There may be scenarios involving both physical and mental impairments that were “present”
(i.e., “established” per DI 28010.001B.1.) at the CPD, and at CDR, there is medical improvement in one impairment but not the
other (e.g., improvement in a physical impairment but no MI in mental impairment).
If physical and mental impairments were established at the CPD and there is medical
improvement in only one impairment (e.g., improvement in a mental impairment) at the
CDR, a finding of no MI is not supported (unless the flexible approach is supported
– see DI 28005.005C). When both physical and mental impairments are involved, there must be no MI in
BOTH physical and mental impairments to support a continuance at step 3 for adults
and step 1 for children. The MC and PC must complete their assessments based on the
supported findings in medical evidence.
If the medical disposition is no MI, an MC/PC should complete a medical assessment
form, see B.2. in this section.
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•
If no MI is found for both physical and mental impairments, the MC will complete an
SSA-416 and the PC will complete an SSA-416 (or PRT).
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•
If no MI is found for one impairment, the MC and PC will complete the appropriate
assessment(s) form, and the adjudicator will continue with the sequential evaluation
process.
EXAMPLE:
Initial
allowance and CPD Information:
The initial allowance by an administrative law judge (ALJ) involved mental and physical
impairments. For physical, the ALJ assessed an RFC limiting the individual to standing
and walking 4 hours, avoiding unprotected heights. The ALJ also assessed a PRT/MRFC
finding moderate limitations in understanding, remembering and applying information
and in concentration persistence and pace, as well as mild limitation in interacting
with others and in adaptation. At the CPD, the MC completed an SSA-416 no MI assessment
and the PC completed a no MI PRT.
CDR
Information: At the CDR, the PC determines there is MI for the mental impairments and the MC determines
there is no MI for the physical impairments. The MC completes a SSA-416 citing evidence
to support no MI, stating that the prior RFC still applies. Noting that the prior
RFC still applies is policy compliant per DI 28015.005A. No other assessment needs to be created by the MC because there is no MI in the physical
impairments.
Because the PC finds MI at step 3 based on the MI in the mental impairment, they continue
to step 4 to evaluate if the MI relates to the ability to work. The PC completes a
PRT and MRFC, rating mild limitations in understanding, remembering and applying information
and in concentration persistence and pace, and no limitation in interacting with others
and in adaptation.