Identification Number:
DI 28040 TN 6
Intended Audience:See Transmittal Sheet
Originating Office:ORDP ODP
Title:Medical Improvement Not Expected (MINE) or Medical Improvement Not Expected - Equivalent (MINE - Equivalent) Cases
Type:POMS Transmittals
Program:Disability
Link To Reference:
 

PROGRAM OPERATIONS MANUAL SYSTEM
Part DI – Disability Insurance
Chapter 280 – Continuing Disability Review Cases
Subchapter 40 – Medical Improvement Not Expected (MINE) or Medical Improvement Not Expected - Equivalent (MINE - Equivalent) Cases
Transmittal No. 6, 04/01/2021

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

Upon Receipt

Background

This is a Quick Action Transmittal. These revisions do not change or introduce new policy or procedure. These changes are in accordance to the Musculoskeletal regulation implementation.

Summary of Changes

DI 28040.125 Determining the Need for a Medical Source or Third Party Contact in Medical Improvement Not Expected (MINE) or MINE-Equivalent Cases

Section B1a: Included words "prior listings"

Section B1b: Added: Amputation of both upper extremities occurring at any level at or above the wrists, up to and including the shoulder (1.20A, 101.20A)

Section B1c: Added: Hemipelvectomy or hip disarticulation (1.20B, 101.20B; prior 1.05D, 101.05D). Removed: Amputation of leg at hip.

Section B2e: Added words "prior listings"

Section B2f: Added: Age 55 and over with Abnormality of a Major Joint(s) in any Extremity (1.18)

DI 28040.130 Development Guidelines for Medical Improvement Not Expected (MINE) or MINE-Equivalent Impairments

Section B1: Replaced Listing 1.05A or D with Listing 1.20A or B. Removed: statement Amputation of both hands; or hemipelvectomy or hip disarticulation. Replaced with: cases with a CPD prior to April 2, 2021 that were found to meet or equal listing 1.05A for amputation of both hands or 1.05D for hemipevelctomy or hip disarticulation; and cases with a CPD on or after April 2, 2021 that were found to meet or equal listing 1.20A for amputation of both upper extremities, occurring at any level at or above the wrist (carpal joints), up to and including the shoulder (glenohumeral) joint, or 1.20B for hemipelvectomy or hip disarticulation

 

 

DI 28040.125 Determining the Need for a Medical Source or Third Party Contact in Medical Improvement Not Expected (MINE) or MINE-Equivalent Cases

 

A. Introduction to sources in MINE and MINE-equivalent cases

The disability determination services (DDS) must contact a current medical source when possible. However, DDS may use other third party contacts if there is no medical source and certain conditions are met. The actions required in these cases depend on the nature of the impairment(s) and on the availability of other knowledgeable third parties who can verify the individuals' statements. The main purpose of the third party contact is to verify the continued severity of the impairment(s) as alleged by the disabled individual.

B. Is a medical source needed?

1. Medical source not available; third party contact not necessary

The DDS should contact current medical sources if available. However, there are certain impairments which may not require frequent medical attention but which are nonetheless so obviously severe that full continuing disability review (CDR) development is not necessary. In those cases, and assuming no work issues exist, the DDS may process a continuance based on the evidence in file and the contact with the individual if no medical source is available for verification.

The DDS may prepare a continuance on the evidence of record, if the individual, payee, or representative indicates that there is no medical source and the file clearly establishes one of the following impairments. A nonmedical third party contact is not required in these cases. The specific impairments are:

  1. a. 

    Amputation of both hands (prior listings 1.05A, 101.05A)

  2. b. 

    Amputation of both upper extremitites, occuring at any level at or above the wrists, up to and including the shoulder (1.20A, 101.20A)

  3. c. 

    Hemipelvectomy or hip disarticulation (1.20B, 101.20B; prior l.05D, 101.05D)

  4. d. 

    Statutory blindness; except if due to cataracts, detached retina, keratoconus, corneal scar opacity or vitreous hemorrhage (2.02, 2.03A, 102.02, 102.03A).

  5. e. 

    Loss of visual efficiency (visual efficiency of better eye after best correction 20 percent or less) (2.04); except if due to cataracts, retinal detachment, keratoconus, corneal scar opacity, or vitreous hemorrhage.

  6. f. 

    Hearing loss not treated with cochlear implantation (2.10). The disability examiner should be alert to situations where surgery such as stapedectomy, or cochlear implantation have improved the individual’s ability to hear. In such cases, a current personal contact interview is required.

  7. g. 

    Severe intellectual disability, with manifestations as required by the applicable listing (12.05A or B, 112.05B)

2. Medical source contact mandatory

For some MINE impairments, the lack of a medical source may indicate some possibility of improvement. For the diagnoses given below, if the individual cannot provide any medical source for verification of continued impairment severity, refer the case, as instructed in DI 28040.125B.4. in this section, to the field office (FO) with a request to initiate a full CDR with a personal contact. If the FO is aware of some compelling reason not to complete the CDR, it may be deferred under the regular deferral procedures outlined in DI 28003.010. The specific impairments are:

  1. a. 

    Ischemic Heart Disease with Chest Pain of Cardiac Origin (4.04 A or B)

  2. b. 

    Peripheral Arterial Disease (4.12)

  3. c. 

    Chronic kidney disease, with chronic hemodialysis or peritoneal dialysis (6.03, 106.03); Chronic kidney disease, with impairment of kidney function (6.05)

  4. d. 

    Diabetes Mellitus with manifestations as required by the applicable listing

  5. e. 

    Age 55 and over with Major Dysfunction of a Joint(s) (due to any cause) (prior listing 1.02A)

  6. f. 

    Age 55 and over with Abnormality of a Major Joint(s) in Any Extremity (1.18)

  7. g. 

    Age 55 and over with Ischemic Heart Disease (Chest Pain of Cardiac Origin) (4.04C)

  8. h. 

    Age 55 and over with two substantiated Myocardial Infarctions

3. Nonmedical third party contact when medical source is not available and medical source contact is not mandatory

If the individual reports no medical sources, and the diagnosis is not one of those listed in DI 28040.125B.1. or DI 28040.125B.2. in this section, the DDS should contact any third party the individual believes can verify his or her statements. A signed permission to contact a nonmedical third party is not necessary.

Contact any nonmedical third party that has knowledge of the individual's condition and can provide an objective assessment of the individual's condition. Nonmedical third party contacts may include:

  • Custodial institutions.

  • Sheltered workshop administrators.

  • Schools or organizations for persons with the same type of impairment as the individual.

  • Social service organizations that provide some form of assistance.

  • Members of the clergy.

  • Caretaker organizations.

Explain to the third party that we are conducting a CDR on the individual as required by law. Assure the person that we have permission from the individual to contact them. Do not tell the third party any information about the individual other than that we are conducting a CDR. Ask the contact how recently he or she saw the individual, and whether the individual remains impaired and unable to work or, in a Title XVI child case, unable to return to normal activities.

Prepare a summary of the statement (Form SSA-795 or other locally approved form) and forward it to the source for review and signature; include a business reply envelope.

The DDS cannot complete a determination (if the determination is based on the nonmedical third party statement) prior to receiving the statement back from the nonmedical third party source. If the third party statement:

  • Verifies the individuals statements, the DDS may process a continuance.

  • Creates a continuing disability issue, the DDS should send the case to the FO for a full CDR in accordance with DI 28040.215.

  • Is not received by 14 calendar days from the date of the cover letter, follow up with the nonmedical third party contact via telephone. If applicable, return the case to the FO in accordance with DI 28040.125B.4. in this section, or schedule a consultative examination if possible.

The DDS will include the third party statement in the file, if it is received prior to completing the case. When receiving evidence in Certified Electronic Folder (CEF) cases, see DI 81020.060. The DDS will process statements or other evidence received after the determination as “trailer material”.

4. Referral to FO when a nonmedical third party is not available

In rare situations, the FO may serve as the nonmedical third party in cases where:

  • There is no medical source available.

  • A third party contact who can confirm the individual's statement(s) is necessary but not available; and

  • The impairment is not listed in DI 28040.125B.2. in this section.

In these instances, send an assistance request to the FO requesting a field contact and documentation of their findings. Indicate what specific observations would be helpful, and provide specific questions for the FO to ask the individual or a third party (e.g., neighbor) based on the impairment involved and the individual's or payee's statement. For more information on field contacts, see DI 13005.110C.

C. References

DI 28040.130 Development Guidelines for Medical Improvement Not Expected (MINE) or MINE-Equivalent Impairments

A. Introduction to the development guidelines

The guidelines in this section, discuss individual MINE or MINE-equivalent impairments, groups of impairments, and situations in which there may be documentation deficiencies or contradictory situations, or a greater possibility of medical improvement.

These guidelines will assist the disability examiner (DE) in making appropriate judgments about the level of documentation required and the questions to ask medical source contacts.

Certain impairments are noted for which the lack of any medical source indicates a possibility of improvement; these require a full continuing disability review (CDR) if there is no medical source to verify impairment severity.

NOTE: Not all MINE or MINE-equivalent impairments are discussed below. For the most current list of MINE or MINE-equivalent impairments, see DI 26525.045. The principles illustrated in the examples below are generally applicable to those MINE or MINE-equivalent impairments not specifically discussed.

B. Medical improvement and the listings

1. Listing 1.20A or B and prior listing 1.05A or D

Cases with a CPD prior to April 2, 2021 that were found to meet or equal listing 1.05A for amputation of both hands or 1.05D for hemipevelctomy or hip disarticulation; and cases with a CPD on or after April 2, 2021 that were found to meet or equal listing 1.20A for amputation of both upper extremities, occurring at any level at or above the wrist (carpal joints), up to and including the shoulder (glenohumeral) joint, or 1.20B for hemipelvectomy or hip disarticulation.

These cases will not improve. Only an actual return to work would call for a full CDR.

2. Listing 2.02, 2.03A, 2.04, 102.02, 102.03A

Statutory blindness except due to cataracts or detached retina...not correctable by surgery, other treatment or glasses; loss of visual efficiency

Identify the etiology of each instance of statutory blindness or loss of visual efficiency to separate those conditions not expected to improve, from those in which improvement might be possible.

 

Improvement not expected

Improvement possible

(Third party contact not necessary if no medical source available)

(Medical source or other third party contact necessary)

Glaucoma

Cataracts

Retinitis pigmentosa

Retinal Detachment

Optic atrophy

Keratoconus

Macular degeneration or scar

Corneal scar opacity

Phthisis bulbi

Vitreous hemorrhage

Congenital defects

 

3. Listing 2.10

Hearing loss not treated with cochlear implantation

In cases where hearing loss is sensori-neural there is no possibility of improvement. These cases should require only minimal development, such as contact with the individual or payee. However, the original decision must be reviewed to determine whether proper methodology was used during the audiological testing in the prior favorable determination. If proper methods were not used, repeat testing may be indicated.

The DE should be alert to situations where surgery such as stapedectomy, or cochlear implantation have improved the individual’s ability to hear. In such cases, personal contact for CDR development is required.

4. Listing 3.02

Chronic pulmonary insufficiency

These cases are not expected to show significant medical improvement.

5. Listing 4.04A or B

Ischemic heart disease with chest pain of cardiac origin

If there has been no surgical intervention and the individual reports chest pain of cardiac origin, no significant improvement would be expected.

However, if the individual no longer reports cardiac chest pain or has had surgery performed, the telephone contact with the medical source should address the effects of the surgery. After evaluation of the information secured during this contact, personal contact for CDR development may be necessary. Lack of any medical source indicates the need for a full CDR.

6. Listing 6.03 and 6.05

Chronic kidney disease, with chronic hemodialysis or peritoneal dialysis and chronic kidney disease, with impairment of kidney function

In cases where the individual remains on dialysis and no transplantation surgery is contemplated (6.03), no significant medical improvement is expected.

In cases allowed under 6.05, where the individual is not on dialysis and has not had kidney transplantation, personal contact may be needed for CDR development. Lack of any medical source indicates the need for a full CDR.

7. Listing 11.04, 11.06, 11.07, 11.08, 11.09, 11.10, 11.11, 11.13 and 11.17

Central nervous system vascular accident, parkinsonian syndrome, cerebral palsy, spinal cord or nerve root lesions, multiple sclerosis, amyotrophic lateral sclerosis, anterior poliomyelitis, muscular dystrophy, degenerative disease such as huntington’s chorea, friedrich’s ataxia, and spino-cerebellar degeneration, with manifestations as required by the applicable listings.

Medical improvement is not expected.

8. Listing 12.02

Organic mental disorders

In cases where the individual is institutionalized, contact with a medical source should resolve any inconsistencies, or indicate that a personal contact for CDR development may be necessary.

9. Listing 12.03 and 12.04

Schizophrenic, paranoid and other psychotic disorders and affective disorders, if institutionalized in a licensed mental hospital for past 12 months without releases that would indicate improvement

If the individual remains institutionalized, the only development needed is a contact with the mental institution confirming the period of institutionalization.

Contact a medical source if the individual was discharged. After evaluation of the information secured during that contact, personal contact for CDR development might be required (e.g., a patient formerly hospitalized at a licensed mental hospital now discharged to a nursing home would not necessarily indicate medical improvement).

However, discharge to an independent living arrangement program may indicate improvement. Following the source contact, the DE should decide with the assistance of a DDS psychiatrist or psychologist, whether to undertake personal contact for CDR development of the case.

10. Listing 12.05A or B, and 112.05B

Severe intellectual disability

Medical improvement is not expected. However, if there are inconsistencies in the file or the contact raises an issue, an individual assessment of the need for personal contact for CDR development should be made with the assistance of a DDS psychiatrist or psychologist.

C. Age 55 or over

In cases involving individual age 55 or over, it is unlikely that that the individual will return to substantial gainful activity due to medical improvement. Cases involving individuals of advanced age will be processed using the same criteria found in DI 28040.000, to include obtaining evidence and contact of the individual. Process a continuance unless there is contradictory information in the file or from the medical source, or the claimant indicates medical improvement.


DI 28040 TN 6 - Medical Improvement Not Expected (MINE) or Medical Improvement Not Expected - Equivalent (MINE - Equivalent) Cases - 4/01/2021