TN 2 (08-15)

This section contains examples of summary rationales. Every rationale must include the factors covered in the decision making process in order of continuing disability review (CDR) evaluation. The types of summary (SSA-832/833, Cessation or Continuance of Disability or Blindness Determination and Transmittal) rationale examples are as follows:

NOTE: These samples are intended to show the proper format and the sequence of the various elements following the medical improvement review standards (MIRS). They are not intended to serve as policy statements nor as examples of how medical findings are to be evaluated.

A. Sample rationale A - Impairment meets listing requirements - continuance

The following reports were used to decide if disability continues:

• Alfred Sandman, M.D., Internist, report dated 2/16/14

• Charles Hall, Jr., M.D., report of 3/1/14

• Frederick James, M.D., Orthopedist, consultative examination of 3/8/14

The individual was found to be disabled beginning 1/5/11 because of a combination of obesity and osteoarthritis of both knees. These impairments limited the disabled individual to the performance of sedentary work and Vocational Rule 201.09 directed a finding of disabled. The current evaluation is necessary as medical improvement is possible. The individual has not engaged in substantial gainful activity since onset and maintains he is unable to perform any work activity because of obesity and arthritis. He stated he seldom goes to his doctor as it's difficult for him to get around.

The disabled individual's treating internist reported on 2/16/14, that the individual continues to gain weight in spite of a weight reduction program and medication. He noted that the individual weighed 331 pounds at the last examination on 4/12/13. Because the medical evidence of record was not complete enough to permit evaluation of current severity, a consultative examination was arranged.

The consulting orthopedist reported on 3/8/14 that the disabled individual was 70 inches in height and weighed 325 pounds. He had difficulty getting on and off the examining table and complained of constant knee pain. Range of motion studies revealed that flexion of the right knee was 90 degrees. Flexion of the left knee was limited to 75 degrees. X-rays were consistent with osteoarthritic changes of both knees.

Since the record shows that the disabled individual's obesity and osteoarthritis of the knees meet the requirements of Listing 1.02A, he continues to be disabled.

B. Sample rationale B - Impairments equal listing - continuance

The following reports were used to determine whether disability continues:

• Hillary Watson Women's Hospital, outpatient treatment of 4/17/13 and 10/06/13

• William Green, M.D., report dated 3/20/14

• Grace Monafo, M.D., reports dated 3/29/14 and 4/10/14

The individual was found to be disabled beginning 8/17/10, due to obesity, heart disease, and arthritis. Medical records document an anteroseptal myocardial infarction in June 2008. The impairments were determined to be equivalent to the severity reflected in Listing 1.02. Current evidence is needed because medical improvement is possible. The disabled individual states that she is still disabled because of a heart condition and arthritis. She has not worked since her established onset date.

At examination on April 10, 2014, she had no recurrence of angina, but complained of shortness of breath on walking 1 1/2 blocks and dependent edema at night. Her persistent knee joint pain was exacerbated by walking or prolonged standing. She also complained of generalized joint pain and morning stiffness. Her height was 62 inches, weight 249 pounds. Blood pressure with a large cuff was 150/95. She was in no acute distress. There was mild ankle edema. The knees were enlarged and crepitant, but without heat or inflammation. Range of motion of the knees was normal. Both Heberden's and Bouchard's nodes were present. There was no jugular vein distention and the liver was not palpable. The lungs were clear, but breath sounds were somewhat distant. Heart rhythm was markedly irregular and the apical pulse was 120, with a radial pulse of 100. There was a soft systolic aortic ejection murmur. Chest film shows clear lungs. CT ratio is 53 percent, with mild left ventricular prominence. ECG tracing shows multifocal PVC's, and QS complexes through lead V5. Fasting blood sugar is 130. Serum creatinine is 1.4. X-ray films show moderate osteoarthritic changes in the knees.

The review physician's analysis demonstrates that the individual does not meet the disability criteria for Listing 1.02. However, her mobility continues to be severely limited by impairment-related shortness of breath and by joint pain. It is determined that the combination of heart disease, obesity, and osteoarthritis of the knees continues to be equivalent to the severity reflected in the criteria for Listing 1.02 Therefore, she is disabled within the meaning of the Social Security Act and disability is continued.

C. Sample rationale C – MI occurred, RFC shows the W/E cannot do SGA - continuance

The following reports were used at the comparison point decision of 4/12/11 to determine disability:

• Philip Smith, M.D., report of 4/7/11

• St. John's Hospital, reports of inpatient treatment, 10/7/10 to 10/27/10

The following reports were used to determine whether disability continues:

• Philip Smith, M.D., report dated 2/25/14

• Khalil Kashir, M.D., report dated 3/10/14

• Charles White, M.D., Internist, consultative examination of 3/20/14 and ventilatory testing of 3/26/14

The individual was determined to be disabled from 11/10/10 because of multiple injuries sustained in an automobile accident. These injuries limited him to the performance of light work and Vocational Rule 202.06 directed a finding of disabled. Current evidence is needed because medical improvement is possible. The disabled individual states that he is still unable to work due to a leg condition and shortness of breath. He is not engaging in substantial gainful activity.

Current medical evidence shows the individual has a mild restriction of movement of his left ankle but has normal gait and station. An x-ray of his left ankle reveals a healed fracture with degenerative changes. He has good range of motion of his hips and knees. There are no sensory, motor or reflex abnormalities. Abnormal breath sounds and labored breathing were noted. A diagnosis of chronic obstructive pulmonary disease has been made.

A consultative respiratory examination was obtained since a chest x-ray and ventilatory studies were needed to evaluate this additional impairment. Ventilatory studies performed on 3/26/14 revealed that the pulmonary disorder has resulted in reduced breathing capacity with an FEV1 of 1.6 and MVV of 67. His height is 6 feet without shoes. The impairments do not meet or equal the Listings.

At the time of the CPD, the individual was recuperating from multiple rib fractures, internal injuries, and a compound, comminuted fracture of the left ankle. Current evidence shows complete healing of the rib and ankle fractures and healed internal injuries. The only residual of the accident currently is mild limitation of motion of the left ankle. Therefore, medical improvement has occurred. This individual previously had an RFC for light work at the CPD. Considering only the impairment present at the CPD, there is currently no significant restriction of function. Therefore, the medical improvement is related to the ability to work. The disabled individual's respiratory impairment is severe as he is limited in his ability to lift more than 20 pounds occasionally or 10 pounds frequently and to work in polluted environments. Therefore, based on all the current impairments, he is found to be restricted to a limited range of light work.

The disabled individual is 58 years of age with a high school education and a 25 year work history as a rigger in the shipbuilding industry (skilled work at a heavy exertional level). This involved maintaining the weight-handling gear on ships, arranging the weight distribution of the load and organizing the movement of the gear. He cannot perform this past relevant work because of the heavy exertional requirement, as he can only do a limited range of light work. His skills are not transferable to light work. In view of his remaining occupational base translated from his RFC and considered in conjunction with his advanced age, education, and work experience, he would be unable to make the adjustment to other unskilled work. Accordingly, he continues to be disabled within the framework of Vocational Rule 202.06. Therefore, although medical improvement related to ability to work has occurred in the original impairment, the current impairment is severe and precludes the individual from performing SGA, so disability continues.

D. Sample rationale D – MI occurred, not severe - cessation

E. Sample rationale E - MI occurred - cessation

The following reports were used to decide the claim initially on 7/15/11, the date of the comparison point decision:

• Oak Ridge Hospital, reports covering admissions of 8/24/10 to 9/15/10 and 5/30/11 to 6/17/11

• Marvin Henry, M.D., report of 7/10/11

• Keven R. Connolly, O.D., report of 7/12/11

The following reports were used to determine if disability continues:

• University Hospital, reports covering admission of 10/7/12 to 10/20/12

• Michael Wilson, M.D., report of 2/28/14

• Marvin Henry, M.D., report of 3/4/14

• Keven R. Connolly, O.D., report of 3/10/14

The individual has been disabled since August 23, 2010. Her impairment met Listing 1.04C as a result of a back injury with spinal stenosis. Current evaluation is necessary since improvement was expected. The individual states she is still unable to work because of back and right leg pain. There has been no work activity since onset.

In December 2012, a myelogram revealed an L4-5 extradural defect, and the individual underwent a right L4-5 laminectomy and excision of the nucleus pulposus. Office notes show that her symptoms improved although she continued to experience periodic back and right foot pain. Current findings show that she has good range of motion of her lumbosacral spine with 80 degree forward flexion and normal lateral bending. Motor exam reveals normal mass and tone. Deep tendon reflexes and sensation are normal. She is able to heel and toe walk normally. An x-ray shows evidence of a past laminectomy and degenerative arthritis.

A physical exam at the time of the comparison point decision showed the individual had markedly decreased range of motion of the spine. Muscle spasm was present. There was L5 motor weakness and hypoesthesia to pin prick. She was unable to heel or toe walk.

Current medical evidence shows that the back impairment has decreased in severity since the individual now has good range of motion of her lumbosacral spine, normal motor, reflex and sensory examinations, and normal ability to heel and toe walk. Therefore, medical improvement has occurred. Since the individual met a listing at the CPD and now no longer meets or equals that listing, the medical improvement is related to the ability to work. Current medical findings do not establish an impairment that produces pain of such severity as to preclude the individual from engaging in any gainful work. The current impairment does not meet or equal a listing; thus, disability is ceased as of March 2014 and benefits will be terminated as of May 2014.

F. Sample rationale F - MI occurred, can perform past work - cessation

The evidence used in the CPD of 12/10/10 was:

• Concord Hospital, inpatient records from 8/17/10 to 8/31/10

• Cliff Adams, M.D., report of 11/1/10

• Frederick Thompson, M.D., Cardiologist, consultative examination of 11/13 /10.

The following reports were used to decide this claim:

• Concord Hospital, inpatient records from 6/5/11 to 6/28/11, 4/4/12 to 4/15/12

• Cliff Adams, M.D., report dated 2/9/14

• Elsie Friehold, M.D., Cardiologist, report dated 3/15/14

This individual was found to be disabled beginning 8/17/10 because of coronary artery disease. The impairment equaled Listing 4.04C. The individual has completed a 9-month trial work period. She continues to work as a telephone solicitor with earnings indicative of SGA. Benefits have been stopped as indicated on SSA-833 on 11/13/13. She feels she still has a severe heart condition which limits activity. A current medical decision is needed to determine “impairment severity” and thus, entitlement for an extended period of eligibility.

Medical evidence indicates the individual underwent bypass surgery in June 2011. Although she initially progressed well, she subsequently began to complain of chest pain and shortness of breath. She underwent a second bypass surgery in April 2012. Current examination revealed normal heart sounds with only occasional premature ventricular contractions. The individual experiences chest pain infrequently with heavy exertion. The pain is relieved with nitroglycerin or rest. The doctor stated that the patient would not be able to return to work activity. The treating cardiologist reported in March 2014 that the individual performed a stress test to 7 METS. A chest x-ray revealed only mild cardiomegaly. She assessed that because of the individual's history of heart disorder, she should avoid lifting in excess of 25 pounds.

The record reveals the patient underwent two bypass surgeries for her heart disorder. She experiences chest pain of cardiac origin infrequently, but a treadmill exercise test was negative at 5 METS. It showed abnormalities at 7 METS. Therefore, the evidence does not show current findings that meet or equal the listed impairments. The second bypass surgery improved circulation to the heart and symptoms have decreased. Therefore, medical improvement has occurred.

At the time of the CPD, a listing was equaled. Since the impairment no longer meets or equals that listing, the medical improvement is related to the ability to work.

The record reveals the individual continues to have a severe cardiovascular impairment which limits her ability to perform basic work activities. There is a current capacity to lift a maximum of 20 pounds occasionally and 10 pounds frequently.

The individual is limited to light work activity. She last worked from 3/05 to 8/10 as a laundry marker, which involved such activities as sorting laundry, putting names on articles, etc. This is a light job. Accordingly, she can do her past relevant work as she has the functional capacity to do light work.

Although the individual's treating physician stated she would not be able to do work, the weight given such statements depends upon the extent to which they are supported by specific and complete clinical findings and are consistent with other evidence in the individual's case. The clinical findings and other evidence do not support the conclusion that the individual is disabled for any gainful work.

Since medical improvement has been demonstrated by a decrease in medical severity related to the ability to work and since the individual is able to engage in SGA, impairment severity ceases in 3/14.

G. Sample rationale G - MI occurred, cannot perform past/other work - continuance

The following report was used at the comparison point decision of 8/19/11:

• Joseph Anderson, M.D., report of 7/5/11

The following reports were used to determine whether disability continues:

• St. John's Hospital, reports covering admission of 4/8/12 to 4/17/12

• Joseph Anderson, M.D., report dated 2/9/14

• Janice Urban, M.D., Cardiologist, report of 3/25/14

The individual was found to be disabled beginning 1/17/11 because of coronary artery disease and thrombophlebitis. The impairment limited the individual to the performance of sedentary work and Vocational Rule 201.10 directed a finding of disabled. New medical evidence is needed because medical improvement is considered possible. The individual alleges that he is still disabled due to a heart condition. He has not performed substantial gainful activity since 1/17/11, his date of onset.

Medical evidence from the individual's treating cardiologist indicates that the individual underwent bypass surgery in April 2012. Current examination revealed normal heart sounds with only occasional premature ventricular contractions. There are infrequent episodes of angina. A cardiologist reported in March 2014 that the individual performed a stress test to 7 METS with no angina. A chest x-ray revealed only mild cardiomegaly. The individual has a history of thrombophlebitis, but the lower extremities show no abnormalities. The medical findings do not document an impairment that meets or equals the listings.

At the CPD the individual had severe inflammation of the leg veins which was persistent in spite of treatment. The individual experienced crushing chest pain with exertion for which he had bypass surgery. At present, the individual has no problems with his legs and the lower extremities were described as normal on physical examination. The evidence shows a decrease in the medical severity of his impairment; therefore, medical improvement has occurred. Based on the individual's current impairment he has the capacity to lift 20 pounds occasionally and 10 pounds frequently with no further restrictions. Medical evidence at the time of the CPD shows that the individual was restricted to sedentary work. Current medical findings demonstrate that the individual now has the capacity to perform light work. Therefore, the medical improvement is related to the ability to work. The individual's impairment imposes significant restrictions on his ability to perform basic work activities and is severe.

The individual is 58 years old and has 10 years of education. He has 5 years of relevant work history as a nurses' aide which is a medium, semiskilled job. Since the individual is limited to light work he would be unable to perform his past work due to the exertional demands involved. His skills are not transferable to jobs of a light or sedentary type. The individual satisfies the criteria for Vocational Rule 202.02, which directs a decision of disabled. Since the individual does not have the ability to do SGA, even though MI has occurred, disability is found to continue.

H. Sample rationale H - MI occurred, can do other work - cessation

The following evidence was used at the CPD, 4/12/12:

• St. John's Hospital, inpatient 2/6/11 to 3/1/11

• Lakeside Rehabilitation Center, outpatient 3/1/11 to 3/27/12

• Claude Arakari, M.D., report of 4/1/12

The following reports were used to determine whether disability continues:

• Lakeside Rehabilitation Center, outpatient 4/5/12 to 4/21/13

• Robert Franklin, M.D., report dated 2/8/14

• Samuel Glassner, M.D., Orthopedist, consultative examination of 3/1/14

The individual has been disabled since 2/6/11 because of musculoskeletal injuries sustained in a motorcycle accident. He was found to be limited to sedentary work and Vocational Rule 201.09 directed a finding of disabled. He has not worked since his established onset date. The individual alleges he remains unable to return to any work activity because he still has knee pain. Current evaluation is needed because medical improvement was expected.

Currently, the treating physician reported that he continued treating the individual for complaints of pain to the lower extremities. He states that he treated the individual with medication and advised him to exercise. X-rays taken at the examination on 1/8/14 revealed only spurring in the right knee in addition to old healed fractures. A consultative examination was arranged to obtain range of motion. Evidence from the consulting orthopedist dated 3/1/14 reveals the individual continues to walk with an abnormal gait. Flexion of the right knee is limited to 120 degrees. The left knee can be fully flexed. Range of motion of the hips and ankles is normal. The impairment does not meet or equal the requirements of the Listings.

At the comparison point the individual was able to ambulate for only short distances as a result of his right knee impairment. X-rays revealed that all other injuries were healed except the right knee which did not have complete healing. Current medical evidence demonstrates a decrease in severity since an x-ray revealed that the right knee fracture is well-healed with minimal spurring and there is only mild limitation of motion. Therefore, medical improvement has occurred as there is a decrease in medical severity. He now has the ability to stand and walk 6 out of 8 hours and to lift 20 pounds occasionally and 10 pounds frequently, which is a wide range of light work. The medical improvement that has occurred is related to his ability to work, since he could only do sedentary work activity at the CPD. The individual's impairment imposes significant restrictions on his ability to perform basic work activities and is severe.

Although the individual alleges pain in the right knee, the fracture is well-healed with minimal spurring and mild limitation of motion. He is restricted to light work but the clinical findings do not establish an impairment that produces pain of such severity as to prevent the individual from performing any gainful activity.

The disabled individual is 53 years old, has a limited education, and has a 20 year work history as a general laborer in a foundry which is unskilled work involving heavy lifting and carrying. Since the individual is limited to light work, he would be unable to perform his past work due to the exertional demands involved. The special medical-vocational characteristics pertaining to those cases involving arduous, unskilled work or no work are not present. The facts in this case correspond exactly with the criteria of Vocational Rule 202.10 which directs a finding of not disabled. Since there is medical improvement and the individual has the ability to do SGA, disability is ceased in 2/14 and benefits will be terminated as of 4/14.

I. Sample rationale I - MI occurred, multiple not severe impairments combined effect is severe, but one impairment is a subsequent impairment, can perform other work - cessation

The following reports were used at the CPD of 2/13/09:

• Meadeville Medical Center, inpatient treatment of 11/12/08 to 11/21/08; outpatient treatment, 10/19/08, 12/2/08

• Alexander Doone, M.D., report of 1/17/09

The following reports were used to determine if disability continues:

• Renee Legere, M.D., report of 2/28/14

• Alexander Doone, M.D., report of 3/10/14

• Consultative examination, John R. Smith, M.D., Internist, 3/26/14

The individual has been under a disability since 10/19/08 due to rheumatic heart disease with mitral stenosis and peptic ulcer which led to an allowance in the framework of Vocational Rule 201.10. The case is being evaluated as medical improvement is possible. The individual believes he is still disabled because of his heart condition plus recent pulmonary disease. He attempted working a few years ago but had to stop after three weeks. There is no SGA issue.

Current medical evidence reveals a history of rheumatic heart disease that required hospitalization for congestive heart failure. This has responded to treatment and currently there is no chest pain and no evidence of pulmonary or peripheral edema, according to his physician. There are no symptoms related to peptic ulcer disease since his diet has been adjusted. Recently, shortness of breath has been increasing. He had been smoking two packs of cigarettes per day for 20 years, but has stopped because of respiratory problems. A consultative examination was scheduled for evaluation of his respiratory impairment with pulmonary function testing.

On physical examination, height was 69" and weight was 180 pounds. Breath sounds were diminished with prolonged expiration and an expiratory wheeze. The chest was otherwise clear. On examination of the heart, a diastolic rumble at the apex was noted. An ECG showed a prominent wide P-wave suggestive of left atrial enlargement, which was confirmed on the chest x-ray. The heart size otherwise was within normal limits. The lung fields were hyperaerated and diaphragms were somewhat flattened. Ventilatory function studies done by the consultant revealed postbronchodilator FEV1 was 1.9 liters and MVV 76 liters per minute.

Current medical findings do not meet or equal the findings described in any listed impairment. There is no current evidence of congestive heart failure and no active ulcer. This shows medical improvement as there is a decrease in the medical severity of impairments present at the CPD. At that time the functional capacity was for light work activity. The current RFC, considering only the rheumatic heart disease and peptic ulcer, shows full capacity to do all work activities and these impairments are now not severe. Therefore, medical improvement related to ability to do work is demonstrated.

Although the heart and digestive impairments are not severe when considered alone, considering their effect on the ability to perform work activities in combination with a respiratory impairment, the individual would be restricted to lifting up to 50 pounds occasionally and 25 pounds frequently. The individual now has the capacity to perform a full range of medium work. He cannot perform his prior work as baker helper (heavy, unskilled work). It involved much lifting of things, such as bags of flour (up to 100 pounds), racks of baked items, and piles of unfolded boxes. Although his most recent work was arduous and unskilled, it lasted only 17 years and he previously did semiskilled work. Therefore, the special medical-vocational characteristics pertaining to arduous, unskilled work, or no work, are not present. He is of advanced age (56) with limited education (grade 6) and meets Vocational Rule 203.11, which indicates the ability to do SGA. Since there is medical improvement, demonstrated by decreased medical severity and related to the ability to work, and the individual has the ability to do SGA, disability is ceased on 4/14. Benefits will be terminated 6/14.

J. Sample rationale J - MI occurred, and it is obvious that the vocational exception also applies, can perform other work - cessation

In making the determination on the issue of continuing disability, all of the evidence listed on the decision dated 3/13/13 has been considered, as well as the following additional evidence:

• Vocational Rehabilitation Counselor, Department of Vocational Rehabilitation, reports covering 3/10/11 to 3/15/14

• T. Weston, M.D., report dated 4/19/14

• L. Lehman, M.D., report dated 4/21/14

• G. Robertson, M.D., report dated 5/01/14

The individual was allowed disability benefits from 12/7/11 because of injuries received in a motorcycle accident. At the time of the CPD, he had a traumatic left above the knee amputation with persistent stump complications, inability to use a prosthesis, and a right recurrent shoulder dislocation. The impairment was found to meet Listing 1.05B. The current evaluation is necessary as medical improvement was expected. The individual states he is still disabled because of a left leg amputation and difficulty walking with his prosthesis. He has not worked since the onset date.

The medical evidence reveals that following his left above the knee amputation in 12/11 the individual experienced persistent pain and tenderness about the stump and underwent three stump revisions. The most recent revision was 2/1/13 for excision of a bony spur and painful scar. Office notes from the individual's treating physician show that following the latest stump revision the individual was able to wear his prosthesis over an extended period of time without much discomfort. Recent examination of the stump revealed no neuromatous changes or other abnormalities. An x-ray did not demonstrate any bony spurs or complications. Furthermore, the individual has had no recent problems with right shoulder dislocation. He had full range of motion of his shoulder without pain or instability. The individual no longer has an impairment that meets or equals the level of severity described in the Listings.

The individual was unable to use his prosthesis at the time of the comparison point decision because of repeated stump complications. Current medical findings show that these complications have resolved and the individual is able to ambulate with his prosthesis for an extended period of time without discomfort. Therefore, medical improvement has occurred. Although he alleges difficulty walking with his prosthesis, the individual has the residual functional capacity to stand and walk for 2 hours and to sit for six hours with no further restrictions. Since his current condition no longer meets or equals Listing 1.05B, his medical improvement is related to the ability to work.

The individual received evaluation and counseling through the Department of Vocational Rehabilitation. He obtained funds to attend a 2 year program at Central University. In December 2005 he received an associate degree in computer science. The combination of education and counseling constitute vocational therapy.

The individual has a severe impairment that limits him to the performance of sedentary work. The individual is 30 years old with 16 years of education. He has 4 years of relevant work experience as a painter. This job involved standing and walking at least 6 out of 8 hours. The individual is unable to perform his past work because of limitations on standing and walking. The special medical-vocational characteristics pertaining to arduous, unskilled work or no work are not present. Additionally, his ability to perform sedentary work has been enhanced by vocational therapy; therefore, the vocational therapy exception applies. The individual meets Vocational Rule 201.28 which directs a decision of not disabled. Medical improvement is established, the vocational therapy exception applies and the individual is able to engage in SGA. Therefore, the individual is no longer disabled under the provisions of the Social Security Act as of May 2014 and benefits are terminated as of July 2014.

K. Sample rationale K - No MI, but error exception applies, cannot perform past or other work - continuance

In making the determination of continuing disability, all the evidence cited in the CPD of 2/23/10 has been considered, as well as the following:

• Ervin Medical Center, outpatient treatment 12/7/09, 12/19/12, and 4 /12/13

• Commonwealth Hospital, outpatient report of 9/23/13

• Georgia Ebenezer, M.D., report of 3/02/14

• William A. Bell, M.D., office notes from 1/3/11 to 3/1/14

• Edward Burgin, M.D., report of 3/17/14

The individual has been under a disability since 7/29/09 because of ischemic heart disease which met Listing 4.04C based on the angiogram done 12/7/09. Current evaluation is needed as medical improvement is possible. The individual says she is still as bad off as she was when she applied and she still gets bad chest pain. She also has arthritis in her hands. There is no SGA issue.

Current medical evidence shows that the individual continues to have crushing chest pain on exertion, such as lifting her grandson, which stops with rest or medication. Her doctor has told her to avoid strenuous activity. When she limits exercise, she rarely has angina. She has stiffness in her finger joints and a 12/19/12 x-ray shows degenerative arthritis of her hands and wrists, greater than normal for her age. There is also evidence of an old healed fracture of her left wrist, which is her dominant hand. Limitation of motion is noted in the left wrist and thumb. Her blood pressure is 110/70 and heart sounds are normal. There is infrequent angina for which nitroglycerin has been prescribed. The results of a treadmill exercise test done 2/19/10 were included in response to medical evidence requested covering the last 12 months. The test was negative to 7 METS when it was stopped due to fatigue. Bypass surgery was considered then but was not done due to obesity (197 pounds). Current weight is 165 pounds and height is 67-1/2 inches. She still does not want to risk surgery. Further weight reduction is planned. A treadmill test done 9/23/13 was stopped due to chest discomfort at 7 METS with no ECG abnormalities present as described in the listings.

There is no evidence of decreased medical severity in relation to the individual's cardiac impairment. Therefore, no medical improvement has been demonstrated. The evidence now shows that a treadmill exercise test, done around the time of the initial allowance but not obtained then and not considered in making that decision, was negative at 7 METS. Had the test been considered at the time of the initial decision, the case would not have met the listing since the treadmill results have precedence over the angiogram. There would have been an RFC for light work. The individual's past relevant work involved mounting tissue specimens on glass plates, doing blood and urine tests, keeping laboratory test tubes and other equipment clean and in order, and other duties, a job classified as light work in the Dictionary of Occupational Titles (DOT). Therefore, a denial based on the ability to perform her past work as a medical-laboratory assistant would have been the appropriate decision. If the treadmill results had been considered at the time of the prior determination, disability would not have been found. Therefore, the error exception applies.

Currently there is an additional impairment, arthritis of the hands, which was not present at the CPD. Current RFC permits lifting 20 pounds occasionally and 10 pounds frequently based on the cardiac impairment. However, because of the limitation of the use of the left wrist and the dominant hand, constant handling would be precluded. The current impairments are severe and restrict the individual to light work with additional non-exertional restrictions. Since constant handling was an integral part of her past work as a medical-laboratory assistant, she could not perform this work now.

The individual is 56 years old. She is a high school graduate with a background of skilled work. She no longer has the use of her hands required in her type of work and thus has no transferable skills. The framework of Vocational Rule 202.06 and 201.06 indicates she is not able to do SGA. Therefore, although the error exception applies, disability is found to continue because the individual is not able to do SGA.

L. Sample rationale L - Unable to determine if MI occurred, folder lost - continuance

The following reports were used to determine if disability continues:

• Wharton Hospital, outpatient 5/12/13 to 1/5/14

• Fred Josephs, M.D., report of 2/20/14

• Consultative examination, Constance A. Binns, M.D., Otologist 2/28/14

Current evaluation is necessary because the diary date has been reached and indicates medical improvement was considered possible. The prior folder cannot be located. The available evidence indicates the claim was allowed as equaling a listing with an onset of 9/6/06. The individual states that he continues to be disabled due to his heart condition. He also had some trouble hearing. He has not worked since he first became disabled. It is unclear whether a decision has been made since then. He remembers going for an examination set up by the DDS which he thinks was more recent than 2014.

Medical evidence reveals a history of a myocardial infarction 9/6/06 and cardiac arrhythmia which was due to digitalis. His medication was changed and his heart symptoms decreased. A treadmill exercise test done 5/12/13 was positive at 10 METS according to the cover sheet describing the results of the test. The tracings are not available. The individual no longer has any chest pain. A consultative examination was arranged to evaluate the severity of his hearing impairment. He has a 40 decibel loss in the right ear and 60 decibel loss in the left ear. A hearing aid was recommended. The individual's impairments do not meet or equal any listed impairment.

A current assessment of functional capacity showed the ability to lift up to 25 pounds occasionally and 10 pounds frequently with no limit on walking and standing. He should not work in a very noisy atmosphere or in a job that requires hearing perfectly. Since the individual's past relevant work was accounting, a sedentary skilled job, he would be able to perform this past work. Therefore, he is currently able to engage in SGA and reconstruction of the prior folder is required if the date of the comparison point decision can be established. Attempts to reconstruct prior medical evidence have not been made because the comparison point is not clear. Therefore, neither medical improvement nor any of the exceptions to medical improvement have been demonstrated and disability must be continued.

M. Sample rationale M - No MI or exception - continuance

The sources for the CPD of 12/22/12 are:

• St. Anthony Hospital, inpatient treatment 6/14/12 to 6/27/12; outpatient treatment 7/15/12 to 10/16/12

• James Gregory, M.D., report dated 11/2/12

The following reports were used to decide the issue of continuing disability:

• St. Anthony Hospital, outpatient treatment 9/13/13 to 9/19/13 and inpatient treatment 9/27/13 to 10/14/13

• Vincent Moberg, M.D., Cardiologist report dated 3/5/13

• James Gregory, M.D., reports dated 2/19/14 and 3/15/14

The individual has been disabled since 6/14/12, because of coronary artery disease. A medical-vocational allowance was made because of an RFC for light work. He has not engaged in substantial gainful activity since onset. Current review is necessary since medical improvement was expected. The individual states he continues to be unable to work because of a bad heart.

The medical record reveals that the individual was hospitalized on 9/13/13 with complaints of chest pain and shortness of breath. He was treated conservatively and released on 9/19/13 but again hospitalized on 9/27/13 to undergo further evaluation. At that time, angiography revealed significant blockage of the left anterior descending artery and the right coronary artery. The individual underwent bypass surgery and although his recovery was uneventful, he continued to complain of chest pain and shortness of breath with any exertion. An electrocardiogram was interpreted as abnormal and an echocardiogram showed a decreased ejection fraction. The treating cardiologist indicated that further surgery was not anticipated and the individual would continue to be treated with conservative therapy including medication, rest and an exercise program. The cardiologist indicated the individual would be limited in his ability to perform any strenuous activities because of the continued chest pain, shortness of breath and easy fatigability. The cardiologist noted the possibility of further cardiac damage.

The individual's coronary artery disease does not meet or equal the requirements of the listings. The medical record reveals that the individual has coronary artery disease for which he has undergone surgical procedure. In spite of surgery, he has shortness of breath, chest pain on exertion, and easy fatigability. At the CPD, the individual experienced angina and had an abnormal treadmill exercise test, positive at 6 METS. He has not had an exercise test since then because of his chest pain, post-surgery. The individual has not had a decrease in severity of his coronary artery disease as evidenced by the medical findings. Medical improvement has not occurred and no exception to MI applies; therefore, disability continues.

N. Sample rationale N - No MI or exception - continuance

The following reports were used at the comparison point decision of September 22, 2001:

• Veterans Administration Hospital, admissions of 8/14/00 to 8/22/00 and 10/27/00 to 11/05/00

• Herbert Roberts, M.D. report of 7/15/01

The following reports were used to determine whether disability continues:

• Veterans Administration Hospital, admission of 2/25/14 to 3/3/14 and outpatient records covering 1/21/05 to 3/17/14

• John Albrecht, M.D., report of 3/27/14

• George Baylis, M.D., report of 4/02/14

The individual was initially determined to be disabled from 8/22/99 because of uncontrollable diabetes, peripheral neuropathy, and decreased vision. His impairment was considered to be equivalent to Listing 9.08. Current medical evidence was obtained as medical improvement was possible. The individual alleges that he is still disabled because of “sugar diabetes, pins and needles in his legs, and cataracts.” He has not worked since onset.

The individual has a history of diabetes which has not been well controlled by diet and insulin. Current medical reports show a recent hospitalization for control of his diabetes. Subsequent office visits revealed some elevated blood sugars. The individual has never had hypoglycemic reaction or acidosis. An ECG and chest x-ray were normal. Eye ground showed no retinopathy and there were good peripheral pulses throughout. Findings indicated that there was bilateral hypalgesia to pinprick and diminished vibratory sense in both lower extremities. DTR's were diminished bilaterally at the ankles. The individual was ambulatory with a normal gait. Visual exam revealed the presence of cataract in the left eye and best corrected visual acuities were 20/100 OS, 20/25 OD. The individual does not have an impairment or combination of impairments that meets or equals the Listings.

The record shows that at the time of the comparison point decision, the individual had diabetes of 6-years duration. He had diabetic neuropathy with mild sensory changes. There were presence of a cataract in the left eye with decreased vision to 20/100 best correction and normal vision in the right eye. The record shows the individual continues to have diabetes which is difficult to control, mild diabetic neuropathy, and decreased vision in his left eye. Additionally, there has been no change in the medical findings to show medical improvement. Since medical improvement has not occurred, and none of the exceptions to MI applies, disability continues.

O. Sample rationale O - MI is not related to ability to do work, but vocational therapy exception applies, can perform other work - cessation

The following reports were used to determine disability at the comparison point decision of 9/25/11:

• Mark Green, Jr., M.D., report of 6/2/11

• Washington Community Hospital, reports covering admission of 8/3/11 to 9 /4/11

The following reports were used to determine whether disability continues:

• Washington Community Hospital, reports covering admission of 9/13/12 to 9/23/12 Vocational Rehabilitation Counselor, Department of Rehabilitation Services, report of 12/17/13

• William Jacobs, M.D., report of 2/27/14

• Howard Goodman, M.D., Orthopedist, consultative exam of 3/11/14

The individual was found to be disabled beginning 8/3/11 due to a crush injury with fracture of his left ankle. He was restricted to the performance of light work and thereby met the requirements of Vocational Rule 202.06, which directed a decision of disabled. Current medical evidence was obtained because medical improvement was expected. The individual states that he continues to be disabled because of left ankle pain and difficulty standing and walking. He has not worked since onset of his disability.

Recent medical information from the individual's physician shows that the individual continues to have pain and numbness in his left foot. An ankle fusion was done in 9/13 to provide a stable joint and to permit weight bearing. He is fully weight bearing now, but walks with a prominent limp. In order to further document severity and obtain a current x-ray, the individual was examined by a consulting orthopedic physician. Clinical examination of the left ankle revealed some thickening of the heel but the fusion appeared to be stable. Ankle movements are limited to 10 degrees dorsiflexion and 20 degrees plantar-flexion. An x-ray was consistent with a healed subtalar arthrodesis and moderate traumatic degenerative changes. Neurological evaluation revealed an absent left ankle jerk and inability to walk on heels and toes. There was decreased sensation over the lateral and dorsal aspects of the left foot and decreased strength of the left extensor hallucis longus.

The individual's impairments do not meet or equal the level of severity described in the listings. An x-ray shows that arthritis has developed at the fracture site. The individual continues to experience left ankle pain. Further, he has an abnormal gait and limitation of motion of his ankle. However, since the ankle fusion the individual has full weight-bearing, which is medical improvement since the CPD. His left ankle impairment continues to restrict his ability to stand and walk to 6 hours during an 8-hour day. The individual remains limited to the performance of a wide range of light work, lifting 20 pounds occasionally and 10 pounds frequently. This is the same RFC as that at the CPD. Therefore, the medical improvement is not related to his ability to work.

Since the comparison point decision, the individual underwent vocational counseling through the Department of Rehabilitation Services and enrolled in an 18-month training program on small appliance repair. He completed the course on 11/30/13 after working on appliances such as radios, electrical tools and a variety of small household appliances.

The recent completion of this specialized training course in conjunction with counseling constitutes vocational therapy. This therapy has enhanced the individual's ability to perform work since he has acquired a skill that provides for direct entry into light work.

Although the individual continues to experience left ankle pain, he is fully weight-bearing and is able to perform light work. The clinical findings do not establish an impairment that results in pain of such severity as to preclude him from engaging in any substantial gainful activity.

The individual has a severe impairment that restricts him to light work. He is 57 years old with 12 years of education. He has 6 years of relevant work experience as a truck driver that is a medium semiskilled job. The individual is unable to perform work as a truck driver because of the exertional demands of the job and there are no transferable skills. The special medical-vocational characteristics pertaining to arduous, unskilled work or no work are not present. However, as a result of vocational therapy since the comparison point decision, the individual has obtained job skills which are useful in the performance of light work and, therefore, meets Vocational Rule 202.08 which directs a decision of not disabled. He can do such occupations as an Electrical-Appliance Repairer (DOT 723.381-010), a Radio Repairer (DOT 720.281-010) or as an Electrical Tool Repairer (DOT 729.281-022), all skilled light work in the electrical equipment industry. According to the Labor Market Trends Bulletin and the Virginia Department of Labor and Industry, over 30,000 individuals are employed in the electrical equipment industry in Virginia; and the cited occupations are well represented throughout that industry. It can be inferred that the occupations exist as individual jobs in significant numbers in the region where the individual lives and throughout the national economy.

While there has been no medical improvement related to the ability to work in the individual's impairment, the vocational therapy exception to medical improvement applies and the individual is able to engage in SGA. The individual is no longer disabled as of 3/14 and benefits are terminated as of 5/14.

P. Sample rationale P - No MI or exception, unchanged medical findings - continuance

The following reports were used to evaluate disability at the comparison point decision of 12/18/09:

• George Washington Hospital, admission of 10/22/09 to 10/27/09

• Nicholas Lawrence, M.D., report of 11/29/09

• John Webster, M.D., Cardiologist, consultative exam of 12/12/09

The following reports were considered in evaluating whether disability continues:

• Nicholas Lawrence, M.D., report of 2/13/14

• Paul Bush, M.D., report of 2/15/14

• Richard Wilson, M.D., report of 2/21/14

• Bernard Parker, M.D., Vascular Surgeon, consultative exam of 3/10/14

The individual was previously determined to be disabled beginning 10/17/09 by peripheral vascular disease, hypertension, and obesity. The combination of impairments was determined to be equivalent to the severity reflected in Listing 11.14. Current evaluation is necessary because medical improvement was possible. The individual reports that she is still disabled because of poor circulation of blood in her legs and high blood pressure. She has not engaged in SGA since she “became disabled”.

The individual's treating physician reported that the individual continues to be overweight (232 pounds) despite adherence to a strict diet and continues to complain of left leg swelling with necessity for using an elastic stocking. A consultative exam was obtained for specific findings regarding any peripheral vascular disease. The physical exam was remarkable for weight of 232 pounds, height of 5 feet 4 inches, and reported blood pressure of 190/110 with an appropriate size cuff. A chest x-ray showed the heart to be at the upper limits of normal size but otherwise unremarkable. An ECG showed left axis deviation. The left leg showed evidence of prior surgery and pigmentary changes from venous stasis. There were scars over the right ankle compatible with old healed ulcers.

At the comparison point, the individual had a recent history of vein ligation and stripping on the left. Physical findings revealed a weight of 214 pounds and a blood pressure reading of 180/118. There was induration and edema of the right leg and recently healed stasis ulcers. A comparison with present findings show that the individual's weight has increased 17 pounds, her diastolic blood pressure remains elevated to excess of 100, and there is still evidence of vascular disease.

The current physical findings do not demonstrate a decrease in severity of the impairments from those at the comparison point and therefore, medical improvement has not occurred. Exceptions to medical improvement have been considered and do not apply in this case. The individual continues to be disabled.

Q. Sample rationale Q - No MI, not severe impairment(s), but error exception applies - cessation

The following reports were used to determine disability at the comparison point of 12/26/07:

• Thomas Noonan, M.D., report of 11/25/07

• University Hospital, admission of 10/22/07 to 10/27/07, outpatient, report of 12/20/07

The following reports were used to decide whether disability continues:

• Charles Miller, M.D., report of 3/15/14

• David Morehead, M.D., Internist Pulmonary, consultative exam of 4/2/14

The individual was initially allowed disability benefits effective 6/21/07 because of chronic obstructive pulmonary disease and asthma. She was restricted to light work and Vocational Rule 202.09 was applied. Current findings were obtained because medical improvement is possible. The individual alleges that she is still unable to work because of emphysema and has not worked since her onset.

Currently, a report from the individual's treating physician states that the individual has chronic obstructive pulmonary disease and complains of shortness of breath. She also has been diagnosed with asthma, allergic sinusitis, and hay fever. These conditions are controlled with medications. A consultative exam was necessary to obtain ventilatory studies. A chest x-ray revealed mild chronic obstructive pulmonary disease. Pulmonary function studies showed FEV1, of 1.7 and MVV of 75. A physical exam showed a height of 5 feet 2 inches and weight of 120 pounds. There were decreased breath sounds; otherwise, the chest was clear to percussion and ausculation. The impairment does not meet or equal the level of severity described in the listings.

The individual was receiving treatment for asthma and COPD at the comparison point. She was hospitalized in October 2007 for an asthma attack. Ventilatory studies done during the admission showed a functional restriction to light work and the claim was allowed using a vocational rule. Review of the records demonstrates that the studies were done while the individual was in the acute phase of asthma. Wheezes and rales were noted and no bronchodilator was administered prior to testing. Documentation guidelines in effect at the CPD prohibit the use of ventilatory studies performed in the presence of bronchospasm. Outpatient records sent later as trailer material reveal that ventilatory testing was repeated in December 2007. These studies show an FEV1 of 1.9 and MVV of 84. Medical improvement has not occurred. However, the error exception applies since the individual was allowed using ventilatory studies performed in the presence of bronchospasm without the administration of bronchodilators and additional evidence that relates to the CPD shows that if that evidence had been considered in making the CPD, disability would not have been established.

The individual does not have any restrictions on standing, walking, or lifting due to her breathing impairment and her impairment is not severe. Therefore, the individual retains the capacity to do SGA.

The error exception of the MIRS applies, and the individual has the ability to perform SGA. Disability ceases April 2014 and benefits will terminate as of June 2014.

R. Sample rationale R - Failure to cooperate - cessation

The following reports were used for the comparison point decision of 8/07/08:

• Wadsworth Memorial Hospital, inpatient treatment, 5/21/08 to 7/12/08

• Gene Keller, M.D., report of 7/12/08

• The following evidence was used to determine if disability continues: Wadsworth Memorial Hospital, outpatient treatment, 8/18/08 to 12/8/12

The individual has been under a disability since 4/13/08 due to histiocytic lymphoma of the ileum that equaled the listing. Current evaluation is needed as medical improvement is possible. There has been no work since onset. The individual says he is still disabled because of stomach problems. He had chemotherapy and radiation therapy after his operation. Because he has ulcers, he must avoid certain foods.

The only treatment source given by the individual was Wadsworth Memorial Hospital. The Oncology Clinic notes indicate he had completed chemotherapy. He was last seen 12/8/12 at which time he was progressing satisfactorily. He weighed 170 with height of 6 feet. Lymph nodes were shotty and the liver was enlarged. Since no current medical evidence was available, a consultative examination was scheduled for February 10, 2014.

The individual failed to keep the consultative examination. He was contacted and another appointment was scheduled which he again failed to keep. On 3/1/14, the Field Office made contact with the individual. The need for current medical evidence and for his cooperation in going for a CE was explained. There was no indication of any mental impairment or other condition that would make him unable to cooperate. Since he agreed to keep a CE, another appointment was scheduled for 3/9/14. The individual did not keep the CE and the DDS was unable to contact him by telephone. On 3/5/14 written notice that failure to cooperate could result in termination was sent to the individual. He did not respond.

At the CPD, the individual had malignant lymphoma of the ileum with metastasis. The most recent available evidence from 12/8/12 indicates satisfactory progress. There is no current medical evidence available to determine if medical improvement has occurred and the individual has repeatedly failed to cooperate in efforts to obtain current medical evidence. Therefore, since there is failure to cooperate, a group II exception to medical improvement, disability is ceased 3/14, the month the individual was notified that failure to cooperate could result in termination of benefits. Disability will terminate 5/14.

S. Sample rationale S - MINE case - continuance

The following reports were used at the CPD:

• John Smith, M.D., report of 2/25/07

• General Hospital, inpatient treatment, 2/3/07 to 3/15/07

The following report was used to decide if disability continues:

John Smith, M.D., report of 4/30/14

The individual was found to be disabled beginning 2/3/07 due to Huntington's Chorea which met Listing 11.17. Medical improvement was not expected, but current review is required by law. The individual advises that he has not worked and there is no improvement in his impairment.

Contact with the current evidence source reveals that the individual is under the care of a physician. The treating physician confirmed the individual's statements and further stated that the individual's condition continues to deteriorate, there has been no treatment and none is planned.

The individual's impairment has shown no medical improvement and no exception applies; therefore, a continuance is appropriate.