TN 5 (06-15)

DI 28005.001 Legal Standard for Determining if Disability Continues

A. Background of the medical improvement review standard (MIRS)

Under the continuing disability review (CDR) instructions in effect before October 9, 1984, adjudicators considered only the individual's current ability to engage in substantial gainful activity (SGA), and did not consider medical improvement (MI) in deciding if disability continued. The “Social Security Disability Benefits Reform Act of 1984” (P.L. 98-460), provided the MIRS in CDR cases.

B. Definition of MIRS

The MIRS refers to the legal standard for determining if disability continues in a CDR. For policy on when the MIRS does and does not apply, see DI 28005.001D. The MIRS includes consideration of both MI and the exceptions to MI.

C. Basic MIRS requirements

1. Basic MIRS description

a. Title II and adult Title XVI individual

We will determine that individuals receiving Title II and Adult Title XVI benefits are no longer disabled only if the evidence demonstrates either:

• MI related to the ability to work (or a Group I exception to MI) and ability to engage in SGA.

OR

• a Group II exception applies.

b. Title XVI child

We will determine that a Title XVI child is no longer disabled only if the evidence demonstrates either:

• MI (or a Group I exception to MI), and the child's impairment(s) no longer results in marked and severe functional limitations.

OR

• a Group II exception applies.

2. MIRS additional discussion

Regulations establish the CDR evaluation process. For more information on this process, see DI 28005.005.

The MIRS includes exceptions. The Group II exceptions do not require a finding of ability to engage in SGA, or, for Title XVI child, that the impairment(s) no longer results in marked and severe functional limitations. The Group II exceptions also do not require a finding of MI.

D. Application of MIRS

1. Cases when MIRS applies

MIRS applies in the following cases:

1. All CDRs after October 8, 1984.

2. The part of the determination or decision that finds that disability ended in all closed period determinations or decisions beginning with the adjudicative date of December 6, 1985.

3. Reopenings to a cessation or denial with an adjudicative date of October 8, 1984, or later, based on a revised determination or decision concerning the individual's disability, except as noted in DI 28005.001D.2.c., in this section.

2. Cases when MIRS does not apply

MIRS does not apply in the following cases:

1. Initial claims where the requirements for a closed period of disability are not met.

2. Appeals of partially favorable disability determinations. For example, the individual files for reconsideration, requesting an earlier onset date and, on reconsideration, the claim is denied.

3. Adverse reopenings to a later onset based on medical or non-medical issues, whether status as a recipient of disability benefits is preserved or not. For example, revised medical onset after date last insured may result in revision to a denial.

4. Adverse reopenings based on a revised determination or decision concerning insured status or other non-disability issues.

5. Age-18 and childhood disability redeterminations that are processed like CDRs, but evaluated using the rules for new applicants (except for the rules related to performance of SGA).

E. References

• DI 23570.001 Public Law 104-193 – General

• DI 25510.001 Closed Period

• DI 28005.003 Disability Redeterminations Required in Certain Cases Instead of a CDR

• DI 28020.000 Exceptions to Medical Improvement – Table of Contents

• DI 28020.900 Group II Exceptions