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The Advocate Study Guide

Lesson Six

Case Evaluation Process Revisited

In Lesson Four you learned to identify key elements in your client’s medical evidence to use as ammunition in creating a disability argument. In Lesson Six we provide additional insights into the Case Evaluation process that will allow you to prepare a stronger Formal Argument on your clients’ behalf. As you may remember from Lesson One, the Case Evaluation process is the process that is made possible by the Case Development process. Once you've acquired the appropriate evidence, you're ready to carefully review it in order to extract data that can be used to support your argument for a total disability.

Case Evaluation consists of two basic steps:

1.      Review medical evidence

2.      Perform a Vocational Analysis

You then combine the results to formulate an argument.

In this lesson, we delve into the differences in evaluating adult and child cases.

The Case Evaluation Process

In the Case Evaluation process you analyze medical and vocational evidence and use the findings to identify the signs and symptoms that directly affect ability to perform work. You then prepare a formal argument on behalf of your client.

You review medical evidence using Sequential Analysis (SA). SA is a systematic tool that removes the emotional element from the review of a claimant’s medical documentation.

Sequential Analysis: Adult and Child Cases are Different

We introduced you to the SA process for adults in Lesson Three. In adult cases, SA has six steps because of the vocational issues typical of adult situations. The last two steps ask the questions: “Can the claimant do his/her past work?” and “If not, can he/she do other less demanding work?”

In child cases, there are no vocational issues so there’s no need for VA. Instead of vocational questions, SA in a child case asks the question: “Can the child perform age-appropriate activities?” This new question replaces Steps Five and Six of the adult analysis.

Below are two SA flow charts to guide you in evaluating disability cases. One chart is for adults and the other for child cases. These charts will help direct you through the steps used in formulating an allowance decision.

SA Process A:

·   Used in any disability case that has a vocational issue

·    Involves both medical and vocational data

Only adult cases have vocational issues. Most disability cases, including disabled widower cases, now involve vocational factors in the decision. The term “Medical - Vocational” means that the case is an adult case that will be decided based on the claimant's medically-evidenced ability to perform either his/her past work or other less demanding work.

SA Process B:

·   Used with cases that do not have vocational issues

·   Usually involves child cases, which have no work history and therefore no Vocational
      Analysis

·   Decided based on the claimant's ability to perform normal age-related activities instead of
      work

Note: Even if an adult has never worked, SSA applies Vocational Analysis to his/her case. SSA evaluates his/her perceived ability to do work and bases the decision on the adult version of SA.

Sequential Analysis Process A: Adults

SA with vocational issues is also referred to as an “adult” case. The following is a review of Lesson Three in which we described the step-by-step process for an adult who has applied for Social Security Disability benefits. We have added new information to enhance your understanding of SA.

Step One/Question One:

Does the claimant have a medically determinable impairment?

To be “Medically determinable”, the claimant’s condition must be diagnosable with modern medical practices. To decide this, review the evidence of record. If you do not initially have this information but the claim seems valid, request that the claimant provide you a copy of whatever evidence he/she has as well as the contact information for his/her medical sources. If the claimant does not have a medically determinable impairment, the claim will be denied. If you find evidence of a valid impairment, move to Step Two.

Step Two/Question Two:

Is the Impairment severe?

Review the medical evidence. The claimant’s description of his/her impairment is also a clue to its severity. If the answer to this question is “no”’ SSA will deny the case. If the answer is “yes”, move to Step Three.

Step Three/Question Three:

Will the impairment last for twelve continuous months?

Review the medical evidence. Common sense and the claimant’s description of his/her impairment history also play a part in your decision as to whether the case is viable. If the answer is “no”, SSA will deny the case because it doesn’t meet the duration requirement. If the answer is “yes”, move to Step Four.

Step Four/Question Four:

Does the impairment meet or equal the medical listing?

This step is a little different from the previous SA steps because it is the first place in the process where analysis can stop and the claim can be allowed. If the claimant’s impairment is so serious that it meets or equals SSA’s medical listing, the case will be quickly allowed. Most adult disability cases do not meet or equal the listing, and are won based on Medical-Vocational issues. If a claimant does not meet or equal the medical listings, move to Step Five.

Step Five/Question Five:

Can the claimant still do his/her past work?

Now we enter the Vocational Analysis portion of SA in which you use the medical evidence to establish physical and/or mental limitations. You then compare these limitations to the past work demands. If the claimant can function in his/her past occupation, SSA will deny the claim. Otherwise, move to the final step.

Step Six/Question Six: Adult

Can the claimant perform other less demanding work?

From your standpoint as a Disability Advocate, Step Six is crucial. If you have gotten this far, it is here that the case will be won or lost. You must bring together all of the claimant’s physical and mental limitations and compare them to available work in the national economy.

But, how do you rule out all work? You must understand how SSA views work. SSA policy contains a host of internal caveats that can be exploited by a knowledgeable Advocate because they allow room for interpretation. The Disability Associates course works because of our use of these policies.

What are some of these policies? Not only can you use the medical and vocational evidence to make the claimant appear limited, you can also use SSA’s own policies. SSA always takes into account certain characteristics:

Age

Education level

Skill level of past work

Skill transferability

Perceived RFC

Because of certain SSA policies, an adult of advanced age with less than twelve years of education, non-professional skills which are not transferable, and a low perceived RFC is much more likely to be found disabled than any other adult with the same afflictions.

“Other less demanding work” is the crux of SA Step Six. This work can be less demanding physically, mentally or both. If the answer to Question Six is “yes”, SSA will deny benefits. If the claimant is not capable of adjusting to other less demanding work, SSA will grant disability.

Sequential Analysis Process B: (Child)

The SA process for children is different because there are no vocational issues. These cases normally involve children from ages one month to twenty-one years. Child cases are usually evaluated in the same way as adult claims, minus Steps Five and Six. In other words, in a child case you skip the VA process. Instead, you ask a different question: “Can the child perform in an age-appropriate manner despite impairment?”

This approach to evaluating childhood cases began with the results of a Supreme Court decision: Zebley vs. HHS. The Supreme Court Judges forced SSA to take age-appropriate functionality into account in juvenile decisions.

The following is a step-by-step description of the SA process for children who have applied for disability benefits:

Step One/Question One:

Does the claimant have a medically determinable impairment?

“Medically determinable” carries the same definition in child cases as in those of adults. Once again, to answer the question you review the medical evidence. As with adult cases, if the answer is “no”, SSA will deny the case. If the answer is “yes”, move to Step Two.

Step Two/Question Two:

Is the Impairment severe?

Again, you answer this question based on the medical evidence. If the answer is “no”, SSA denies the case. If the answer is “yes”, move to Step Three.

Step Three/Question Three:

Will the impairment last for twelve continuous months?

If the medical evidence indicates the answer is “no”, SSA will deny the case. If the answer is “yes”, move to Step Four.

Step Four/Question Four:

Does the impairment meet or equal the childhood medical listing?

As in adult cases, this is the first step where the case might be allowed. SSA uses less demanding listing criteria for children. If the child’s condition is so serious that it meets or equals SSA’s childhood listing, the case will be allowed.   If a child does not meet or equal the childhood listings, move to SA Step Five, which in child cases is the final step.

Step Five/Question Five:

Can the child perform age-appropriate activities?

This question is different from Question Five in adult cases. In a child case, the Disability Advocate must seek to show that the claimant is incapable of performing age-appropriate activities such as dressing and feeding himself/herself. If the claimant cannot perform appropriate activities due to physical and/or mental impairment, SSA will allow the case.

A Final Note: Organizing Evidence

Organizing a client's evidence of record is an important part of a successful advocacy service. Organize information by:

· Date

· Source

· Content

· Type of activity

This will help you make better sense of the data and write stronger arguments. Olivia© contains an argument composer to assist you in bringing all relevant case facts together. Your ammunition will then be at your fingertips, eliminating hours of extra labor and bringing greater efficiency to your service.

Lesson Seven Preview

Lesson Seven demonstrates how to effectively communicate with the SSA when representing a disability claim. It instructs you on writing a Formal Argument based on the evidence you gathered in Case Evaluation.