TN 36 (09-15)

DI 28020.001 General - Groups I and II of Exceptions to Medical Improvement (MI)

A. Intent of Group I and Group II exceptions

The exceptions to Medical Improvement (MI) allow a finding that disability ceased in limited situations where, even though there has been no MI or MI is not related to the ability to work, evidence shows that the person should no longer be considered disabled or never should have been considered disabled.

NOTE: The Group II exceptions to MI do not require a finding of ability to engage in substantial gainful activity (SGA), or for Title XVI children that the impairment(s) no longer result in marked and severe functional limitations.

B. Policy for Group I and Group II exceptions to MI

There are two groups of exceptions to MI:

1. Group I exceptions

The Group I exceptions apply at step 5 of the continuing disability review (CDR) sequential evaluation for Title II and adult Title XVI claims and step 2 of CDR sequential evaluation for Title XVI children. Group I exceptions require a finding that the person is not currently disabled. For adults, that finding would be that the person is able to engage in SGA, and in the case of a Title XVI child, a finding that the child’s impairment(s) no longer results in marked and severe functional limitations.

See DI 28005.030 for more information on applying Group I exceptions in child cases.

The Group I exceptions are:

  • SGA (for field office use only);

  • Advances in medical or vocational therapy or technology (does not apply to Title XVI children);

  • Vocational therapy (does not apply to Title XVI children);

  • New or improved diagnostic or evaluative techniques; and

  • Prior error, which includes:

    • Error on the face of the record;

    • Required and material evidence was missing; or

    • New evidence related to the prior determination or decision.

2. Group II exceptions

Group II exceptions can apply at any step of the CDR sequential evaluation process. These exceptions do not require a finding that the individual is not currently disabled; i.e. do NOT require a finding of ability to engage in SGA. See DI 28020.900 Group II Exceptions for further information.

The Group II exceptions are:

  • Fraud or similar fault;

  • Failure or refusal to cooperate;

  • Whereabouts unknown; and

  • Failure to follow prescribed treatment

C. Procedure for using Group I and Group II exceptions to MI

1. When to consider exceptions

  1. Consider Group I exceptions at step 5 of the CDR sequential evaluation process for Title II and adult Title XVI claims and step 2 of the CDR sequential evaluation process for Title XVI children.

  2. Consider Group II exceptions at any step. For the CDR evaluation process summary charts, see DI 28005.010 and DI 28005.025.

2. Development of exceptions

Develop only when there is strong indication that an exception may apply. Avoid routine development only for the purpose of pursuing an exception(s).

3. Caution in applying exceptions

Do not apply any exception to medical improvement if there is reasonable doubt on the part of the current adjudicator or reviewer regarding whether the exception applies.

D. Exclusions for Group I exceptions to MI

Under the relevant provisions of the Social Security Act (as amended by P.L. 104-193, enacted August 22, 1996), the “Advances in Medical or Vocational Therapy or Technology” and “Vocational Therapy” Group I exceptions do not apply to Title XVI children. See DI 28020.050C and DI 28020.150E for other types of claims to which Group I exceptions do not apply.

E. Additional considerations when more than one exception applies

In the rare situation when more than one exception applies (or one exception applies and there is MI related to the ability to work), discuss this in a rationale. For additional discussion of exception CDR rationale, see DI 28090.055.

F. References