TN 32 (03-08)

DI 23535.005 Field Office (FO) Responsibilities in Presumptive Disability/Presumptive Blindness (PD/PB) Cases

A. Identifying PD/PB cases

1. Basis for the PD/PB finding

a. FO PD/PB finding

FO findings are based on the individual’s allegations, which must be supported by:

  • Observations made during an interview that are consistent with the allegations; or

  • Contact with other sources that confirm the allegations, e.g., treating medical sources, parents, spouses, or other knowledgeable third parties.

b. No FO PD/PB finding

If the FO does not make a PD/PB finding, the DDS may make a PD/PB finding when additional evidence indicate it is appropriate.

2. Categories for PD/PB findings

The following chart lists the special categories in which the FO is authorized to make a PD/PB finding:

NO.

PD/PB CATEGORIES

1

Obsolete - Reserved for future use.

2

Amputation of a leg at the hip.

3

Allegation of total deafness; that is, no sound perception in either ear.

4

Allegation of total blindness; that is, no light perception in either eye.

5

Allegation of bed confinement and immobility without a wheelchair, walker, or crutches, due to a longstanding condition, excluding recent accident and recent surgery.

6

Allegation of stroke (cerebral vascular accident) more than 3 months in the past and continued marked difficulty in walking or using a hand or arm.

7

Allegation of cerebral palsy, muscular dystrophy or muscle atrophy, and marked difficulty in walking (e.g., the use of braces), speaking, or coordination of the hands or arms.

8

Obsolete - Reserved for future use.

9

Allegation of Down syndrome.

NOTE: Down syndrome is usually characterized by developmental delays and intellectual disability, and by abnormal physical findings such as diagnostic physical features (lateral upward slope of the eyes, extra skin folds between the eye and nose, protruded large tongue, short nose with a flat bridge, and frequently with small, abnormally aligned teeth); generalized low muscle tone; short arms and legs; and hands and feet that tend to be broad and flat. Fifty percent of individuals with Down syndrome have congenital heart disease. Individuals with Down syndrome may also have congenital bowel abnormalities, vision and hearing problems, or other medical conditions.

10

Allegation of severe mental deficiency made by another individual filing on behalf of a claimant who is at least 7 years of age. For example, a mother filing for benefits for her child states that the child attends (or attended) a special school, or special classes in school, because of mental deficiency or that the child is unable to attend any type of school (or if beyond school age, was unable to attend), and requires care and supervision of routine daily activities.

NOTE: This PD category pertains to individuals with intellectual disability or other cognitive impairment (e.g., autistic spectrum disorder) who are extremely limited in mental functioning such that they depend upon others for meeting personal care needs (e.g., toileting, eating, dressing, or bathing) to a degree that grossly exceeds age-appropriate dependence.

11

A child has not attained his or her first birthday and the birth certificate or other medical evidence shows a weight below 1200 grams (2 pounds, 10 ounces) at birth.

12

Symptomatic human immunodeficiency virus (HIV) infection or acquired immunodeficiency syndrome (AIDS) (see DI 11055.241). Form SSA-4814 or SSA-4815 is needed.

13

A child has not attained his or her first birthday and available medical evidence shows a gestational age (GA) at birth with the corresponding birth-weight indicated:

GA: 37-40 weeks
Weight at Birth: Less than 2000 grams (4 pounds, 6 ounces)

GA: 36 weeks
Weight at Birth: 1875 grams or less (4 pounds, 2 ounces)

GA: 35 weeks
Weight at Birth: 1700 grams or less (3 pounds, 12 ounces)

GA: 34 weeks
Weight at Birth: 1500 grams or less (3 pounds, 5 ounces)

GA: 33 weeks
Weight at Birth: At least 1200 grams, but no more than 1325 grams (2 pounds, 15 ounces)
For infants weighing under 1200 grams at birth, see category 11.

NOTE: GA is based upon the date of conception. If more than one GA is noted in the medical evidence, the FO forwards the case to the DDS for consideration of a PD finding.

14

A physician confirms by telephone or in a signed statement that an individual has a terminal illness with a life expectancy of 6 months or less; or a physician or knowledgeable hospice official (e.g., hospice coordinator, staff nurse, social worker, or medical records custodian) confirms that an individual is receiving hospice services because of a terminal illness. (For terminal illness procedures, see DI 23020.045 and DI 11005.601.)

NOTE: The term “hospice” refers to a program of palliative and supportive care for terminally ill persons. Such services may be provided in the home or in an inpatient facility. Under Federal guidelines, the hospice benefit is available to individuals who have been certified by a physician to be terminally ill. An individual is considered to be terminally ill if he or she has a medical prognosis that his or her life expectancy is 6 months or less.

15

Allegation of a spinal cord injury producing an inability to ambulate without the use of a walker or bilateral hand-held assistive devices for more than 2 weeks, with confirmation of such status from an appropriate medical professional as defined in DI 22505.003B.1.

16

Allegation of end stage renal disease (ESRD) requiring chronic dialysis and the file contains a completed CMS-2728-U3 (End Stage Renal Disease Medical Evidence Report-Medicare Entitlement and/or Patient Registration). (See HI 00801.233.)

17

Allegation of amyotrophic lateral sclerosis (ALS) known as Lou Gehrig’s disease.

B. FO Development of PD/PB cases

1. Completing non-medical development

The FO completes all necessary non-medical development as appropriate, e.g., income and resources and completes the SSA-3367, Presumptive page in Electronic Disability Collect System (EDCS) with the PD/PB category.

2. Flagging PD/PB cases

  1. For Certified Electronic Folders (CEFs), use the EDCS PD/PB flag with remarks as appropriate, i.e. ‘FO PD (or PB) finding’ in the ‘Notes’ field. (See DI 81010.080.)

  2. For EDCS exclusion cases with paper Modular Disability Folders (MDFs), the FO:

    • Attaches Form SSA-408 (Route Slip) with a note to “Expedite – FO PD (or PB) finding.”

3. Faxing Medical Evidence of Record (MER) in PD/PB cases

When MER is submitted with the claim, the FO faxes the documents into the CEF and alerts the DDS. Regional limits should be followed regarding page limits for FO faxing. For faxing instructions, see DI 81010.090.

C. References

FO instructions for determining and processing PD/PB cases are in:

  • Presumptive Disability and Presumptive Blindness Procedures (DI 11055.230)

  • PD and PB Cases Determined and Processed by the FO (DI 11055.240)

  • Processing Claims for Individuals with an Allegation of HIV Infection (DI 11055.241)

  • Emergency Advance Payments in Cases of Disability and Blindness (DI 11055.245)

  • Electronic Disability Guide (eDG) Procedures for the Electronic Process (DI 81000.000)


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DI 23535.005 - Field Office (FO) Responsibilities in Presumptive Disability/Presumptive Blindness (PD/PB) Cases - 08/14/2013
Batch run: 08/14/2013
Rev:08/14/2013