TN 14 (11-22)

DI 28005.030 Step-by-Step Discussion of the Title XVI Child Continuing Disability Review (CDR) Sequential Evaluation Process

CITATION

A. Introduction

The discussion in subsection DI 28005.030C is numbered to correspond to the summary chart in DI 28005.025.

B. Overview of Title XVI child assessment at CDR

1. For Title XVI disability purposes, a child is anyone under age 18

For Title XVI disability purposes, “Adult means a person who is age 18 or older. Child means a person who has not attained age 18” (20 CFR 416.902(c)).

2. Development

Follow the development guides in DI 28030.020. Do not focus development on a particular impairment(s). Although the medical improvement review standard (MIRS) sequence as it applies to title XVI children focuses first on the CPD impairment(s) and later on the current impairment(s), initiate development of all current evidence simultaneously.

See DI 28005.003 if the CPD was prior to August 22, 1996, and a disability redetermination may be required.

3. For Title XVI child CDRs, "equals" includes medically equals and functionally equals

For Title XVI child CDR cases, wherever the term “equals” (and related terms, e.g., “equaled”) appears without “medically” or “functionally” as a modifier, it includes both of those concepts.

NOTE: For evaluation purposes at step 2 of the Title XVI child CDR sequential evaluation process, functional equivalence is separated from meets or medically equals a listing. This is because functional equivalence does not represent a specific listed impairment, see DI 28005.030C.2. below for additional information.

4. Some Group I exceptions do not apply to Title XVI child CDRs

P.L. 104-193, enacted August 22, 1996, changed the medical improvement review standard (MIRS) exceptions that apply to Title XVI children.

The following Group I exceptions that are applicable to Title II CDR cases and adult Title XVI CDR cases do not apply to Title XVI child CDR cases:

  • Advances in Medical or Vocational Therapy or Technology (see DI 28020.100);

  • Substantial Gainful Activity (SGA) (applicable to Title II CDR cases only, see DI 28020.050); and

  • Vocational Therapy (see DI 28020.150).

5. 1619 Provisions Apply

SGA is not a reason for disability cessation for title XVI child CDR cases because of the 1619 provisions (see DI 28005.015B.)

C. The sequential evaluation steps for Title XVI child CDR cases

Follow the CDR evaluation process shown and summarized in the chart in DI 28005.025. There is a step-by-step discussion of the MIRS sequence for title XVI children in DI 28005.030. Use a flexible approach when conducting the CDR (DI 28005.005C) when appropriate. If evidence in a particular case clearly documents a continuance at a later step in the process, earlier steps may be skipped. Skip evaluation process steps as necessary to process a continuance (but not a cessation). Do not skip any step that could affect outcome, and do not routinely consider steps out of order.

1. Has there been medical improvement (MI)?

The first step in the sequential evaluation process for evaluating Title XVI child CDR cases is to determine whether MI has occurred, see DI 28010.015 for a definition of MI. If there has been no MI, we will find that disability continues unless one of the exceptions in DI 28020.250 through DI 28020.900 applies. If there has been medical improvement, the adjudicator will go to the next step in the sequential evaluation process.

Determine whether there has been MI in any impairment(s) the child had at the time of the comparison point decision (CPD), see DI 28010.015.

  1. a. 

    If there is no MI, consider whether a Group I or Group II exception applies. See DI 28020.001.

    • If no exception applies, find that disability continues.

    • If a Group I exception applies (see DI 28020.001B1), go to step 3.

    • If a Group II exception applies (see DI 28020.900), find that disability has ended. Group II exceptions may apply at any point in the CDR sequential evaluation process.

  2. b. 

    If MI has occurred, go to step 2.

2. Does the impairment(s) meet/equal the severity of the listing met/equaled at the CPD?

If there has been MI, consider whether the impairment(s) that we considered at the CPD still meets or equals the listing it met or equaled at that time. Consider the current severity of that impairment(s), and the same listing section and any subsections of that listing used to make that determination or decision as it was written at that time, even if it has since been revised or removed from the Listing of Impairments.

  •  

    Example 1: At the CPD, a child was 4-years old, and their hearing impairment showed average air conduction hearing threshold of 60 decibels. The hearing impairment met listing 102.10A. If the average air conduction hearing threshold was still 60 decibels at the CDR three years later, the impairment would not meet listing 102.10A or B.1 because the child has surpassed the age in the listing criteria for 102.10A (which applies for children from birth to age 5) and listing 102.10B requires average air conduction hearing threshold of 70 decibels or greater in the better ear.

    For listings that indicate a non-specific period of disability (see DI 28010.030A2.), do not consider the same criteria at the CDR that were applicable at the CPD if the child has surpassed the age requirement in the designated listing. For listings with different criteria for different ages, use the criteria applicable to the child’s age at the time of the CDR, not the CPD.

  •  

    Example 2: At the CPD, a child met listing 105.10, which indicates the need for supplemental daily enteral feeding via a gastrostomy for children who have not attained age 3. At CDR, the child is 4-years old and still requires daily enteral feeding via a gastrostomy. We would find the listing criteria for 105.10 is no longer met at CDR, as the child has surpassed the age requirement. Therefore, we find medical improvement has occurred at step 1 of Title XVI child CDR sequential evaluation, and we proceed to the next step in the evaluation process. We evaluate the residual impairment(s), considering criteria in 105.00H in the preamble criteria for the body system as the listing directs.

Does the impairment(s) meet/equal the severity of the listing met/equaled at the CPD?

  1. a. 

    If the CPD basis was meets or medically equals a listing, determine if the CPD impairment(s) still meets or medically equals the same listing as the listing appeared at the CPD. If the CPD basis was a functional equivalence, determine if the CPD impairment(s) still supports a finding of functional equivalence at the CDR. Find that disability continues if the impairment(s) still meets or equals the listing met or equaled at the CPD, UNLESS a Group I or Group II exception applies (see DI 28020.001).

    • If no exception applies, find that disability continues

    • If a Group I exception applies (see DI 28020.001B1), go to step 3.

    • If a Group II exception applies (see DI 28020.900), find that disability has ended. Group II exceptions may apply at any point in the CDR sequential evaluation process.

  2. b. 

    If the impairment(s) does not still meet or equal the listing met or equaled at the CPD, go to step 3.

  3. c. 

    If there is MI in the impairment(s) (step 1) and the child did not meet or equal a listing at CPD, go to step 3.

NOTE: See Social Security Ruling (SSR) 05-03p (in DI 28005.021) for how we apply the functional equivalence rules at this step and how we apply this step when the CPD was based on functional equivalence to the listings. The basis for evaluating functional equivalence changed effective January 2, 2001. Prior to that date, functional equivalence was based on functionally equaling a listed impairment. On or after January 2, 2001, functional equivalence is not based on a specific listing or a specific listed impairment; instead, it applies when a child has “marked” limitations in two domains of functioning or an “extreme” limitation in one domain. For additional information, see DI 25225.001

3. Is the child currently disabled?

If there has been MI, and the impairment(s) no longer meets or equals the severity of the listing it met or equaled at the time of the CPD, or if a Group I exception applies, consider whether the child is currently disabled under the rules in DI 25220.010 and DI 25225.001, taking into account all factors relevant to assessing impairment severity -- e.g., basic consideration (DI 25210.001 through DI 25210.040) and pain and other symptoms (DI 24501.021). Consider all impairment(s) the child now has, including any impairment(s) that existed but was not considered at the time of the CPD. The steps in determining current disability are summarized as follows:

  1. a. 

    Is the current impairment(s) severe? (DI 25220.005)

    • If the impairment(s) is not severe, find that disability has ended.

    • If the impairment(s) is severe, go to b.

  2. b. 

    Does the current impairment(s) meet or medically equal any current listing? (DI 25220.010)

    • If the impairment(s) meets or medically equals a current listing, find that disability continues.

    • If the impairment(s) does not meet or medically equal a current listing, go to c.

  3. c. 

    Does the current impairment(s) functionally equal the listings? (DI 25225.001)

    • If the impairment(s) functionally equals the listings, find that disability continues.

    • If the impairment(s) does not functionally equal the listings, find that disability has ended.

4. Completion of the SSA-538 (the Childhood Disability Evaluation Form or "CDEF"), or the Childhood Disability Evaluation (CDE)

a. Instructions for completing the SSA-538 or the CDE for Title XVI child CDR cases

Explain the CDR determination on the SSA-538 or the CDE for cases processed in the Electronic Claims Analysis Tool (eCAT) or in the Disability Case Processing System (DCPS). For additional information on completing these forms, see DI 25230.001 and DI 25230.005.

An SSA-538 or CDE is only required if the severe impairment(s) require a domain evaluation. There are certain scenarios where an SSA-416-UF may be used instead of the SSA-538 or the CDE, see DI 28005.030C4b below.

Conversely, there are times where two SSA-538 or CDE assessments may be necessary, see DI 28005.030C4c below for details.

b. When a SSA-538, CDEF or CDE is not necessary in a CDR

A CDEF or CDE is not necessary in all Title XVI child CDR cases processed in eCAT or DCPS. Consistent with the instructions in DI 25230.001B1, a CDE or CDEF is only required if the severe impairment(s) require a domain evaluation.

A CDEF or CDE is not necessary in CDRs in situations where a child’s impairment(s):

  • Meets, medically equals, or functionally equals a listing based on example (this may be for a current listing or if the CPD listing continues to be met), or

  • Demonstrates no MI, or

  • Are all considered not severe (i.e. no limitation) in all Domains.

If one of the three scenarios above are met and the CDE or CDEF are not completed, the medical consultant or psychological consultant must use the SSA-416-UF to document their full claim analysis in eCAT or DCPS.

c. When a second SSA-538, CDEF, or CDE is necessary

A second SSA-538, CDEF, or CDE is necessary when:

  • There is MI in the CPD impairment(s) and the impairment(s) does not meet, medically, or functionally equal the severity of the listing that was met or equaled at the CPD, and

  • There are new impairments that were not established at the CPD; then

Assess only the CPD impairments in the first SSA-538, CDEF, or CDE. This will be the "MIRS" version of the document. In the second SSA-538, CDEF, or CDE, assess the current severity of ALL impairments, not only comparing those that were established at the CPD.

If all current impairments were considered at the time of the CPD, a second CDEF or CDE is not necessary.

5. Subsequent Action

Follow DI 22520.001through DI 22520.020 for handling any additional evidence received after processing the decision.


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DI 28005.030 - Step-by-Step Discussion of the Title XVI Child Continuing Disability Review (CDR) Sequential Evaluation Process - 11/23/2022
Batch run: 11/23/2022
Rev:11/23/2022