ParaRegs-Disability-Sequential Evaluation

1310    Sequential Evaluation

1311    SGA

1312    Severe / Nonsevere / Duration

1313    Meets / Equals listing

1314    RFC (nonmental)

1315    Age / Education

1316    Skills / Transferability

1317    Past Relevant Work / Work availability

1318    Nonexertional limitations (Nonmental)

1319    Pain

Code

Effective

ParaReg Text

1310-1



The Social Security Administration (SSA) issued the following Social Security Ruling (SSR) in regards to the Sequential Evaluation Process.

 

If a Title XVI claimant is not working or his or her work does not demonstrate the ability to engage in any substantial gainful activity (SGA) during the period in which disability is alleged, we give primary consideration to the severity of the individual's impairment(s). In addition, if medical considerations alone are not determinative of the issue of disability for a childhood disability claimant or for a Title XVI claimant age 18 or older, we consider the ability to do past relevant work and the individual's age, education, training and work experience, as they relate to the ability to perform any other work.

 

The following evaluation steps are followed in sequence shown, but when a determination or decision that an individual is or is not disabled can be made at any step, evaluation under a subsequent step is not necessary.

 

Is the Individual Engaging in Substantial Gainful Activity?

 

When an individual is actually engaging in SGA or did so during any pertinent period, and there is no possibility of establishing a period of disability which ended prior to the date of the decision, a finding shall be made without consideration of either medical or vocational factors that the individual is not under a disability. When a Title XVI claimant is not (or was not) actually engaging in SGA, primary consideration is given to the severity of the individual's impairment(s).

 

Does the Individual Have a Severe Impairment?

 

Fundamental to the disability determination process is the statutory requirement that to be found disabled, an individual must have a medically determinable impairment "of such severity" that it precludes his or her engaging in any substantial gainful work. A finding of ability to engage in SGA, therefore, may be justified on the basis of medical considerations alone when a medically determinable impairment(s) is found to be not severe. An impairment is not severe if it is a slight abnormality or a combination of slight abnormalities which would have no more than a minimal effect on the individual's physical or mental ability(ies) to perform basic work activities. When an impairment is not severe, a finding of "not disabled" is made irrespective of an individual's age, education, or work experience.

 

When assessing the severity of multiple impairments, the adjudicator must evaluate the combined impact of those impairments on an individual's ability to function, rather than assess separately the contribution of each impairment to the restriction of function as if each impairment existed alone. When multiple impairments, considered in combination, would have more than a minimal effect on the ability to perform basic work activities, adjudication must continue through the sequential evaluation process.

 

The impairment severity requirement cannot be satisfied when medical evidence shows that the impairment(s) has a minimal effect on a person's ability(ies) to perform basic work activities, that is, when he or she has the abilities and aptitudes necessary to do most jobs. Examples of these are sitting, standing, walking, lifting, carrying, handling, reaching, pushing or pulling; seeing, hearing, and speaking; understanding, carrying out, and remembering simple instructions; use of judgment, responding appropriately to supervision, coworkers, and usual work situations; and dealing with changes in a routine work setting.

 

It is reasonable to conclude, in the absence of contrary evidence, that an individual whose impairments do not preclude the performance of basic work activities, is able to perform his or her past relevant work. However, if medical evidence establishes only a slight abnormality(ies) that would have no more than minimal effect on the individual's ability to do basic work activities, but evidence shows that the person cannot perform 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, and adjudication should continue through subsequent steps in the process.

 

Does the Individual Have an Impairment(s) Which Meets or Equals the Listing?

 

The level of severity described in the Listing is such that an individual who is not engaging in SGA and has an impairment or the equivalent of an impairment described therein is generally considered unable to work by reason of the medical impairment alone. Thus, when such an individual's impairment or combination of impairments meets or equals the level of severity described in the Listing, and also meets the duration requirement, disability will be found on the basis of the medical facts alone in the absence of evidence to the contrary (e.g., the actual performance of SGA, or failure to follow prescribed treatment without a justifiable reason). The claimant's impairment(s) must meet or equal a listed impairment for a favorable determination or decision to be based on medical considerations alone.

 

Evaluating Medical Equivalence -- Medical Judgment Required

 

For an impairment to be found to be equivalent in severity to a listed impairment, the set of symptoms, signs and laboratory findings in the medical evidence supporting a claim must be compared with, and found to be equivalent in terms of medical severity and duration to, the set of symptoms, signs and laboratory findings specified for listed impairment. When the individual's impairment is not listed, the set for the most closely analogous listed impairment is used.

 

Where an individual has a combination of impairments, none of which meets or equals a listed impairment, and each impairment is manifested by a set of symptoms and relevant signs and/or abnormal laboratory findings, the collective medical findings of the combined impairments must be matched to the specific set of symptoms, signs, and laboratory findings of the listed impairment to which they can be most closely related. The mere accumulation of a number of impairments will not establish medical equivalency. In no case are symptoms alone a sufficient basis for establishing the presence of a physical or mental impairment.

 

Any decision as to whether an individual's impairment or impairments are medically equivalent of a listed impairment must be based on medical evidence demonstrated by medically acceptable clinical and laboratory diagnostic techniques, including consideration of a medical judgment about medical equivalence furnished by one or more physicians designated by the Secretary. The Disability Determination Services physician's documented medical judgment as to equivalency meets this regulatory requirement.

 

Interrelationship of Medical and Vocational Factors: Title II Worker or Childhood Disability Beneficiary/Title XVI Claimant Age 18 or Older

 

When a determination cannot be made on the basis of the medical factors alone (i.e., when the impairment falls short of the level of severity depicted by the Listing, yet has more than a minimal effect on the ability to perform basic work-related functions), the sequential evaluation process must continue with consideration of the vocational factors in the claim.

 

Evaluation under 20 CFR §416.920(e) and (f) requires careful consideration of whether the individual can do past relevant work (PRW), and if not, whether he or she can reasonably be expected to make a vocational adjustment to other work. When the individual's residual functional capacity (RFC) precludes meeting the physical and mental demands of PRW, consideration of all the facts of the case will lead to a finding that (1) the individual has the functional and vocational capacity for other work, considering the individual's age, education, and work experience, and that jobs which the individual could perform exist in significant numbers in the national economy, or (2) the extent of work that he or she can do, functionally and vocationally, is too narrow to sustain a finding of ability to engage in SGA.

 

Since the severity of the impairment must be the primary basis for a finding of disability, this step of the evaluation process begins with an assessment of the claimant's functional limitations and capacities. Then a determination or decision must be made as to whether the individual retains capacity to perform past relevant work. An evaluation is then made of age, education, work experience and training. Consideration of the following principles will help identify the key issues for resolution with respect to these factors. No single factor should be considered as conclusive. They should be applied in combination to the range of work that remains within the claimant's RFC

 

The vocational factors as well as RFC are described in detail as follows:

 

>          RFC -- RFC is the remaining ability to perform work-related physical and mental activities. The claimant's functional capacity must be defined in terms of the claimant's ability to function in a work setting. When multiple impairments are involved, the assessment of RFC reflects the restrictions resulting from all impairments (both severe and not severe impairments). This assessment is based on all relevant evidence pertaining to RFC consistent with appropriate clinical and laboratory findings.

 

Assessment of physical capacities (e.g., strength and exertional capabilities) includes an evaluation of the individual and indicates his or her maximum RFC for sustained activity on a regular basis. Such assessment also includes an evaluation of the ability to perform significant physical functions such as walking, standing, lifting, carrying, pushing, or pulling, and such other physical traits and sensory characteristics as reaching, handling, seeing, hearing, and speaking insofar as limited capacity to perform these activities may affect the individual's capacity for work for which he or she would otherwise be qualified.

 

Any medically determinable impairment(s) not resulting in exertional limitations (such as certain mental, sensory or skin impairments) must be considered in terms of the limitations resulting from the impairment. When an individual has such impairment(s) in addition to an exertional impairment(s), remaining functional capacity must be assessed in terms of the degree of any additional narrowing of the individual's work-related capabilities. The assessment of impairments because of mental disorders includes consideration of such factors as the ability to understand, to carry out and remember instructions, and to respond appropriately to supervision, coworkers, and customary work pressures in a routine setting.

 

The RFC assessment is based primarily on the medical findings, i.e., the symptoms, signs, and laboratory results, which must be complete enough to permit and support the necessary judgments concerning the individual's physical, medical, and sensory capacities and any environmental restrictions. Descriptions and observations of the claimant's restrictions by medical and nonmedical sources in addition to those made during formal medical examinations must also be considered in the determination of RFC.

 

Where no issue with respect to specific physical or mental capacities is raised by the allegations of the individual or the evidence obtained, the individual is considered to have no restrictions with respect to those capacities. The individual has the burden of proving that he or she is disabled and of raising any issue bearing on that determination or decision.

 

For the purpose of determining the exertional requirements of work in the national economy, jobs are classified as "sedentary," "light," "medium," "heavy," and "very heavy." Such terms have the same meanings as are used in the Dictionary of Occupational Titles (DOT), published by the Department of Labor (DOL). In order to evaluate the claimant's skills and to help determine the existence in the national economy of work the claimant is able to do, occupations are classified as unskilled, semiskilled, and skilled. For classifying these occupations, materials published by the DOL are used.

 

>          Age -- The term "age" refers to chronological age and the extent to which it affects the individual's ability to adapt to a new work situation and engage in work in competition with others.

 

The following age classifications are established in 20 CFR §416.963: younger person, person approaching advanced age, and person of advanced age. These designations of age are an expectancy only, not arbitrary limits, and may not be crucial in a particular case. Age categories are not applied mechanically in borderline cases.

 

>          Education and Training -- Education generally refers to formal schooling; training refers to skills and knowledge acquired on the job or through general experience in an industry or field of work. 20 CFR §416.964 establishes the following classifications of educational levels: illiteracy, marginal education, limited education, high school and above, and inability to communicate in English.

 

Training that is vocationally significant prepares an individual to do a specific job or provides background to do a number of jobs in the same field. Training that is not reflected in the individual's actual work experience would raise questions as to its adequacy and current usefulness to the individual. Content, duration, and recency should be considered in determining the scope and application of training and its current usefulness. Normally, if an individual completed training more than 15 years prior to the point at which the claim is being considered for adjudication (or when the earnings requirement was last met if earlier) and did not make use of it in his or her work, it would not affect the claimant's vocational outlook at the present time. Moreover, even if completed with a 15-year period, training would not ordinarily be expected to qualify an individual for more than entry level (e.g., at the apprenticeship or lowest beginning level) occupations.

 

>          Experience -- The jobs a person has done, the length of time spent at them, and the recency of the work are major factors in determining his or her ability to work. Work experience is relevant when it was performed within the pertinent 15-year period, lasted long enough for the individual to learn the job, and consisted of SGA. Work experience must be examined in the light of available knowledge of the physical and skill demands of different kinds of work in order to evaluate the effect of the impairment on the person's ability to return to past relevant work or to utilize remaining capacities in other jobs.

 

The RFC assessment is used to determine whether an individual can perform past relevant work or -- considering an individual's age, education and work experience -- other work which exists in the nation's economy.

 

>          Capacity to Do Past Relevant Work -- The RFC to meet the physical and mental demands of jobs a claimant has performed in the past (either the specific job a claimant performed or the same type of work as it is customarily performed throughout the economy) is generally a sufficient basis for a finding that the individual is not disabled. Past work experience should be considered carefully to assure that the available facts support conclusions regarding the claimant's ability or inability to perform this work.

 

Where an individual with a marginal education and long work experience of 35 years or more limited to the performance of arduous unskilled labor is not working, and is no longer able to perform such labor because of a severe impairment(s), such an individual will generally be found to be disabled. (See 20 CFR §416.962.) Also a person generally will be found disabled if he or she has a severe impairment of any nature, is of advanced age, has a limited education, and has no relevant work experience.

 

If the individual is able to meet the physical and mental demands of past relevant work, he or she should be found not disabled. However, the inability to do past relevant work is not in itself a basis for a finding of disability.

 

>          Capacity to Do Other Work -- If an individual cannot perform any past relevant work because of a severe impairment(s), but the remaining physical and mental capacities are consistent with meeting the physical and mental demands of a significant number of jobs (in one or more occupations) in the national economy, and the individual has the vocational capabilities (considering age, education, and past work experience) to make an adjustment to work different from that performed in the past, it shall be determined that the individual is not disabled. However, if an individual's physical and mental capacities in conjunction with his or her vocational capabilities (considering age, education and past work experience) do not permit the individual to adjust to work different from that performed in the past, it shall be determined that the individual is disabled.

 

The assessment ability to engage in SGA involves the evaluation of such factors as the functional capacity to perform the physical or mental exertion of work and to sustain work at a level which meets the standards of SGA on a regular and continuing basis. In all such cases where a determination or decision regarding disability is to be made, the evidence must be sufficient to permit a comparison between the claimant's capabilities and limitations and the requirements of relevant occupations.

 

The regulations require that, at this point in the sequential evaluation process, the rules established in Appendix 2 to Subpart P of Regulations No. 4 must be used to direct or to guide the determination as to whether the individual is "disabled." Where all factors relative to an individual coincide with those in a rule in the Appendix, that rule directs a conclusion as to whether the individual is "disabled." When all factors do not coincide with a rule (e.g., the individual has the RFC for more than light work but for less than the full range of medium work), the rules are used as a frame of reference for determining whether the individual is "disabled."

 

Similarly, when an individual has a combination of exertional and nonexertional impairments, the rules are used as a frame of reference for determining "disability." The exertional impairment is considered first under the applicable rule, and then the additional restriction(s) imposed by the nonexertional impairment is considered.

 

When an individual has a solely nonexertional impairment, the principles established in the regulations are applied in determining "disability," giving consideration to the rules for specific case situations described in Appendix 2 (i.e., use of the rules as a frame of reference). When the nonexertional impairment is a mental impairment, the ability to concentrate, to understand, to carry out and remember instructions, and to respond appropriately to supervision, coworkers, and pressures in a work setting are considered. (See 20 CFR §416.945(c).)

 

(SSR No. 86-8)

1310-2



The issues before the federal Administrative Law Judge (ALJ) include "all the issues brought out in the initial, reconsidered, or revised determination that were not decided entirely in your [the applicant’s] favor."  However, if evidence presented before or during the hearing causes the ALJ to question a fully favorable determination, the ALJ will notify the applicant of the fact that this will be an issue at the hearing.  (20 CFR §416.1446(a))

1310-3

 

 

Counties are reminded that there is now a program, the 250% Working Disabled Program that allows individuals to earn above the Substantial Gainful Activity (SGA) limit and still qualify for linkage through disability. Because of this, counties must not base a decision to process a disability determination for working persons on SGA.  The county must refer the case to the Disability and Adult Programs Division (DAPD) and alert the DAPD analyst to evaluate the individual’s disability based on criteria for the 250% Working Disabled program.  (All County Welfare Director’s Letter (ACWDL) 02-40, July 3, 2002)

1311-1



The Social Security Act encourages severely disabled persons to seek and maintain employment.  These severely impaired working individuals, whose earnings from substantial gainful activity are too high to retain financial eligibility for SSI/SSP continue to remain eligible for Medicaid as deemed SSI recipients as long as their income without consideration of earnings does not exceed the SSI/SSP payment level.  They are referred to as “1619(b)” recipients, because eligibility is established under Title XVI, §1619(b) of the Social Security Act.

 

The CDHS has issued instructions for determining eligibility for such individuals.  There are four basic requirements.  These individuals must:

 

1.         Depend on Medicaid to continue working.

 

2.         Meet all nondisability requirements for SSI/SSP benefits except for earnings.

 

3.         Have insufficient earnings to replace SSI cash benefits, Medicaid, publicly-funded personal or attendant care which would be lost due to the individual's earnings.

 

AND

 

4.         Have received SSI, or have been eligible as a 1619(b) person, in the month before the Medi-Cal Only determination/eligibility is initially established.

 

(All-County Welfare Directors Letter No. 97-27, June 20, 1997)

1311-2



Federal law provides, in pertinent part, that if a claimant is performing SGA, he or she will not be found to be disabled.  If the claimant is working and the work is SGA, he or she will be found not disabled regardless of his or her medical condition.  (20 CFR §416.920)

1311-2A

 

 

Counties are reminded that there is now a program, the 250% Working Disabled Program that allows individuals to earn above the Substantial Gainful Activity (SGA) limit and still qualify for linkage through disability. Because of this, counties must not base a decision to process a disability determination for working persons on SGA.  The county must refer the case to the Disability and Adult Programs Division (DAPD) and alert the DAPD analyst to evaluate the individual’s disability based on criteria for the 250% Working Disabled program.  (All County Welfare Director’s Letter (ACWDL) 02-40, July 3, 2002)

1311-3

 

 

Federal law provides that SGA is work that is both substantial and gainful.  It is substantial if it involves doing significant physical or mental activities, even on a part-time basis.  It is gainful if it is done for pay or profit.  (20 CFR §416.972)

1311-4

 

 

The SGA guidelines are a basis for determining whether an individual is engaged in SGA.  The guidelines are concerned only with those earnings which represents a person's own productivity. To determine an employee's countable earnings for SGA purposes:

 

1.         Determine gross earnings, including payment in kind (e.g., room and board).

 

2.         Deduct the amount of any subsidized earnings and the amount of certain impairment-related work expenses.  Do not deduct standard payroll deductions.

 

3.         Average monthly earnings.

 

(POMS DI 10505.001A.)

1311-5

REVISED 3/07

 

Federal law provides, in pertinent part, that earnings of $300 per month or more during the period January 1, 1980 through December 31, 1989 will ordinarily show that a claimant has engaged in SGA.  . The SGA amount was $830 effective January 2005 $860 effective January 2006 and $900 effective January 2007. (20 CFR §416.974(b); All-County Welfare Directors Letters No. 04-40, December 29, 2004; 05-42, December 19, 2005; 06-34, November 16, 2006; Medi-Cal Eligibility Procedures Manual 22C-2.1)

1311-5A

 

 

Substantial Gainful Activity (SGA) Earnings Guidelines only apply to blind Title II individuals, not to those under Title XVI (the SSI program).  In 1998, the SGA countable earnings figure for Title II blind individuals was $1050; in 1999, it was $1110.  (POMS DI 24001.025B.3)

1311-5B

ADDED 2/05

 

SGA rules do not apply to legally blind persons who meet the Supplemental Security Income criteria, Medi-Cal beneficiaries who return to work after disability has been approved, or to individuals applying for Medi-Cal under the 250 percent Working Disabled Program. (All County Welfare Director’s Letter 04-40, December 29, 2004)

1311-6

 

 

There is a presumption that when an applicant's earnings are above the statutory minimum, the applicant is engaged in Substantial Gainful Activity (SGA).  (Keyes v. Sullivan (1990) 894 F.2d 1053) This presumption can be rebutted.  Factors to be considered in addition to the amount earned include the time spent working, quality of a person's performance, special working conditions, and the possibility of self-employment.  (Katz v. Secretary of HHS (1992) 972 F.2d 290)

1311-7

 

 

The determination of whether a self-employed person is engaging in Substantial Gainful Activity (SGA) will not be based on income alone, but on the activities performed and their value to the business. The individual is considered engaging in SGA if:

 

(1)        The work activity, in terms of hours worked, skills, energy output, efficiency, duties and responsibilities, is comparable to that of unimpaired individuals in the community who are in the same or similar business;

 

(2)        The work activity, although not comparable to that of unimpaired individuals, is clearly worth $700 ($780 as of January 1, 2002) a month when considered in terms of its value to the business, or when compared to the salary an employee would be paid; or

 

(3)        The services rendered are significant to the operation of the business and receive a substantial income from the business.

 

(20 CFR §416.975(a))

1311-8

 

 

A self-employed person or an employee who is forced to stop work after a short period of time because of an impairment is considered to have engaged in an unsuccessful work attempt and earnings from that work will not show an ability to perform substantial gainful activity.  (20 CFR §§416.974(a) and 416.975(a))  A short period of time is considered to be no more than six months.  (POMS DI 10505.001C.)

1311-9

 

 

Illegal activities can constitute SGA if they are both substantial (involving significant physical and mental activity) and gainful (the kind of work usually done for pay or profit, whether or not a profit is realized). When an applicant engages in illegal activity (theft) to support a drug habit, he is not entitled to deduct the cost of the narcotics he purchases as an impairment-related work expense.  (Social Security Ruling 94-1c, adopting Dotson v. Shalala (7th Circuit 1993) 1 F. 3d 571)

1311-10

 

 

When a heroin addict acquires approximately $4,200 of heroin in a month, there is a presumption that he is engaging in SGA as his earnings exceed $500 per month. However, in Corrao v. Shalala (1994) 20 F. 3d 943, the 9th Circuit held that the presumption was rebutted.  Mr. Corrao spent only a minimal amount of time working--25 minutes to 45 minutes per transaction.  Second, he did not have to exert himself significantly either physically or mentally.  He did not organize drug dealers; he did not use his own money; and he did not receive cash for his portion of the drugs.  There was no indication of initiative, organization, or responsibility. In general, the Court held that the ALJ has the duty to develop the record fully and fairly when the income exceeds the guideline.  To determine “whether the presumption is rebutted, the factors to be considered include the responsibilities and skills required to perform the work, the amount of time the individual spends working, the quality of the individual's work, special working conditions, and for individuals who are self-employed, the value of their work to the business.”  (Corrao, supra, 20 F. 3d at 948)

1311-11

 

 

Illegal activities can be considered substantial gainful activities.  (See Hart v. Sullivan (1992) 824 F.Supp. 903) In Hart, the District Court of the Northern District of California held that the federal ALJ correctly denied the claimant's request for Social Security benefits on the basis that the claimant engaged in SGA.  The claimant was moving $700 of heroin daily, and received $140 of heroin for his personal use.  His work involved significant physical or mental activities, because of the scope of the operation and because of the claimant's ability to avoid apprehension by the authorities. In Speaks, the District Court of the Central District of California followed the principles established in Corrao v. Shalala (1994) 20 F. 3d 943.  The Speaks court stated that prostitution was a profession, illegal in California but legal elsewhere.  The court held that Ms. Speaks, who earned at least $600 per month, was engaging in SGA, and was thus ineligible for Social Security benefits.  (Speaks v. Secretary of HHS)

1312-1



The POMS states that for an impairment or combination of impairments to be considered severe, it must significantly limit the individual's physical or mental ability to perform one or more basic work activities needed to do most jobs, for example, walking, standing, sitting, lifting, pushing, pulling, reaching, carrying or handling; seeing, hearing and speaking; understanding, carrying out and remembering simple instructions; use of judgment, responding appropriately to supervision, coworkers, and usual work situations; and dealing with changes in a routine work setting. If an individual does not have a condition which significantly limits his/her physical or mental capacity to perform basic work-related functions, a finding must be made that he/she does not have a severe impairment and, therefore, is not disabled. This is a decision based on medical considerations alone; no consideration of vocational factors is necessary. When there is no significant limitation in the ability to perform basic work-related functions, an impairment or combination of impairments will not be considered severe even though it may prevent an individual from doing work that he/she has done in the past. If the individual had a highly specialized job involving unusual work-related functions, the inability to do this work would be due to the specific demands of the highly specialized work rather than to the impairment(s). Since the individual clearly is able to perform basic work activities as they are required in most jobs, he/she does not have a severe impairment and is not disabled.  (POMS DI 22001.015)

1312-2

 

 

The POMS sets forth guidelines in the evaluation of medical impairments that are not severe for purposes of evaluating Title XVI individuals over 18 years of age.  While an impairment is not severe if it has no more than a minimal effect on an individual's physical or mental abilities) 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 adjudicator 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 under this concept only if the evidence shows that the individual's impairments, when considered in combination, are medically not severe (i.e., do not have more than a minimal effect on the persons' physical or mental abilities) to perform basic work activities).  (POMS DI 24505.005A.) 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 careful evaluation of the medical findings and an informed judgment about the limiting effect on physical and mental abilities to perform basic work activities, no evaluation of past work (or age, education, and work experience) is needed.  (POMS DI 24505.005B.) 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 since, by definition, basic work activities are the abilities and aptitudes necessary to do most jobs. If the medical evidence established only a slight abnormality, 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 perform 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.  (POMS DI 24505.005C.)

1312-3

 

 

The POMS states that duration of disability is that period of time that an individual is continuously unable to engage in SGA because of a medically determinable impairment. It extends from the onset of an impairment that prevents SGA to the time that the claimant no longer has an impairment that prevents SGA as demonstrated by medical evidence or the actual performance of SGA. An individual who was previously entitled to a period of disability must again meet the duration requirement for any subsequent period of disability. Severe impairments lasting less than 12 months cannot be combined with successive unrelated impairments to meet the duration requirement. In order to determine the duration of the impairment, the medical reports should reflect all the pertinent symptoms, signs, and laboratory findings, as well as prescribed treatment, and the response to that treatment in terms of changes in symptoms, signs, and laboratory findings. An impairment will be considered likely to result in death if, on the basis of established medical knowledge, it is found to be in a terminal state under the particular circumstances in the case, or if it does actually result in death. Subsection E indicates that if a claimant has two or more concurrent, not severe impairments which, when considered in combination are found to be severe, it is necessary to determine whether the combined effect of those impairments can be expected to continue to be severe for 12 months. If one or more of the impairments improves or is expected to improve within 12 months, so that the combined effect of the remaining impairments is no longer severe, the individual will not meet the 12-month duration test. (POMS DI 25505.001)

1312-4

 

 

The POMS states that when the evidence shows that within 12 months of onset the individual's impairment(s) did not or will no longer prevent SGA, a durational denial is appropriate. It is necessary to consider duration in the context of the sequential evaluation process, however, since duration does not become an issue unless at some time an impairment is severe and prevents SGA. In most cases in which the evidence substantiates a finding of disability, it will be readily apparent from the same evidence whether or not the impairment is expected to result in death or has lasted or is expected to last 12 months from the onset of disability. When the application is being adjudicated before the impairment has lasted 12 months, the nature of the impairment, therapeutic history, and prescribed treatment will serve as the basis for determining whether or not the impairment is expected to result in death or will continue to prevent the individual from engaging in any SGA for the additional number of months needed to obtain the required duration.  (POMS DI 25505.010)

1312-5

 

 

In projecting the individual's RFC 12 months from onset, consider all the evidence, including but not limited to:

 

1.         The nature of the impairment.

 

2.         Therapeutic history.

 

3.         Prescribed treatment.

 

4.         Functional restrictions.

 

5.         Daily activities.

 

6.         Type, dosage, effectiveness, and adverse side effects of any medication.

 

7.         Nature, location, onset, duration, frequency, radiation and intensity of any pain, and response to treatment.

 

8.         Precipitating and aggravating factors for pain or other symptoms (e.g., movement, activity, environmental conditions).

 

(POMS DI 24510.020B.)

1312-6

 

 

Federal law provides, in pertinent part, that we will consider all of your symptoms in making a determination as to disability (including pain, shortness of breath, weakness or nervousness) so long as there are objective medical signs and/or findings which show that there is a medical condition that could be reasonably expected to produce these symptoms.  (20 CFR §416.929)

1313-1

 

 

The federal Administrative Law Judge (ALJ) must obtain an opinion from a “medical expert” (as defined in 20 CFR §§416.927(f) and 416.912(b)(6)) when there is a question as to medical equivalence and:

 

1.         No additional medical evidence has been received, but in the ALJ's opinion the reported symptoms, signs, and laboratory findings suggest a judgment of equivalence is reasonable.

 

2.         Additional medical evidence is received which in the opinion of the ALJ may change the prior state determination that medical equivalency does not exist.

 

(POMS DI 24515.013C.1; Social Security Ruling 96-6p)

1313-2

 

 

It was reversible error when the ALJ denied the disability claim based on the fact there were no limitations which prevented the claimant from performing his past work when the ALJ failed to find that the claimant's impairment did not meet or equal a listing. (Fanning v. Bowen (1987) 827 F.2d 631.)

1313-3

 

 

A finding of "disabled" will be made for persons who are not working; who have a history of 35 years or more of arduous unskilled work; who can no longer perform this past arduous unskilled work because of a severe impairment; and who have no more than a marginal education.  (20 CFR §416.962; POMS DI 25010.001B.(1))

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A finding of “disabled” will be made for persons who have a severe impairment, have no past relevant work (PRW), are age 55 or older, and have no more than a limited education.  (POMS DI 24510.006B.(2))

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The disability applicant was unable to use any prosthesis that was reasonably available to him, because as a practical matter he could not afford a suitable prosthesis.  The 9th Circuit Court of Appeals held that the applicant, whose leg was amputated above the tarsal region, met Listing §1.10 because of his inability to obtain a prosthesis which met his needs.  (Gamble v. Chater (1995) 68 F. 3d 319)

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In determining whether a disability applicant equals the Affective Disorder Listing §12.04, the 9th Circuit Court of Appeals held that one must evaluate whether the combined effect of the applicant's mental and physical impairments satisfies the criteria set forth in §12.04B.  (Lester v. Chater (1995) 69 F. 3d 1453)

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An impairment is considered medically equivalent to a listed impairment if the medical finings are at least equal in severity and duration to the listed findings.  The symptoms, signs and laboratory findings for the medical records in the case are compared to the corresponding medical criteria shown for any listed impairment.  Medical equivalence may be shown in two ways:

 

(a)(1)(i)            If you have an impairment that is described in the Listing of Impairments in 20 CFR §404, App. 1, Subpart P, but--

 

(A)       You do not exhibit one or more of the medical findings specified in the particular listing, or

 

(B)       You exhibit all of the medical findings, but one or more of the findings is not as severe as specified in the listing:

 

(ii)        We will still find your impairment is medically equivalent to that listing if you have other medical findings related to your impairment that are at least of equal medical significance.

 

(2)        If you have an impairment that is not described in the Listing of Impairments, or you have a combination of impairments, no one of which meets or is medically equivalent to a listing, we will compare your medical findings with those for closely comparable listed impairments.  If the medical findings related to your impairments are at least of equal medical significance to those of a listed impairment, we will find that your impairment is medically equivalent to the comparable listing.

 

Medical equivalence must be based on medical evidence only, and the medical evidence must be supported by medically acceptable clinical and laboratory diagnostic techniques.  The opinion of one or more medical or psychological consultants may also be considered.  A medical consultant is defined as a physician, and a psychological consultant (as defined in 20 CFR §416.1016) must be a qualified psychologist.

 

The responsibility for determining medical equivalence rests with the Administrative Law Judge for cases at the hearings level.

 

(20 CFR §416.926(a) - (d))

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Federal law provides, in pertinent part, that a finding of disability is not precluded where an individual cannot perform a full range of sedentary work in light of the adverse factors which further narrow the range of sedentary work (even for a younger individual).  (20 CFR Part 404, Subpart P, Appendix 2, §201.00(h))

 

Limitation to less than a full range of sedentary work makes the Grids inapplicable.  The Secretary must make specific findings of an ability to perform specified jobs, based on reliable evidence in order to support a denial.  (Gonzales v. Secretary (1986) 784 F.2d 1417)

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