TN 1 (12-05)

DI 25235.006 Medical Diary Criteria for Low Birth Weight (LBW) Infants under Title XVI

A. Policy

1. General – Age 1 Diary Requirement

In general, the Act requires a Continuing Disability Review (CDR) 12 months after the birth of an infant whose LBW was material to the disability determination. Most often, this will be under listing 100.04. LBW is “material” if considering the LBW would result in a determination of “disabled,” and if not considering the LBW would result in a determination of “not disabled.”

NOTE: Although most LBW infants are born prematurely, premature birth is not required to satisfy listing 100.04.

2. Exception to Age 1 Diary Requirement

The Act does not require a CDR when the infant turns age 1 if:

  • at the time we initially find the infant disabled, we determine that the infant is expected to remain disabled at age 1, and

  • we schedule a CDR for a date that is after the infant attains 1 year of age.

3. Long-term Complications of LBW May Support a Later Diary Date

a. Long-term Complications

LBW infants may experience problems related to their prematurity and associated perinatal complications. The lower the infant’s birth weight, the greater is the likelihood and severity of problems. Such problems can require lengthy initial hospitalizations; are often followed by the need for re-hospitalization; and can result in long-term complications involving the infant’s growth, developmental patterns, physical health, and age-appropriate functioning. LBW infants who are additionally small for gestational age under SSA’s rules (i.e., the table in listing 100.04B) are also more likely to have long-term complications.

b. Later Diary Date

Evidence about such medical problems and complications may support a later diary date. It is not necessary to develop for such evidence if you already have enough information to allow the case. However, if such evidence is in the file, you must consider it when setting the CDR diary. Medical conditions that require a longer diary are discussed in DI 25235.006B.2.a.

4. When LBW Is Not Material to Determination

When LBW is not material to a finding of disability, set a MIE, MIP, or MINE diary, as appropriate, based on all evidence in file and clinical judgment regarding the probability and timing of medical improvement. If a MIE diary is applicable, assign Reason Code A or B, as appropriate, per DI 26525.025B.2.

B. Procedure – Setting Medical Diaries in LBW Cases

1. General Guidelines

a. The General Principles

Several medical factors support longer diaries, because they tend to be associated with long-term complications:

  • Lower birth weights

  • The types of medical problems discussed in DI 25235.006B.2.a.

  • Being small for gestational age under SSA’s rules (see the table in listing 100.04B)

b. When To Set Diary Date at Age 1

If it is expected that the infant will no longer be disabled when he or she attains age 1, set a MIE diary for age 1. Use MIE Reason Code D, per DI 26525.025B.2.

c. When To Set Later Diary Date

If it is expected that the infant will still be disabled when he/she attains age 1, set a MIE, MIP, or MINE diary for a later date, as appropriate, based on:

  • the evidence in the case record; and

  • clinical judgment regarding when it is expected that the infant will no longer be disabled; and

  • the specific criteria for setting later medical diaries in DI 25235.006B.2.

2. Specific Criteria for Setting Later Medical Diaries in LBW Cases

a. Medical Conditions That Usually Direct a Later Diary Date

For most LBW infants, the presence of one or more of these conditions directs a later diary date, because they tend to be associated with a poorer long-term prognosis. It is not necessary to develop for evidence of these conditions, but if the evidence is in file at adjudication, you must consider it in setting the CDR diary. See DI 25235.006B.1.b. and DI 25235.006B.1.c. for specific instructions for each weight range.

  • Cerebral white matter insult (periventricular leukomalacia, intraventricular hemorrhage (IVH) grade 3-4, ventriculomegaly)

  • Chronic lung disease of infancy (CLD), previously known as bronchopulmonary dysplasia, or BPD

  • Retinopathy of prematurity (ROP), stage 3 or greater

  • Necrotizing enterocolitis (NEC) requiring bowel resection surgery

  • Small for gestational age under our rules (i.e., see the table in listing 100.04B)

b. Diary Dates for Listing 100.04A

Follow the chart below to set minimum diary dates for infants who are found disabled under listing 100.04A (birth weight of less than 1200 grams). The DDS consultant may decide that longer diaries are appropriate in some cases.

CA = chronological age

Birth Weight

Diary Date

+ Cerebral white matter insult, BPD/CLD, ROP, or NEC

Diary Date

(1) Less than 500 grams

36 months CA

  

(2) At least 500 but less than 800 grams

24 months CA

+ One of these conditions =

36 months CA

(3) At least 800 but less than 1000 grams

18 months CA

+ One of these conditions =

30 months CA

+ Two of these conditions =

36 months CA

(4) At least 1000 but less than 1200 grams

12 months CA

+ One of these conditions =

24 months CA

+ Two of these conditions =

36 months CA

c. Diary Date for Listing 100.04B

Although these infants have higher birth weights than those described in listing 100.04A, they are small for gestational age under SSA’ rules, a condition that tends to be associated with a poor long-term prognosis. For infants found disabled under listing 100.04B (birth weight between 1250 grams – 2000 grams), set a minimum diary date at 24 months of chronological age. The DDS consultant may decide that longer diaries are appropriate in some cases.

See the table in listing 100.04B to determine “small for gestational age” under our rules.

Problems such as intraventricular hemorrhage and retinopathy of prematurity are less common in gestationally more mature infants. When they are present, however, take this information into account when setting the diary date.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0425235006
DI 25235.006 - Medical Diary Criteria for Low Birth Weight (LBW) Infants under Title XVI - 06/15/2015
Batch run: 06/15/2015
Rev:06/15/2015