TN 38 (09-15)
DI 28030.035 Cessation Without Full Medical Development (Clear-Cut Cessations)
For medical continuing disability review (CDR) processing instructions for individuals with Tickets to Work, see DI 55025.010.
A. Conditions for clear-cut cessation
In medical improvement expected (MIE) cases, a return to work is an indication that disability may have ceased. The disability examiner (DE) may find cessation without current medical development when all of the following apply:
An MIE diary was scheduled.
The individual returns to full-time work with no significant medical restrictions before the scheduled CDR was conducted.
The individual acknowledges that medical improvement (MI) occurred as of the month he or she returned to work.
The individual expects to be able to continue work.
The individual does not wish to have medical evidence from the last 12 months considered before a decision is made.
The individual does not have a mental impairment.
Additional precautions in DI 28030.035B, in this section, also apply.
NOTE: Finding that work is “full-time” in applying the clear-cut medical cessation is not the same as finding that the work constitutes substantial gainful activity (SGA).
The basis for the decision is that the individual has returned to full-time work and acknowledges MI; therefore, MI related to the ability to work has been demonstrated, and the individual's impairment(s) is not of sufficient severity to prevent SGA. If the conditions for use of this provision are met, disability is found to end as of the first month the individual returns to full-time work.
EXAMPLE: The evidence obtained during the initial case processing showed the individual had significant functional restrictions that precluded SGA, and were expected to continue for more than 12 months. Recovery was expected approximately 18 months after onset of disability, and an MIE diary was established accordingly. When the individual notified us that they returned to work, a CDR was initiated. The review showed that 16 months after onset the individual returned to full-time work, acknowledged MI as of the month of return to full-time work, expected to be able to continue work, and did not wish to have medical evidence from the last 12 months considered before a decision is made. It also established that the individual's doctor approved this return to work without imposing any medical restrictions. Cessation without additional development is found in the month the individual returned to work.
These cessation determinations are based on MI related to the ability to work and the capacity for SGA, rather than the work performed.
Under Title II, services rendered cannot be used as the sole basis for termination until a trial work period (TWP) is completed. The trial work period ends if disability ceases for reasons other than work.
Under Title XVI, work performed is not a basis for finding cessation of disability.
However, the concept of cessation without full medical development involves medical determinations and this concept applies to both Title II and Title XVI.
When applying the clear-cut medical cessation concept, the particular job the individual is performing is the controlling factor in determining whether work performed is full-time work. If other workers in a like position in the same shop work the same number of hours, the job is considered full-time even if performed less than the average 40-hour work week.
To establish whether the factors in DI 28030.035A in this section are met, the file should contain a written statement from the individual (or the appointed representative).
A report of telephone contact with the physician satisfies the folder documentation requirements related to medical restrictions, provided the physician's responses do not conflict with those of the individual. In this situation, a physician does not have to sign the report of telephone contact. For additional information on telephone communications, see DI 22505.030.
B. Applying cessation without full medical development
1. General applicability
A cessation without full medical development does not apply to cases in which there is a:
2. Medical recovery
A clear-cut cessation does not apply, and the DE undertakes medical development to resolve the issue of medical recovery in all cases where the evidence in the file is inconclusive (e.g., the individual is working part-time, alleges continuing disability or is working contrary to medical advice, etc.). If the individual described in the example in DI 28030.035A in this section, had returned to part-time work, medical development must be undertaken because it is not clear that the individual has the capacity for full-time work. If medical development is required, a retroactive cessation will not apply under the clear-cut retroactive cessation rule.
3. Ability to work
If an individual alleges an ability to work (or his or her physician says he or she can return to work) but is not working, a CDR is undertaken and medical development is required. If such an individual does not cooperate with the CDR, a cessation, with a retroactive cessation of disability, may be appropriate based on failure to cooperate.
4. Vocational rehabilitation (VR)
Do not make a clear-cut cessation when the individual is receiving VR services at the time of the CDR, since participation in VR constitutes evidence inconsistent with such a determination. The DE must undertake development to resolve the medical issue.
5. Durational impairments
A clear-cut cessation is not be made when an individual with an impairment that contains a designated duration (e.g., Listing 6.04, 7.17, etc.) returns to full-time work prior to the end of the period of disability specified in the medical listing. In these cases, the listing clearly continues to be met which demonstrates the absence of medical recovery as defined for the purposes of a clear-cut cessation. When there is a return to work in such cases, a trial work period is established, if appropriate (i.e., in most Title II cases). In Title XVI cases, Section 1619 provisions apply. In both Title II and Title XVI claims, a medical CDR will not be conducted until after the end of the period designated in the listing involved.
DI 22505.030 Obtaining Medical Evidence by Telephone
DI 28005.205 Determining the Cessation Month in Continuing Disability Review (CDR) Cases
DI 28075.005 Failure to Cooperate (FTC) and Whereabouts Unknown (WU) Cases
DI 28075.600 Overview of the 1619 CDR Process