DI 24505.005 Evaluation of Medical Impairments that are Not Severe
A. Multiple Not Severe Impairments
Although an impairment is not severe if it has no more than a minimal effect on an individual's physical or mental ability(ies) to do basic work activities, the possibility of several such impairments combining to produce a severe impairment must be considered. When assessing the severity of whatever impairments an individual may have, the adjudicative team must assess the impact of the combination of those impairments on the person's ability to function, rather than assess separately the contribution of each impairment to the restriction of his or her activity as if each impairment existed alone. A claim may be denied at step two only if the evidence shows that the individual's impairments, when considered in combination, are not medically severe (i.e., do not have more than a minimal effect on the person's physical or mental ability(ies) to perform basic work activities). If such a finding is not clearly established by medical evidence, however, adjudication must continue through the sequential evaluation process.
B. Functional Evaluation Needed
Inherent in a finding of a medically not severe impairment or combination of impairments is the conclusion that the individual's ability to engage in SGA is not seriously affected. Before this conclusion can be reached, however, an evaluation of the effects of the impairment(s) on the person's ability to do basic work activities must be made. A determination that an impairment(s) is not severe requires a careful evaluation of the medical findings which describe the impairment(s) and an informed judgment about its (their) limiting effects on the individual's physical and mental ability(ies) to perform basic work activities; thus, an assessment of function is inherent in the medical evaluation process itself. At the second step of sequential evaluation, then, evidence is evaluated in order to assess the effects of the impairment(s) on ability to do basic work activities. If this assessment shows the individual to have the physical and mental ability(ies) necessary to perform such activities, no evaluation of past work (or of age, education, and work experience) is needed. Rather, it is reasonable to conclude, based on the minimal impact of the impairment(s), that the individual is capable of engaging in SGA. To document such a determination, it is advisable for the adjudicative team to prepare for the file (e.g., on a Report of Contact) a statement of findings, reasoning, and conclusions about the limiting effects of (or the absence of limitations due to) the alleged impairment(s). The rationale of denial in the formal determination as to disability must also include a statement regarding the individual's present functional abilities which supports the finding of a not severe impairment(s).
C. Not Severe Impairments and Ability to Perform Past Relevant Work
By definition, basic work activities are the abilities and aptitudes necessary to do most jobs. In the absence of contrary evidence, it is reasonable to conclude that an individual whose impairments do not preclude the performance of basic work activities is, therefore, able to perform his or her past relevant work. If the medical evidence establishes only a slight abnormality(ies) which has no more than a minimal effect on a claimant's ability to do basic work activities, but evidence shows that the person cannot perfom his or her past relevant work because of the unique features of that work, a denial at the “not severe” step of the sequential evaluation process is inappropriate. The inability to perform past relevant work in such instances warrants further evaluation of the individual's ability to do other work considering age, education, and work experience.
NOTE: This provision does not conflict with, nor negate, the policy stated in DI 25010.001 concerning cases that meet a special medical-vocational profile. In such cases, an individual must be found to have a severe impairment(s) (i.e., one which has more than a minimal effect on the person's physical or mental capacity to perform basic work activities), in order to be considered under the special provision of that section.
D. Adjudicative Caution
Great care should be exercised in applying the not severe impairment concept. If the adjudicative team is unable to determine clearly the effect of an impairment or combination of impairments on the individual's ability to do basic work activities, the sequential evaluation process should not end with the not severe evaluation step. Rather, it should be continued. In such a circumstance, if the impairment does not meet or equal the severity level of the relevant medical listing, sequential evaluation requires that the adjudicator evaluate the individual's ability to do past work, or to do other work based on the consideration of age, education, and prior work experience.