SSA - POMS: DI 28020.100 - Group I Exception - Advances in Medical or Vocational Therapy or Technology

A. Introduction to the advances in medical or vocational therapy or technology exception to medical improvement (MI)

Advances in medical or vocational therapy or technology are improvements in treatment or rehabilitative methods that have favorably affected the severity of the individual's impairment(s) or increased the individual’s ability to do basic work activities.

This exception applies when substantial evidence demonstrates that an individual has benefited from services that reflect advances in either medical or vocational therapy or technology. For the exception to apply, evidence must show the individual has benefited from medical advances or vocational advances, or both.

In many instances, an advanced medical therapy or technology will result in a decrease in impairment severity as shown by signs, symptoms, and laboratory findings. Therefore, in most situations when an individual received and benefited from advanced medical therapy or technology, the impairment(s) will improve and result in MI related to the ability to work at a step prior to this step 5 exception (e.g., MI at step 3 or MI related to the ability to work at step 4). Therefore, this exception will see very limited application.

For more information see instructions:

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DI 28010.015 Comparison of Symptoms, Signs, and Laboratory Findings When Evaluating Medical Improvement (MI)

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DI 28010.001 Definition and Overview of Medical Improvement (MI)

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DI 28015.001 Context and Scope - Relating MI to Ability to Work

B. When the advances in medical or vocational therapy or technology exception applies

Consider this exception if all of the following criteria are satisfied:

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MI has NOT occurred, or MI is NOT related to the ability to work;

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evidence shows that the individual has benefited from services that reflect advances in medical or vocational therapy or technology; and
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these advances have decreased the severity of the impairment(s) or increased the individual's is ability to do basic work activities.

C. How to apply the advances in medical therapy or technology exception

For the medical portion of this exception to apply, the therapy or technology must relate to the ability to work.

If the criteria in DI 28020.100B are met and the exception applies, provide a rationale in a SSA-5002 Report of Contact or a case note in the disability case processing system (DCPS) imaged to the disability determination explanation (DDE) explaining how and why the exception applies. After applying the exception, continue to the next appropriate step in the sequential evaluation process.

D. How to apply the advances in vocational therapy or technology exception

1. Procedure

Follow development and documentation procedures in DI 28020.150C.

When an individual is in a program with advances in vocational therapy or technology, the adjudicator will evaluate whether advances in vocational therapy or technology have favorably affected the severity of the individual's impairment(s) or their ability to do basic work activities.

If yes, apply the exception at step 5 of the adult continuing disability review (CDR) sequential evaluation process and proceed with the remaining steps in the sequential evaluation process.

If the evidence from the vocational therapy or technology does not indicate a favorable impact to the severity of the individual’s impairment(s) or their ability to complete basic work activities, do not apply the exception.

If it is unclear if the exception applies, the adjudicator must submit a detailed rationale and question to the Regional Office Center for Disability and Program Support to obtain guidance prior to applying the exception or processing a cessation. The rationale and question should outline information about the advanced vocational therapy or technology and why the adjudicator cannot determine if the exception applies (e.g., if there is a question about increased ability to complete basic work activities in the evidence received from the program).

If the exception applies, the adjudicator must proceed to step 6 of the adult CDR sequential evaluation process.

If a cessation is supported after applying the exception and following sequential evaluation, enter cessation code “02” for a Title II case or “51” for a Title XVI CDR case in Item 11 of the SSA-832 or SSA-833, see DI 28084.015B.3.a.

2. Evaluating activities performed in a program with advances in vocational therapy or technology

The adjudicator may use evidence of the physical or mental activities performed in a program with advances in vocational therapy or technology to evaluate function, see DI 28020.100D.2.b.

Occasionally, a program with advances in vocational therapy or technology may include work that is done for pay or profit as an aspect of the program. For certain beneficiaries, if part of the vocational therapy or rehabilitation program involved work for pay or profit, the adjudicator will not be able to consider the physical or mental activities performed in that work when evaluating function as evidence whether disability has ceased. Specifically, if a beneficiary has received Title II benefits for at least 24 months, the adjudicator cannot consider activities the beneficiary performed in work for pay or profit during the current period of entitlement based on disability in order to find that disability has ceased.

If the activities performed in the program (or work performed as part of the program) are inconsistent with other evidence, follow the instructions in DI 24501.016C.

a. Participation in work for pay or profit during a program with advances in vocational therapy or technology

If the individual engaged in a program with advances in vocational therapy or technology during disability entitlement that involved work for pay or profit during the program (i.e., substantial gainful activity (SGA) as defined in DI 10501.001, regardless of SGA earning level), the table in this section indicates when the activities performed in the work during the program may or may not be used as evidence to evaluate function.

The adjudicator may, however, still consider physical or mental activities performed during the program with advances in vocational therapy or technology, but NOT the activities in actual work that was performed for pay or profit when evaluating function and impairment severity. An adjudicator can consider those activities to find an individual’s disability continues, however.

When to Consider Activities Performed in Work During a Current Period of Disability Entitlement

Current Entitlement	Activities Performed in Work Support Conclusion Disability May Have Ended	Activities Performed in Work Support Conclusion Disability Continues
• Title II only or Title II/Title XVI concurrent beneficiary with disability entitlement period less than 24 months (DI 28030.026C.2.) • Title XVI only recipient (DI 28030.026D)* * Excludes Title XVI recipients currently eligible under 1619 or Title XVI recipients who have has been eligible under 1619 within the last 12 months, see DI 28075.600 and DI 28075.610.	Consider any activities the individual has performed in work for pay or profit during a current period of disability entitlement based on disability as evidence of function, along with medical and non-medical evidence. Apply the advances in vocational therapy exception and continue to the next step in the CDR sequential evaluation process, see DI 28005.015A.6.	Consider any activities the individual has performed in work for pay or profit during a current period of entitlement based on disability as evidence of function, along with medical and non-medical evidence. Do not apply the advances in vocational therapy exception. If a Group II exception does not apply, find that disability continues.
Title II only or Title II/Title XVI concurrent beneficiary with disability entitlement period of at least 24 months (DI 28030.026C.3.)	Do not consider any activities the individual has performed in work for pay or profit during a current period of entitlement based on disability as evidence of evidence of increased functional abilities that may result in a finding the individual is no longer disabled. The adjudicator may only consider activities in a vocational program that do NOT involve work done for pay or profit. ONLY apply the advances in vocational therapy exception if the activities in the program do NOT involve work for pay or profit after following the procedures in DI 28020.100D.1. If the advances in vocational therapy or technology applies, apply the advances in vocational therapy exception and continue to the next step in the CDR sequential evaluation process, see DI 28005.015A.6. If the advances in vocational therapy exception does not apply and a Group II exception does not apply, find that disability continues.	Consider any activities the individual has performed in work for pay or profit during a current period of entitlement based on disability as evidence of function, along with medical and non-medical evidence. Do not apply the advances in vocational therapy exception. If a Group II exception does not apply, find that disability continues.

Current Entitlement

Activities Performed in Work Support Conclusion Disability May Have Ended

Activities Performed in Work Support Conclusion Disability Continues

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Title II only or Title II/Title XVI concurrent beneficiary with disability entitlement period less than 24 months (DI 28030.026C.2.)
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Title XVI only recipient (DI 28030.026D)*

* Excludes Title XVI recipients currently eligible under 1619 or Title XVI recipients who have has been eligible under 1619 within the last 12 months, see DI 28075.600 and DI 28075.610.

Consider any activities the individual has performed in work for pay or profit during a current period of disability entitlement based on disability as evidence of function, along with medical and non-medical evidence.

Apply the advances in vocational therapy exception and continue to the next step in the CDR sequential evaluation process, see DI 28005.015A.6.

Consider any activities the individual has performed in work for pay or profit during a current period of entitlement based on disability as evidence of function, along with medical and non-medical evidence.

Do not apply the advances in vocational therapy exception. If a Group II exception does not apply, find that disability continues.

Title II only or Title II/Title XVI concurrent beneficiary with disability entitlement period of at least 24 months (DI 28030.026C.3.)

Do not consider any activities the individual has performed in work for pay or profit during a current period of entitlement based on disability as evidence of evidence of increased functional abilities that may result in a finding the individual is no longer disabled.

The adjudicator may only consider activities in a vocational program that do NOT involve work done for pay or profit.

ONLY apply the advances in vocational therapy exception if the activities in the program do NOT involve work for pay or profit after following the procedures in DI 28020.100D.1.

If the advances in vocational therapy or technology applies, apply the advances in vocational therapy exception and continue to the next step in the CDR sequential evaluation process, see DI 28005.015A.6.

If the advances in vocational therapy exception does not apply and a Group II exception does not apply, find that disability continues.

Consider any activities the individual has performed in work for pay or profit during a current period of entitlement based on disability as evidence of function, along with medical and non-medical evidence.

Do not apply the advances in vocational therapy exception.

If a Group II exception does not apply, find that disability continues.

b. Participation in vocational therapy program that does NOT involve the performance of work for pay or profit

If an individual engaged in a program with advances in vocational therapy or technology during disability entitlement that:

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favorably affected the severity of the individual’s impairment (i.e., may support conclusion that disability has ended) or,
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increased the individual's ability to do basic work activities but the individual did not perform any work for pay or profit in the program during the current period of entitlement based on disability, then:

The adjudicator may consider any activities performed in the therapy or technology program when evaluating the individual’s functional ability and the adjudicator may apply the advances in vocational therapy exception. In this scenario, apply the advances in vocational therapy exception and continue with sequential evaluation, see DI 28005.015A.6.

If activities performed in the vocational therapy or technology program support that an individual’s comparison point decision (CPD) impairment(s) has worsened or there is no MI (or no MI related to the ability to work), the adjudicator may use this as supporting evidence to find that disability continues. In this scenario, do not apply the advances in vocational therapy exception. If a Group II exception does not apply, find that disability continues.

E. Exclusions to the advances in medical or vocational therapy or technology exception

1. Exclusions to the advances in medical therapy or technology exception

This exception does not apply to the following cases:

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Title XVI cases where the recipient is currently eligible under section 1619 or when the beneficiary has been eligible under section 1619 within the last 12 months; or
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Title XVI child cases (as amended by PL 104-193, enacted August 22, 1996).

2. Exclusions to the advances in vocational therapy or technology exception

This exception does not apply to the following cases:

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Title XVI cases where the recipient is currently eligible under section 1619 or when the beneficiary has been eligible under section 1619 within the last 12 months.
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Title XVI child cases (as amended by PL 104-193, enacted August 22, 1996).
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Cases meeting all of the following criteria:
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  The individual’s impairment has improved or the individual’s ability to do basic work activities has increased due to an advancement in vocational therapy or vocational technology, and
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  The individual’s impairment(s) met or equaled a listing at the CPD, and
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  MI has occurred but MI is not related to the ability to work because the individual’s impairment(s) continues to meet or equal the CPD listing

F. Example - advances in vocational therapy exception applies

CPD: A Title II beneficiary was allowed at the CPD based on their anxiety based on marked limitations in interacting with others and adapting and managing oneself.

CDR: The individual’s activities of daily living and evidence from the individual’s primary medical source do not demonstrate medical improvement of the individual's anxiety. However, the individual participated in a vocational rehabilitation program and records are received from the vocational rehabilitation program. The individual underwent exposure therapy sessions using virtual reality software presenting different scenarios and cognitive-behavioral therapy during the vocational rehabilitation sessions.

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The exposure therapy took place in the office setting and included specific virtual reality situations that were triggers for the individual’s anxiety. During these sessions, the individual was under medical surveillance and spoke with the psychologist about the event demonstrated on the screen. The psychologist offered coping mechanisms in various scenarios.
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In addition to exposure therapy, the individual responded well to cognitive behavioral therapy. The cognitive behavioral therapy notes indicate the individual was better able to understand how their thoughts affected their actions and the individual was successful in re-framing negative thoughts and behaviors.
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The psychologist indicated that the exposure therapy assisted the individual in the office setting and allowed the individual to respond to hypothetical scenarios in a calm manner without triggering an anxiety episode.
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The psychologist noted successful completion of therapy and was confident in the individual’s ability to perform work in a setting with minimal interaction with the public, performing duties without strict demands or quotas.

Explanation: In this scenario, the individual received advanced rehabilitative methods, that increased their ability to do basic work activities. The adjudicator will apply the advances in vocational therapy exception and continue with the sequential evaluation process.

Social Security

Program Operations Manual System (POMS)

DI 28020.100 Group I Exception - Advances in Medical or Vocational Therapy or Technology