BASIC (10-01)

DI 13005.022 Overview of the CDR Process for MINE or MINE-equivalent Cases

A. Introduction

Cases having “medical improvement not expected” (MINE) medical reexamination diaries, sometimes referred to as “permanent impairment” cases, are a primary continuing disability review (CDR) workload category. These are cases in which the medical impairment is extremely severe, as determined on the basis of existing medical technology and /or our experience in administering the disability programs. These impairments do not improve over time, and more likely are progressive either by themselves or by reason of related complications. The likelihood of medical improvement so as to permit the individual to engage in substantial gainful activity is extremely remote.

Public Law (P.L.) 96-265 amended the Social Security Act, and required, in part, that cases involving permanent impairments be reviewed on a schedule to be determined by the Secretary (now Commissioner).

The review schedule for MINE cases is established in the Social Security Regulations as no more often than every 5 years and no less often than every 7 years.

A primary object of the MINE review procedure is to minimize inconvenience to the individual by structuring the review in a manner that is sensitive to the individual"s concerns and needs. Since these impairments are considered irreversible, development is geared toward assuring that the original medical documentation was thorough and fully supports the MINE impairment classification. Hence, the need for extensive current medical development is not anticipated.

The identification of what impairments are considered permanent and warrant a MINE medical reexamination diary has changed over time as new diagnostic procedures and new types of treatment are available. Social Security policy has responded to these advances, and to our experiences with prior CDRs.

There are cases in which anticipated medical improvement has not been realized. The result, in part, is that cases previously assigned medical improvement expected (MIE) or medical improvement possible (MIP) medical reexamination diaries may, in some instances, be considered "MINE-equivalent" cases for purposes of field office (FO) and Disability Determination Service (DDS) CDR processing.

For a complete discussion of medical reexamination diaries, see DI 13005.010 and DI 26525.020-26525.045. For a complete discussion of DDS MINE CDR processing, see DI 28040.000.

B. Process - FO Folder Review to Identify MINE or MINE-equivalent Cases

1. CDRs Covered by These Instructions

These instructions apply to all full medical CDRs, whether they are Title II-only, concurrent Title II/XVI or Title XVI-only cases. They apply whether the CDR is the result of processing a CDR mailer (SSA-455 or SSA-455-OCR-SM), or was alerted in any of the direct release processes.

2. Why the MINE or MINE-equivalent Instructions Were Created

The current methods for alerting MINE CDRs to the field differ from the prior routing described in DI 28040.005A. Processing centers (PCs) no longer do medical folder reviews of MINE cases, and no longer route MINE cases requiring a CDR directly to the servicing DDS. This results in MINE diary cases being alerted to the FO instead of the DDS.

In addition, in some cases with medical improvement expected (MIE) or medical improvement possible (MIP) medical diary reasons, review of the claims folder, the mailer responses and/or information obtained by the FO prior to the CDR interview, indicates that the beneficiary has a very severe impairment. Just as importantly, medical diary criteria have been redefined, such that some cases with MIE or MIP diaries now meet the MINE diary criteria.

Finally, some cases are alerted that have incorrect or no diary information on the MBR and/or SSR.

Most importantly, these instructions were created to eliminate the FO SSA-454-BK interview where such interview is not necessary for the DDS to do sufficient development of current evidence to make the CDR determination.

C. Procedure - Screening Cases for MINE or MINE-equivalent Processing

1. Complete DI 13005.020 Folder Review and Screen Out Processing

Before determining whether MINE or MINE-equivalent processing is appropriate, the FO will have reviewed the claims folder to determine that the comparison point decision (CPD) and supporting medical evidence are in the folder, and that no other screen out conditions apply.

What and where is the CPD? - The comparison point decision is the most recent prior favorable disability determination. This may be the favorable determination or decision on the initial application for benefits or on a subsequent CDR. It may be a Disability Determination Service (DDS) determination, a Disability Hearing Officer determination, or a decision issued by the Office of Disability Adjudication and Review (ODAR) or by a Federal Court. For a discussion of CPD from the DDS perspective, see DI 28010.105.

In every case, the CPD findings should be reflected on a SSA-831-U3 (initial claims, all titles), SSA-832-C3/U3 (Title XVI CDRs) and/or SSA-833-C3/U3 (Title II CDRs). The DDS makes its determinations on the forms. If ODAR issues a multi-page decision, subsequently a SSA-831-U3, SSA-832-C3/U3 and/or SSA-833-C3/U3 is prepared to reflect the paper decision. This form should be prong-filed on the left side of the brown claims folder or the Yellow (Front) section of a Modular Disability Folder (MDF), but may be drop-filed in the folder. The form includes key identifying information, the onset of disability, the basis for the favorable determination or decision, the medical reexamination diary type (MIE, MIP, or MINE) and diary date information, and the date of the determination. The determination often describes the medical evidence that was considered in making the determination.

The medical evidence that was used to make the CPD is prong-filed on the right side of the brown folder or the Yellow (Back) section of a MDF, but may be drop-filed in the folder.

For a thorough description of the SSA-831-U3, see DI 27015.000 Medical diary type and date information is in item 17 of the SSA-831-U3.

For a thorough description of the SSA-832-C3/U3, see DI 28085.000 Medical diary type and date information is in item 23 of the SSA-832-C3/U3 and is described in DI 28085.023.

For a thorough description of the SSA-833-C3/U3, see DI 28086.000 Medical diary type and date information is in item 23 of the SSA-833-C3/U3 and is described in DI 28086.023.

For a thorough discussion of the MDF, see DI 70005.005.

2. Review First Before the SSA-454-BK Contact and Interview

The FOs should review the claims folders before the notice of CDR and SSA-454-BK package is sent, because it is expected that many of these cases can be processed without a FO interview under the "MINE or MINE-equivalent" procedures.

Once a SSA-454-BK interview/contact has been initiated, the MINE or MINE-equivalent procedures are no longer applicable and the interview must be completed.

3. Identifying MINE or MINE-equivalent Cases

In order to reduce the FO work burden and to facilitate completion of a CDR on these cases, the FO is authorized to route the CDR, without a CDR interview and completed SSA-454 package, to the DDS to invoke the MINE procedures in DI 28040.000 if:

DIARY/IMPAIRMENT
REQUIREMENTS

EXCEPTIONS

MINE CASES - Review of the most recent prior SSA-831, SSA-832, or SSA-833 (all versions) in the claims file shows that a MINE/5 or 7-year diary was established on the case.

MINE EQUIVALENT CASES - A MIE or MIP diary was set, but the case involves a very severe impairment which could be considered a permanent impairment in terms of duration of the condition and the unlikelihood that medical improvement will occur (i.e., total deafness; total blindness; cases involving amputation of more than one limb, amputation of a leg at the hip, or amputation as a consequence of diabetes; a longstanding condition which has resulted in bed confinement or the need for a wheelchair, walker or crutches; and human immunodeficiency virus (HIV) infection, etc.).

Do not invoke this process if information (including answers to questions on an SSA-455 CDR mailer) received since the date of the most recent SSA-831, SSA-832 or SSA-833 (all versions), show 1 or more of the following:

A report of medical improvement by the beneficiary or a third party;

A report that a physician has told the beneficiary he or she can work;

The beneficiary has attended school or received vocational training/services;

The beneficiary has performed SGA in the last 3 years (SEQY query mandatory);

The CPD medical evidence is not in the folder and efforts to obtain it have not been successful;

The FO has initiated the CDR interview.

4. FO Actions Upon Identifying a MINE or MINE-equivalent Case

  1. Do not send the notice of CDR or the SSA-454-BK interview.

  2. Instead, prepare a SSA-5002 Report of Contact to the DDS explaining the basis for the FO"s conclusion that the case should be processed under the DI 28040.000 MINE procedures.

  3. Prong-file the SSA-5002 in the claims file. Include a reference to these instructions.

  4. Enter "MINE or MINE-equivalent CDR case-process per DI 28040.000." on the route slip when sending the claim file to the DDS.

  5. Clear the system case controls to reflect the referral of a CDR to the servicing DDS.

5. DDS Returns the MINE or MINE-equivalent Referral to the FO for a Full SSA-454-BK Interview

The DDS may determine that the case can not be processed under the MINE procedures in DI 28040.000 and must be returned for a full CDR interview and/or other development (see DI 13005.105-DI 13005.115, and DI 28040.205-DI 28040.215). In particular, the DDS may not agree with the identification of a case as a MINE-equivalent case. If this occurs, the FO should proceed with the CDR interview in accordance with DI 13005.025, and complete any necessary development.


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DI 13005.022 - Overview of the CDR Process for MINE or MINE-equivalent Cases - 09/06/2012
Batch run: 09/06/2012
Rev:09/06/2012