TN 21 (10-04)
DI 40510.040 Medical Folder Review
A. Policy – Medical Folder Review (MFR)
To qualify for the EPE and other work incentive benefits, except 301 cases (See DI 14505.001.), the individual must continue to have a disabling impairment.
1. When MFR is performed
A MFR is performed to determine whether an individual continues to have a disabling impairment when:
an individual has completed 7 or more TWP months as of the COM; or
an individual has entered or will enter the EPE and/or extended Medicare eligibility period; or
an individual files for premium HI for the working disabled.
2. MFR does not apply
A MFR is not applicable if the individual is:
eligible for CDR protection per DI 13010.012; or
participating in the Ticket to Work program and has a Ticket in use (see DI 55025.001 and DI 55025.010); or
in the EPE and/or the extended Medicare period and is age 61 or older.
In these situations, the individual is considered currently disabled without a MFR and is eligible for the EPE and other work incentives.
B. Procedure - MFR
1. Currently Disabled Screening Criteria
When an MFR is applicable, determine if the individual can be found to be currently disabled. A person is considered currently disabled and eligible for the EPE and other work incentives if:
A CDR was conducted within the 12-month period preceding the current MFR, or
Any of the following medical criteria is met:
The impairment is one of those listed in DI 26525.045.
The impairment currently meets or equals a set of criteria in the Listing of Impairments.
NOTE: Some medical listings require current, recent, or persistent symptoms or findings to support a conclusion that the Listing is met/equaled. In such a case current information would be necessary to verify that the individual's condition currently meets the listing, e.g., information on recent blood transfusions in listing 7.02A chronic anemia.
The allowance/most recent CDR determination was based on vocational factors coupled with a medical condition which resulted from an anatomical loss, or is otherwise irreversible, and there is no material change in the individual's vocational factors. Such a person would be considered permanently impaired but not necessarily permanently disabled since a subsequent change in vocational factors could result in a finding of “not disabled.” However, in the absence of information that a change in vocational factors has occurred, the individual can be considered currently disabled.
EXAMPLES: An example of an anatomical loss which would indicate current disability in the absence of a change in vocational factors would be the loss of a limb, e.g., leg, arm, or hand. Examples of otherwise irreversible impairments which would reflect current disability in the absence of a change in vocational factors would be deafness which is near total and is not correctable; and impaired vision which approaches statutory blindness in severity and is not correctable.
2. Review of medical diary
a. No MIE diary on record
If based on screening criteria, the individual is found to be currently disabled, complete Form SSA-899-U2.
If based on screening criteria, we cannot establish current disability, a DDS medical CDR must be performed unless the EPE has terminated and extended Medicare coverage will end before the CDR can be completed.
If FO assistance is needed to resolve a work issue or personal contact is needed for a DDS medical CDR, forward the folder to the FO via an SSA-5526-U3.
Advise the FO either that “no medical issue” exists, or that a “medical issue” exists which requires DDS resolution on Form SSA-5526-U3.
3. MIE diary on record
Refer to DI 40505.100 for handling MIE cases with work activity.
4. Past-due medical diary
Refer to DI 40505.015 for handling cases with past-due medical diaries.
5. Title II CDR with Title XVI involvement
See DI 40505.210 for handling certain Title II CDR cases with title XVI involvement.