TN 2 (06-15)

DI 28010.055 Medical Improvement (MI) in the Continuing Disability Review (CDR) Evaluation Process When Drug Addiction or Alcoholism (DAA) Is Involved

Citations:

Public Law 104-121, Section 105 and 223(d)(2)(C) and 1614(a)(3)(J) of the Social Security Act, as amended;

SSR13-2p

A. Introduction to DAA and MI

In this section, we discuss the determination of whether the individual’s continuing disability is affected by DAA, and whether MI would occur if the individual were to stop using drugs or alcohol.

The disability examiner (DE) will make a DAA materiality determination only when:

  • Medical evidence from an acceptable medical source establishes that a claimant has a substance use disorder, and

  • The DE determines (using the 8-step CDR evaluation process shown in DI 28005.010) that disability continues considering all impairments, including DAA.

The DE next follows the 7-step process in DI 28005.045 for determining whether DAA is material.

B. MI with DAA involvement

1. DAA defined

DAA is a substance use disorder(s) as defined in the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association. In general, the DSM defines Substance Use Disorders as maladaptive patterns of substance use that lead to clinically significant impairment or distress. Exceptions to DAA include nicotine use disorder and caffeine-induced disorder.

2. Is DAA material?

We make a DAA materiality determination when we have medical evidence documenting the existence of a substance use disorder and the DE determines that the individual’s disability continues considering all impairments, including DAA.

To determine whether DAA is material, the DE must determine whether we would still find an individual disabled if he or she stopped using drugs or alcohol (See SSR-13-2p, Question 2). DAA is material to the determination of continuing disability if the individual would not meet our definition of disability if he or she were not using drugs or alcohol based on the 7-step process in DI 28005.045. DAA is not material if the individual would meet our definition of disability absent DAA. For scenarios of when DAA is material, see DI 90070.050C.3. For scenarios of when DAA is not material, see DI 90070.050C.4.

3. Definition of MI with DAA involvement

Medical improvement (MI) is any decrease that would occur in the medical severity of the impairment(s) (considered in the current determination of continuance), if the individual were to stop using drugs or alcohol. This requires the DE to exclude both the direct effects of DAA, and its impact on any other impairment(s).

4. Impairment(s) to consider in evaluating MI, absent DAA

Consider only the impairment(s) upon which the current (CDR) determination of continuance is based as the basis for finding MI. Use any changes (improvement) in symptoms, signs, or laboratory findings that would occur if DAA were to stop. Disregard minor changes that obviously do not increase physical or mental abilities.

C. Responsibility for DAA evaluation

1. DE referral to medical consultant/psychological consultant (MC/PC)

Not every CDR case involving DAA needs a note from an MC/PC discussing the MI issue. However, the DE should refer medical questions to an MC or a PC, as appropriate to determine the medical aspects of the DAA analysis, such as what limitations a claimant would have in the absence of DAA. (See SSR 13-2p, Question 13a).

2. MC/PC role

The MC/PC will prepare comments concerning:

  • changes in symptoms, signs, or laboratory findings that would occur in relationship to medical severity if DAA were to stop, and

  • his or her medical judgment on the issue of MI.

3. DE role

At the initial and reconsideration CDR levels of the administrative review process (except in disability hearings), a DE makes the finding of whether DAA is material to the determination of disability (See SSR 13-2p, Question 13a). The DE will assess the significance of the projected changes recorded by the MC/PC and his or her conclusion regarding MI, following the sequential evaluation process outlined in DI 28005.045.

D. Reviewing cases involving DAA

1. Basic approach to deciding MI in a case with DAA involvement

DEs will review several factors when deciding MI in a case with DAA involvement.

  1. Consider the symptoms, signs, and laboratory findings concerning all the impairments upon which the DE made the current determination of continuance.

  2. Based on the evidence in file and adjudicative judgment, consider the changes that would occur in the symptoms, signs, and laboratory findings concerning all the impairments if DAA were to stop.

  3. Identify any changes and their importance to medical severity under current rules for assessing severity (i.e., the current Listing of Impairments).

  4. Decide whether the changes reflect decreased medical severity of any single impairment upon which the DE found the current determination of continuance.

2. Consider history

Examiners must consider the history of evidence and DAA involvement.

  1. In determining what, if any, changes would occur if DAA were to stop, consider all of the evidence relevant to making a finding of improved or worsened function.

  2. Consider evidence of a period of abstinence, as long as it provides information as to what, if any, symptoms, signs, and laboratory findings remained after the acute effects of intoxication and withdrawal abated. (See SSR 12-2p, Question 9)

  3. When multiple mental impairments are involved, consideration of the longitudinal history may assist in determining the impact of one impairment upon the other(s) and which findings would remain if DAA were to stop.

  4. There may be cases when there is no medical basis for deciding whether a particular finding results from a substance use disorder or some other impairment(s) (upon which the current determination of continuance is based). In this circumstance, when evidence indicates the substance use disorder began after the other impairment(s), assume that particular finding results from the other impairment(s).

3. Evaluating MI in a case with DAA involvement

a. Medical basis

The MC/PC must have a medical basis for indicating that more than minor changes would occur if DAA were to stop. The MC/PC should base his or her medical opinion on the changes that would occur when the individual would achieve maximum recovery, without regard to the length of time needed for such maximum recovery.

b. Physical impairment and DAA

DAA can cause or exacerbate the effects of a physical impairment(s). In some cases, the impairment(s), and its effects, may resolve or improve in the absence of DAA.

We expect some physical impairments, such as alcoholic hepatitis or alcoholic cardiomyopathy, to improve with abstinence. The DE may consider medical opinions from treating and non-treating sources about the likely effects that abstinence may have on the physical impairment(s). Usually, evidence from a period of abstinence is the best evidence for determining whether a physical impairment(s) would improve to the point of non-disability. The period of abstinence should be relevant to the period we are considering in case (See SSR 13-2p, Question 6 b). This evidence need not always come from an acceptable medical source. We note these sources in DI 22505.001.

If we are evaluating whether an individual's work-related functioning would improve, we may rely on evidence from other medical sources, such as physician assistants or nurse practitioners, and other sources, such as family members, who are familiar with how the individual has functioned during a period of abstinence. (See SSR 13-2p, Question 6)

The MC/PC may use his or her knowledge and expertise to project improvement of a physical impairment(s). Such improvement includes the changes that would occur in the symptoms, signs, and laboratory findings for the substance use disorder if DAA were to stop. (See SSR 13-2p, 6 c iii)

  • The MC/PC may not be able to project whether there would be more than minor changes in the symptoms, signs, and laboratory findings for the physical impairment(s) if DAA were to stop.

  • The MC/PC could conclude that there would be MI in the substance use disorder, but no MI in the physical impairment(s).

  • The MC/PC should include in his or her findings an assessment of the changes that would occur for the substance use disorder if DAA were to stop.

If the MC/PC is unable to determine whether there would be any, minor, or more than minor changes in the impairment severity if DAA were to stop, he or she may advise the DE to use the current CDR assessment of physical impairment(s) to determine that disability continues.

c. Mental impairment and DAA

Many people with DAA have co-occurring mental disorders; that is, a mental disorder(s) diagnosed by an acceptable medical source in addition to the DAA. We do not know of any research data that we can use to predict reliably that any given claimant's co-occurring mental disorder would improve, or the extent to which it would improve, if the claimant were to stop using drugs or alcohol. (See SSR 13-2p, Question 7)

To support a finding that DAA is material, we must have evidence in the case record that establishes that an individual with a co-occurring mental disorder(s) would not be disabled in the absence of DAA. MC/PCs should not rely exclusively on their medical expertise and the nature of a claimant’s mental disorder to project improvement of a mental impairment(s). (See SSR 13-2p, Question 7b)

We may purchase a consultative exam (CE) in a case involving a co-occurring mental disorder(s). We will purchase CEs primarily to help establish whether an individual who has no treating source records has a mental disorder(s) in addition to DAA. For more information on purchasing CEs, see DI 22510.005.

We will find that DAA is not material to the determination of disability, and will find continuing disability, if the record is fully developed and the evidence does not establish that the individual's co-occurring mental disorder(s) would improve to the point of non-disability in the absence of DAA. (See SSR 13-2p, Question 7)

4. MI in “lost folder” or reconstructed cases

Find MI if:

  • The basis for the CDR continuance is “no MI” because the prior folder is not reconstructable, and

  • There is current medical evidence of a substance use disorder, and

  • There would be any decrease in the medical severity of the impairment(s) upon which the current determination of continuance is based if DAA were to stop.

5. MI when DAA not material or not considered at the comparison point decision (CPD)

If DAA was not material, or was not considered at the CPD and there is current evidence of a substance use disorder that is found not material, assess MI on the impairment(s) for which benefits were allowed or continued.

E. Examples of findings with DAA involvement

1. MI based on a skin condition

Current findings: The treatment records establish the existence of a severe substance use disorder that continues to be disabling. They also indicate a skin condition that imposes no current functional limitations.

If DAA were to stop: There would be changes (improvement) in the symptoms, signs, and laboratory findings for the substance use disorder, and no functional limitations would remain if DAA stopped. Therefore, DAA is material.

Decision: Find MI

2. No MI based on a liver disease

Current findings: The treatment records establish the existence of severe chronic liver disease that satisfies the criteria of listing 5.05F and a substance use disorder. They also indicate the individual stopped drinking six months ago.

If DAA were to stop: Although there may be some additional changes (improvement) in liver function, the MC projects that the liver disease would continue to satisfy the criteria of listing 5.05F. Therefore, DAA is not material.

Decision: Find no MI.

More scenarios of DAA materiality are located in DI 90070.050C.

F. References

  • DI 28005.010 The Continuing Disability Review (CDR) Evaluation Process Summary Chart for Title II and Adult Title XVI Individuals

  • DI 28005.040 Drug Addiction or Alcoholism (DAA) Material Continuing Disability Review (CDR) Evaluation Process for Title II and Adult Title XVI Individuals

  • DI 28035.020 Disability Determination Services (DDS) Reconstruction of Prior Folder

  • DI 90070.041 Evaluating Cases Involving Drug Addiction and Alcoholism (DAA) SSR 13-2p

  • DI 90070.050 Adjudicating a Claim Involving Drug Addiction or Alcoholism (DAA)

  • DI 90070.060 DAA Condition


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DI 28010.055 - Medical Improvement (MI) in the Continuing Disability Review (CDR) Evaluation Process When Drug Addiction or Alcoholism (DAA) Is Involved - 03/24/2017
Batch run: 03/28/2017
Rev:03/24/2017