DI 25505.035 Medical Deferment Involving the Duration Requirement
Regulations — 20 CFR Appendix 1 to Subpart P of Part 404 – Listing of Impairments
CAUTION: Do not view the examples provided in this section as strict requirements of when you should and should not defer a claim. Apply adjudicative judgment on an individual case basis.
A. Determining the need for medical deferment
Medical deferment is necessary in claims where you need future medical evidence to assess the duration of disability. The predictability of a claimant’s response to treatment is a major consideration in deciding whether to defer medical development. For example, if the response to treatment is more predictable, such as treatment for a simple fracture, the case is less likely to require medical deferment.
REMINDER: Medical deferment is an exception to routine case processing because most impairments of a disabling level of severity are static or progressive in nature. Determining whether medical deferment is appropriate requires making a sound medical judgment based on the specific case facts.
B. Factors to consider when determining whether medical deferment is appropriate
Do not delay requests for non-medical information (activities of daily living (ADL), Work History Report, etc.) or development of evidence from the medical source(s) cited in the application or elsewhere, even though you may need to postpone final adjudication. Use good judgment when requesting ADLs in particular. If you request and receive ADLs immediately following a trauma, the ADLs may not give an accurate assessment of the response to treatment.
1. Recovery period
We characterize some impairments, such as a cerebrovascular accident (CVA) or a myocardial infarction (MI), as a major event followed by a period of stabilization and varying degrees of improvement. Therefore, a longitudinal clinical record covering a period of at least 3 months after the event is necessary to assess the medical severity and duration of the impairment(s).
Some impairments, such as certain cancers, require multimodal treatment (surgery, radiation, or chemotherapy) to provide a remedy. Therefore, a longitudinal clinical record may be necessary to assess treatment response. Consider each case on an individual basis, as therapy may vary greatly and have different effects on different claimants.
Make favorable determinations without medical deferment when it is evident from the medical and other evidence that the claimant has little or no chance of regaining significant function. If the best recovery following the major event or the treatment will still result in an allowance under medical or vocational considerations, then medical deferment is not necessary. For example, if a claimant had a CVA, with or without coma, and an acceptable medical source indicates that the claimant has disabling limitations with little or no chance of regaining significant function, you can make a favorable determination at any time before 3 months, without medical deferment.
2. Medical evidence after 12 months
Do not defer medical development to obtain evidence more than 12 months after the onset of disability.
3. Approaching end of duration period
An impairment(s) that is close to meeting the duration requirement is less likely to need medical deferment.
C. Examples of when medical deferment may be appropriate
Medical deferment may be necessary if:
a listing or other policy requires a specific time frame for evaluating severity;
an impairment(s) is likely to improve, but the current findings are not sufficient to make an informed projection of severity or residual functional capacity; or
the claimant will shortly undergo treatment that is expected to correct or significantly improve his or her impairment
The following impairments are examples of when medical deferment would likely be necessary.
Unless the claimant’s impairment(s) meets or medically equals a listing with current evidence, evaluate the claimant’s response to treatment after enough time has passed to allow a determination as to whether the treatment will achieve its intended effect. For example, in cases of tumors with distant metastases that are expected to respond to antineoplastic therapy, such as testicular and non-anaplastic thyroid cancers, you may need at least 3 months of longitudinal history after therapy starts to determine response to treatment.
2. Coronary artery bypass graft (CABG) surgery
Unless an allowance is indicated, you will need to know the claimant’s symptoms and clinical findings after his or her cardiac condition has stabilized, usually 3 months status post CABG.
3. Myocardial infarction (MI)
Unless an allowance is indicated, (i.e., need for emergent CABG, evidence of severe and ongoing heart failure, or evidence of severe ongoing dysrhythmias), you will need to know whether the claimant continues to have cardiac symptoms and clinical findings at least 3 months status post MI.
Exception: For an uncomplicated MI, follow-up evidence from the claimant’s medical source, generally several weeks status post MI, will be persuasive for a functional capacity assessment and the 3-month deferral period would not apply. See also, DI 24545.001B.3.
4. Drug therapy for cardiac impairment(s)
If the claimant has started new drug therapy and the response to treatment has not been established, you will need to obtain evidence 3 months following the event before evaluating the impairment; for example, beta-blocker therapy for dilated congestive cardiomyopathy.
5. Cerebrovascular accident (CVA)
Evaluate evidence of any residual impairment(s) at more than 3 months following a CVA, unless the claimant demonstrates an unusually rapid recovery. Do not medically defer the claim when an allowance is appropriate if the evidence clearly indicates little or no chance of recovery.
NOTE: Do not medically defer a claim for a transient ischemic attack (TIA). A TIA produces neurological deficits lasting no more than 24 hours and does not result in any significant residual neurological deficits.
6. Traumatic brain injury (TBI)
If evidence of a profound neurological impairment is not sufficient to permit a finding of disabled within 3 months post-injury, defer adjudication until there is enough evidence of impairment caused by cerebral trauma at least 3 months post-injury. If a finding of disabled is not possible at that time, defer adjudication and obtain evidence at least 6 months post-injury, which is when a severe mental impairment may become apparent.
7. First-time psychotic episodes
When there is no history of psychosis and the claimant applies for disability shortly after a first-time episode, you must obtain evidence describing the claimant’s mental status after the condition has stabilized. You need information about the level of functioning, usually at least 1 month following hospital discharge or at least 2 to 3 months after the initial psychotic episode, to determine if the claimant can return to his or her earlier level of functioning or if he or she has residual symptoms. For those who have a psychotic episode and recover relatively quickly to the pre-episode level of functioning without further episodes, a durational denial is appropriate.
D. Examples of when medical deferment may not be appropriate
The following impairments are examples of when medical deferment would likely be unnecessary. However, in some situations, medical deferment may still be appropriate.
Base the determination on normal healing times and the degree of expected residual impairment, unless there is indication of significant complications or healing delays (e.g., comminuted or non-union fractures). Most fractures do not require medical deferment to assess duration or severity.
It is not necessary to defer adjudication in every case involving stump complications; deferring the case should be the exception, rather than the rule. If there is progressive improvement, it may be reasonable to project severity or RFC without deferring the claim. When progress is delayed or there are complications, it may be necessary to hold the case until the next follow-up visit or until a reasonable projection of severity can be made, but there is no specific amount of time to defer a case. Consider each case on an individual basis, making a sound medical judgment based on the specific case facts.
3. Laminectomy, fusion, and other surgeries
Consider the preoperative pathology, operative findings, surgical procedure, and response to the surgery including reports on any postoperative complications. Do not defer medical development to resolve the specific maximum RFC attained following the initial surgical procedure when the claimant’s vocational outlook is favorable at all exertional levels. In most instances, surgery will improve function to the point that severity is not of listing level.
4. Percutaneous transluminal coronary angioplasty (PTCA)
PTCA stent procedures do not normally require medical deferment. In most cases, claimants may return to normal activities within a few days or weeks of the procedure.
5. Acute liver disease
There are several possible outcomes for a claimant with acute liver disease, including complete recovery, progression to chronic liver disease (active or inactive), or fulminant (acute) liver failure. Prothrombin time/INR, serum albumin, and bilirubin tests are measures of liver function. Do not defer a case of acute liver disease if PT/INR, serum albumin, or bilirubin tests have returned to normal levels. Note that these tests are not the same as liver enzymes, which, in severe chronic liver disease, may be normal.
Generally, seizure disorders respond readily to anticonvulsant treatments. In most cases, claimants with epilepsy who are under appropriate treatment are capable of engaging in SGA. You will not need to defer the majority of these cases.
7. Terminal illness (TERI) cases
We expect that TERI cases, which involve an allegation or an indication in the medical record that an impairment(s) is untreatable, will result in death. Medical deferment to assess the response to treatment or level of residual impairment is rarely applicable to TERI cases. In the rare instance when medical deferment may be necessary for a TERI case, obtain documented approval from a medical consultant (MC) and include it in the case record. For more information on the documentation required for medically deferring TERI cases, see DI 23020.045.