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Example Social Security Case 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 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. 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. The evidence also
shows that despite his impairment, he is still capable of performing work of a light RFC
(according to SSA), with limitations in bending, stooping and walking. Also according to SSA, claimant remains capable of
returning to his past work as an accountant as this job is generally performed. For this reason, 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 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. Client Phone Interview: 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 2004 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 a Dr. Mann who
discovered small fractures in his spine in June of 2004.
This was not the first time these fractures have been seen. He suffered similar fractures before in January of
2000 and recovered. Claimant also states that he has had this problem
since at least January of 2000 and that the fractures are slow to heal. Claimant now feels that his condition
has worsened and
that he is no longer able to engage in work. Even
in a sitting position, 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 in 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 law suits against 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 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 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 make sure that this information was immediately placed into the claimant's
records to be considered by 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 Patient was admitted to the Kansas Medical Center on
2-5-04 due to complaints of extreme back pain. Physical
examination was remarkable for decreased range of motion of the lumbar spine and All lab
data was within normal limits (WNL). Patient
was placed in a removable body cast and was told not to perform any type of physical
activities. 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 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.
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 hair line 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 DRG, Systems
Explorer CD-ROM or the Merck Manual. This
action would constitute step three in Flow Chart A from lesson six. Try to get a general picture of claimant's
condition and how it might keep him from performing work.
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. 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 claimant is incapable of
performing his past work, we are ready to argue that he 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 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. CASE DISCUSSION 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 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 which 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 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). 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 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 less than two hours per day, you should use this
restriction as 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
claimant's current physical capabilities. Pain
also would play an extremely important role in reducing 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!
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 a 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. 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, claimant requested a 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, claimant was again denied benefits on reconsideration based on Social Security's opinion that the claimant could do sedentary work. Since 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:
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, 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 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 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 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 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. 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 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. Claimant was given an RFC for sedentary work which corresponds to the RFC requirement of both his accounting and social worker jobs. However, it is our contention that 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 require 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 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 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, claimant would be restricted both physically and mentally from performing these occupations. It is further felt that if claimant were to try to perform his past work, he would experience excruciating back pain that would have a significant negative impact upon the quality and quantity of the work performed. This would further reduce the claimant's ability to acquire and maintain competitive employment. Summation Mr. Shane is suffering from a severe and progressive medical impairment that has limited him to an 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 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. 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 be 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 onset placed at 2/1/05, which is the date the claimant stopped working as a result of his impairment. Sincerely, Authorized Representative Special Note 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. Shane 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.
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.
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