TN 11 (01-17)
DI 13005.055 Processing Possible Medical Recovery Issues Raised in the Field Office (FO)
The disability determination services (DDS) is responsible for the issue of medical recovery. The FO's should be alert to situations that indicate the occurrence of medical recovery. This section provides instructions for addressing the issues of possible medical recovery when the issues rise at the FO level. Situations in which medical recovery issues arise are when:
There is a report of medical recovery regardless of the diary type, and
Work activity by individuals with a medical improvement diary (MIE) diary scheduled in Title II cases.
NOTE: For medical continuing disability review (CDR) processing instructions for beneficiaries in the Ticket to Work program, see DI 55025.010.
B. Determining whether a MIE diary is scheduled
A key factor in determining whether medical recovery is the issues for the CDR is the FO’s ability to determine the establishment of an MIE diary. Several ways in which the FO may verify a MIE diary and the date it will mature, by completing the following:
1. FO has the folder
The best way to determine establishment of an MIE diary is to examine the most recent disability action filed in the folder. The FO must review the following:
Item 17 on the SSA-831 if this form displays the most recent disability decision, and
Item 23 on the SSA-832 or SSA-833 if this forms displays the most recent disability decision.
A date entry (month/year) indicates the establishment of a diary and the maturity date.
The coding determines the case by a medical improvement possible (MIP), medical improvement not expected (MINE) or MIE diary. Do not use the form SSA-899-U2 (Continuing Disability Review) as a reliable source for diary information. In this instance, use the disability action prior to the form SSA-899-U2 or a current Master Beneficiary Record (MBR) in order to determine the diary maturity date. When the FO has the folder and it involves medical recovery, send the folder and the development to the DDS unless otherwise directed by a development request.
2. FO does not have or cannot locate the folder
There are several ways to determine establishment of an MIE diary, by reviewing the following:
a. MBR or Supplemental Security Record (SSR)
The best source for determining the establishment of an MIE diary for a Title II claim is by viewing the MBR. Review the Periodic Review Data (PRV) field on the MBR for the schedule of the MIE diary, see SM 00505.275. If the Medical Reexamination Diary Date (MRED) field displays a date entry (month/year) and the Medical Diary Reason (MDR) field displays an alpha (A. through Z.), an MIE diary has been established. For Title XVI only claims, the SSR query in the Disability Information (DISB) field displays a code of A-Z in the MDR field when there is a MIE diary.
An “M” entry as an MIE indicator on the microfiche means a past schedule of an MIE diary for the beneficiary at some point during entitlement history. It does not indicate that there is a diary for MIE scheduled presently. Therefore, the microfiche is not nearly as reliable as the MBR for determining whether an MIE diary has been set and is currently running.
c. Award or continuance notice
When an MIE diary is established in connection with a disability action (either an initial or continuing disability action), the individual is told in the notice that there may be future contact to determine whether disability continues. At the time a continuing disability issue arises, the individual may bring the notice to the FO. While the notice is a good indicator that an MIE diary was set at some point, a subsequent action may have resulted in cancellation of that diary. Also, some early cases containing a “periodic review” (for example, MIP or MINE) diaries had the MIE paragraph generated on the award notices. Therefore, the FO should not rely on the notice as a conclusive indication of a current MIE diary.
d. The impairment
The DDS or Office of Disability Operations (ODO)/ Program Service Center (PSC)- Disability Processing Branch (DPB) establishes an MIE diary, since we expect certain impairments to improve. While some medical expertise is necessary to determine whether an MIE diary should be set, there are some impairments which are obviously of short duration and are highly likely to be reexamined. Examples of these impairments are fractures, burns and gunshot wounds.
If, for any reason, none of these MIE indicators is available and require an immediate decision as to how the case is to be processed, the FO will assume that an MIE diary has been set. By so doing, the FO development will be associated with the folder and it will then be determined whether a diary has actually been set. An assumption that there is no MIE diary scheduled could result in an unwarranted delay in initiating the CDR. When the FO does not have the claims folder, send all completed development to ODO/PSC-DPB unless otherwise directed by a development request.
C. Procedure for reported medical recovery and no work activity
When there is a report that the disabled individual has medically improved but has not worked:
Conduct a personal CDR interview,
Obtain an SSA-454-BK, and
Request the disabled individual to sign a SSA-827 see, DI 11005.057.
NOTE: For electronic case procedures, see DI 81010.000.
Some states require state releases to secure medical evidence; if needed, obtain the state release in accordance with regional policy. Accept any medical evidence the individual may offer but do not request medical evidence. If the folder is in the FO, complete the SSA-5526-U3 (Request For Assistance - Disability) if attached or an SSA-882 (FO Report of Field Review of Continuing Disability), checking the appropriate blocks in part II.C and use the form to transmit the material to the DDS. Do not suspend benefits. If the FO does not have the folder, forward the material to ODO/PSC-DPB by using an SSA-882.
NOTE: For cases in EDCS requiring a request for assistance, see DI 81010.100.
D. Procedure for reported medical recovery and full-time work for MIE diary scheduled (possible clear-cut cessation)
When we receive a report that an disabled individual for whom a MIE diary has been established (and for whom the scheduled CDR has not yet been conducted) returns to full-time work without medical restrictions and the individual no longer considers himself or herself disabled, conduct a CDR interview. In your development, include statements from the individual as to whether his or her impairment(s) has medically improved, whether he or she expects to be able to continue working, and whether he or she wishes to have medical evidence from the last 12 months included in the file before a decision on terminating benefits. Do not suspend benefits if any of the following applies:
the work is other than full time;
medical restrictions are alleged;
the individual alleges continuing disability or indicates that he or she does not expect to be able to continue working;
the individual does not acknowledge that medical improvement occurred as of the month he or she returned to work;
the individual wishes to have medical evidence from the last 12 months included in the file before a decision is made on termination of benefits;
the individual is receiving vocational rehabilitation services; or
the individual has a mental impairment.
Have the disabled individual sign the form and record the information on an SSA-795 (Statement of Claimant or Other Person). Obtain a statement from the individual's physician concerning the presence and absence of medical restrictions. A report of telephone contact with the physician is sufficient.
In a Title II only case, if the disabled individual states that the full-time work was performed in two or more calendar months, and the other conditions outlined above are met, give due process and suspend the Title II benefits. For purposes of this situation, do not consider the earnings and the duration of the work, provided the work is full-time. If the work began near the end of a month (even on the last day of the month) but the disabled individual works on a full-time basis, consider that month as one of the work months.
Suspension is not applicable in concurrent (Title II and Title XVI) and Title XVI only cases. If the disabled individual does not perform the work in all or part of two calendar months, do not suspend the benefits. For the Title XVI case, the FO must review the record to determine if the individual is eligible under Section 1619 provisions, see SI 02302.006. For Section1619 cases with alleged medical recovery, see DI 13005.018F.
The DDS has jurisdiction, since this is a decision regarding possible medical recovery. Therefore, transmit the folder(s) to the DDS if the folder is in the FO and attach the SSA-5526-U3 (Request For Assistance-Disability) or the SSA-882 (FO Report of Field Review Of Continuing Disability). If the folder is not in the FO, using an SSA-882 as a transmittal send the material to ODO/PSC-DPB. Complete Block 1.A. and Part III of the SSA-882. For handling of Section 1619 cases with alleged medical recovery, see DI 13005.018F.
If any of these criteria are not met, for example, medical improvement is not reported, work is not full-time, there are medical restrictions, or the individual considers himself or herself still disabled, follow DI 13005.055D in this section.
NOTE: In accordance with the instructions in this section, process military service cases involving military personnel released from a military hospital to active duty. The resumption of active duty equates to return to full-time work as discussed in this section.
E. MIE diary scheduled for work activity
When the FO learns that a Title II beneficiary has worked and the MIE diary is for review, we must start an immediate investigation, since the work activity indicates possible medical recovery. The FO will:
Conduct a CDR interview and obtain an SSA-454-BK, SSA-827's, and SSA-821-F4 or SSA-820-F4;
Make an SGA determination on the SSA-823 regarding the work activity from the SSA-821-F4 (Item 11) or the SSA-820-F4 (Item 14).
In Title XVI cases, review the medical folder to determine if the individual is eligible for Section 1619 benefits, see SI 02302.001.
Annotate the folder with the references to complete proper evaluation of the case. If the folder is in the FO, send it to the DDS using the SSA-5526-U3 if attached or an SSA-882. If the FO does not have the folder, send the SSA-454-BK along with any other documents to ODO/PSC-DPB using an SSA-882 completing Block II.D., except for Section 1619 cases, see DI 13005.018. Do not suspend benefits. To create an electronic CDR (eCDR) in EDCS, see DI 81010.230.
Occasionally, the FO may find the establishment of an MIE diary but a cessation clearly indicates work issues alone on Title II. This may occur when there is a delay in report of returning to work to the extent that the trial work period (TWP) is complete before SSA is aware of the work activity. More frequently, this situation may occur when a disabled individual beneficiary (DIB) is not entitled to a TWP and he or she returns to work but does not timely notify SSA of the work activity. Complete an SSA-454-BK, an SSA-827 and a SSA-821-F4 or SSA-820-F4, make an SGA determination on a SSA-823 and take the following actions:
1. FO has the folder
If the folder is in the FO, and a Title II substantial gainful activity (SGA) cessation is appropriate:
afford due process, see DI 13010.185 and
if the TWP and extended period of eligibility (EPE) provisions apply, suspend the Title II benefits by using the appropriate procedures.
In concurrent (Title II and Title XVI) folders, if a Title II SGA cessation is appropriate:
To determine eligibility for Section 1619 on a Title XVI case, see SI 02302.006. In concurrent cases, route both folders to the DDS for a Section 1619 CDR (any cessation decision would apply to both claims). Send the Title II only folders to the DDS for disabling impairment severity determination, if it is not already in the folder.
NOTE: If the 1980 Amendments do not apply, follow the guides for termination of benefits in Title II only cases and for concurrent claims, see DI 13010.100. Prepare the SSA-832 and SSA-833.
2. FO does not have the folder
If the FO does not have the folder, complete the SSA-454-BK, SSA-827, SSA-823 and SSA-821-F4 or SSA-820-F4, using a SSA-882 with Block II.D completed and route it to the ODO/PSC-DPB. Do not prepare an SSA-833 and do not suspend the benefits.
NOTE: These instructions also apply in those instances when the beneficiary reports medical improvement or medical recovery, but no MIE diary has been set and there is no work activity.