Identification Number:
DI 28030 TN 39
Intended Audience:See Transmittal Sheet
Originating Office:ORDP ODP
Title:General Development of CDR Cases
Type:POMS Transmittals
Program:All Programs
Link To Reference:
 

PROGRAM OPERATIONS MANUAL SYSTEM
Part DI – Disability Insurance
Chapter 280 – Continuing Disability Review Cases
Subchapter 30 – General Development of CDR Cases
Transmittal No. 39, 03/31/2021

Audience

PSC: CS, DE, DEC, DTE, IES, RECONR, SCPS, TSA, TST;
OCO-OEIO: CR, ERE, FDE, RECONE;
OCO-ODO: BET, CR, CTE, CTE TE, DE, DEC, DS, PETE, PETL, RECONE;
ODD-DDS: ADJ, DHU;

Originating Component

ODP

Effective Date

03/31/2021

Background

This Programs Operations Manual System (POMS) is part of the Office of Disability Policy's (ODP) plan for updates and revisions of various POMS. None of the revisions change policy or procedure.

 

Summary of Changes

DI 28030.020 Development of Medical Evidence

DI 28030.020A. Fourth bullet: We revised the text to provide more clarity concerning currency of medical evidence.

DI 28030.020B. We added a second paragraph to provide guidance regarding how to obtain necessary medical evidence from a paper comparison point decision (CPD) file and place it into the eCDR file.

DI 28030.020D. We deleted this subsection title, "When to purchase a CE."

DI 28030.020D. We renamed subsection D "Development of evidence."

DI 28030.020D. 4. NOTE: We changed the word "maybe" to two words, "may be."

DI 28030.020D.6. "Development of CE evidence." We incorporated the text from the deleted subsection D into the new subsection D.6.

DI 28030.020D.6. First bullet: We deleted the incorrect reference, DI 28015.055B.3.b., and replaced it with DI 28015.050.

DI 28030.020F. We renumbered this subsection to "E."

DI 28030.020E. Example: In the third sentence, we deleted the commas around the phrase "from the VR agency"...

DI 28030.020 Development of Medical Evidence

Citations : 20 CFR 404.1512, 404.1513, 404.1517, 404.1519a, 404.1519b, 404.1579, 404.1593, 404.1594, 416.912, 416.913, 416.917, 416.919a, 416.919b, 416.993, and 416.994

A. Medical evidence and the medical improvement review standard (MIRS)

The disability determination services (DDS) periodically conducts a continuing disability review (CDR) after an individual has been receiving disability benefits. The CDR will determine whether the individual continues to be disabled. The time frame and method (e.g., full CDR, deferment review, mailer process) for processing CDRs is based on the specific circumstances of each case. The goal of the CDR is to make the correct determination of continuance or cessation in a timely, accurate, and cost effective manner.

To adjudicate CDRs, the disability examiner (DE) does not use the 5-step sequential evaluation process used for initial and reconsideration claims. Instead, the DE uses an 8-step sequential evaluation process based on the MIRS. The MIRS compares the individual’s symptoms, signs, and laboratory findings at the time of the most recent favorable medical determination, which we call the comparison point decision (CPD), to the current symptoms, signs, and laboratory findings of the same medically determinable impairment(s) (MDI). If the individual’s MDI has improved or if an exception (DI 28020.000) to medical improvement (MI) applies, then we proceed through the later steps of the CDR sequential evaluation process. To review the CDR sequential evaluation process charts, see DI 28005.010B and DI 28005.025.

REMEMBER:

  • When an MDI is established at any point in time by evidence from an acceptable medical source (AMS), do not develop to establish that same MDI again during the CDR. Generally, the MDI is established in the CPD case file. For information on AMSs, see DI 22505.003.

  • The DE may use other medical sources that are not AMSs to evaluate the current severity of the MDI(s) and how it affects an adult’s ability to work or a child’s ability to function.

  • In certain medical improvement not expected (MINE) or MINE-equivalent cases, the DE may use nonmedical evidence without new medical evidence to find that disability continues. For more information on MINE or MINE-equivalent cases, see DI 28040.125.

  • How recent the medical evidence must be depends on the type of case and the nature of each impairment. The development in a CDR case is different from that in an initial claim. Generally, in an initial claim, the DE develops sufficient evidence to determine whether the individual’s impairment(s) meets the definition of disability and if the individual is eligible for benefits. In a CDR case, the DE uses the 8-step sequential evaluation process to determine if the individual’s MDI(s) has had MI or if an exception applies.

  • The DE will make every reasonable effort to obtain necessary medical evidence from the individual’s medical source(s) prior to ordering a consultative examination (CE). For further discussion on reasonable effort, see DI 22505.001A.2.

  • The DE may stop development and process a continuance whenever the evidence in file is sufficient to make a continuance determination. However, prior to making a cessation determination, the DE must develop for all impairments and vocational issues.

B. What medical evidence is needed for a CDR determination

The DE will usually have the CPD case file with the medical evidence used to establish, or continue, the individual’s disability. Therefore, for the CDR, the DE generally needs to obtain current medical evidence to make a determination as defined under the MIRS. However, depending on the impairment(s) in MINE or MINE-equivalent cases, the DE may not need current medical evidence.

When a CPD case file contains relevant evidence that documents the existence of an MDI, or a test score that may be needed in a future CDR, or a longitudinal history that documents severity of an MDI, the DDS must copy or scan relevant documents to the current CDR case file whether it is paper or electronic. For example, IQ test scores, x-ray results, pathology findings, cardiac tests, and operative reports may still be valid for future reviews. For instructions on adding relevant paper CPD evidence to the eCDR case file, see DI 81020.230.

C. Obtaining evidence from the individual's medical source(s)

During initial development of a CDR, the individual completes an SSA-454-BK, Continuing Disability Review Report. He or she lists medical sources who have treated or evaluated him or her, as well as any other evidence that will help the DE determine if the individual is still disabled.

The individual must:

  • inform the DE about or submit all evidence known to him or her that relates to whether he or she is blind or disabled;

  • identify and inform the DE of his or her medical sources;

  • provide any evidence, already in his or her possession, that is not contained in other medical records (e.g., a functional assessment paid for by a third party);

  • cooperate with the DE’s case development requests (e.g., to complete forms and provide information); and

  • cooperate with the DE’s request to attend a consultative examination (CE).

The DE develops a complete medical history covering at least 12 months preceding the date the individual signs the SSA-454. This development procedure differs from initial and reconsideration claims for which the DE develops medical history at least 12 months prior to the alleged onset date.

The DE will make every reasonable effort to obtain evidence from the individual’s medical sources. When the DE asks the individual to contact his or her medical sources to help the DDS get the medical evidence, the individual must do so or risk having benefits ceased due to failure to cooperate.

D. Development of evidence

1. Development of medical and other evidence

Develop a complete medical history for the 12 months prior to the date that the individual signs the SSA-454. Use judgment in developing evidence outside the 12-month period. For information on electronic processes, see DI 81020.060.

During case development, consider:

  • The individual’s current impairment(s), and

  • The status of the MDI(s) present at the time of the CPD.

Resolve any conflict between evidence provided by the individual and his or her medical source(s). For more information on specific evidence evaluation, see DI 24501.016.

Some individuals may not have a current medical source(s). Actions required in these cases depend on the nature of the impairment(s) or the availability of knowledgeable third parties who can verify the individual’s statements. For source requirements in MINE or MINE-equivalent cases, see DI 28040.125.

2. Development of evidence from an AMS

DDS requires evidence from an AMS to establish any new or previously existing (but not established) medical impairment(s), whenever consideration of that impairment(s) is relevant to the current CDR determination.

NOTE: 

The DE does not need to re-establish any MDI(s) established previously, such as at the CPD.

3. Development of evidence from a non-acceptable medical source

Current medical evidence from an AMS is not always necessary in CDR cases. Once an MDI has been established in a CDR case, evidence from sources who are not AMSs may be used to show the current severity of the impairment(s) and how it affects an adult’s ability to work or a child’s ability to function. For more information, see DI 22505.001 and DI 22505.003.

EXAMPLE: At CPD, an AMS established a diagnosis of osteoarthritis of the lumbar spine. On current CDR, the individual reports ongoing arthritis in the low back. It is not necessary to re-establish the existence of this impairment by current evidence from an AMS. DEs may use evidence from other sources, such as a physical therapist or chiropractor, to establish current severity and functioning.

4. Development of nonmedical evidence

When an MDI is established, the DE may use nonmedical evidence to assist in determining the current severity of the MDI(s), and to show how the MDI(s) affects an adult’s ability to work or a child’s ability to function. Nonmedical evidence may give important information about how the individual functions in his or her daily life. Activities of daily living (ADL) offer valuable insight into an individual’s daily function. The DE may use ADLs in conjunction with medical evidence or nonmedical evidence for a determination. Examples of nonmedical evidence include (but are not limited to) information from educational personnel, public and private social welfare agency personnel, spouses, parents, other relatives, and friends. See DI 22505.003A.3.

NOTE: 

In certain MINE or MINE-equivalent cases, nonmedical evidence may be the only evidence needed for a determination. For more information on MINE or MINE-equivalent case development, see DI 28040.125.

5. Development of CPD evidence

Do not develop additional CPD evidence, except in unusual situations (e.g., CPD evidence was clearly inadequate and more evidence relevant to the CPD is known to be readily available). Do not obtain additional evidence just to consider the error exceptions. For development for Group II exceptions, see DI 28020.900.

For procedures applicable to lost folder cases, see DI 28035.000.

6. Development of CE evidence

Make every reasonable effort to obtain all medical evidence from the individual’s medical source(s) necessary to make a determination. After receiving medical and nonmedical evidence from the source(s), if you still need additional evidence for a determination, consider whether it is readily available from these sources. If so, re-contact the source(s) for the additional evidence.

Situations may exist when the DDS needs additional evidence to determine whether the individual’s disability continues. Some examples include: if the medical source(s) is unable to provide certain needed tests or procedures, if the medical source(s) has previously been non-productive or uncooperative, or if the individual does not have a treating source or recent treatment.

A CE is necessary only when the evidence as a whole, both medical and nonmedical, is not sufficient to support a determination. For guidelines on purchasing CEs, see DI 22510.001 through DI 22510.006.

Do not order a CE if:

  • The impairment(s) continues to meet a listing (even an obsolete listing) as it was written at the CPD. For additional information on obsolete listings, see DI 28015.050 and DI 28015.055. For obsolete versions of Part A, see DI 34100; for Part B, see DI 34200.

  • The impairment(s) meets the requirement(s) for MINE or MINE-equivalent cases. For additional information on MINE or MINE-equivalent cases, see DI 28040.005 and DI 28040.125B.1.

7. When current evidence is necessary

To determine whether the individual’s impairment(s) shows MI, the DE needs current medical evidence to compare the symptoms, signs, and laboratory findings of the MDI(s) at the time of the CPD to the symptoms, signs, and laboratory findings of the same (MDIs) at the time of the current review.

The nature of each MDI determines how current the medical evidence must be. Therefore, the DE must resolve this issue on a case-by-case basis. For example, if the MDI(s) is acute or of an exacerbating and remitting nature, the DE may need recent medical evidence for a determination. However, if the MDI(s) is chronic or progressive then less recent medical evidence or nonmedical evidence may be the only evidence the DE needs for the determination.

E. Vocational rehabilitation (VR) agency

When an individual is known to a State, or other accredited, VR agency at the time of the CDR, contact the agency for a full report about the individual, including medical reports relating to the individual’s current medical status and other evidence pertinent to a determination. If evidence previously obtained from the agency (e.g., in connection with the initial adjudication) indicated the case was closed and the individual states the case has not been reopened, do not make further contact with the VR agency. Evidence obtained from the individual’s medical sources, together with evidence available through the VR agency, may be sufficient to permit a sound determination as to whether disability continues. For procedures on VR involvement “301” cases, refer to DI 28001.040.

If an individual is actively involved in VR-type services, clarify through the FO whether the “Ticket to Work” program is in use. If the individual is using a “ticket,” DDS may need to stop development and return the case to the FO for possible screen-out. See DI 13005.020, DI 55025.001, and DI 55025.010.

Do not make a clear-cut cessation (i.e., cessation without current medical evidence, on the basis that medical recovery is indicated by return to full-time work without medical restrictions) when VR services are continuing (DI 28030.035). When current medical evidence establishes MI and a present capacity for doing substantial gainful activity, find that disability ceases despite the fact that the individual may be an active participant in a State-sponsored VR program.

EXAMPLE: The DDS found the individual disabled based on multiple fractures and complications that indicated the disabling MDI would meet the 12-month duration requirement. When the medical diary came due, the CDR established that the individual is enrolled in a two-year bookkeeping course under a State-sponsored VR program. The DDS obtained evidence from the VR agency that stated one year of schooling remained. The DDS then obtained current medical evidence that clearly established MI. Therefore, the DDS made a cessation determination.

F. References

  • DI 22501.002 Responsibilities for Case Development of Disability Claims

  • DI 22505.001 Medical and Nonmedical Evidence

  • DI 22505.003 Evidence from an Acceptable Medical Source (AMS)

  • DI 22505.006 Requesting Evidence – General

  • DI 22505.030 Obtaining Medical Evidence by Telephone

  • DI 28010.015 Comparison of Symptoms, Signs, and Laboratory Findings

  • DI 28030.035 Cessation Without Full Medical Development (Clear-Cut Cessations)

  • DI 28040.130 Development Guidelines for MINE or MINE-Equivalent Impairments

  • DI 28060.001 General - VR or Similar Program Participation

  • DI 81020.020 Electronic Case Development

  • DI 81020.065 Electronic Case Documentation


DI 28030 TN 39 - General Development of CDR Cases - 3/31/2021