The disability determination services (DDS) periodically conducts a continuing disability review (CDR) after an individual has been receiving disability benefits. The CDR will determine whether the individual continues to be disabled. The time frame and method (e.g., full CDR, deferment review, mailer process) for processing CDRs is based on the specific circumstances of each case. The goal of the CDR is to make the correct determination of continuance or cessation in a timely, accurate, and cost effective manner.

To adjudicate CDRs, the disability examiner (DE) does not use the 5-step sequential evaluation process used for initial and reconsideration claims. Instead, the DE uses an 8-step sequential evaluation process based on the MIRS. The MIRS compares the individual’s symptoms, signs, and laboratory findings at the time of the most recent favorable medical determination, which we call the comparison point decision (CPD), to the current symptoms, signs, and laboratory findings of the same medically determinable impairment(s) (MDI). If the individual’s MDI has improved or if an exception (DI 28020.000) to medical improvement (MI) applies, then we proceed through the later steps of the CDR sequential evaluation process. To review the CDR sequential evaluation process charts, see DI 28005.010B and DI 28005.025.

REMEMBER:

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  When an MDI is established at any point in time by evidence from an acceptable medical source (AMS), do not develop to establish that same MDI again during the CDR. Generally, the MDI is established in the CPD case file. For information on AMSs, see DI 22505.003.

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  The DE may use other medical sources that are not AMSs to evaluate the current severity of the MDI(s) and how it affects an adult’s ability to work or a child’s ability to function.

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  In certain medical improvement not expected (MINE) or MINE-equivalent cases, the DE may use non-medical evidence without new medical evidence to find that disability continues. For more information on MINE or MINE-equivalent cases, see DI 28040.125.

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  How recent the medical evidence must be depends on the type of case and the nature of each impairment. The development in a CDR case is different from that in an initial claim. Generally, in an initial claim, the DE develops sufficient evidence to determine whether the individual’s impairment(s) meets the definition of disability and if the individual is eligible for benefits. In a CDR case, the DE uses the 8-step sequential evaluation process to determine if the individual’s MDI(s) has had MI or if an exception applies.

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  The DE will make every reasonable effort to obtain necessary medical evidence from the individual’s medical source(s) prior to ordering a consultative examination (CE). For further discussion on reasonable effort, see DI 22505.001A.2.

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  The DE may stop development and process a continuance whenever the evidence in file is sufficient to make a continuance determination. However, prior to making a cessation determination, the DE must develop for all impairments and vocational issues.

The DE will usually have the CPD case file with the medical evidence used to establish, or continue, the individual’s disability. Therefore, for the CDR, the DE generally needs to obtain current medical evidence to make a determination as defined under the MIRS. However, depending on the impairment(s) in MINE or MINE-equivalent cases, the DE may not need current medical evidence.

When a CPD case file contains relevant evidence that documents the existence of an MDI, or a test score that may be needed in a future CDR, or a longitudinal history that documents severity of an MDI, the DDS must copy or scan relevant documents to the current CDR case file whether it is paper or electronic. For example, IQ test scores, x-ray results, pathology findings, cardiac tests, and operative reports may still be valid for future reviews. For instructions on adding relevant paper CPD evidence to the eCDR case file, see DI 81020.230.

During initial development of a CDR, the individual completes an SSA-454-BK, Continuing Disability Review Report. The individual lists medical sources who have treated or evaluated them, as well as any other evidence that will help the DE determine if the individual is still disabled.

The individual must:

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  inform the DE about or submit all evidence that relates to whether the individual is blind or disabled;

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  identify and inform the DE of their medical sources;

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  provide any evidence, already in the individual's possession, that is not contained in other medical records (e.g., a functional assessment paid for by a third party);

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  cooperate with the DE’s case development requests (e.g., to complete forms and provide information); and

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  cooperate with the DE’s request to attend a consultative examination (CE).

The DE develops a complete medical history covering at least 12 months preceding the date the individual signs the SSA-454. This development procedure differs from initial and reconsideration claims for which the DE develops medical history at least 12 months prior to the alleged onset date.

The DE will make every reasonable effort to obtain evidence from the individual’s medical sources. When the DE asks the individual to contact their medical sources to help the DDS get the medical evidence, the individual must do so or risk having benefits ceased due to failure to cooperate.

When an individual is known to a State, or other accredited, VR agency at the time of the CDR, contact the agency for a full report about the individual, including medical reports relating to the individual’s current medical status and other evidence pertinent to a determination. If evidence previously obtained from the agency (e.g., in connection with the initial adjudication) indicated the case was closed and the individual states the case has not been reopened, do not make further contact with the VR agency. Evidence obtained from the individual’s medical sources, together with evidence available through the VR agency, may be sufficient to permit a sound determination as to whether disability continues. For procedures on VR involvement “301” cases, refer to DI 28001.040.

If an individual is actively involved in VR-type services, clarify through the FO whether the “Ticket to Work” program is in use. If the individual is using a “ticket,” DDS may need to stop development and return the case to the FO for possible screen-out. See DI 13005.020, DI 55025.001, and DI 55025.010.

Do not make a clear-cut cessation (i.e., cessation without current medical evidence, on the basis that medical recovery is indicated by return to full-time work without medical restrictions) when VR services are continuing (DI 28030.035). When current medical evidence establishes MI and a present capacity for doing substantial gainful activity, find that disability ceases despite the fact that the individual may be an active participant in a State-sponsored VR program.

EXAMPLE: The DDS found the individual disabled based on multiple fractures and complications that indicated the disabling MDI would meet the 12-month duration requirement. When the medical diary came due, the evidence received at the time of the CDR established that the individual is enrolled in a two-year bookkeeping course under a State-sponsored VR program. The DDS obtained evidence from the VR agency that stated one year of schooling remained. The DDS then obtained current medical evidence that clearly established MI. Therefore, the DDS made a cessation determination.

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  DI 22501.002 Responsibilities for Case Development of Disability Claims

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  DI 22505.001 Medical and Nonmedical Evidence

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  DI 22505.003 Evidence from an Acceptable Medical Source (AMS)

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  DI 22505.006 Requesting Evidence – General

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  DI 22505.030 Obtaining Medical Evidence by Telephone

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  DI 28010.015 Comparison of Symptoms, Signs, and Laboratory Findings

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  DI 28030.035 Cessation Without Full Medical Development (Clear-Cut Cessations)

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  DI 28040.130 Development Guidelines for MINE or MINE-Equivalent Impairments

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  DI 28060.001 General - VR or Similar Program Participation

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  DI 81020.020 Electronic Case Development

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  DI 81020.065 Electronic Case Documentation