periods of time to do any type of sedentary work. The same is true of the claimant’s social worker’s job.
Since it is doubtful that you will have a DOT at this time, we have summarized this information below. Accountant: SCO 11.06.01, Sedentary, physical demands 4 and 6. (If the SCO says 5, this is a typing error). The environment is indoors, SVP is 8. Clinical social worker: SCO 10.01.02, Sedentary, physical demands 4, 5, and 6. Environ is indoors, SVP of 7. Can the claimant return to his past work as an accountant or a social worker? We have restricted claimant’s RFC to less than sedentary work in order to achieve an allowance determination in a logical fashion, which is backed by the DOT as well as the medical evidence. The medical findings indicate that the claimant is unable to stand, sit, or walk for extended periods. The most important restriction here is sitting because all sedentary jobs require at least six hours of sitting with a minimum of two hours at a time. Since the claimant, his doctors, and the medical findings all support a reasonable sitting restriction of fewer than two hours per day, you should use this restriction as to the cornerstone of your argument for a less than sedentary RFC. The claimant has also provided ADLs that are reasonable considering his impairment. His statements have been verified by his wife and attending physician, both of which are credible sources. Mr. Shane’s jobs as an accountant and a social worker both require extended sitting by virtue of being sedentary jobs. Thus we have ruled out these jobs as being within the claimant’s current physical capabilities. Pain also would play an extremely important role in reducing the claimant’s RFC. We have now decided that due to pain and the claimant’s inability to sit for extended periods, he is unable to do other forms of sedentary work as well. Mr. Shane is now for all intents and purposes a medical-vocational allowance. Can Mr. Shane do other types of work? We have already shown that Mr. Shane cannot do other work by virtue of the medical evidence. An RFC for less than sedentary work appears reasonable and supportable by the evidence. Since Mr. Shane cannot do his past work that was sedentary in nature, it stands to reason that he cannot do any type of work that would require sitting. Remember, a claimant must be able to perform a job within his current capabilities before he can be denied benefits. A sedentary RFC is the least physically demanding type of work. If a person can’t do sedentary work, he can’t do any work! Ruling out similar work: A similar job is any job that is similar in nature to the job performed by the claimant. In the case of Mr. Shane, we do not have to be concerned with similar work. His RFC for less than sedentary automatically rules out similar work. However, in a case where a person has an RFC above sedentary, we may want to logically rule out these jobs by showing how each physical restriction would prevent the performance of that job. Now all you need do is summarize these findings into a formal argument.
Mr. Shane is a 40y/o individual who alleges disability due to osteopenia and hypertension. The claimant also alleges an inability to stand, sit, or walk for extended periods of time without experiencing debilitating pain. In the claimant’s initial application, it was determined by SSA that he retained the ability to perform light work. SSA felt that despite his impairment, the claimant retained the ability to return to his past work as an accountant and or social worker. SSA has denied the claimant’s application for disability benefits based on the claimant’s remaining ability to perform his past work. Subsequent to the initial application, the claimant requested reconsideration of his previous denial based on a continuing disability due to the above-mentioned impairments. It was on the reconsideration appeals level that I, (Advocate’s Name) entered into the case on the claimant’s behalf. Despite the evidence, in this case, showing a severely disabled individual, the claimant was again denied benefits on reconsideration based on Social Security’s opinion that the claimant could do sedentary work. Since the claimant’s past work was sedentary in nature, the case was again denied. On the client’s behalf, I am now requesting an Administrative Law Judge review of this case. The following is a list of medical evidence in support of claimant’s severe and disabling impairments: Note: Evidence should be dated from onset to most current date. Dates are given to make it easier for the reviewing party at Social Security to cross-reference allegations with supporting evidence. The easier you make it for Social Security to find evidence supporting your position, the more likely you are to win. University of Kansas Medical Center. (Date of reports). Dr. Thomas Mann, M.D.report. (Date of report). UKMC X-ray (Date of report). The medical evidence listed above indicates that Mr. Shane has a documented history of a back disorder with severe pain as a result of a condition known as osteopenia. The evidence further shows that Mr. Shane was evaluated by Dr. Mann in February of 2004 for severe back discomfort. It was subsequently discovered by Dr. Mann that Mr. Shane had experienced pathological fractures of the spine as a result of his condition. Since that date, the claimant has experienced increasingly intolerable back pain with a progressive inability to stand, sit or walk without great discomfort. Dr. Mann’s report refers to his first evaluation of the claimant’s back disorder in 2004 to the present time. Dr. Mann states that the claimant was suffering from osteopenia of unknown etiology. X-rays taken at that time revealed multiple pathological fractures of Mr. Shane’s spine, believed to be as a result of his underlying condition. Dr. Mann goes on to say that since the claimant’s first evaluation, he has experienced four to five additional fractures of the spine as a result of his progressive disease. Dr. Manu states, and I quote, “Patient is in great discomfort and is unable to stand, sit or walk without severe pain.” Dr. Mann also points out that the claimant should be restricted from any type of physical activity in order to avoid additional spinal fractures. Evidence from the UKMC dated 2-6-04 reveals that the claimant was hospitalized for extreme back pain. X-rays taken at that time showed continuing problems with spinal fractures as a result of his disorder. The claimant is currently forced to wear a removable spinal cast as treatment and protection from further injury. The evidence, in this case, is conclusive and proves that the claimant’s impairment is progressive and clearly restricts him from performing any type of work. On reconsideration, it was felt that claimant could return to his past work as an accountant or social worker. The claimant was given an RFC for sedentary work that corresponds to the RFC requirement of both his accounting and social worker jobs. However, it is our contention that the claimant should be restricted to less than sedentary work, based on the medical findings in this case. Claimant’s past work as an accountant and a social worker requires physical demands (4) and (6) as indicated in the SCO. These demands are reaching, handling, fingering, feeling, and seeing. With the exception of reaching, it appears that the claimant is still capable of performing these rudimentary movements. However, common sense would indicate that in order to perform any sedentary job, a person must also be able to sit for an extended period of time (at least two hours of an eight hour day). The medical evidence in file clearly indicates that due to multiple and progressive spinal fractures, this individual could not be realistically expected to sit for the time required to complete the task of an accountant DOT 160.167-010 or a social worker (DOT 195.107-034) without suffering from extreme discomfort. I believe the claimant’s physical discomfort would create an unreasonable burden that would significantly interfere with his ability to concentrate. Since both of claimant’s past jobs require significant intellectual focus, the claimant would be restricted both physically and mentally from performing these occupations. It is further felt that if the claimant were to try to perform his past work, he would experience excruciating back pain that would have a significant negative impact on the quality and quantity of the work performed. This would further reduce the claimant’s ability to acquire and maintain competitive employment.
Mr. Shane is suffering from a severe and progressive medical impairment that has limited him to a Residual Functional Capacity of less than sedentary work. The claimant’s condition is so severe as to prevent him from performing his past work or any other work as described in the national economy. It has been demonstrated by the medical evidence that the claimant is not capable of such physical demands as sitting, reaching, or walking as is required in the performance of sedentary work. The evidence also shows that for the claimant’s own protection and for the avoidance of additional damage to his spine, he should restrict his activities as recommended by his attending physician Dr. Mann. A careful review of the medical evidence, with an emphasis placed on the prognostic outcome of his condition, has led me to request a medical reexamination diary in this case of three years. Because of Mr. Shane’s young age of 40, high level of education, and the particulars of his condition, there is a fair possibility that he will demonstrate medical improvement by the end of the three-year diary. Therefore, I am requesting that Mr. Shane’s case is allowed currently and be reevaluated in thirty-six months for medical improvement. I would like to thank you for this opportunity to present the facts of this case before the Social Security Administration. Your cooperation and understanding of the critical issues of this case are of the utmost importance to this claimant. Please render a favorable decision at your earliest convenience with the onset placed on 2/1/15, which is the date the claimant stopped working as a result of his impairment. Sincerely, Authorized Representative
In the case of Mr. Shane, we limited our argument to the main diagnosis of osteopenia. If you have carefully reviewed the medical data, in this case, you know that Mr. Shan is also suffering from hypertension and anxiety secondary to his financial and medical circumstances. Since the main disorder, in this case, is so limiting, it would not significantly help or hinder our argument by adding the hypertensive and mental allegations. The high blood pressure is under control, and the mental condition has not been documented. However, if this case were weaker, I would not have hesitated to mention anxiety or anything else that might strengthen the case argument. Remember, Social Security is obligated to pursue and consider all allegations of disease or limitation.
The weaker the case, the more medically supportable restrictions are needed to win the case. In this circumstance, look for additional limiting impairments that might further reduce the claimant’s Residual Functional Capacity. If by chance you have a case with two or more serious disorders, all of which cause significant limitations to the claimant’s ability to work, discuss each of these disorders, and show how their collective effects restrict the claimant’s ability to perform work or age-appropriate activities. |