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:

  1. A CDR was conducted within the 12-month period preceding the current MFR, or

  2. 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.