The EXR medical determination is a two-step process. The claimant requesting EXR must be under a disability and meet both of the following criteria to be entitled to reinstatement:

1. 1. 

   the current impairment(s) must be the “same as or related” to those impairments which formed the basis of the most recent disability entitlement; and

2. 2. 

   must be under a disability using the medical improvement review standard (MIRS) normally used in a continuing disability review (CDR). For more information on the CDR process, see DI 28005.005.

Follow standard procedures in DI 23005.000 for whereabouts unknown (WU) and DI 23007.000 for failure to cooperate (FTC), as necessary. Prepare the necessary personalized language for the notice the field office (FO) will issue.

Use the most recent favorable medical decision as the CPD when making EXR medical determinations. An intervening medical determination that the claimant had medically improved does not prevent a claimant from requesting EXR, as long as their previous entitlement terminated due to substantial gainful activity (SGA) for Title II or earned/unearned income for Title XVI. The disability determination services (DDS) must determine that the claimant is disabled under the MIRS in the month of the EXR request in order for them to qualify for EXR.

Likewise, a claimant can request EXR even if a previous EXR request was a denial. In cases where a previous EXR medical denial exists, the DDS should use the most recent favorable medical determination as the CPD for making the current EXR medical determination.

The first issue is to determine whether the current impairment(s) is the “same as or related to” to that which formed the basis of the most recent disability entitlement. Unless the evidence clearly indicates otherwise, determine that the alleged impairment(s) is the same as or related to the CPD impairment(s). Do not make a medical improvement determination if the final evidence clearly establishes that the claimant's current impairment(s) is not the same as or related to the prior impairment(s). Deny the EXR request per DI 28057.020B.

NOTE: While the file may indicate the current impairment(s) is the same as or related to the prior entitlement impairment(s), make that determination after all necessary medical development is complete.

After determining that the alleged impairment(s) is the same as or related to the CPD impairment, conduct a medical evaluation by applying the same MIRS and procedures used in continuing disability reviews, see subchapter DI 28010.000.

Take the following actions:

1. 1. 

   Determine a claimant is disabled when there is no medical improvement (MI) related to the ability to work, no exceptions to MI apply, and the claimant is not capable of performing SGA. Establish the proper month of entitlement (MOE) in the retroactive period for Title II cases. Refer to DI 28057.015E.

2. 2. 

   When a claimant has experienced MI related to the ability to work and is capable of engaging in SGA, or an exception to MI applies, determine the claimant is ineligible for EXR. Group I exceptions to MI require a finding that the claimant is capable of engaging in SGA before an unfavorable determination can be made.

3. 3. 

   To establish retroactive entitlement to Title II disability benefits, follow the same procedures used to establish an onset date for initial disability claims. Use:

   • •

     the same medical evidence used to determine that the impairment(s) is the same as or related to the CPD impairment(s) and that the claimant is under a disability; and

   • •

     the claimant’s allegation that they stopped performing SGA on the Forms SSA-820-BK or SSA-821-BK (Work Activity Report (Self-Employment) or (Work Activity Report (Employee)).

   The FO will indicate the month and year of the EXR request and record the SGA determination including the SGA and non-SGA months for the retroactive period for up to 12-months prior to the date of filing, or from the Benefit Termination Month (BTM), whichever is later on the Form SSA-823 (Report of SGA Determination).

4. 4. 

   Document approval and denial determinations per DI 28057.020. Prepare personalized language to attach to the formal denial notice. The FO and Office of Central Operations (OCO) Program Service Center (PSC) prepares and issues all award and denial notices related to EXR determinations.

NOTE: CDR screen-out policies do not apply to EXR cases.

When the medical determination is favorable, determine the appropriate MOE:

1. 1. 

   If you find that the claimant is under a disability and entitled to EXR in the month of filing for EXR or the following month, you may reinstate benefits retroactively for up to 12 months before the EXR request date, provided the claimant meets all factors of entitlement.

2. 2. 

   Review the “Remarks” section of the SSA-823 for the month and year of the EXR request and the SGA determination, which will indicate the earliest month of non-SGA in the retroactive period up to 12-months prior to the date of filing, or from the BTM, whichever is later. In addition, the FO documents the SSA-823 in remarks, “possible retroactivity exists prior to the month of filing.” If there is SGA in all months of the 12-month retroactive period and in the month of filing, the first possible MOE is the month following the month of filing. The FO documents the SSA-823 with the remarks, “SGA in month of filing. First possible MOE is MM/YY.”

3. 3. 

   Establish the MOE to reinstated benefits. Consider the same evidence used to determine that the claimant is under a disability based on the application of MIRS. The month of entitlement will be the following:

   • •

     the month of the EXR request,

   • •

     the month after the month of the request if there is SGA in the month of filing, or

   • •

     the first month in the 12-month retroactive period that all factors of entitlement are met, whichever is earliest.

     NOTE: We do not pay retroactive Title II disability benefits in EXR cases for any month before January 1, 2001.

4. 4. 

   The MOE can be no later than the month after the month of the EXR request.

5. 5. 

   The claimant cannot have engaged in SGA in the MOE.

6. 6. 

   The claimant must meet the MIRS requirements in the MOE.

7. 7. 

   The MOE cannot be before the BTM of the previous entitlement.

EXAMPLE: Mr. Smith was previously entitled to SSDI for back problems and their earlier entitlement terminated due to work in November 2013 (BTM). In June 2014, Mr. Smith has an accident that reinjures their back and they are unable to work. In September 2014, they decide to file for EXR. When the FO develops the case to send to the DDS, they provide a filing date of September 2014 and note the following SGA and non-SGA months in the retroactive period:

SGA Months: 12/13, 1/14, 2/14, 3/14, 5/14

Non-SGA Months: 4/14, 6/14, 7/14, 8/14, 9/14

The DDS decides that Mr. Smith meets the medical requirements of EXR in the month of filing (September 2014). They then look at the first non-SGA month in the retroactive period, which is April 2014. They determine that though Mr. Smith did not perform SGA, they did not meet the MIRS criteria in April 2014. They then look at the next non-SGA month (June 2014) and determine that Mr. Smith did meet the MIRS criteria in that month. Therefore, the MOE for EXR is June 2014.

When the medical determination is favorable, determine the appropriate month of eligibility:

1. 1. 

   Eligibility for reinstated benefits in Title XVI EXR cases begins with the month following the month of the EXR request. There is no retroactive eligibility to Title XVI payments under EXR.

2. 2. 

   We do not pay Title XVI disability benefits in EXR cases for any month before February 2001, the month after the first possible filing month for EXR.

When a claimant returns to work during the processing of the EXR request, contact the FO. Returning to SGA during the provisional payment period will result in termination of Title II provisional payments, and adjustment of Title XVI provisional payments. Normally, an EXR medical determination will still be necessary if the claimant did not engage in SGA in the EXR request filing month or the month after the month of filing. If the claimant engaged in SGA in the month of the EXR request and the following month, return the case file to the FO. The FO will issue a technical denial, per DI 13050.005A.2.