At the CPD, the evidence established the individual had major depressive disorder and migraines. Medical records indicate depressed mood, decreased energy, suicidal ideation, sleep disturbance, and diminished interest in activities. The evidence notes the individual has tried 4 different medications over the last 3 years without meaningful improvement in symptoms or quality of life. The individual reports sleeping about 3-4 hours per night and napping several times during the day.

Review of the activities of daily living and reports to the medical source indicate significant problems interacting with others. For example, the individual has groceries and items delivered rather than going out in public due to their significant fear of dealing with the public. The individual will not visit family in person and only sends text messages.

The medical evidence indicates significant problems staying on task, noted by frequent redirecting in sessions with medical source. Evidence also notes that the individual was fired from their job three months prior to the CPD for poor performance, crying episodes, and walking off on customers when questioned or problems came up. The individual’s supervisor attempted to minimize public interaction by assigning the individual to work in back room away from the public, but they could not handle simple tasks and remained off task.

Evidence indicates two hospitalizations for suicidal ideation, one voluntary overnight stay and one involuntary stay initiated by a concerned family member that resulted in a three-night hospitalization.

Regarding the individual’s physical impairment, the migraines are controlled and occur once or twice a month on average. The individual takes over the counter medication as needed.

At the CDR, the individual alleges ongoing disability due to depressive disorder, migraines, and a herniated disc. Medical source evidence indicates that the individual is stable on medication with mild depressive symptoms. Compared to the CPD evidence, findings are remarkable for improvement in mood, social activities, and concentration. Evidence does not indicate any tearful events during visits and no suicidal ideation. The individual reports sleeping about 6-7 hours a night.

The individual reports they have joined a small group of neighbors engaged in a biweekly book club. The individual reports to the medical source that they participate in a variety of social activities, such as shopping or attending the farmers markets several times a month with these friends.

The individual reports mending ties with family and babysits their 4-year-old niece three days a week, attends family gatherings but will only stay for a few hours if they start to feel uncomfortable, and the medical source notes indicate that they have set positive boundaries with family and can recognize their limits. This has improved interpersonal relationships. Medical evidence indicates no psychiatric hospitalizations since the CPD.

Regarding the individual’s migraines, the individual notes that migraines occur approximately once or twice a month and are controlled on over the counter medication

Find MI at Step 3 of the Title II and adult Title XVI CDR sequential evaluation process and proceed to Step 4.

Evidence indicates improved mood and concentration and an increase in social activities and social function, demonstrated by the individual’s engagement in activities such as attending a book club, visiting the farmers market to purchase items in person as opposed to only ordering items online to be delivered due to symptoms at the time of the CPD. The individual also demonstrates decreased sleep disturbance, where sleep has improved to 6-7 hours a night as opposed to 3-4 hours a night at the CPD. Additionally, the individual has experienced increased energy, evidenced by engagement in activities and babysitting their niece several days a week, as opposed to napping during the day and avoiding activities at the CPD.

At the CPD, an individual with a herniated nucleus pulposus underwent a laminectomy. A postoperative myelogram showed evidence of a persistent defect in the lumbar spine. The individual had pain in their back, as well as pain and a burning sensation in their right foot and leg. Evidence did not show muscle weakness or neurological changes, but it did show a moderate decrease in motion of the back and leg.

At the CDR, the evidence shows that the individual receives treatment from their primary care physician every two or three months for the past 2 years. No further myelograms have been done. The individual continues to complain of pain in the back and right leg especially when sitting or standing for more than a short period. The doctor reports a moderately decreased range of motion in the back and right leg and still reports no muscle atrophy or neurological changes.

Find no MI, then consider if a Group I or Group II exception to MI applies. If no exception applies, find that disability continues.

The evidence does not show changes in symptoms, signs, or laboratory findings on which to base a finding of decreased medical severity.

At the CPD, benefits were awarded based on laboratory results showing inflammatory arthritis. The individual's physician reported persistent swelling and tenderness of the individual's fingers and wrists and noted that the individual complained of joint pain.

At the CDR, tests still show rheumatoid arthritis. But as a result of therapy, the individual's fingers and wrists have not been significantly swollen or painful for the past year. The decreased pain and swelling has led to an increase in the individual's fine and gross manipulation.

Find MI at Step 3 of the Title II and adult Title XVI CDR sequential evaluation process and proceed to Step 4.

Changes in symptoms and signs show decreased medical severity. Inflammatory arthritis is an example of an impairment subject to temporary remission, and the improvement demonstrated in this example has been sustained long enough to establish remission; see DI 28010.115.

At the CPD, an individual with bronchial asthma met listing 3.03. The individual had spirometry findings and exacerbations requiring four hospitalizations within a twelve month period that were at least 30 days apart, as required by the A and B criteria in listing 3.03.

At the CDR, the individual received medication management and had only one hospitalization for an asthma exacerbation between the time of the CPD and the CDR. Current medical evidence shows decreased frequency, severity, and duration of wheezing attacks. Current evidence does not show changes in spirometry.

Find MI at Step 3 of the Title II and adult Title XVI CDR sequential evaluation process and proceed to Step 4.

Evidence supports an improvement in signs and symptoms. Although the individual's spirometry readings (laboratory findings) have not decreased, there is decreased frequency, severity, and duration of attacks.

At the CPD, the child was allowed based on marked limitations in two domains of function, acquiring and using information and interacting and relating with others (see DI 25225.005). The impairments that resulted in the marked limitations were due to a learning disability and oppositional defiant disorder. School records indicated that the child was not on track to be promoted to the next grade level and would need to repeat the third grade due to significant limitations in reading and writing. The child also demonstrated difficulty interacting with peers, often getting into altercations with other students and bullying peers. The child required intervention and re-direction in such instances and was not able to build or maintain positive relationships.

At the CDR, the child continues to exhibit learning difficulties in reading and writing. The child has an individualized education plan and receives small group instruction three times a week for reading and writing activities. The child remains below grade level based on standardized test scores and achievement testing. The child continues to get into altercations and was diagnosed with oppositional defiant disorder and attention deficit hyperactivity disorder since the CPD. The child attends therapy sessions and continues to exhibit frequent anger outbursts, avoidant behavior, and periods of non-responsiveness when questioned by the therapist. Medication management has not been effective, as the child often refuses to take medication and will become combative when questioned.

Find no MI at Step 1 of the Title XVI child CDR sequential evaluation process and consider if a Group I or Group II exception to MI applies. If no exception applies, find that disability continues.

The evidence supports the conclusion that the child has no improvement in signs, symptoms, or laboratory findings at the CDR.

At the CPD, the child was allowed due to an extreme limitation in moving about and manipulating objects due to limitations from the child's extreme scoliosis. The child underwent surgery to place a rod in their back. After the surgery, the child suffered complications in the lower extremities due to significant atrophy and loss of sensation. The child used a wheeled walker for stability for ambulation and could only ambulate approximately 10 yards without the device.

At the CDR, the child did not undergo any additional surgical interventions. X-rays show the rod in place and persistent scoliosis. The child uses a wheeled walker when traveling longer distances to transfer classes during the school day but does not require any assistive device when walking short distances less than 20 yards. The child is involved in a swimming program three days a week and rides their bike two-to-three times a week with friends.

Find MI at Step 1 of the Title XVI child CDR sequential evaluation process and proceed to Step 2.

Although the laboratory findings have not changed, the child has demonstrated improvement in their symptoms. The child's functional abilities have increased at the CDR as evidenced by the increased ability to ambulate less than 20 yards without an assistive device and to engage in multiple sport activities that do not require walking as far as 60 feet.