Example
one: Insufficient evidence to establish a severe, medically determinable impairment (MDI).
Claimant is 57 years old with a high school education and past relevant work (PRW)
as a cashier. He alleges disability due to carpal tunnel syndrome (CTS). Development
of a complete medical history includes a diagnosis of CTS in the file, but no Tinel’s
sign or Phelan’s test and no electromyography (EMG) or nerve conduction study. Additionally
there is no description of the claimant’s ability to handle or finger objects, nor
is there any evidence regarding treatment for CTS. In his activities of daily living
(ADL), the claimant indicates that he has problems opening jars due to his CTS.
The DDS orders a consultative exam for a Tinel’s sign and Phelan’s test, graded grip
strength, and a description of his fingering abilities. The claimant misses his scheduled
exam despite calling the DDS to tell them he will attend. The DDS documents how they
evaluated the evidence in file using the sequential evaluation process. The claimant
is not performing SGA. There is no severe MDI established by the evidence.
The DDS writes the case as an insufficient evidence denial. The DDS will use an insufficient
evidence regulation basis code (RBC) and PDE because the claimant did not cooperate
with the development process and the evidence available without the claimant’s cooperation
is consistent with a denial for no severe MDI. The insufficient evidence RBC and PDE
are appropriate because had the claimant cooperated, the determination might have
been different.
Example
two: Insufficient evidence to evaluate one of the claimant’s alleged impairments
The case facts are the same as example one with the exception of an additional allegation
of back problems. The claimant has back pain when flexing his spine beyond 70 degrees.
On most visits, he has palpable muscle spasm in the low back. He has negative straight
leg raise (SLR) test bilaterally. X-rays show severe narrowing at L5-S1 and mild degenerative
changes throughout the lumbar spine.
The DDS orders a consultative examination for graded strength of lower extremities,
a gait description, Tinel’s sign and Phelan’s test, graded grip strength, and a description
of fine fingering abilities. The claimant misses his scheduled examination despite
calling the DDS to tell them he will attend. The medical evidence in file establishes
that the claimant’s back impairment is a severe MDI that does not meet or equal a
listing, however the evidence is insufficient to assess whether CTS is an MDI.
Because the claimant has a severe MDI that does not meet or equal a listed impairment,
the adjudicative team must assess an RFC using the evidence available without the
claimant’s cooperation. The medical consultant must indicate in the RFC that the evidence
in file is insufficient to rate limitations on a particular impairment, symptom(s),
or alleged limitation(s), because the evidence necessary for a full medical evaluation
is not available due to the claimant’s failure to cooperate. The medical consultant
adds this statement regarding the claimant’s CTS and assesses an RFC for light work
with occasional postural limitations.
The DDS documents how they processed the evidence available without the claimant’s
cooperation through the sequential evaluation process. The claimant is not performing
SGA. He has a severe MDI of degenerative changes in the lumbar spine. He has a diagnosis
of CTS, but there is nothing in the record to support an MDI of CTS. His impairments
do not meet or equal a listed impairment. An RFC for light work with occasional postural
limitations is consistent with ability to perform his PRW as he described it. The
insufficient evidence RBC and PDE are appropriate because had the claimant cooperated,
the determination might have been different.
Example
three: Insufficient evidence to evaluate whether the claimant can perform Past Relevant
Work (PRW)—expedite applies
All case facts are the same as example two except that the claimant is 50 years old
and did not return his SSA-3369, despite follow-ups.
The claimant lists his PRW as cashier on the SSA-3368, but did not provide any description
of the requirements of his work, nor did he provide evidence we would need to determine
if his work was relevant. In addition, the claimant missed his scheduled consultative
examination.
The evidence establishes that the claimant’s back impairment is a severe MDI that
does not meet or equal a Listing; however, the evidence is insufficient to assess
whether CTS is an MDI. Because the claimant has a severe impairment that does not
meet or equal a listed impairment, the adjudicative team must assess an RFC using
the evidence available without the claimant’s cooperation. The medical consultant
must indicate in the RFC that the evidence in file is insufficient to rate limitations
on a particular impairment, symptom(s), or alleged limitation(s) because the evidence
necessary for a full medical evaluation is not available due to the claimant’s failure
to cooperate. The medical consultant indicates this in the RFC regarding the claimant’s
CTS and assesses an RFC for light work with occasional postural limitations.
The DDS documents how they processed the evidence available without the claimant’s
cooperation through the sequential evaluation process. The claimant is not performing
SGA. He has a severe MDI of degenerative changes of the lumbar spine. He has a diagnosis
of CTS, but there is nothing in the record to support an MDI of CTS. His impairments
do not meet or equal a listed impairment. We cannot determine if he can do any past
relevant work. At age 50, with a light RFC and a high school education all potentially
applicable light rules would result in a denial, therefore, the expedite process would
apply.
The DDS writes the case as an insufficient evidence denial. The DDS will use an insufficient
evidence RBC and PDE because the claimant did not cooperate with the development process.
If the claimant had cooperated and additional evidence about the claimant’s CTS was
available, the determination may have been different.