Identification Number:
DI 25505 TN 1
Intended Audience:See Transmittal Sheet
Originating Office:ORDP ODP
Title:Duration
Type:POMS Transmittals
Program:Disability
Link To Reference:
 

PROGRAM OPERATIONS MANUAL SYSTEM
Part DI – Disability Insurance
Chapter 255 – Onset/Duration/Closed Period
Subchapter 05 – Duration
Transmittal No. 1, 04/01/2021

Audience

PSC: DE, DEC, RECONR;
OCO-OEIO: CR, ERE, FCR, FDE, RECONE;
OCO-ODO: CTE, CTE TE, DE, DEC, DS, RECONE;
ODD-DDS: ADJ, DHU;

Originating Component

ODP

Effective Date

Upon Receipt

Background

QAT - no IRD or AC approval needed

 

Summary of Changes

DI 25505.030 Evaluation of the Duration Requirement for Disability

Updated references

 

DI 25505.035 Medical Deferment Involving the Duration Requirement

Updated references.

DI 25505.030 Evaluation of the Duration Requirement for Disability

CITATIONS:

Social Security Rulings — SSR 82-52

Consider duration in the context of the sequential evaluation process. The duration requirement is not an issue in the disability determination unless the claimant’s impairment(s) is severe and prevents substantial gainful activity (SGA), or for children, the child’s impairment(s) is severe and results in marked and severe functional limitations.

A. Claims involving multiple impairments

If a claimant has multiple impairments, consider the combined effect of all impairments, unless one impairment, when considered separately, is of sufficient severity and duration for an allowance.

1. Unrelated severe impairments

If a claimant has a severe impairment(s) and then develops another unrelated severe impairment(s), but neither one is expected to last for a continuous period of 12 months, you cannot combine the expected duration of the unrelated impairments to meet the duration requirement.

2. Concurrent impairments

If a claimant has two or more concurrent impairments and these impairments, when considered in combination, are so severe as to prevent SGA, decide whether the combined effect of the concurrent impairments is expected to prevent SGA for 12 continuous months. If one or more of the impairments improves, or is expected to improve within 12 months, and the combined effect of the remaining impairment(s) is no longer so severe as to prevent SGA, the 12-month duration requirement is not met.

3. CDRs with a new impairment

In continuing disability review (CDR) cases, if a claimant has a new disabling impairment(s) that begins in or before the month in which the last disabling impairment(s) is no longer disabling, the period of disability continues. The new impairment(s) must be so severe as to prevent SGA, but it does not need to be expected to result in death or last for a continuous period of 12 months. For children, the new impairment(s) must be severe enough to result in marked and severe functional limitations.

Conversely, if a claimant has a new disabling impairment(s) that begins after the cessation month, you must determine if the new disabling impairment can be expected to result in death or has lasted or can be expected to last for a continuous period of not less than 12 months. To establish a new period of disability, the new impairment(s) would need to meet the duration requirement. For more information on the CDR evaluation process regarding new impairments and subsequent disability, see DI 28005.210.

B. When and how to determine “expected duration”

When adjudicating a claim within 12 months of the date the claimant first met the medical criteria for disability, determine the “expected duration” of the claimant’s impairment(s), if necessary, by projecting whether the impairment(s) is expected to result in death or continue to be severe and prevent performance of SGA for a continuous period of not less than 12 months. In child cases, project whether the impairment(s) will continue to be so severe that it causes marked and severe functional limitations.

Consider the nature and course of the impairment(s), as well as the claimant’s treatment history, by evaluating the following evidence:

  • symptoms, signs, and laboratory findings;

  • frequency, dosage, and effects of medication;

  • surgery, radiation, or chemotherapy; and

  • treatment response, such as improvement or worsening in symptoms, signs, and laboratory findings.

Longitudinal evidence is extremely important and necessary when evaluating the severity of a mental impairment(s). A claimant’s level of functioning can vary considerably over time. It is vital to obtain evidence from relevant sources over a sufficiently long period prior to the date of adjudication to establish severity and probable duration of the impairment(s).

C. Severity and the duration requirement

In most cases in which evidence supports a finding of disability, it will be clear whether the impairment(s) is expected to result in death or has lasted or is expected to last for a continuous period of not less than 12 months from the onset of disability. If you adjudicate the case before a disabling impairment(s) has lasted 12 months, it is necessary to project severity. You will need to explain why you believe the impairment(s) is expected to result in death, or has lasted or can be expected to last for a continuous period of not less than 12 months. If you are adjudicating a case within 12 months of onset and the impairment has never been disabling, it is not necessary to project severity.

1. Projecting severity

The nature of the impairment, the medical history, and the prescribed treatment are necessary considerations before you can determine if the impairment(s) is expected to result in death or will continue to prevent the claimant from engaging in SGA for the additional months needed to make up the required 12 months duration. If you expect a claimant’s severe impairment(s) to improve, it may be necessary to project severity at 12 months from onset.

Example of projecting severity where improvement is expected:

A claimant fractured his femur and he is only able to walk by using a walker. At 3 months post fracture, current imaging showed there was not a solid union and he still could not walk without assistance.

You could consider one of the listings (1.00/101.00). However, by assessing the nature of the impairment and evaluating the treatment he is receiving, you can project severity and determine that he will likely recover and return to effective ambulation within 12 months of onset. A durational denial is appropriate because the impairment is not expected to last a continuous period of not less than 12 months.

NOTE: Projecting severity may involve projecting residual functional capacity (RFC) as explained in DI 25505.030E.1. in this section.

2. Severe impairment(s) responsive to treatment

A claimant may have a severe impairment(s) that has responded to treatment and has restored his or her ability to work, or for a child, his or her ability to function. If the claimant has met the duration requirement, he or she may be entitled to a closed period of disability. For more information on closed periods, see DI 25510.000.

NOTE: To support a closed period of disability, the adjudicator must establish that medical improvement has occurred. For more information on the medical improvement standard, see DI 28010.000.

3. Child’s severe impairment(s) does not meet duration requirement

If a child’s medically determinable impairment(s) is or was of listing-level severity, but is not expected to result in death or be of listing-level severity for a continuous period of not less than 12 months, the child’s impairment(s) does not meet duration requirement and you must deny the claim. The child’s Personalized Disability Notice (PDN) should explain that, within 12 months of onset, the child’s impairment(s) no longer results or is no longer expected to result in marked and severe limitations; therefore, the claim is denied.

4. Non-severe durational denial

If there is or will be no significant limitation of the claimant’s ability to perform basic work-related activities due to a physical or mental impairment (i.e., non-severe), the duration requirement is not met and you must deny the claim.

In child cases, if a physical or mental impairment causes or is expected to cause no more than minimal functional limitations by the end of 12 months, the duration requirement is not met and you must deny claim.

The PDN for adults should explain that, within 12 months of onset, there was or is expected to be sufficient restoration of function so that there is or will be no significant limitation of the ability to perform basic work-related functions.

The PDN for children should explain that, within 12 months of onset, there was not or is not expected to be any impairment(s) of such severity that would result in marked and severe functional limitations.

D. Disabling level of severity

The Listing of Impairments (the listings) describe impairments we consider severe enough to prevent a claimant from doing any gainful activity. For children under title XVI, the impairment(s) must be severe enough to cause marked and severe functional limitations. 20 CFR 404.1525(c)(3) states, “We will find that your impairment(s) meets the requirements of a listing when it satisfies all of the criteria of that listing, including any relevant criteria in the introduction, and meets the duration requirement.”

IMPORTANT: Medical deferment may be necessary to allow enough time to secure the medical evidence needed to determine duration. For information on medical deferment, see DI 25505.035.

E. Impairment(s) does not meet or medically equal a listing

1. Projecting RFC

It may be necessary to project RFC to show the claimant’s predicted functional capacity at 12 months from the onset of disability if:

  • the impairment does not meet or equal a listing, but continues to be severe 12 months from onset;

  • the impairment(s) is currently at listing level but is expected to improve, and there are significant limitations to performing basic work activities;

  • the claimant has a disabling impairment currently, adjudication is within 12 months of onset, and the impairment is not expected to result in death or be disabling at the end of the 12 months; or

  • the claimant has a disabling impairment currently, adjudication is within 12 months of onset, and the impairment is expected to result in death or be disabling at the end of 12 months.

In certain instances, more than one RFC assessment may be necessary to address onset and duration, although this would be unusual. For more information on multiple RFC assessments, see DI 24510.020C.3.

The effects of any type of limitation(s) when projecting RFC vary greatly, depending upon the degree of the claimant’s limitations, and you must determine them based upon the facts of each individual case. Projecting RFC is a matter of adjudicative judgment.

Example of projection of RFC:

The claimant had a skiing accident and sustained multiple broken bones, a collapsed lung, and abrasions on 01/25/2011. You are assessing the claim on 04/03/2011, after receiving all of the requested medical evidence.

The claimant’s condition is not of listing level; however, he is still very slow in recuperating. You anticipate that the claimant’s current condition is much worse than it will be on 01/24/2012.

Since his condition prevents SGA, you should project his RFC to reflect his predicted functional capacity on 01/24/2012; i.e., 12 months from the date the claimant first met the medical criteria for disability.

When projecting RFC, on page 1 of the RFC Assessment form (SSA-4734-BK or SSA-4734-F4-SUP), select the block that says “Date 12 Months After Onset” and enter the applicable date. You must explain in your narrative that the RFC reflects the claimant’s functioning 12 months from the date the claimant first met the medical criteria for disability. For more information on how to complete the physical RFC assessment form, see DI 24510.050.

NOTE: Do not project the RFC if a claimant’s impairment(s), though severe, does not currently prevent the claimant from engaging in SGA. In this case, a denial based on performance of SGA or an assessment of function and ability to do past or other work is appropriate. For an explanation of policy for projecting the RFC, see DI 24510.020A.

2. RFC and the duration requirement

If you expect a claimant to be able to engage in SGA before the end of 12 months despite significant remaining limitations, then the claimant has not met the duration requirement and you will deny the claim. The PDN must explain that within 12 months of onset, there was, or is expected to be, sufficient restoration of function that, in spite of significant remaining limitations, the claimant should be able to engage in SGA considering the vocational factors of age, education, and previous work experience.

If there is not sufficient evidence in file to determine response to treatment in order to project severity or a claimant’s RFC, obtain supplemental evidence. Consider whether deferred development could potentially provide the evidence necessary to project RFC. For guidance on medical deferment, see DI 25505.035.

IMPORTANT: It is extremely important to thoroughly evaluate, document, and rationalize the claimant’s RFC, work history, and vocational potential when considering a durational denial. The determination may require consulting with all members of the adjudicative team. For further discussion on adjudicative roles and responsibilities of disability examiners (DE), medical consultants (MC), and psychological consultants (PC), see DI 24501.001.

NOTE : When considering vocational issues for claimants with a disabling impairment(s) requiring a projected RFC, the relevant period for past work is 15 years before the end of the projected 12-month period. For a chart on relevant work periods, see DI 25001.001B. If it is necessary to proceed to Step 5, use the age the claimant will be at the end of the 12-month period.

F. Performance of work activity before meeting the duration requirement

If a claimant with a severe impairment(s) performs work prior to meeting the 12-month duration requirement, then the claimant may:

  • have medically recovered;

  • be working despite meeting the medical requirements for Social Security Disability; or

  • have work that may be an unsuccessful work attempt (UWA), subsidized, or involve impairment-related work expenses (IRWE).

For more information on these topics, see DI 24005.001, DI 24001.025, and DI 24001.035 respectively.

The appropriate action, as explained below in this section, depends on factors such as the type of claim (title II or title XVI) or the timing of the return to SGA.

The answers to the following questions will help determine which action(s) is necessary:

  • Is the work SGA?

  • When did the work begin?

  • Is the work continuing?

  • If not, when did the work end?

If you have not adjudicated the claim and the Disability Determination Services (DDS) receives information indicating there is work activity that could be SGA, cease further development and contact the field office (FO) for a resolution of the work issue.

If you have adjudicated and allowed the claim, then disability may continue, subject to a trial work period (TWP), or you may have to reopen and revise the prior favorable determination to a denial or establish a later onset date.

See also:

  • DI 10501.025 Field Office (FO) and Disability Determination Services (DDS) Responsibilities and Procedures for Work Issue Cases

  • DI 25501.390 Considering Substantial Gainful Activity (SGA) and Past Work when Establishing the Established Onset Date (EOD)

DI 25505.035 Medical Deferment Involving the Duration Requirement

CAUTION: Do not view the examples provided in this section as strict requirements of when you should and should not defer a claim. Apply adjudicative judgment on an individual case basis.

A. Determining the need for medical deferment

Medical deferment is necessary in claims where you need future medical evidence to assess the duration of disability. The predictability of a claimant’s response to treatment is a major consideration in deciding whether to defer medical development. For example, if the response to treatment is more predictable, such as treatment for a simple fracture, the case is less likely to require medical deferment.

REMINDER : Medical deferment is an exception to routine case processing because most impairments of a disabling level of severity are static or progressive in nature. Determining whether medical deferment is appropriate requires making a sound medical judgment based on the specific case facts.

B. Factors to consider when determining whether medical deferment is appropriate

Do not delay requests for non-medical information (activities of daily living (ADL), Work History Report, etc.) or development of evidence from the medical source(s) cited in the application or elsewhere, even though you may need to postpone final adjudication. Use good judgment when requesting ADLs in particular. If you request and receive ADLs immediately following a trauma, the ADLs may not give an accurate assessment of the response to treatment.

1. Recovery period

We characterize some impairments, such as a cerebrovascular accident (CVA) or a myocardial infarction (MI), as a major event followed by a period of stabilization and varying degrees of improvement. Therefore, a longitudinal clinical record covering a period of at least 3 months after the event is necessary to assess the medical severity and duration of the impairment(s).

Some impairments, such as certain cancers, require multimodal treatment (surgery, radiation, or chemotherapy) to provide a remedy. Therefore, a longitudinal clinical record may be necessary to assess treatment response. Consider each case on an individual basis, as therapy may vary greatly and have different effects on different claimants.

Make favorable determinations without medical deferment when it is evident from the medical and other evidence that the claimant has little or no chance of regaining significant function. If the best recovery following the major event or the treatment will still result in an allowance under medical or vocational considerations, then medical deferment is not necessary. For example, if a claimant had a CVA, with or without coma, and an acceptable medical source indicates that the claimant has disabling limitations with little or no chance of regaining significant function, you can make a favorable determination at any time before 3 months, without medical deferment.

2. Medical evidence after 12 months

Do not defer medical development to obtain evidence more than 12 months after the onset of disability.

3. Approaching end of duration period

An impairment(s) that is close to meeting the duration requirement is less likely to need medical deferment.

C. Examples of when medical deferment may be appropriate

Medical deferment may be necessary if:

  • a listing or other policy requires a specific time frame for evaluating severity;

  • an impairment(s) is likely to improve, but the current findings are not sufficient to make an informed projection of severity or residual functional capacity; or

  • the claimant will shortly undergo treatment that is expected to correct or significantly improve his or her impairment

The following impairments are examples of when medical deferment would likely be necessary.

1. Cancer

Unless the claimant’s impairment(s) meets or medically equals a listing with current evidence, evaluate the claimant’s response to treatment after enough time has passed to allow a determination as to whether the treatment will achieve its intended effect. For example, in cases of tumors with distant metastases that are expected to respond to antineoplastic therapy, such as testicular and non-anaplastic thyroid cancers, you may need at least 3 months of longitudinal history after therapy starts to determine response to treatment.

2. Coronary artery bypass graft (CABG) surgery

Unless an allowance is indicated, you will need to know the claimant’s symptoms and clinical findings after his or her cardiac condition has stabilized, usually 3 months status post CABG.

3. Myocardial infarction (MI)

Unless an allowance is indicated, (i.e., need for emergent CABG, evidence of severe and ongoing heart failure, or evidence of severe ongoing dysrhythmias), you will need to know whether the claimant continues to have cardiac symptoms and clinical findings at least 3 months status post MI.
Exception: For an uncomplicated MI, follow-up evidence from the claimant’s medical source, generally several weeks status post MI, will be persuasive for a functional capacity assessment and the 3-month deferral period would not apply. See also, DI 24545.001B.3.

4. Drug therapy for cardiac impairment(s)

If the claimant has started new drug therapy and the response to treatment has not been established, you will need to obtain evidence 3 months following the event before evaluating the impairment; for example, beta-blocker therapy for dilated congestive cardiomyopathy.

5. Cerebrovascular accident (CVA)

Evaluate evidence of any residual impairment(s) at more than 3 months following a CVA, unless the claimant demonstrates an unusually rapid recovery. Do not medically defer the claim when an allowance is appropriate if the evidence clearly indicates little or no chance of recovery.

NOTE: Do not medically defer a claim for a transient ischemic attack (TIA). A TIA produces neurological deficits lasting no more than 24 hours and does not result in any significant residual neurological deficits.

6. Traumatic brain injury (TBI)

If evidence of a profound neurological impairment is not sufficient to permit a finding of disabled within 3 months post-injury, defer adjudication until there is enough evidence of impairment caused by cerebral trauma at least 3 months post-injury. If a finding of disabled is not possible at that time, defer adjudication and obtain evidence at least 6 months post-injury, which is when a severe mental impairment may become apparent.

7. First-time psychotic episodes

When there is no history of psychosis and the claimant applies for disability shortly after a first-time episode, you must obtain evidence describing the claimant’s mental status after the condition has stabilized. You need information about the level of functioning, usually at least 1 month following hospital discharge or at least 2 to 3 months after the initial psychotic episode, to determine if the claimant can return to his or her earlier level of functioning or if he or she has residual symptoms. For those who have a psychotic episode and recover relatively quickly to the pre-episode level of functioning without further episodes, a durational denial is appropriate.

D. Examples of when medical deferment may not be appropriate

The following impairments are examples of when medical deferment would likely be unnecessary. However, in some situations, medical deferment may still be appropriate.

1. Fractures

Base the determination on normal healing times and the degree of expected residual impairment, unless there is indication of significant complications or healing delays (e.g., comminuted or non-union fractures). Most fractures do not require medical deferment to assess duration or severity.

2. Amputation

It is not necessary to defer adjudication in every case involving stump complications; deferring the case should be the exception, rather than the rule. If there is progressive improvement, it may be reasonable to project severity or RFC without deferring the claim. When progress is delayed or there are complications, it may be necessary to hold the case until the next follow-up visit or until a reasonable projection of severity can be made, but there is no specific amount of time to defer a case. Consider each case on an individual basis, making a sound medical judgment based on the specific case facts.

3. Laminectomy, fusion, and other surgeries

Consider the preoperative pathology, operative findings, surgical procedure, and response to the surgery including reports on any postoperative complications. Do not defer medical development to resolve the specific maximum RFC attained following the initial surgical procedure when the claimant’s vocational outlook is favorable at all exertional levels. In most instances, surgery will improve function to the point that severity is not of listing level.

4. Percutaneous transluminal coronary angioplasty (PTCA)

PTCA stent procedures do not normally require medical deferment. In most cases, claimants may return to normal activities within a few days or weeks of the procedure.

5. Acute liver disease

There are several possible outcomes for a claimant with acute liver disease, including complete recovery, progression to chronic liver disease (active or inactive), or fulminant (acute) liver failure. Prothrombin time/INR, serum albumin, and bilirubin tests are measures of liver function. Do not defer a case of acute liver disease if PT/INR, serum albumin, or bilirubin tests have returned to normal levels. Note that these tests are not the same as liver enzymes, which, in severe chronic liver disease, may be normal.

6. Epilepsy

Generally, seizure disorders respond readily to anticonvulsant treatments. In most cases, claimants with epilepsy who are under appropriate treatment are capable of engaging in SGA. You will not need to defer the majority of these cases.

7. Terminal illness (TERI) cases

We expect that TERI cases, which involve an allegation or an indication in the medical record that an impairment(s) is untreatable, will result in death. Medical deferment to assess the response to treatment or level of residual impairment is rarely applicable to TERI cases. In the rare instance when medical deferment may be necessary for a TERI case, obtain documented approval from a medical consultant (MC) and include it in the case record. For more information on the documentation required for medically deferring TERI cases, see DI 23020.045.

E. References


DI 25505 TN 1 - Duration - 4/01/2021