TN 2 (06-15)

DI 28010.015 Comparison of Symptoms, Signs, and Laboratory Findings

Citations:

20 CFR 404.1594(b)(1) 416.994(b)(2)(i), and 416.994a(c)

A. Reviewing medical improvement (MI) in symptoms, signs, and laboratory findings

1. Determining MI

Consider current symptoms, signs, or laboratory findings related to the comparison point decision (CPD) impairment(s) and identify changes or improvement as the basis for finding MI (decreased medical severity). For detailed information about symptoms, signs, or laboratory findings, see DI 24501.020.

Although the decrease in severity may be of any quantity or degree, we will disregard minor changes in the individual’s symptoms, signs, or laboratory findings that obviously do not represent MI and could not result in a finding that disability has ended. The MI determination must be based on improvements in the symptoms, signs, or laboratory findings associated with the individual’s documented CPD impairment(s).

NOTE: The wording concerning MI in the three relevant sections of the cited regulations is slightly different, but the substance and intent are the same.

2. Change in symptoms only

Adjudicators must consider whether signs or laboratory findings have worsened since the CPD. However, improvement in symptoms alone, without associated changes in signs or laboratory findings, may support an MI determination. For more information on the evaluation of symptoms, SSR 16-3p, “Titles II and XVI: Evaluation of Symptoms in Disability Claims.”

3. Referral to medical or psychological consultant (MC/PC)

Not every continuing disability review (CDR) case needs a note from an MC/PC discussing the MI issue. However, refer questions (on whether MI occurred) to a State or Federal agency MC/PC. The MC/PC will prepare comments concerning:

  • changes in symptoms, signs, or laboratory findings in relationship to medical severity, and

  • his or her opinion on the issue of MI.

B. Example of MI in bronchial asthma

At the time of the CPD, an individual with bronchial asthma had frequent attacks of wheezing. Examining physicians found physical findings and spirometry within normal limits between attacks. At the time of the CDR, the physician instituted effective therapy. Current medical evidence, by history, shows decreased frequency, severity, and duration of wheezing attacks. Current evidence does not show changes in physical findings or spirometry. Find MI.

C. Using symptoms, signs, and laboratory findings

1. Basic approach to deciding MI

  1. Consider the symptoms, signs, and laboratory findings, including any additional evidence received after the CPD, regarding the impairment(s) present at the time of the CPD.

  2. Consider current (CDR) symptoms, signs, and laboratory findings related to the same impairment(s).

  3. Identify changes in symptoms, signs, or laboratory findings, and evaluate their importance under medical severity according to current guidelines for assessing severity (e.g., the current Listing of Impairments, the evaluation of specific issues instructions in DI 24515.000, and the guidance on considering symptoms in 16-3p, “Titles II and XVI: Evaluation of Symptoms in Disability Claims.”

  4. Decide whether the changes reflect a decrease in medical severity. Note that a significant decrease in medical severity of any one of the impairments present at the time of the CPD shows MI.

2. Do not substitute judgment

Do not decide MI by formally assessing current severity, and then comparing current severity to the prior assessment made by the CPD adjudicator.

Avoid the use of such a process because, despite having no change in symptoms, signs, and laboratory findings, this could result in a finding of MI based on substitution of judgment.

Substitution of judgment example:

At CDR: The individual complains currently of back pain and is taking over-the-counter medications because he no longer has a regular doctor. He reports difficulty standing due to the pain, but is able to perform some light household chores. Exams show he walks with a slight limp on the right side. Recent x-rays show mild-moderate lumbar stenosis. Based on this evidence the current adjudicator prepares a light residual functional capacity (RFC) assessment. The individual’s benefits are ceased because the vocational rules indicate “not disabled”.

At CPD: The individual reported difficulty standing and walking, and was taking medicine prescribed by his pain management doctor. X-rays showed mild-moderate stenosis. The CPD adjudicator prepared an allowance based on a sedentary RFC due to back pain.

Discussion: In the example provided, the individual currently complains of back pain and difficulty standing and walking, and is taking pain medications (symptoms), he walks with a limp (signs), and x-rays (lab findings) are consistent with films from the CPD. The current adjudicator substituted judgment (a light RFC) for that of the CPD adjudicator (a sedentary RFC). There was no need for a current RFC assessment since the symptoms, signs and lab findings have not significantly changed since the CPD. The current adjudicator should have prepared a “no MI” determination.

3. Consider history

Consider all of the evidence relevant to a disability determination at each point in considering prior and current symptoms, signs, and laboratory findings; this ordinarily includes consideration of a 12-month medical history but may involve a different period, depending on the impairment involved. Do not focus on a particular day, i.e., the day of the CPD. For information on the 12-month developmental policy, see DI 28030.020E.

For example, adjudicators should view impairments like fractures with a narrower focus than neoplasms, which require longer timeframes to evaluate the success or failure of treatment. For information concerning impairments subject to exacerbations and remissions, see DI 28010.115

4. Inadequate CPD documentation

If the evidence from the CPD is available but is inadequate and does not permit a reasonable determination (based on symptoms, signs, or laboratory findings) as to whether medical severity (of the impairment(s) present at the time of the CPD) decreased, then:

  1. Do not find MI,

  2. Make sure current documentation is adequate for future CDRs,

  3. Find that disability continues (in the absence of an exception), and,

  4. Code such continuances “insufficient data to assess MI."

D. References


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0428010015
DI 28010.015 - Comparison of Symptoms, Signs, and Laboratory Findings - 03/25/2016
Batch run: 03/25/2016
Rev:03/25/2016