TN 2 (07-15)

DI 25230.005 Documenting Disabled Child (DC) Determinations on Prescribed Forms

A. Impairments

List all established impairments considered in reaching a finding. Also list any condition(s) or impairment(s) recorded in the case record but not established. State clearly which impairments were actually established and which were not.

NOTE: The established impairments must be the same impairments shown on the SSA-831 or SSA-832.

B. Case Disposition

The consultant having overall responsibility for the findings must ensure that the disposition checked is the one that best describes the disability case findings, and that any required explanation is entered on the form. The dispositions are:

1. Not Severe

(Step 2 of Initial and Reconsideration claims, and Step 3 for CDR claims)

Complete this disposition for all cases in which the evidence shows no medically determinable impairment or an impairment or combination of impairments that is a slight abnormality or a combination of slight abnormalities that results in no more than minimal functional limitations.

Use the appropriate section on the prescribed form to explain the factors and evidence that support this finding.

2. Meets Listing

(Step 3 of Initial, Reconsideration, and CDR claims)

Complete this disposition if a child's impairment(s) meets the severity of a listing. Record the complete listing number and subsection. When applicable, complete additional sections on the prescribed form to show how a medical opinion(s) or inconsistent evidence was weighed, or to make clear any issue related to the finding. Although no explanation is required, the adjudicative team may use additional sections on the prescribed form to explain a finding of “meets.”

3. Medically Equals Listing

(At Step 3 of Initial, Reconsideration and CDR claims)

Complete this disposition if a child’s impairment(s) medically equals the severity of a listing. Document the complete listing number and subsection. Cite the medical findings that are at least equal to the significance of the findings specified in a listing. If the impairment is not a listed impairment, or the child has a combination of impairments, none of which meets or is medically equivalent to a listing, cite the medical findings that compare to findings in closely analogous listed impairments.

4. Functionally Equals the Listing

(At Step 3 of Initial, Reconsideration and CDR claims)

Complete this disposition if a child's impairment(s) results in marked limitations in two domains or an extreme limitation in one domain.

NOTE: A functional equals based on example does not require a CDE in eCAT.

5. Impairment or Combination of Impairments is Severe, But Does Not Meet, Medically Equal, or Functionally Equal the Listings

(At Step 3 of Initial, Reconsideration, and CDR claims)

Complete this disposition if a child's impairment(s) is severe, but is not of listing-level severity. Make this finding only after considering the factors and evidence, and evaluating and rating the domains.

6. Does Not Meet the Duration Requirement

Complete this disposition if an impairment of listing-level severity is not expected to (or did not) last 12 continuous months, or result in death. Explain in the appropriate section of the prescribed form the relevant factors and evidence that support the finding.

7. Other Disposition

Complete this disposition in all other case dispositions, e.g., whereabouts unknown, failure to cooperate, or continuing disability reviews.

Explain the relevant factors and evidence in the case record that support the finding in the appropriate section of the prescribed form.

C. Assessment of Functioning Throughout Sequential Evaluation

Consider the factors outlined in the prescribed form in evaluating a child's functioning, and determine the kinds of evidentiary issues that you must explain. The consultant having overall responsibility for the findings affirms that all relevant factors were considered. Any additional consultant(s) who provides input on the case must also sign and date the form.

D. Medical Signatures

1. “Consultant with Overall Responsibility”

The medical or psychological consultant who decides the disposition of the case can be:

  • A medical consultant who is a licensed physician, or

  • A medical consultant who is not a physician, i.e., a licensed optometrist, a licensed podiatrist, or a qualified speech-language pathologist, or

  • A psychological consultant

2. Who Can Decide the Disposition of a Case

Non-physician consultants are limited in the types of impairments that they may assess. This limitation affects who can be the consultant with overall responsibility in deciding the disposition of the case.

The table below illustrates who can decide the disposition of a case:

Scenario

Favorable

Overall Signature may be:

Partially Favorable or Unfavorable

Overall Signature must be:

Impairment or combination of impairments within a single discipline

  • Physician consultant

  • Non-physician consultant when the impairment is within the consultant’s discipline

  • Physician consultant

  • Non-physician consultant when the impairment is within the consultant’s discipline

Combination of impairments within multiple disciplines: Wholly favorable determination

  • Physician consultant

  • Non-physician consultant if all impairments are within non-physician disciplines

Note: Two signatures are not required in a wholly favorable determination, if all impairments are within the non-physician consultant’s discipline.

N/A

Impairments within multiple disciplines: Partially favorable or unfavorable determination

Physician

Physician

3. The Role of Non-Physician Consultants

a. If impairment or combination of impairments is within a single discipline

A non-physician consultant can be the consultant with overall responsibility for cases in which the only impairment(s) is within that consultant's discipline, whether the determination is favorable or unfavorable.

b. If the impairments are within multiple disciplines

A non-physician consultant can be the consultant with overall responsibility for:

  • fully favorable determinations based solely on an impairment(s) within that consultant's discipline, or

  • fully favorable determinations based on a combination of impairments within multiple non-physician disciplines.

4. The role of physician consultants

A physician must be the consultant with overall responsibility for:

  • fully favorable determinations in which there are impairments in multiple disciplines if the case cannot be allowed based solely on an impairment(s) within a non-physician consultant's discipline;

  • all unfavorable and partially favorable determinations involving impairments in multiple disciplines.

NOTE: A physician can also be the consultant with overall responsibility for determinations involving non-physician disciplines.

E. References

  • DI 24501.001 The Disability Determination Services (DDS) Disability Examiner (DE), Medical Consultant (MC), and Psychological Consultant (PC) Team

  • DI 26510.090 Completing SSA-831 Signature Information, Items 30-33” and 24501.002 Introduction to Medical Evaluation

  • DI 28005.030 The CDR Evaluation Process Title XVI Child Step-by-Step Discussion


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0425230005
DI 25230.005 - Documenting Disabled Child (DC) Determinations on Prescribed Forms - 08/27/2015
Batch run: 08/27/2015
Rev:08/27/2015