TN 20 (09-90)

DI 28055.025 DDS Evaluation and Processing of EPE Cases

A. Policy

The DDS will perform a medical/vocational CDR on EPE cases referred by ODIO /PSC-DRS through the FO or directly by the FO. A person will be considered to have a disabling impairment until a formal determination is made that the person is not disabled, with written notice of the determination and right to reconsideration.

NOTE: The FO or ODIO/PSC-DRS will not  delay reinstatement / suspension actions (i.e., due to change in earnings) pending completion of a DDS medical review or by requesting the folder. The FO can reinstate/ suspend benefits without the folder via teletype request to ODIO/PSC-DRS.

B. Procedure

1. CDR Required

Conduct a CDR when the FO forwards a claim in which an SGA determination has been made and the front end interview has been conducted, unless, in the rare instance, ODIO/PSC-DRS did not do the medical review and the evidence in file establishes that the individual is currently disabled in accordance with DI 28055.020. Also conduct a CDR when the FO finds indication of possible MI subsequent to ODO/PSC-DRS's finding that no DDS determination is necessary.

2. CDR Discontinued

If the CDR should be discontinued, record the specific reason and the specific POMS reference on a signed and dated SSA-5002. Send the notice shown in DI 28055.060.

NOTE: If the person has a MINE impairment, the medical development is minimal. See DI 28040.001ff.

3. Development and Evaluation

  1. a. 

    Follow established guidelines used in developing medical CDRs.

  2. b. 

    Medical Improvement Review Standard (MIRS)

    • When the FO has used the SGA exception in finding that a person's disability ceased due to work activity, do not use it in the medical determination, i.e, impairment severity determination.

    • See DI 28005.015A.7 concerning work performed during the TWP, EPE, or extended Medicare eligibility as it relates to past relevant work.

4. Determination- Disability vs. Impairment Severity

  1. a. 

    Prepare a regular medical CDR, i.e., a determination to continue/

    cease “disability”,when the FO finds disability to continue despite work activity (i.e., FO prepares an SSA-833-U3 SGA continuance determination.)

  2. b. 

    Prepare an “impairment severity” determination when disability previously ceased due to SGA.

    • When the month in which the impairment is no longer disabling is the same or after the month disability ceases due to SGA, process an “impairment severity” cessation determination, not to cease “disability”, but to terminate the EPE, cash benefits and/or Medicare in accordance with DI 28055.030 through DI 28055.040.

    • Follow DI 28005.205 in establishing the month of cessation in impairment severity cessation cases.

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DI 28055.025 - DDS Evaluation and Processing of EPE Cases - 11/27/1990
Batch run: 08/16/2017