Effective Dates: 05/08/2023 - Present Previous | Next

TN 9 (05-23)

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

A. Introduction to DAA and how it is evaluated in a CDR

1. DAA defined

DAA is a substance use disorder(s) (SUD) defined in the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association. We generally define an SUD based on diagnostic criteria in the DSM, as a maladaptive or problematic pattern of substance use that leads to clinically significant impairment or distress, see SSR 13-2p. For our evaluation purposes, we do not consider nicotine-use disorder or caffeine-induced disorder to be DAA.

2. When is a DAA materiality determination needed in a CDR?

We make a DAA materiality determination when all of the following criteria are met:

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    The adjudicator determines that the individual’s disability continues considering all impairments, including DAA, and

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    Medical evidence from an acceptable medical source establishes a medically determinable impairment of a SUD.

If the above criteria are met, the adjudicator must determine whether we would still find the individual disabled if the individual 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 be disabled under our rules if they were not using drugs or alcohol. DAA is not material if the individual would still demonstrate continued disability regardless of whether they are using drugs or alcohol.

3. Overview of sequential evaluation

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 adjudicator will make a DAA materiality determination only when:

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    Medical evidence from an acceptable medical source establishes that an individual has a medically determinable SUD and

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    The adjudicator determines (using the 8-step CDR sequential evaluation process shown in DI 28005.010 for Title II or adult Title XVI CDR cases, or the 3-step CDR sequential evaluation process shown in DI 28005.025 for Title XVI child CDR cases) that disability continues considering all impairments, including DAA.

If the adjudicator determines that disability continues, then the adjudicator must follow an additional evaluation process to determine whether DAA is material. This additional evaluation process is described in DI 28005.045 for Title II and adult Title XVI CDR cases, and DI 28005.050 for Title XVI child CDR cases.

NOTE: We do not make a determination regarding materiality if an individual has a history of DAA that is not relevant to the CDR period.

B. MI with DAA involvement

1. Definition of MI with DAA involvement

In the context of evaluating MI when DAA is involved, 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 adjudicator to exclude both the direct effects of DAA, and its impact on any other impairment(s).

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

Consider the impairment(s) that support the current (CDR) continuance determination when evaluating MI if the individual were to stop using drugs or alcohol in the CDR DAA steps discussed in DI 28005.045B and DI 28005.050B. Use any changes (improvement) in symptoms, signs, or laboratory findings that would occur if DAA were to stop. Disregard minor changes that would not obviously increase physical or mental abilities.

C. Adjudicator and medical consultant/psychological consultant (MC/PC) roles for DAA evaluation

Although the adjudicator determines whether DAA is material, the MC/PC is responsible for determining 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.)

1. Adjudicator role

At the initial and reconsideration CDR levels of the administrative review process (except in disability hearings before a Disability Hearing Officer), an adjudicator makes the finding of whether DAA is material to the determination of disability.

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    The adjudicator will evaluate the MC/PC’s projection of what limitations, if any, would remain if the individual were to stop using drugs/alcohol. The adjudicator may return the case to the MC/PC for additional input specific to the analysis of DAA and projected MI to make the determination whether DAA is material or is not material.

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    The adjudicator must follow the sequential evaluation process outlined in DI 28005.040 for Title II and adult Title XVI CDR cases and DI 28005.050B for Title XVI child CDR cases.

2. MC/PC role

The MC/PC must prepare comments concerning:

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    Projected changes in symptoms, signs, or laboratory findings that would occur in relationship to medical severity if substance use were to stop, or

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    If the MC/PC cannot project what changes would occur or what limitations would remain if the individual stopped using drugs or alcohol, the MC/PC should record findings to that effect.

The MC/PC must prepare their comments and analysis about DAA in an SSA-416; see DI 24501.006C. The comments should address relevant changes, such as specific aspects of the RFC that may be affected.

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 their medical evaluation of the changes that would occur when the individual would achieve maximum recovery, without regard to the length of time needed for such maximum recovery.

NOTE: An MC/PC is not required to provide a DAA analysis or comments for every case involving DAA or an SUD, but the MC/PC must provide comments when the adjudicator has specific medical questions to determine DAA materiality.

D. Review and evaluation of cases involving DAA

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

Adjudicators must review several factors when evaluating MI in a case with DAA involvement.

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    Consider the symptoms, signs, and laboratory findings concerning all the impairments upon which the adjudicator found the current continuance determination (with the effects of DAA).

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    Consider medical history and DAA involvement, see DI 28010.055D.2. below.

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

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

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    Decide whether the projected changes reflect decreased medical severity of any single impairment upon which the adjudicator based the current determination of continuance.

2. Consider history

Consider the history of evidence and DAA involvement.

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    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.

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    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 13-2p, Question 9)

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    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.

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    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 SUD began after the other impairment(s), assume that particular finding results from the other impairment(s).

3. Specific considerations for physical and mental impairments when evaluating MI in a case with DAA involvement

a. 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 adjudicator may consider statements from medical 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 the case; see SSR 13-2p, Question 6 b. This evidence may come from an acceptable medical source (AMS) or a non-acceptable medical source; see DI 22505.003. If we are evaluating whether an individual's work-related functioning would improve, we may rely on evidence from other non-acceptable medical sources, such as licensed mental health counselors, 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 their 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)

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    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.

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    For purposes of evaluating the effect of DAA on a finding about whether there has been MI in the physical impairment, only those impairments from the time of the CPD are relevant.

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

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    The MC/PC should include in their 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, they may advise the adjudicator to use the current CDR assessment of physical impairment(s) to determine that disability continues.

b. Mental impairment and DAA

Many people with DAA have co-occurring mental disorders; that is, a mental disorder(s) diagnosed by an AMS in addition to the DAA. We do not know of any research data that we can use to predict reliably that any given individual's co-occurring mental disorder would improve, or the extent to which it would improve if the individual 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 cannot rely exclusively on their medical expertise and the nature of an individual'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 medical source records has a mental disorder(s) in addition to DAA. For more information on purchasing CEs, see DI 22510.005.

We must find that DAA is not material to the determination of disability, and must 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. Evaluating DAA in lost folder or reconstructed cases

Under the MIRS, the adjudicator cannot determine whether medical improvement has occurred for CDR review without the comparison point decision (CPD) folder or medical evidence. If the adjudicator is unable to locate the appropriate CPD folder or reconstruct the medical evidence, the adjudicator cannot evaluate MI or MI related steps (meaning the adjudicator cannot evaluate steps 3 through 5 of the Title II and adult Title XVI CDR sequential evaluation process in DI 28005.015A, or steps 1 and 2 of the Title XVI child CDR sequential evaluation process in DI 28005.030C). If reconstruction of the folder is not possible, the adjudicator will process a continuance, following procedures in DI 28035.025.

However, if the CDR determination is projected to be a continuance based on the inability to reconstruct pertinent evidence from a lost CPD folder (see DI 28035.020) but the following DAA criteria apply:

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

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    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, then:

The adjudicator must process a cessation based on the current CDR impairment(s) and the DAA material condition.

NOTE: If the CPD folder or related evidence can be adequately reconstructed, the above information does not apply and the MIRS can be applied.

5. MI when DAA not material or not considered at the CPD

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

E. Examples of findings with DAA involvement

1. MI based on epilepsy

CPD evidence: The individual's impairment(s) met listing 11.02 due to epilepsy with generalized seizures, occurring at least once a month for at least 3 consecutive months despite adherence to prescribed treatment.

CDR evidence:

The medical records indicate that the individual's condition was improving, with their epilepsy controlled by a new medication and no breakthrough seizures or other symptoms for several consecutive months, up until about 7 months after the CPD. At that time, the records note several hospitalizations for drug overdose. The individual missed several follow up appointments with their primary care physician for epilepsy follow up and medication management. The records from the hospitalizations due to drug overdose include two observed generalized tonic-clonic seizures, which appeared to be associated with the drug use. The individual recently attended a neurologist appointment, where they reported generalized seizures recurring about once a week, and the neurologist counseled and urged the individual to abstain from drug use, indicating this was also now causing the breakthrough seizures and interfering with the effectiveness of the medication. The neurologist indicated that the individual’s seizures were consistent with symptoms of chronic drug abuse and that the individual needed to stop using drugs in order to prevent further seizures.

Discussion: If DAA were to stop, there would be changes (improvement) in the symptoms, signs, and laboratory findings for the substance use disorder, and listing-level limitations would not remain. Therefore, DAA is material.

Find MI. Continue to follow the CDR sequential evaluation process to determine whether the individual would still be disabled in the absence of DAA.

2. No MI based on a liver disease

CPD evidence: The individual's impairment(s) met listing 5.05F at the CPD. The CPD records demonstrate a longitudinal history of alcohol use disorder. At the time of the CPD, the individual was actively drinking alcohol. DAA was considered and was determined not to be material to the determination.

CDR evidence: The medical records at CDR demonstrate no MI in the individual's chronic liver disease and associated encephalopathy. The records 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 if DAA were to stop, the MC projects that the liver disease would continue to satisfy the criteria of listing 5.05F. Therefore, DAA is not material.

Find no MI.

More scenarios regarding DAA materiality are in DI 90070.050C.

F. References

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

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    DI 28005.040 Drug Addiction or Alcoholism (DAA) In a Title II or Adult Title XVI Continuing Disability Review (CDR) - Summary Chart for the CDR Sequential Evaluation Process When DAA is Present in a CDR

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

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

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

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    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 - 05/08/2023
Batch run: 05/08/2023
Rev:05/08/2023