DI DAL22505.010 Deferment Of Medical Development

See DI 22505.010

This supplement discusses potential medical deferment situations. The examples provided should not be viewed as rigid requirements but rather as guidelines around which judgment should be applied on an individual case basis.

A. Reasons for Deferment

Medical development is deferred when evidence at some point in the future is essential to assess the duration of disability and no current actions could reasonably resolve the issue. Deferment will usually involve one or both of the following situations:

  • The Listing of impairments or POMS sets a specific time frame for evaluating severity;

  • The condition is likely to improve, but current findings do not support a projection of severity or RFC specific enough to make a reasonable decision of allowance or denial.

Since most impairments are static or progressive, medical deferment is expected to be an exceptional situation rather than a route procedure.

Medical issues - The predictability of treatment response is a major consideration in deciding to defer. The more predictable the less need for deferment.

Adjudicative Issues - If the range of treatment outcomes would not substantially change the decision to allow or deny, the case should not be deferred. If the best recovery following an MI would still result in an allowance under medical/vocational considerations, deferment would not be necessary.

Administrative Issues - A claim would never be deferred to obtain evidence more than 12 months after onset of disability. The closer the condition is to meeting the duration requirement, the less likely it is to require deferred development.

B. Examples

1. When to Defer

  1. Post Myocardial Infarction - Unless a medical/vocational allowance is supported, the DDS will need to know whether the individual continues to have cardiac symptomatology three months following an infarct.

  2. Post Coronary Artery Bypass Surgery — Unless a medical/vocational allowance is indicated, the DDS will need to know the symptoms and clinical findings after the cardiac condition has stabilized, usually two to three months following surgery.

  3. Post CVA — Unless the claimant demonstrates unusually rapid recovery, evaluating the residuals following a CVA requires evidence more than three months following the acute event. This principle applies to other types of cerebral trauma, but does not apply to transient ischemic attacks.

  4. Acute Psychoses - When there is no past history and application is made shortly after the acute episode, evidence will generally be needed to describe the mental status after the condition has stabilized. This would generally be about one month following hospital discharge or 2-3 months following onset.

2. When Not to Defer

  1. Fractures — Unless significant complications or healing delays are indicated, most fractures will not require deferment to assess duration or severity. The DDS should base its decision on normal healing times and the degree of expected residuals.

  2. Laminectomy, Fusion and Other Surgeries — In most instances, surgery will improve function to the point that listing level severity is not met. Thus, when a claimant has a favorable vocational outlook at all exertional levels, the DDS would not need to defer development to resolve the specific maximum RFC attained following surgery.

  3. Abnormal Liver Function Studies — Generally an individual with severe liver disease will be receiving medical treatment. In the absence of medical history demonstrating chronic liver disease, a current finding of abnormal liver function studies would not require deferment to demonstrate persistent findings. The decision may be based on the expectation that the condition will substantially improve with treatment.

  4. Epilepsy — Seizure disorders will generally respond very rapidly to anticonvulsant treatments. It is not necessary to defer development when treatment has only recently been initiated.

C. Notice to Claimant When Medical Development Must be Delayed

When medical development must be delayed, the DDS should sent a notice to the claimant and/or his representative explaining the reason for the delay and when development will begin. The letter should be sent under the DDS letterhead. The following model letter may be used or modified to suit the individual State's needs. If modifications are made the letter should contain the following essential elements:

  1. An explanation of the 12-month duration requirement.

  2. The recency of onset.

  3. The month, day and year on or about which development will begin.

MODEL LETTER

The claim you filed for disability benefits with the Social Security Administration has been sent to the (State of) (Name of agency, etc.) for processing.

Our job is to decide whether you have a disability severe enough to qualify under the law. To be disabled for these programs you must be unable to work because of an impairment which has lasted or will last for at least 12 months.

Since (your impairment began) (you had an operation) so recently, we will need to know what your condition is as of (MM/DD/YY). No decision will be made on your claim until that information is received. We will contact you or your doctor on or about that date.

A copy of the notice should be put in the file, and another sent to the DO to serve as an update for their controls. For DO control and follow up purposes, it is important to show the month, day and year development is expected to begin.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0422505010DAL
DI DAL22505.010 - Deferment Of Medical Development - 07/09/2012
Batch run: 07/09/2012
Rev:07/09/2012