PROGRAM OPERATIONS MANUAL SYSTEMPart DI – Disability InsuranceChapter 280 – Continuing Disability Review CasesSubchapter 15 – Relating Medical Improvement to the Ability to Work - Title II and Adult Title XVI BeneficiariesTransmittal No. 4, 02/01/2019
This is a Quick Action Transmittal (QAT). These revisions do not change or introduce new policy or procedure.
This POMS discusses two mechanisms to relate medical improvement to the ability to work. The requested change to DI 28015.005 is due to incorrect wording in the the first mechanism (#1).
Summary of Changes
DI 28015.005 Two Mechanisms to Relate Medical Improvement (MI) to the Ability to Work
1. - In the first sentence, changed the last phrase from "...if there has been medical improvement." to "... whether MI is related to the ability to work."
Two different mechanisms may apply in deciding if MI relates to the ability to work. The basis for the comparison point decision (CPD) determines which mechanism applies.
If CPD determination was based on the impairment(s) meeting or equaling a listing, use the prior listing mechanism to determine whether MI is related to the ability to work. Consider whether the CPD impairment still meets or equals that prior listing.
Consider the “MI related” step if the Disability Determination Services (DDS) finds at the “meets/equals” step that the impairment(s) does not meet or equal any current listing. If the impairment(s) does not meet or equal any current listing, it cannot meet or equal the CPD listing either, unless the CPD listing is no longer current (i.e., it has been changed or deleted). Thus, the “prior listing” mechanism of the “MI related” step may determine the outcome of the continuing disability review (CDR) where the CPD listing is no longer current.
If we based the CPD determination on medical-vocational factors using an RFC assessment, use the RFC comparison mechanism to determine if there has been MI related to the ability to work. Compare the CPD residual functional capacity (RFC) and medical improvement review standard (MIRS) RFC to determine whether improvement is related to the ability to work.
For more information on using this mechanism, see DI 28015.300 through DI 28015.320.
If the CPD was based on:
Then, decide whether MI is related to the ability to work
Meet or equal a listing of impairments
Consider whether the prior listing is currently met or equaled.
You can consider all CPD sub-sections (EXAMPLE: If previously met listing 5.05A consider 5.05A, 5.05B, 5.05C).
Compare CPD RFC and MIRS RFCs
When assessing MIRS RFC, consider only impairments present at the time of CPD.
No MI (related) or exception
Use 1. or 2. in this table, as appropriate, depending on the basis for the most recent pre-CPD favorable medical decision, which was made on a basis other than “no MI.”
If we based the CPD on “no MI,” document in the file that the prior CPD RFC still applies. See DI 28015.850 for more information
If we originally allowed an adult as a Title XVI child, and there has been no age-18 disability redetermination, see DI 28005.003.
For additional information regarding Public Law 104-193, see DI 23570.001.
Reference DI 28015.005A in the chart in this section, and if there is no change or no change to MI at CPD, use the earlier decision only to decide which mechanism applies. Do not use the earlier decision as the CPD.
If the basis for the CPD is unclear, carefully consider the following factors to reasonably determine the basis for the CPD:
Basis code or vocational rule was cited (if any),
Presence or absence of an RFC assessment (whether on an RFC form or noted elsewhere in file), and
The evidence and circumstances.
At the CPD, benefits continued without a basis code or citation of a vocational rule. Consider the prior listing shown in DI 34100.000 if the file does not contain an RFC assessment, and evaluation of the evidence shows a listing was met at the time of the CPD (i.e., DI 28015.005B.1. in this section applies).
If you are unable to make a reasonable determination about the basis for the CPD, assume a medical/vocational basis, and use the instructions in the general approach to RFC comparison located in DI 28015.300.
Use this assumption only to determine if MI is related to the ability to work, and not for any other purpose.
DI 28015.050 Consideration of Prior Listing
DI 28015.055 What is a Listing?
DI 28015.060 “Prior Listing” Mechanism – Changes in Symptoms, Signs, or Laboratory Findings
DI 28005.015 Step-by-Step Discussion of the Adult Continuing Disability Review (CDR) Evaluation Process
DI 28020.001 Groups I and II of Exceptions to Medical Improvement