Identification Number:
DI 23535 TN 35
Intended Audience:See Transmittal Sheet
Originating Office:ORDP ODP
Title:Presumptive Disability/Presumptive Blindness (PD/PB) Cases
Type:POMS Transmittals
Program:Title XVI (SSI),Disability
Link To Reference:
 

PROGRAM OPERATIONS MANUAL SYSTEM
Part DI – Disability Insurance
Chapter 235 – Specific Case Instructions
Subchapter 35 – Presumptive Disability/Presumptive Blindness (PD/PB) Cases
Transmittal No. 35, 04/14/2022

Audience

PSC: CS, DE, DEC, DTE, IES, RECONR, SCPS, TSA, TST;
OCO-OEIO: CR, CTE, ERE, FCR, FDE, FDEC, RECONE;
OCO-ODO: CST, DE, DEC, DS, RECONE;
ODD-DDS: ADJ, DHU;
FO/TSC: CS, CS TII, CS TXVI, CSR, CTE, DRT, FR, OA, OS, RR, TA, TSC-CSR;

Originating Component

ODP

Effective Date

Upon Receipt

Background

This transmittal is updating DI 23535.010 because of the COVID-19 pandemic. Social Security disability applicants, especially those applying for disability under the Supplemental Security Income (SSI) program, may experience unprecedented financial hardships and delays in the disability adjudication process due to no fault of their own. To minimize the impact created by the COVID-19 crisis, we reviewed our policy on presumptive disability (PD) and presumptive blindness (PB). Based on this policy review, we revised our language regarding the requirement to consider all initial SSI claims for a potential PD/PB finding. We also added several impairments to the high probability for a PD finding category.

 

Summary of Changes

DI 23535.010 Disability Determination Services (DDS) Responsibilities in Presumptive Disability/Presumptive Blindness (PD/PB) Cases – Title XVI only

Subsection A.1. - Revised language to encourage adjudicators to make PD/PB findings when appropriate.

Subsection A.2. - Revised language to encourage adjudicators to make PD/PB findings when appropriate.

Subsection B.5. - Added four impairments/case types to consider as having a high potential for a PD finding.

DI 23535.010 Disability Determination Services (DDS) Responsibilities in Presumptive Disability/Presumptive Blindness (PD/PB) Cases – Title XVI only

A. Identifying PD/PB cases

1. General guidelines for identifying PD/PB cases

Adjudicators are encouraged to make a PD/PB finding at any point in the Title XVI initial claims development process when the available evidence, although not sufficient for a formal determination, demonstrates a strong likelihood that:

  • Disability or blindness will be established when complete evidence is obtained, or the evidence establishes a reasonable basis for presuming the individual is currently disabled, and

  • The disabling impairment has lasted or is likely to last at least 12 months.

NOTE: Do not make a PD/PB finding in any case when the available evidence in file is sufficient to make a formal determination.

2. Basis for a PD/PB finding

  1. a. 

    Evaluate the categories in DI 11055.231 for a PD/PB finding.

  2. b. 

    Consider whether the medical and non-medical information furnished by the applicant or claimant at the time of initial application, and other facts supplied by the field office (FO) interviewer, are sufficient for a PD/PB finding.

NOTE: DDS staff should make a PD/PB finding at any point during the adjudicative process, for any impairment in which the evidence suggests an allowance. However, the available evidence in file must be insufficient for a formal determination.

B. Making PD/PB findings

1. General guidelines for making PD/PB findings

Make PD/PB findings in appropriate claims, balancing the agency's commitment to expedite provisional Title XVI payments when a claimant meets the PD/PB criteria with the fact that incorrect PD/PB findings run counter to this commitment and create unnecessary additional work.

Because all PD/PB claims require some degree of double handling that could impede the flow of the general Title XVI workload, consider PD/PB findings in these situations:

  • Cases the FO flags as meeting the financial conditions for advance payment and in which the FO was unable to make a PD/PB finding (see DI 23020.015);

  • Cases in which the formal disability or blindness determination is unduly delayed; and

  • Cases in which evidence received during development permits the DDS evaluation team to make a judgment that the total evidence, although not sufficient for a formal determination, is sufficient to make a PD/PB finding. You may consider vocational factors in a PD finding but not in a PB (statutory blindness) finding.

2. Types of PD/PB evidence

Evidence for PD/PB findings may include:

  • Routinely received medical records; or

  • Special reports for PD/PB purposes; or

  • Facts reported by the FO interviewer.

3. Impairments with limited PD potential

  1. a. 

    Generally, to determine the severity and limiting effects of a respiratory impairment, pulmonary function tests are necessary. Therefore, do not make PD findings for respiratory impairments unless there is convincing evidence that we will allow the claim.

  2. b. 

    Do not make PD findings for back impairments unless the case involves traumatic injury to the spinal cord.

  3. c. 

    Do not make PD findings for impairments requiring medical deferment unless you have convincing evidence that those impairments meet severity and durational requirements. For medical deferment policy, see DI 25505.035.

4. Impairments with PD potential but requiring caution

PD may apply in the following categories, but exercise caution when predicting severity and duration:

  1. a. 

    Diabetes mellitus.

  2. b. 

    Epilepsy.

  3. c. 

    Essential hypertension.

  4. d. 

    Hypertensive heart disease.

  5. e. 

    Peptic ulcer.

  6. f. 

    Cirrhosis of the liver.

  7. g. 

    Bone fractures.

  8. h. 

    Mental disorders - (other than intellectual and neurodevelopmental disorders as described in 5.a), where medical evidence is from an acceptable medical source (AMS), establishes a mental disorder, and demonstrates significant limitations in mental functioning (e.g., understand, remember or apply information; interact with others; concentrate, persist or maintain pace; and adapt or manage oneself). Additionally, the available evidence indicates a strong likelihood of an allowance but is insufficient for a formal determination.

5. Impairments with high PD/PB potential

The following conditions have a high potential for a PD/PB finding:

  1. a. 

    Intellectual disorder or another neurodevelopmental impairment (for example, autism spectrum disorder) with complete inability to independently perform basic self-care activities (such as toileting, eating, dressing or bathing).

  2. b. 

    Cancers identified as Stage IV, inoperable, or those that meet a listing based solely upon pathology.

  3. c. 

    Central nervous system diseases resulting in significant and persistent motor dysfunction in two or more extremities.

  4. d. 

    Renal disease requiring chronic dialysis.

  5. e. 

    Symptomatic human immunodeficiency virus (HIV) infection or acquired immunodeficiency syndrome (AIDS). For information on PD/PB findings in disability claims involving HIV or AIDS refer to DI 23535.012.

  6. f. 

    Cerebral palsy with documented seizure activity in spite of medication compliance.

  7. g. 

    Major organ transplants (i.e., lung, liver, heart, kidney, bone marrow, and stem cell transplants), in which the transplant occurred within the period of alleged disability and the case has not been identified as a Terminal Illness (TERI), Compassionate Allowance (CAL), or Quick Disability Determinations (QDD) claims.

  8. h. 

    Any QDD exclusion case (cases removed from QDD selection due to lengthy development issues - see DI 23022.055).

  9. i. 

    Conditions requiring hospice care that are not currently identified as TERI, CAL, or QDD claims.

C. Examples of choosing the right onset for PD/PB findings

PD onset is the date we determine the claimant is presumptively disabled or presumptively blind. To assist you in determining the correct PD/PB onset date, we provide the following examples.

NOTE: Do not enter a PD or PB onset earlier than the month in which the claimant filed his or her application.

  • If you make the PD or PB finding in the month in which the claimant filed his or her application, enter the application date as the onset date.

    EXAMPLE: Claimant met PD eligibility requirements in the same month the claimant filed the application

    Mr. Jones filed a Supplemental Security Income (SSI) application based on disability on 04/15/21. The FO determined that Mr. Jones met all the non-medical eligibility requirements in April 2021 and input the PD decision. The FO enters 04/15/21, the date of application, so that Mr. Jones receives payment beginning May 2021.

  • If the current month is the month immediately following the month of filing, use the application date as the onset date.

    EXAMPLE: Claimant met PD eligibility requirements in the month immediately following the month the claimant filed the application

    Ms. Smith filed an SSI application on March 24, 2021. The FO determined she met the non-medical eligibility requirements in March 2021.

    The DDS determined that she was presumptively disabled, inputting the PD finding on April 2, 2021. The DDS enters 03/24/21 (the application date) so that Ms. Smith may receive payments beginning April 2021.

  • If you make the PD or PB finding two or more months after the month of filing, enter the month and year prior to the month in which you made the PD or PB finding as the onset date.

    EXAMPLE: Claimant met PD eligibility requirements after the month the claimant filed the application

    Mrs. Williams filed an SSI application on April 5, 2021. The FO determined she met the non-medical eligibility requirements in April 2021. The DDS determined that she was presumptively disabled, inputting the PD finding on June 2, 2021. The DDS enters 05/01/21 (which is the month, day, and year prior to the month the DDS made the PD finding) so that Mrs. Williams may receive payments beginning June 2021.

NOTE: If the PD/PB onset is not the filing date, then use the first day of the month.


DI 23535 TN 35 - Presumptive Disability/Presumptive Blindness (PD/PB) Cases - 4/14/2022