For the purposes of evaluating MI, only consider an impairment(s) "present" at the time of the CPD if the supporting evidence at the CPD established the existence of the impairment(s). We consider an impairment(s) established if the CPD file included medical evidence that established a medically determinable impairment (MDI). For additional information about MDIs, see DI 24501.020 and DI 25205.005.

When assessing MI, we do not consider impairments that were only alleged at the CPD. If the CPD file did not contain supporting evidence to establish an MDI, the impairment is "unestablished."

Unestablished impairments or new impairments that have occurred since the CPD are evaluated at the following steps in the CDR sequential evaluation process:

For Title II and adult Title XVI CDR cases-

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  Step 2 - meets or equals a current listing; see DI 28005.015A.2.

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  Step 6 - severity of current impairment(s); see DI 28005.015A.6.

For Title XVI child CDR cases-

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  Step 3 - current severity and meets, medically or functionally equals a listing; see DI 28005.030C.3.

The MI determination must be based on improvements in the symptoms, signs, or laboratory findings associated with the individual’s established comparison point decision (CPD) impairment(s). Evaluating MI requires a comparison of the symptoms, signs, or laboratory findings that were documented in connection with the CPD impairment(s) at the time of the CPD with closely related symptoms, signs, or laboratory findings that are associated with the same impairment(s) currently. To find MI has occurred, it is not necessary to have improvement in symptoms, and signs, and laboratory findings.

It may be possible to find MI if there is an improvement only in a symptom(s), a sign(s), or specific laboratory finding. For example, if an individual was allowed at the CPD due to a back disorder causing them to ambulate with a walker and the continuing disability review (CDR) evidence shows that the individual is no longer ambulating with an assistive device yet some of the symptoms and laboratory findings remain unchanged, a finding of MI may be appropriate. In order to make a determination that MI has occurred, there must be a decrease in the medical severity based on improvement in symptoms, signs, or laboratory findings associated with the CPD impairment(s). When evaluating if MI has occurred, the adjudicator must disregard minor changes in symptoms, signs, or laboratory findings that do not obviously represent medical improvement and could not result in a finding that an individual's disability has ended, see DI 28010.015C.

For examples of cases with MI and no MI, see DI 28010.025.

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  Consider the symptoms, signs, and laboratory findings related to the impairment(s) established at the time of the CPD.

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  Consider current (CDR) symptoms, signs, and laboratory findings related to the impairments that were established at the time of the CPD.

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  Identify changes or improvement in symptoms, signs, or laboratory findings, and evaluate their medical severity according to current guidelines for assessing severity (e.g., the instructions in DI 24515.000 on the evaluation of specific issues and the guidance on considering symptoms in SSR 16-3p, “Titles II and XVI: Evaluation of Symptoms in Disability Claims”). For detailed information about symptoms, signs, or laboratory findings, see DI 24501.020.

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  Decide whether the changes reflect a decrease in medical severity. Note that a decrease in medical severity of any one of the impairments present at the time of the CPD shows MI. See DI 28010.001A for additional information.

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  Follow the instructions in DI 28010.029 if the CPD involved an impairment that met a listing with a period for which the impairment is considered disabling.

Consider all the evidence relevant to a disability determination at each point in considering prior and current symptoms, signs, and laboratory findings; this includes consideration of a 12-month medical history but may involve a different period, depending on the impairment involved. Do not focus on a particular day, i.e., the day of the CPD. For information on the 12-month developmental policy, see DI 28030.020D.

For example, adjudicators should view impairments like fractures with a narrower focus than neoplasms, which require longer timeframes to evaluate the success or failure of treatment. For information concerning impairments subject to exacerbations and remissions, see DI 28010.115

Disregard minor changes in an individual’s symptoms, signs, or laboratory findings that do not represent MI and could not result in a finding that disability has ended, see DI 28010.001A. This guidance applies to adults as well as to children. For additional information on comparing symptoms, signs and laboratory findings, see DI 28010.015C.

Symptoms, signs, and laboratory findings include any evidence of physical and mental functioning used with medical findings at the time of the CPD. For example, in the adult and child mental disorders listings, the “paragraph B” criteria refer to function that may be affected by a mental impairment and therefore demonstrate medical severity. As such, they may constitute medical findings. If the CPD considered such abnormalities as medical findings, the adjudicator must also consider evidence about such function when considering whether there is MI. This also applies to the criteria in listings that have been revised since the CPD or are now obsolete.

Symptoms are the individual's own description or statement of their physical or mental impairment(s), and cannot always be measured through objective medical evidence (signs or laboratory findings). Objective medical evidence may, however, be used to draw reasonable conclusions about the intensity and persistence of symptoms, including whether changes in symptoms may show MI.

Adjudicators must consider whether an individual's statements about the limiting effects of their symptoms are consistent with the medical signs or laboratory findings of record.

Improvement in symptoms alone, without associated changes in signs or laboratory findings, may, however, support finding MI. If a sign or laboratory finding remains unchanged but the individual’s symptoms have improved and resulted in an increase in function, a finding of MI may be appropriate. Although improvement in symptoms alone may support an MI determination, the adjudicator must continue with the remainder of the required CDR analysis in order to reach a determination. For more information on the evaluation of symptoms, see DI 24501.012 and SSR 16-3p: “Titles II and XVI: Evaluation of Symptoms in Disability Claims.”

Children demonstrate different age-appropriate activities as they grow and develop. Given these changes, the adjudicator must consider the relationship of prior and current findings to the individual's prior and current age. Do not base the MI decision solely on the presence or absence of change in such findings.

Do not decide MI by formally assessing current severity, and then comparing current severity to the prior assessment made by the CPD adjudicator. To evaluate MI, the adjudicator must carefully evaluate signs, symptoms, and laboratory findings to determine whether MI has occurred, as discussed in DI 28010.001A. For additional information on substitution of judgment, see DI 28005.007.

Do not substitute judgment based on the prior adjudicator or medical consultant or psychological consultant’s (MC/PC) assessment to find MI by formally assessing current severity, and then comparing current severity to the prior assessment made by the CPD adjudicator. For example, a MC at the time of a CDR feels the individual was capable of standing and walking six-hours as opposed to the CPD MC’s rating of standing and walking four-hours. If the signs, symptoms and laboratory findings present at the CPD were discussed and evaluated appropriately, the current MC must not substitute his judgment for the supported evaluation and rationale completed by the MC at the CPD.

To appropriately assess MI, we look carefully at findings (signs, symptoms, or laboratory findings) that were used to support the medical assessments (SSA-416, residual functional capacity (RFC), psychiatric review technique (PRT), mental residual functional capacity (MRFC), SSA-538, etc.) at CPD to see if there are any changes to those signs, symptoms or laboratory findings. The RFC and other aforementioned assessments provide administrative medical findings of fact. This is not to be confused with the medical findings in the evidence, such as signs and laboratory findings.

CPD evidence: The individual reported difficulty standing and walking due to a back disorder, exhibited by ambulating with a limp. The individual was taking medicine prescribed by their pain management doctor to mitigate pain symptoms associated with their back impairment. X-rays showed mild-to-moderate spinal stenosis The CPD adjudicator prepared an allowance based on a sedentary RFC due to back pain.

CDR evidence: The individual currently complains of back pain and is taking over-the-counter medications because the individual no longer has a regular doctor. The individual reports difficulty standing due to the pain, but they are able to perform some light household chores. Exams show ambulation with a slight limp on the right side. Recent x-rays show mild-to-moderate lumbar stenosis. Based on this evidence the current adjudicator prepares a light RFC assessment. The individual’s benefits are ceased because the vocational rules indicate “not disabled.”

Discussion: In the example provided, the individual currently complains of back pain, difficulty standing and walking due to pain, and is taking pain medications for their symptoms, the individual walks with a limp (signs), and x-rays (lab findings) are consistent with films from the CPD. The current adjudicator substituted judgment (a light RFC) for that of the CPD adjudicator (a sedentary RFC). There was no need for a current RFC assessment since the symptoms, signs and lab findings have not improved since the CPD. The current adjudicator should have prepared a “no MI” determination.

When the CPD folder is inadequate to permit a reasonable determination about MI or whether MI is related to the ability to work, and current evidence clearly supports finding the individual is disabled (i.e., impairment(s) currently meets or medically equals a listing or can be a current medical-vocational continuance), use the flexible approach to skip steps in sequential evaluation. See DI 28005.005C.

If the evidence from the CPD is available but is inadequate to permit a reasonable determination of whether there is MI, or whether MI is related to the ability to work, then:

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  Do not find MI,

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  Make sure current documentation is adequate for future CDRs, and

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  Find that disability continues (in the absence of an exception).

Code such continuances as "insufficient to assess MI", please see the table below.

For additional instructions on completing the SSA-832 or SSA-833 and scheduling a reexamination diary, see DI 28035.025E.

When CPD evidence is adequate, but is incomplete on points emphasized in current available evidence (for example, functional information about concentration or pace), carefully examine all the prior documentation for related information that may have been present at the CPD but is not immediately evident.

Assume no (or minimal) prior limitation or abnormality of finding in areas where a thorough search of CPD evidence provides no information about the factor in question. Apply this assumption only in assessing MI and comparing residual functional capacity.

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  The adjudicative team must disregard changes within the SEM of the particular test involved.

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  If questions arise, a DDS medical or psychological consultant with the appropriate specialty should analyze the SEM of the test or equipment used.

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  If necessary, the DDS must re-contact the source(s) of the evidence for clarification as needed.

For procedures on test error of IQ scores, see DI 24583.055 and DI 28010.150.

The following types of decisions are CPDs (see DI 28010.020A) when they meet the following criteria:

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  Decisions (based on medical evidence that was current at the time of the decision) that the individual continues to have a disabling impairment, or

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  Adoption decisions (or decisions which let to the application of collateral estoppel on subsequent claim) where there was a usual level of development and current medical evidence that included consideration of medical, functional, or medical/vocational issues, or

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  The earlier medical decision (usually under a different title) used as the basis for an adoption decision (i.e., without development and consideration of medical evidence at the time of adoption).

The following types of decisions do not involve development of current medical evidence or consideration of medical issues. They are not appropriate CPDs because the supporting evidence for the decision does not provide a suitable basis for medical improvement review standard (MIRS) comparisons. Therefore, do not use the following types of decisions as CPDs:

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  Collateral estoppel decisions without medical development completed. Use the decision that was the basis for collateral estoppel, such as the most recent prior favorable determination or decision based on meeting or equaling a listing (or functionally equaling a listing), an allowance based on medical-vocational rules, or a CDR related decision (such as a decision finding no MI) that included full medical development.

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  SSA-899-U2's (Continuing Disability Review) categorizing individuals as permanently impaired, without evaluation of then-current medical evidence

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  Reinstatement under a CDR moratorium

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  Decisions based solely on work

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  Decisions not involving consideration of the issue of current disability (e.g., most decisions on appeals requesting an earlier onset)

At the CPD, the evidence established the individual had major depressive disorder and migraines. Medical records indicate depressed mood, decreased energy, suicidal ideation, sleep disturbance, and diminished interest in activities. The evidence notes the individual has tried 4 different medications over the last 3 years without meaningful improvement in symptoms or quality of life. The individual reports sleeping about 3-4 hours per night and napping several times during the day.

Review of the activities of daily living and reports to the medical source indicate significant problems interacting with others. For example, the individual has groceries and items delivered rather than going out in public due to her significant fear of dealing with the public. The individual will not visit family in person and only sends text messages.

The medical evidence indicates significant problems staying on task, noted by frequent redirecting in sessions with medical source. Evidence also notes that the individual was fired from their job three months prior to the CPD for poor performance, crying episodes, and walking off on customers when questioned or problems came up. The individual’s supervisor attempted to have her work in back room away from the public, but she could not handle simple tasks and remained off task.

Evidence indicates two hospitalizations for suicidal ideation, one overnight stay and one Baker Act initiated by a concerned family member resulting in a three-night hospitalization.

Regarding the individual’s physical impairment, the migraines controlled occurring once or twice a month on average. The individual takes over the counter medication as needed.

At the CDR, the individual alleges ongoing disability due to depressive disorder, migraines, and a herniated disc. Medical source evidence indicates that the individual is stable on medication with mild depressive symptoms. Compared to the CPD evidence, findings are remarkable for improvement in mood, social activities, and concentration. Evidence does not indicate any tearful events during visits and no suicidal ideation. The individual reports sleeping about 6-7 hours a night.

The individual reports they have joined a small group of neighbors engaged in a biweekly book club. The individual reports to the medical source that they participate in a variety of social activities, such as shopping or attending the farmers markets several times a month with these friends.

The individual reports mending ties with family and babysits their 4-year-old niece three days a week, attends family gatherings but will only stay for a few hours if they start to feel uncomfortable, and the medical source notes indicate that they have set positive boundaries with family and can recognize their limits. This has improved interpersonal relationships. Medical evidence indicates no psychiatric hospitalizations since the CPD.

Regarding the individual’s migraines, the individual notes that migraines occur approximately once or twice a month and are controlled on over the counter medication

Find MI at Step 3 of the Title II and adult Title XVI CDR sequential evaluation process and proceed to Step 4.

Evidence indicates improved mood and concentration and an increase in social activities and social function, demonstrated by the individual’s engagement in activities such as attending a book club, visiting the farmers market to purchase items in person as opposed to only ordering items online to be delivered due to symptoms at the time of the CPD. The individual also demonstrates decreased sleep disturbance, where sleep has improved to 6-7 hours a night as opposed to 3-4 hours a night at the CPD. Additionally, the individual has experienced increased energy, evidenced by engagement in activities and babysitting their niece several days a week, as opposed to napping during the day and avoiding activities at the CPD.

At the CPD, an individual with a herniated nucleus pulposus underwent a laminectomy. A postoperative myelogram showed evidence of a persistent defect in the lumbar spine. The individual had pain in his back, as well as pain and a burning sensation in his right foot and leg. Evidence did not show muscle weakness or neurological changes, but it did show a moderate decrease in motion of the back and leg.

At the CDR, the evidence shows that the individual receives treatment from their primary care physician every two or three months for the past 2 years. No further myelograms have been done. The individual continues to complain of pain in the back and right leg especially when sitting or standing for more than a short period. The doctor reports a moderately decreased range of motion in the back and right leg and still reports no muscle atrophy or neurological changes.

Find no MI, then consider if a Group I or Group II exception to MI applies. If no exception applies, find that disability continues.

The evidence does not show changes in symptoms, signs, or laboratory findings on which to base a finding of decreased medical severity.

At the CPD, benefits were awarded based on laboratory results showing inflammatory arthritis. The individual's physician reported persistent swelling and tenderness of the individual's fingers and wrists and noted that the individual complained of joint pain.

At the CDR, tests still show rheumatoid arthritis. But as a result of therapy, the individual's fingers and wrists have not been significantly swollen or painful for the past year.- The decreased pain and swelling has led to an increase in the individual's fine and gross manipulation.

Find MI at Step 3 of the Title II and adult Title XVI CDR sequential evaluation process and proceed to Step 4.

Changes in symptoms and signs show decreased medical severity. Inflammatory arthritis is an example of an impairment subject to temporary remission, and the improvement demonstrated in this example has been sustained long enough to establish remission; see DI 28010.115.

At the CPD, an individual with bronchial asthma met listing 3.03. The individual had spirometry findings and exacerbations requiring four hospitalizations within a twelve month period that were at least 30 days apart, as required by the A and B criteria in listing 3.03.

At the CDR, the individual received medication management and had only one hospitalization for an asthma exacerbation between the time of the CPD and the CDR. Current medical evidence shows decreased frequency, severity, and duration of wheezing attacks. Current evidence does not show changes in spirometry.

Find MI at Step 3 of the Title II and adult Title XVI CDR sequential evaluation process and proceed to Step 4.

Evidence supports an improvement in signs and symptoms. Although the individual's spirometry readings (laboratory findings) have not decreased, there is decreased frequency, severity, and duration of attacks.

At the CPD, the child was allowed based on marked limitations in two domains of function, acquiring and using information and interacting and relating with others (see DI 25225.005). The impairments that resulted in the marked limitations were due to a learning disability and oppositional defiant disorder. School records indicated that the child was not on track to be promoted to the next grade level and would need to repeat the third grade due to significant limitations in reading and writing. The child also demonstrated difficulty interacting with peers, often getting into altercations with other students and bullying peers. The child required intervention and re-direction in such instances and was not able to build or maintain positive relationships.

At the CDR, the child continues to exhibit learning difficulties in reading and writing. The child has an individualized education plan and receives small group instruction three times a week for reading and writing activities. The child remains below grade level based on standardized test scores and achievement testing. The child continues to get into altercations and was diagnosed with oppositional defiant disorder and attention deficit hyperactivity disorder since the CPD. The child attends therapy sessions and continues to exhibit frequent anger outbursts, avoidant behavior, and periods of non-responsiveness when questioned by the therapist. Medication management has not been effective, as the child often refuses to take medication and will become combative when questioned.

Find no MI at Step 1 of the Title XVI child CDR sequential evaluation process and consider if a Group I or Group II exception to MI applies. If no exception applies, find that disability continues.

The evidence supports the conclusion that the child has no improvement in signs, symptoms, or laboratory findings at the CDR.

At the CPD, the child was allowed due to an extreme limitation in moving about and manipulating objects due to limitations from the child's extreme scoliosis. The child underwent surgery to place a rod in their back. After the surgery, the child suffered complications in the lower extremities due to significant atrophy and loss of sensation. The child used a wheeled walker for stability for ambulation and could only ambulate approximately 10 yards without the device.

At the CDR, the child did not undergo any additional surgical interventions. X-rays show the rod in place and persistent scoliosis. The child uses a wheeled walker when traveling longer distances to transfer classes during the school day but does not require any assistive device when walking short distances less than 20 yards. The child is involved in a swimming program three days a week and rides their bike two-to-three times a week with friends.

Find MI at Step 1 of the Title XVI child CDR sequential evaluation process and proceed to Step 2.

Although the laboratory findings have not changed, the child has demonstrated improvement in their symptoms. The child's functional abilities have increased at the CDR as evidenced by the increased ability to ambulate less than 20 yards without an assistive device and to engage in multiple sport activities that do not require walking as far as 60 feet.

Some Part B listings designate an age for which an impairment should meet the listing OR a timeframe after a procedure or treatment an impairment meets the listing, whichever is more favorable to the individual (i.e., “whichever is later”).

For example:

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  Listing 102.11“Hearing loss treated with cochlear implant” - states that the child must be considered “under a disability until the attainment of age 5 or for 1 year after initial implantation, whichever is later.”

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  If a 3-year-old received the transplant, the listing is met until attainment of age 5.

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  If a 4½-year-old received the transplant, the listing is met for 1 year.

Although Listing 102.11 above contains age criteria, the intent of scheduling a diary for this listing is to use the age criteria (age 5) or 1 year after implantation of the cochlear implant, whichever is more favorable to the child. The diary length will vary due to the age designated in the listing and the child’s age at the time of adjudication. At the CDR, it may be appropriate to use the flexible approach to facilitate a continuance at Step 3 if the “later” time period criteria have not passed at the time of the CDR; see DI 28005.005C.

For evaluation purposes at the CDR, once the child has passed the age designated in the listing or the time period after the procedure or treatment has passed, the impairment cannot continue to meet the comparison point decision (CPD) listing with that age criteria when considering the prior listing step in the CDR sequential evaluation process.

Some cancer listings include a specified timeframe, and some cancer listings indicate a minimum period of disability in the listing criteria.

Listings with a specified timeframe include a specific fixed point for establishing how long an impairment will be considered disabling. This may be ‘x’ year(s) from the date of a transplant or surgery, etc. Examples of listings with specified timeframes are provided in DI 28010.030B.

Minimum periods of disability will not always occur at a fixed point for establishing a diary length based on the nature of the disabling impairment(s) and the individual’s age or treatment status. There is variance in the specific length of the diary assigned based on the factors involved in the listing criteria. Examples of such listings are provided in DI 28010.035B. For additional information on evaluating listings with minimum periods of disability at the CDR, see DI 28010.035.

Regardless of whether the listing indicate a time period for which the listing is met, we must follow the CDR sequential evaluation process, including consideration of MI and related issues.

If the listing at CPD that was met or equaled was a cancer listing with a specified timeframe, follow the instructions and guidelines in DI 28010.030. For related instructions involving cancer listings with a minimum time period, see DI 28010.035.

The 3-year remission rule that applies to most cancers is not the same as the specified timeframe of disability directed by some cancer listings.

If an individual’s impairment(s) meets or medically equals the cancer listings (13.00 and 113.00), a 3-year period of remission is generally required before cessation under the Medical Improvement Review Standard (MIRS) is possible. However, there are exceptions to considering a 3-year remission period.

The 3-year period of remission does not apply to cases where:

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  The listing indicates a specified timeframe, or

• •

  The listing indicates a minimum period of disability.

Cancer impairments that meet or equal a cancer listing that does not indicate a specified timeframe or a minimum period of disability in the listing criteria will require a 3-year period of remission prior to considering whether there is medical improvement. After the 3-year remission period in these listings has expired at the CDR, find MI has occurred because the impairment no longer meets the cancer listing. However, it is possible that the individual may continue to be disabled at the CDR when their impairment(s) meets a current cancer listing criteria at Step 2 of the Title II and adult Title XVI CDR sequential evaluation process or Step 3 of the Title XVI CDR sequential evaluation process.

In most cases, a medical improvement possible (MIP) diary would have been set at the CPD for listings when the remission rule applies. The remission rule applies at the time of the CDR unless the cancer was in remission at the time of the CPD.

For additional information, see DI 26525.010.

CPD evidence: A 24-year-old individual was diagnosed with profound bilateral hearing loss and they underwent bilateral cochlear implantation. The individual’s condition met the criteria of listing 2.11A and for the adjudicator scheduled the diary to expire 1 year following implantation.

CDR evidence: The CDR is initiated 14 months after the cochlear implantation. Current medical evidence indicates that the individual’s word recognition score is 52% based on valid Hearing in Noise Test (HINT), and the individual’s hearing loss currently meets listing 2.11B.

Discussion: The individual’s impairment currently meets listing 2.11B at Step 2 of the Title II and adult Title XVI CDR sequential evaluation process. MI and the CPD listing are not considered in this example because the impairment meets a current listing earlier in the sequential evaluation process.

CPD evidence: A 45-year-old individual underwent a heart transplant in 03/2021 that met listing 4.09. The individual’s ejection fraction (EF) was 16% pre-transplant, and greater than 65% post-transplant. The language of the listing specified “consider under a disability for 1 year…” Due to the individual’s heart failure, they exhibited a decreased ability to perform activities of daily living, including limitations in standing and walking to only 10 yards before experiencing shortness of breath and fatigue.

CDR evidence: The individual reports intermittent chest pain and inability to stand for extended periods. The evidence indicates the individual’s heart has regular rate and rhythm, and a recent echocardiogram shows an EF of 60%. At the CDR, the individual also experienced an improvement in the ability to perform daily activities and standing and walking. Evidence indicates the individual walks a mile each day for exercise without shortness of breath of significant fatigue.

Discussion: Evidence does not show a condition that meets or equals any other current listing at Step 2 and MI is demonstrated at Step 3 based on the improved EF, improvement in daily functional activities such as standing and walking, and the improvement in shortness of breath and fatigue with activity. The specified timeframe in listing 4.09 has expired; therefore, the individual’s heart condition no longer meets the CPD listing at Step 4 and the MI is related to the individual’s ability to work. The adjudicator must proceed to Step 6 and evaluate residual functioning if a Group II exception does not apply.

CPD evidence: A 56-year-old individual had complaints of fatigue and abdominal pain. The individual underwent a kidney transplant in 10/2014. The individual’s condition met listing 6.02B and the language of the listing contained the following language: “Consider under a disability for 12 months following surgery.” At the CPD, the pre-transplant laboratory values documented stage 4 kidney disease. The individual experienced fatigue, unintended weight loss of 15 pounds from their baseline, swelling in the feet and ankles, and abdominal pain. Due to their fatigue and painful swelling, the individual reported that they were only able to stand and walk to perform activities for approximately 15 minutes at the time before needing to rest at least 45 minutes before resuming activities.

CDR evidence: Conducted in 01/2016: The transplanted kidney is functioning well, based on laboratory values within the normal range. The individual no longer has swelling in the feet and ankles and has gained approximately 10 pounds from the CPD due to increased appetite. However, the individual still complains of fatigue and abdominal pain. Evidence indicates that the individual is able to stand and walk to perform activities, such as grocery shopping, for about one hour before needing to rest.

Discussion: The individual does not have a condition that meets or equals any current listing at Step 2 of the Title II and adult Title XVI CDR sequential evaluation process. MI is demonstrated at Step 3 based on improved laboratory values, an increase in functional ability, and reduced swelling in the feet and ankles. At Step 4, it is important to recognize that listing 6.02B, which was met at the CPD, is obsolete at the time the CDR is initiated. The impairment cannot meet or equal subsection B of obsolete listing 6.02 because it is more than one year post-transplant. The impairment also does not meet the other subsections of obsolete listing 6.02. Therefore, the adjudicator must find that MI relates to the ability to work. The adjudicator must proceed to Step 6 and evaluate residual functioning if a Group II exception does not apply.

CPD evidence: A 14-year-old child was diagnosed with Hodgkin lymphoma with bone marrow involvement, meeting listing 113.05B1. The listing contains the following language: “Consider under a disability for 24 months from the date of diagnosis.” The evidence documented fevers occurring approximately twice a month, decreased energy, loss of appetite with accompanying weight loss, and chest pain. The child had swollen lymph nodes in the neck and armpit, causing limitations in reaching objects.

CDR evidence: The CDR is initiated 26 months from the date of the Hodgkin lymphoma diagnosis. The child maintains normal weight, strength, and range of motion with the improved ability in reaching objects. The child received bone marrow transplant on 07/2021 and current laboratory findings show no evidence of disease. The evidence indicates the child has not experienced a fever over the last 4 months and there is no swelling present in the lymph nodes in the armpit or neck. The child has increased energy and appetite, and has gained five pounds since the CPD.

Discussion: MI is demonstrated at Step 1 based on the improvement in signs and symptoms and the laboratory findings that show no evidence of disease. At Step 2, the CPD impairment (Hodgkin lymphoma) does not meet or equal the CPD listing or any subsections of the listing due to expiration of the timeframe. The adjudicator must proceed to Step 3 of the sequential evaluation process if a Group II exception does not apply.

CPD evidence: The individual’s impairment(s) met listing 13.06A at the CPD due to acute leukemia. The listing directs that the individual should be considered under a disability for at least 24 months from the date of the diagnosis or relapse, or at least 12 months from the date of bone marrow or stem cell transplantation, whichever is later. The individual was diagnosed with leukemia on 04/03/2020 and underwent a bone marrow transplantation on 09/17/2020. The adjudicator set the medical re-examination diary for 24 months after the date of diagnosis.

CDR evidence: Conducted in 05/2022. The individual underwent treatment after the CPD, and a bone marrow biopsy from 03/02/2021 showed no active signs of disease and indicated that the individual’s cancer was in remission. Approximately 8 months after the bone marrow biopsy, the individual followed up with the oncologist with complaints of general fatigue, light-headedness, and dizziness. The oncologist ordered lab testing and noticed abnormal white blood cells and platelets. A bone marrow aspirate was completed in 01/2022 that confirmed the presence of recurrent acute leukemia. The individual started chemotherapy again in 02/2022 and treatment is scheduled for a course of approximately 10 months. The individual did not receive another bone marrow transplant after the CPD and was not scheduled for one when the disability examiner spoke with the individual in 05/2022.

Discussion: The adjudicator processes a continuance at step 2 of the Title II and adult Title XVI CDR sequential evaluation process, finding that the individual’s impairment meets listing 13.06A due to a relapse of the individual’s leukemia. The adjudicator sets a medical re-examination diary for 24 months from the date of relapse (i.e., 01/2024). MI and the CPD listing are not considered in this example because the impairment meets a listing at an earlier step in the sequential evaluation process.

CPD evidence: The individual’s impairment(s) met listing 13.10E at the CPD due to breast cancer with secondary lymphedema to an upper extremity. The listing directs that the individual should be considered under a disability for at least 12 months from the date of the surgery that treated the secondary lymphedema. The individual had surgery on the upper extremity on 06/12/2021 and the examiner set the medical re-examination diary for 12 months after the date of this surgery.

CDR evidence: Conducted in 08/2022. The individual continued chemotherapy treatment after the CPD and the surgery to the upper extremity. At a follow-up visit on 06/18/2022, the individual still complained of tenderness and swelling in the upper extremity. Since the surgery, the individual has had difficulty with range of motion due to scar tissue and has persistent numbness and tingling in the hands. She has not had additional surgery to the upper extremity since the last surgery performed 06/12/2021. A PET scan performed in 06/2022 shows the breast cancer has responded to treatment and has reduced in grade, but the cancer is still present. The oncologist notes from 06/2022 indicate that the individual will take a break from chemotherapy for two months to allow her body time to recover, as she has not been tolerating the continuous treatment well and has significant fatigue and weakness.

There is a plan to start at least 6 more cycles of treatment, beginning in 09/2022. At a follow-up in 07/2022, her surgeon notes that an additional surgery to her upper extremity will likely be scheduled after she completes the additional rounds of chemotherapy. The surgeon remarks that another surgery is necessary to reduce scar tissue and try to improve function but feels that given the claimant’s fatigue and difficulty tolerating treatment, an additional surgical recovery period is not ideal while she is enduring chemotherapy treatment.

Discussion: The adjudicator processes a continuance at step 2 of the Title II and adult Title XVI CDR sequential evaluation process and meets listing 13.10E.” The adjudicator sets a medical re-examination diary for 09/2025. MI and the CPD listing are not considered in this example because the impairment meets a current listing earlier in the sequential evaluation process.

The adjudicator reasons that the individual’s impairment persists and determines that a 3-year diary is appropriate given the ongoing treatment and residual limitations in the upper extremity. The adjudicator further reasons that the 3-year diary is appropriate in this situation as the individual continues to exhibit a listing level impairment, has additional chemotherapy and surgery planned, and already received an MIE diary at the CPD. The determination is also consistent with instructions in DI 26525.020B.2.

CPD evidence: The child’s congenital heart disease met listing 104.06D at the CPD. At two months of age, the child underwent surgery due to a life-threatening congenital heart impairment. The child was diagnosed with ventricular septal defect. The adjudicator scheduled the diary to expire on the child’s first birthday.

CDR evidence: The CDR is initiated when the child is 13 months old. Medical evidence notes that the child recovered well from the surgery performed at two months of age, and has no tachypnea, and a normal heart rate and rhythm on examination. O2 saturation on room air is normal on examinations and there are no episodes of syncope or hypoxemia. The child does not have difficulty feeding and is in the seventh percentile in terms of weight-for-length.

Discussion: The examinations indicate successful recovery from the heart surgery to repair a ventricular septal defect and improvement in cardiac function without respiratory impairment. Therefore, MI is demonstrated at Step 1. The CPD listing is no longer met at Step 2, as the listing criteria is not met at the CDR and the minimum timeframe has passed. If a Group II exception does not apply, the adjudicator will continue to Step 3.

At the CDR, evaluate the impairments that met or equaled a listing with an age-based period of disability by following the child CDR sequential evaluation process. For additional information about the child CDR sequential evaluation process, see DI 28005.030.

• •

  If the adjudicator determines that MI has occurred at Step 1, the adjudicator will then consider if the prior listing that was met or equaled at the CPD continues to be met or equaled at the CDR.

• •

  If a child's impairment(s) met or equaled a listing with an age-specific period of disability at the time of the CPD, and the child has attained or passed the maximum age designated in the listing (or the longest applicable diary length designated in the listing), adjudicators must find the impairment(s) does not meet or medically equal the CPD listing at Step 2 of the Title XVI child CDR sequential evaluation process unless the impairment(s) meets or medically equals a different section of the CPD listing. For example, the child had an esophageal stricture at the CPD, causing the inability to adequately feed by mouth. At 12 months of age, the child underwent gastrotomy placement and required supplemental daily enteral nutrition via a feeding gastrostomy. The diary was set to expire at age 3 and the adjudicator met listing 105.10. At the CDR, the child has obtained age 4, and the adjudicator must evaluate any residual impairments as directed by listing 105.10 under the appropriate body system(s). In this scenario, there is the child cannot meet the CPD listing 105.10 as there is no applicable subsection for their age specific to this listing.

• •

  The adjudicator must evaluate any resulting impairment(s) under the appropriate body system criteria as designated in the preamble or as directed in the current listing(s).

• •

  If a Group II exception does not apply, the adjudicator must proceed to Step 3 of the evaluation process to make a CDR determination.

Although the adjudicator determines whether MI has occurred, the MC/PC must review the evidence and the analysis of MI by the adjudicator and prepare comments on:

• •

  changes in symptoms, signs, or laboratory findings in relationship to medical severity, and

• •

  their opinion on the issue of MI.

Consistent with the policy in DI 24501.002A, a disability determination must contain a medical evaluation unless the case does not contain medical evidence or collateral estoppel applies. Policy requires that the medical evaluation address the impairment(s) on one or more medical forms. The comments provided from the MC/PC should not be in standard medical assessment forms because those forms do not call for addressing MI.

• •

  The RFC is an administrative determination of an individual's capacity to perform work-related physical and mental activities despite limitations and restrictions resulting from a medically determinable impairment(s), see DI 24510.001;

• •

  The PRT is an assessment for to evaluate mental impairments in adults under Part A of the Listing of Impairments, see DI 24583.005;

• •

  The CDE is an administrative determination of whether a title XVI child’s impairment is severe, meets or medically equals a listing, or does or does not functionally equal the listings, see DI 25230.001.

The MC/PC will prepare their comments about MI in an SSA-416 or another appropriate assessment form, see DI 28010.050B.2.

Not every continuing disability review (CDR) case needs a note from an MC/PC discussing the MI issue. Comments from the MC/PC may not be necessary in the following scenarios:

• •

  A Title II or adult Title XVI individual meets or equals a current listing, or

• •

  The flexible approach applies and is used to facilitate a continuance that does not require the assessment of MI; see DI 28005.005C.

DAA is a substance use disorder(s) (SUD) defined in the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association. We generally define an SUD based on diagnostic criteria in the DSM, as a maladaptive or problematic pattern of substance use that leads to clinically significant impairment or distress, see SSR 13-2p. For our evaluation purposes, we do not consider nicotine-use disorder or caffeine-induced disorder to be DAA.

We make a DAA materiality determination when all of the following criteria are met:

• •

  The adjudicator determines that the individual’s disability continues considering all impairments, including DAA, and

• •

  Medical evidence from an acceptable medical source establishes a medically determinable impairment of a SUD.

If the above criteria are met, the adjudicator must determine whether we would still find the individual disabled if the individual stopped using drugs or alcohol (see SSR-13-2p, Question 2). DAA is material to the determination of continuing disability if the individual would not be disabled under our rules if they were not using drugs or alcohol. DAA is not material if the individual would still demonstrate continued disability regardless of whether they are using drugs or alcohol.

• •

  For scenarios of when DAA is material, see DI 90070.050C.3.

• •

  For scenarios of when DAA is not material, see DI 90070.050C.4.

In this section, we discuss the determination of whether the individual’s continuing disability is affected by DAA, and whether MI would occur if the individual were to stop using drugs or alcohol.

The adjudicator will make a DAA materiality determination only when:

• •

  Medical evidence from an acceptable medical source establishes that an individual has a medically determinable SUD and

• •

  The adjudicator determines (using the 8-step CDR sequential evaluation process shown in DI 28005.010 for Title II or adult Title XVI CDR cases, or the 3-step CDR sequential evaluation process shown in DI 28005.025 for Title XVI child CDR cases) that disability continues considering all impairments, including DAA.

If the adjudicator determines that disability continues, then the adjudicator must follow an additional evaluation process to determine whether DAA is material. This additional evaluation process is described in DI 28005.045 for Title II and adult Title XVI CDR cases, and DI 28005.050 for Title XVI child CDR cases.

In the context of evaluating MI when DAA is involved, MI is any decrease that would occur in the medical severity of the impairment(s) (considered in the current determination of continuance), if the individual were to stop using drugs or alcohol. This requires the adjudicator to exclude both the direct effects of DAA, and its impact on any other impairment(s).

Consider the impairment(s) that support the current (CDR) continuance determination when evaluating MI if the individual were to stop using drugs or alcohol in the CDR DAA steps discussed in DI 28005.045B and DI 28005.050B. Use any changes (improvement) in symptoms, signs, or laboratory findings that would occur if DAA were to stop. Disregard minor changes that would not obviously increase physical or mental abilities.

At the initial and reconsideration CDR levels of the administrative review process (except in disability hearings before a Disability Hearing Officer), an adjudicator makes the finding of whether DAA is material to the determination of disability.

• •

  The adjudicator will evaluate the MC/PC’s projection of what limitations, if any, would remain if the individual were to stop using drugs/alcohol. The adjudicator may return the case to the MC/PC for additional input specific to the analysis of DAA and projected MI to make the determination whether DAA is material or is not material.

• •

  The adjudicator must follow the sequential evaluation process outlined in DI 28005.040 for Title II and adult Title XVI CDR cases and DI 28005.050B for Title XVI child CDR cases.

The MC/PC must prepare comments concerning:

• •

  Projected changes in symptoms, signs, or laboratory findings that would occur in relationship to medical severity if substance use were to stop, or

• •

  If the MC/PC cannot project what changes would occur or what limitations would remain if the individual stopped using drugs or alcohol, the MC/PC should record findings to that effect..

The MC/PC must prepare their comments and analysis about DAA in an SSA-416; see DI 24501.006C. The comments should address relevant changes, such as specific aspects of the RFC that may be affected.

The MC/PC must have a medical basis for indicating that more than minor changes would occur if DAA were to stop. The MC/PC should base their medical evaluation of the changes that would occur when the individual would achieve maximum recovery, without regard to the length of time needed for such maximum recovery.

Adjudicators must review several factors when evaluating MI in a case with DAA involvement.

• •

  Consider the symptoms, signs, and laboratory findings concerning all the impairments upon which the adjudicator found the current continuance determination (with the effects of DAA).

• •

  Consider medical history and DAA involvement, see DI 28010.055D.2. below.

• •

  Based on the evidence in file and adjudicative judgment, consider the projected changes that would occur in the symptoms, signs, and laboratory findings concerning all the impairments if DAA were to stop.

• •

  Identify any projected changes and their importance to medical severity under current rules for assessing severity (i.e., the current Listing of Impairments).

• •

  Decide whether the projected changes reflect decreased medical severity of any single impairment upon which the adjudicator based the current determination of continuance.

Consider the history of evidence and DAA involvement.

• •

  In determining what, if any, changes would occur if DAA were to stop, consider all of the evidence relevant to making a finding of improved or worsened function.

• •

  Consider evidence of a period of abstinence, as long as it provides information as to what, if any, symptoms, signs, and laboratory findings remained after the acute effects of intoxication and withdrawal abated. (See SSR 13-2p, Question 9)

• •

  When multiple mental impairments are involved, consideration of the longitudinal history may assist in determining the impact of one impairment upon the other(s) and which findings would remain if DAA were to stop.

• •

  There may be cases when there is no medical basis for deciding whether a particular finding results from a substance use disorder or some other impairment(s) (upon which the current determination of continuance is based). In this circumstance, when evidence indicates the SUD began after the other impairment(s), assume that particular finding results from the other impairment(s).

Under the MIRS, the adjudicator cannot determine whether medical improvement has occurred for CDR review without the comparison point decision (CPD) folder or medical evidence. If the adjudicator is unable to locate the appropriate CPD folder or reconstruct the medical evidence, the adjudicator cannot evaluate MI or MI related steps (meaning the adjudicator cannot evaluate steps 3 through 5 of the Title II and adult Title XVI CDR sequential evaluation process in DI 28005.015A, or steps 1 and 2 of the Title XVI child CDR sequential evaluation process in DI 28005.030C). If reconstruction of the folder is not possible, the adjudicator will process a continuance, following procedures in DI 28035.025.

However, if the CDR determination is projected to be a continuance based on the inability to reconstruct pertinent evidence from a lost CPD folder (see DI 28035.020) but the following DAA criteria apply:

• •

  There is current medical evidence of a substance use disorder, and

• •

  There would be any decrease in the medical severity of the impairment(s) upon which the current determination of continuance is based if DAA were to stop, then:

The adjudicator must process a cessation based on the current CDR impairment(s) and the DAA material condition.

If DAA was not material, or was not considered at the CPD and there is current evidence of a SUD that is found not material, assess MI for the CDR based on the impairment(s) for which benefits were allowed or continued.

CPD evidence: The individual's impairment(s) met listing 11.02 due to epilepsy with generalized seizures, occurring at least once a month for at least 3 consecutive months despite adherence to prescribed treatment.

CDR evidence:

The medical records indicate that the individual's condition was improving, with their epilepsy controlled by a new medication and no breakthrough seizures or other symptoms for several consecutive months, up until about 7 months after the CPD. At that time, the records note several hospitalizations for drug overdose. The individual missed several follow up appointments with their primary care physician for epilepsy follow up and medication management. The records from the hospitalizations due to drug overdose include two observed generalized tonic-clonic seizures, which appeared to be associated with the drug use. The individual recently attended a neurologist appointment, where they reported generalized seizures recurring about once a week, and the neurologist counseled and urged the individual to abstain from drug use, indicating this was also now causing the breakthrough seizures and interfering with the effectiveness of the medication. The neurologist indicated that the individual’s seizures were consistent with symptoms of chronic drug abuse and that the individual needed to stop using drugs in order to prevent further seizures.

Discussion: If DAA were to stop, there would be changes (improvement) in the symptoms, signs, and laboratory findings for the substance use disorder, and listing-level limitations would not remain. Therefore, DAA is material.

Find MI. Continue to follow the CDR sequential evaluation process to determine whether the individual would still be disabled in the absence of DAA.

CPD evidence: The individual's impairment(s) met listing 5.05F at the CPD. The CPD records demonstrate a longitudinal history of alcohol use disorder. At the time of the CPD, the individual was actively drinking alcohol. DAA was considered and was determined not to be material to the determination.

CDR evidence: The medical records at CDR demonstrate no MI in the individual's chronic liver disease and associated encephalopathy. The records also indicate the individual stopped drinking six months ago.

If DAA were to stop: Although there may be some additional changes (improvement) in liver function if DAA were to stop, the MC projects that the liver disease would continue to satisfy the criteria of listing 5.05F. Therefore, DAA is not material.

Find no MI.

More scenarios regarding DAA materiality are in DI 90070.050C.

• •

  The longitudinal history of the impairment (including the occurrence of prior remissions and prospects that the impairment will worsen again in the future),

• •

  All available evidence, including medical evidence and opinions, and

• •

  Medical literature about the nature of the impairment.

Examples of impairments subject to temporary remission include (but are not limited to):

• •

  Multiple sclerosis,

• •

  Rheumatoid arthritis,

• •

  Many mental impairments,

• •

  Sickle cell anemia,

• •

  Epilepsy, and

• •

  Asthma.

To determine whether the remission is temporary, consider the longitudinal history of the impairment (including the occurrence of prior remissions and prospects f that the impairment will worsen again in the future), in relationship to the particular impairment and the changes that have occurred.

Consider improvement temporary unless it has been sustained long enough to have a significant impact on the individual's functioning, or, in a Title XVI child case, on the child's functioning under ordinary conditions on a sustained basis.

When remission has not yet lasted long enough, find that disability continues. For more information on length of temporary remission, see DI 28010.115B.3. in this section.

Consider setting a medical improvement expected (MIE) diary for a time when evidence will provide a better basis for determining whether the remission is long enough to demonstrate MI.

• •

  When a listing timeframe currently applies, consider setting the MIE diary to be due after the end of the period specified by the listing.

• •

  In other situations where remission has not yet lasted long enough, consider setting a MIE diary due in about 1 year.

Include a special paragraph in continuance notices in the above situations. Inform the individual that while their health improved, it appears to be too early for an accurate medical decision about the degree of improvement; therefore, disability is found to be continuing and a reevaluation will be scheduled for (date).

If remission continues until the time of the next scheduled CDR, apply the policies in subsections A. and B., and, if appropriate, find the MI more than temporary.

CPD evidence: The individual's rheumatoid arthritis met listing 14.09. The individual had persistent swelling and tenderness of the fingers and wrists of both hands, and laboratory tests were positive for rheumatoid arthritis. The individual had difficulty dressing and had to wear loose fitting clothing that did not require buttons, zippers or fasteners, she would frequently drop items in either hand, and had joint pain that made it difficult to pick up items when grocery shopping and had switched to a grocery delivery service for this reason.

CDR evidence: Laboratory tests are still positive for the presence of rheumatoid arthritis. The individual has engaged in therapy with different medications for treatment for the last year and has responded favorably. The individual reports continued joint pain, but an improvement in pain and a reduction in swelling. The individual is now able to grocery shop and will buy necessary items a few at a time so they do not have problems lifting and carrying the items. The progress notes from her medical source also demonstrate continued improvement in signs and symptoms over the last year with therapy.

Discussion: Find MI. Medical improvement has occurred because there has been a decrease in the severity of the individual's impairment as documented by the current symptoms and signs reported by the individual's physician. Although the individual's impairment is subject to temporary remission and exacerbations, the improvement that has occurred has been sustained long enough to permit a finding of medical improvement. We would then determine whether this medical improvement is related to the individual's ability to work.

CPD evidence: At the CPD, the individual's impairment(s) met listing 11.02 for epilepsy. Despite adherence to prescribed treatment, the individual was experiencing grand-mal seizures at least once a month consistently for three months in a row.

CDR evidence: The CDR is initiated in August. The individual has continued compliance with prescribed treatment. Within the last 4 months from the date of the CDR initiation in August, the records indicate the following number of seizures despite medication compliance: 2 seizures in April, 1 seizure in May, 2 seizures in June, 0 seizures in July.

Discussion: Find no MI. Despite no seizures for one month in July, the evidence supports the conclusion that there has been no improvement in the pattern of seizures. While the individual did not have any seizures in July, this anomaly may represent a temporary remission, the individual experienced seizures for three consecutive months despite compliance with medication.

The listings in the Cardiovascular System (4.00) provide for use of the ETT as primary evidence in cases involving chronic heart failure and ischemic heart disease (listing 4.04A). However, the listings also provide for use of other types of evidence as the basis for decisions when available evidence does not include acceptable ETT results.

In the above situations, consider ETT results along with other evidence, but do not use them as the sole basis for establishing either decreased severity or increased function.

If the file:

• •

  contains acceptable ETT results from either the time of the comparison point decision (CPD) or the current time, but

• •

  does not show that an ETT was attempted at the other point, then

• •

  the file does not provide a basis for comparing prior and current ETT results.

Find no medical improvement (MI), unless changes in other signs, symptoms, and laboratory findings show MI.

If the file:

• •

  does not include acceptable ETT results from the CPD, but

• •

  shows that a source of medical evidence attempted an ETT but did not obtain acceptable results (e.g., discontinued the test due to the individual's complaints of fatigue or chest pain), and

• •

  contains current acceptable ETT results, then

• •

  the ability to perform an acceptable ETT without it being discontinued due to the individual's complaints may constitute changes in symptoms connected with the ETTs may provide a basis for finding MI.

Consider such changes in the context of other signs, symptoms and laboratory findings in deciding whether MI occurred.

All of the factors considered in assessing mental impairments (e.g., the paragraph A, B, and C criteria in the mental disorders listings) meet the regulations' definition of symptoms, signs, or laboratory findings (12.00B/112.00B of the listing). Consider all these factors in making MIRS comparisons.

Apply DI 28010.015 in the comparison of symptoms, signs, and laboratory findings.

Apply the principles in DI 24583.005 for cases involving the evaluation of mental impairments. For information about which assessments may be used in CDR cases for different scenarios (i.e. no MI, meets a listing, etc.), see DI 28010.050.

• •

  For specific information about completion of the psychiatric review technique (PRT) or mental residual functional capacity (MRFC) in CDR cases, see DI 28010.140 and DI 28010.145, respectively.

• •

  For information about completing the assessment documents and documenting determinations on the prescribed form for Title XVI child cases, see DI 25230.001, DI 25230.005, and DI 28005.030C4.

Several mental impairments are considered permanent and severe enough to warrant a MINE diary, such as intellectual disability (listing 12.05A or B or 112.05A) and autistic or other pervasive developmental disorders (listing 12.10 or 112.10); see DI 26525.045. If the individual had a MINE impairment established at the CPD, evidence development at the CDR can often be abbreviated, and the adjudicator may use nonmedical evidence without new medical evidence to find that disability continues if evidence is consistent with such a conclusion; see DI 28030.020A. Functional information may fully support a continuance without the need for extensive development of medical records at the time of the CDR. For additional information about MINE or MINE-equivalent cases, see DI 28040.125.

Before making an unfavorable MIRS decision in a case involving a mental impairment(s), carefully consider the following:

• •

  Consider the longitudinal history from the evidence, including both medical and non-medical evidence sources. For purposes of evaluating medical improvement, a medically determinable impairment (MDI) does not need to be re-established. Rather, consider sources of medical evidence and functional evidence to evaluate MI; see DI 22511.000.

• •

  Rating the degree of functional limitations resulting from a mental impairment(s) considering different factors; see DI 24583.005D

• •

  Consider whether the evidence has been developed sufficiently so that medical improvement and related issues8 can be evaluated; see DI 28005.009.

• •

  If the impairment is subject to temporary remission, consider whether any improvement demonstrated may actually only represent temporary remission or improvement of an impairment where symptoms wax and wane, see DI 28010.115.

• •

  Consider whether the individual's impairment(s) still meets or equals the listing met or equaled at CPD, see DI 28015.050. The flexible approach to the CDR sequential evaluation process may be appropriate to potentially expedite development; see DI 28005.005C

• •

  Consider whether age and time on the rolls is an applicable factor in Title II and adult Title XVI CDR cases; see DI 28015.310.

If a mental medically determinable impairment(s) exists at the CDR, use the PRT to determine if the mental impairment(s) meet or equal the current mental listing, step 2 of the CDR sequential evaluation process. Consider all mental impairments, even if the impairment(s) is not severe. If evidence clearly supports no medical improvement (MI), a flexible approach may allow a continuance without performing this step and the PRT, see DI 28005.005.

The MINE procedures assume continuing disability given the CPD's basis. Therefore, a PRT is not needed. However, an assessment should document the basis for the continuance, a SSA-416 may be appropriate in these continuance situations. An SSA-416 may be appropriate in these continuance situations.

In situations where there is no appropriate pre-printed block on the PRTF to reflect the CDR disposition (e.g., “no MI”), leave this section blank. Record the CDR medical disposition elsewhere in an SSA-416. In most scenarios, the DDE will alleviate the need for this.

In cases where the CPD used a medical/vocational basis for the allowance(i.e., a CPD residual functional capacity (RFC) is in the file):

1. a. 

   Prepare an MRFC assessment showing the current status of restrictions resulting from (only) the mental impairment(s) present at the time of the CPD. For more information on this MRFC assessment, the “MIRS RFC”, see DI 28015.850A.1.

2. b. 

   Do not prepare an MRFC assessment for the time of the CPD. However, if the medical/vocational decision should have included an RFC assessment but does not, a prior RFC may be prepared. For more information on the “prior RFC,” see DI 28015.315, DI 28015.850A.3., and DI 28015.855D.

3. c. 

   If the CPD used an obsolete mental RFC form or psychiatric review technique form, see DI 28010.140C.3.a. and DI 28010.140C.3.

If there are any current severe mental impairments and no situation in DI 28010.145B.3. exists, prepare a current MRFC form considering all mental impairments. For more information on this MRFC assessment, the “CURRENT RFC,” see DI 28015.850A.4.b.

1. a. 

   When medical/vocational factors do not apply to the category of claim involved (e.g., Title XVI childhood cases).

2. b. 

   In cases where disability was continued on the basis of:

   • •

     meeting/equaling a current listing (Step 2), or

   • •

     no medical improvement (MI) or exception (Step 3 and 5). However, see DI 28015.850A.4. for information about when a current residual functional capacity (RFC) assessment form is needed for future CDRs.

3. c. 

   In medical improvement not expected (MINE) continuances.

4. d. 

   In relating MI to ability to work, if the CPD used the Listing of Impairments as its basis (i.e., if the CPD found that an impairment met or equaled a listing and no longer does, MI is already considered to be related to the ability to work).

IQ scores generally stabilize after age 16. For additional information, see DI 24583.055I.7.

Continuing disability reviews (CDR) for adults usually do not require new IQ tests. Often, an IQ test used in the comparison point decision (CPD), especially a test from age 16 or older, will remain relevant and can be used in the CDR process.

Medical evidence of record sometimes includes new IQ scores. Other cases require new IQ tests because a childhood test score from the CPD is no longer current. Compare prior and current IQ scores in such cases.

IQ scores stabilize after age 16 and may be considered current indefinitely unless there is inconsistency with current functioning or an intervening injury or insult has since occurred that would affect the IQ score. If the individual is retested after age 16 and administered the same test, the score should not demonstrate much variance.

When the CPD and current evidence include IQ scores from the same test (e.g., the WISC-IV) medical improvement (MI) may occur in the individual's intellectual disorder (or related cognitive disorder) only if:

1. a. 

   Improvement in IQ scores exceeds one standard error of measurement (SEM) and cannot be reasonably accounted for by the practice effect (DI 24583.055F.2.) or another confounding variable, and

2. b. 

   The medical or psychological consultant (MC/PC) finds the remaining evidence (including evidence related to adaptive functioning) consistent with a decrease in medical severity.

Changes in IQ scores exceeding the SEM cannot be used as above to determine MI if the CPD and current evidence include IQ scores from different tests or different versions of the same test series (e.g., the WISC-III and the WISC-V). The MC/PC must use clinical judgment to determine whether any IQ score change represents MI. Find MI only if the remaining evidence (including evidence related to adaptive functioning) is consistent with such a finding.

Consider the error exception in the rare case involving clearly invalid CPD IQ scores; i.e., because of:

• •

  Conflict with evidence despite efforts to reconcile the apparent differences, or

• •

  Adverse effect on measured IQ by another mental or physical disorder that cannot be controlled.