Identification Number:
EM 21032
Intended Audience:RO/DDS/DPU/DPB/EST/OQR/OHO/OAO
Originating Office:ORDP ODP
Title:Evaluating Cases with Coronavirus Disease 2019 (COVID-19)
Type:EM - Emergency Messages
Program:Disability
Link To Reference:See Reference at the end of this EM.
 
Retention Date: October 16. 2021

A. Purpose

    This Emergency Message (EM) provides policy guidance for evaluating adult disability cases that include an allegation or diagnosis of Coronavirus Disease 2019 (COVID-19).
    B. Background

      Coronavirus Disease 2019 (COVID-19) is an infectious disease. COVID-19 symptoms can range from no symptoms to severe illness. While COVID-19 is primarily a respiratory disease, emerging data suggests that it may also lead to cardiovascular, renal, dermatologic, neurological, psychiatric, or other complications. For more information, see Long-Term Effects of COVID-19 | CDC. COVID-19 is a new disease and the medical community is still learning about the severity of the illness, its long-term effects, and emerging variants of the virus.
    C. Policy Guidance
        1. Establishing and coding a medically determinable impairment (MDI)
            We need objective medical evidence from an acceptable medical source (AMS) to establish the existence of an MDI for COVID-19, including long-term effects of COVID-19, which means signs, laboratory findings, or both (DI 24501.020A). We establish an MDI for COVID-19 when evidence from an AMS indicates:
              · A report of a positive viral test for SARS-CoV-2,
              · A diagnostic test with findings consistent with COVID-19 (e.g., chest x-ray with lung abnormalities, etc.), or
              · A diagnosis of COVID-19 with signs consistent with COVID-19 (e.g., fever, cough, etc.).

            Follow existing policy for establishing an MDI (DI 24501.020).

            IMPORTANT: A positive antibody test, on its own, does not establish an MDI of COVID-19 because a positive antibody test may indicate that a person has had different Coronavirus or received a vaccination for COVID-19.

            Do not establish an MDI of COVID-19 when a person alleges he or she is medically at high risk for COVID-19 or if the evidence indicates a false positive viral test.

            If a person has an MDI of COVID-19, use the existing diagnosis code 1360 Other Infectious and Parasitic Disorders. Follow existing policy for the primary and secondary diagnosis codes on the SSA-831/832/833 (DI 26510.015C and DI 28084.035).

            For instructions on flagging electronic cases when a person alleges COVID-19 as a medical condition or when we discover a person has an MDI of COVID-19, see EM-20060.
          2. Severity

            If a person has an established MDI of COVID-19, determine if the MDI is both severe and meets the duration requirement (DI 22001.001D.2). For CDRs, follow existing policy for severity (DI 28005.015A.6). In addition, a person may develop a new MDI(s) or experience worsening of an existing MDI(s) resulting from COVID-19. Follow existing policy to assess the severity of COVID-19, one or more new MDIs caused by COVID-19, or any other MDI(s) that has worsened because of COVID-19 (DI 24505.001 and DI 24505.005). Reminder, we must develop evidence for any change in severity at each level of appeal.
          3. Duration
              Duration in the disability context refers to the period of time during which a person is continuously unable to engage in substantial gainful activity (SGA) because of one or more MDIs. A person’s MDI(s) must last or be expected to last for a continuous period of at least 12 months unless we expect the MDI(s) to result in death (DI 25505.025D). We measure duration from the first date the MDI(s) prevented SGA through the date the MDI(s) no longer prevented (or is no longer expected to prevent) SGA or ends in death.
              If a person’s MDI(s) results in death, the duration requirement is met. Remember, we cannot combine two or more unrelated MDIs to meet the duration requirement (DI 25505.030A.1). However, if COVID-19 causes a new MDI(s) or worsens an existing MDI(s), we consider these MDIs related.

              COVID-19 presents initially as an acute illness. If a person recovers from acute COVID-19 with no residual symptoms, limitations, or restrictions, we generally would not expect COVID-19 to meet the duration requirement.

              Some people may have symptoms associated with COVID-19 that last for months or even longer after recovery from acute illness. In these cases, COVID-19 may meet the duration requirement when a person develops:
                · Long-term effects of COVID-19,
                · One or more new MDIs caused by COVID-19, or
                · Any existing MDI(s) have worsened because of COVID-19.

              Follow existing policy to determine whether the MDI(s) meets or is expected to meet the duration requirement (DI 25505.025 and DI 25505.030). For more information on long-term effects of COVID-19, see Long-Term Effects of COVID-19 | CDC. For information on the medical evaluation of COVID-19, see Section C.6 and C.7. For more information on when COVID-19 results in death or is expected to result in death, see Section C.4.

              We may need to project the severity if it is unclear whether or when the MDI(s) will resolve. For example, if the person has been on a ventilator for an extended period, a significant period of rehabilitation may be required to regain the ability to do basic self-care. Recovery from acute COVID-19 or removal of the ventilator itself may not necessarily indicate the end of the duration period. Follow existing policy to determine if projecting severity is needed (DI 24510.020).

              A case may require medical deferment (DI 25505.035) to determine whether COVID-19, or a new or worsening MDI(s) resulting from COVID-19, meets the 12-month duration requirement. Do not defer medical development for duration when evidence indicates a person has little to no chance of regaining significant function (DI 24515.020C.6).

              Follow existing policy to determine if medical deferment is needed (DI 25505.035).

              EXAMPLE: A person with Chronic Obstructive Pulmonary Disease (COPD) contracts COVID-19. We need a pulmonary function test (PFT) because the evidence available is not sufficient to assess the severity of the underlying impairment. The introductory text to the listings for evaluating respiratory disorders requires that a person is medically stable at the time of the PFT (DI 34001.014). Medical deferment is appropriate in this situation to allow time for the person to become medically stable prior to obtaining the testing.
            4. COVID-19 results in death or is expected to result in death

              A person meets the definition of disability when he or she is unable to engage in SGA by reason of any MDI, which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months. An MDI is “expected to result in death” when, based on established medical knowledge and under the particular circumstances in the case, the evidence establishes either that it is terminal, or that it actually results in death (DI 23510.001A). COVID-19 is a new disease and the trajectory of improvement or worsening may be difficult to predict in some cases. If the medical evidence indicates a person is in hospice or palliative care with no possibility of recovery, we may be able to make a favorable determination without medical deferral.

              Most cases involving COVID-19 do not result in death. However, in some cases, a person may die within in a short period after contracting the COVID-19 infection. We may establish disability for a person who has an incapacitating MDI that results in death before it has lasted 12 months (DI 23510.001B). For COVID-19 resulting in death, follow existing policy for processing death cases (DI 23510.000).

              When COVID-19 results in death or is expected to result in death, consider the following medical assessments, depending on the individual case facts:
            5. Symptom evaluation
              COVID-19 is a new disease and the medical community is still learning about the severity of the illness and its long-term effects. COVID-19 symptoms may range from no symptoms to severe illness. In cases when long-term symptoms develop, those symptoms may include, but are not limited to, fatigue, shortness of breath, joint pain, and difficulty thinking and concentrating. For more information, see Long-Term Effects of COVID-19 | CDC.

              Follow existing policy for evaluating symptoms related to COVID-19, or any new or worsening MDI as a result of COVID-19 (DI 24501.021). Remember, we only consider symptoms resulting from MDIs that meet or are expected to meet the 12-month duration requirement.

              NOTE: Issues related to the COVID-19 pandemic, including, but not limited to, evictions, medical facility closures, quarantines, job loss, and insurance loss, may affect a person’s ability to seek treatment to minimize symptoms. Consider whether a person’s lack of treatment is the result of these COVID-19 related issues when evaluating the consistency of his or her statements with the objective medical evidence (DI 24501.021C).
            6. Listing-level severity
                We must consider whether COVID-19, a new MDI(s) caused by COVID-19, or any MDI(s) that has worsened because of COVID-19 meets or medically equals a listing (DI 22001.001D.3 and DI 28005.015A.2). COVID-19, on its own, cannot meet a listing, but it may equal a listing as an unlisted impairment or as part of a combination of impairments (DI 24508.010). COVID-19 may affect respiratory, cardiovascular, renal, neurological, or other body systems. In most cases, the listing relevant to a new MDI(s) caused by COVID-19, or any MDI(s) that has worsened because of COVID-19 will be the appropriate listing to consider.
                IMPORTANT: It is not possible to find medical equivalence to listing 3.14 (Respiratory Failure) solely based on hospitalization for acute COVID-19 because listing 3.14 requires an underlying chronic respiratory disorder, and an acute infection cannot be substituted for a chronic impairment (DI 34001.014). If a person has an underlying chronic respiratory disorder, medical equivalence may be possible if all of the other requirements of the listing are satisfied. If a person subsequently develops a chronic respiratory disorder as a result of COVID-19, it may satisfy the requirement as a chronic respiratory disorder.

                If a listing requires specific evidence (for example, a PFT) and that evidence is not available due to the COVID-19 pandemic, the MDI cannot meet a listing that requires that evidence. However, we may be able to make a favorable determination without a medical deferral, depending on the individual case facts. In this situation, consider the following medical assessments when making a favorable determination:
                  · Equals, or
                  · Residual functional capacity (RFC).
              7. Residual functional capacity (RFC)
                  The RFC is the most a person can do despite functional limitations resulting from his or her MDI(s) and impairment-related symptoms. Due to the duration requirement, we do not include in the RFC assessment any limitations that resolve within 12 months (SSR 82-52). However, we consider both severe and non-severe MDIs that meet the 12-month duration requirement when assessing the RFC (DI 24505.005C). We must also consider functional limitations arising out of any new MDI(s) caused by COVID-19, or any MDI(s) that has worsened because of COVID-19 in the RFC. When assessing the RFC, evaluate both stamina and endurance based on individual case facts (DI 24510.005C.2).

                  In the situation when the person’s MDI(s) does not meet or equal a listing, but evidence clearly indicates he or she is unable to sustain any work related activities for a continuous period, consider an RFC for complete inability to do sustained work-related activity (DI 24510.057B.2.b). Remember, a person’s MDI(s) must last or be expected to last for a continuous period of at least 12 months unless we expect the MDI(s) to result in death (DI 25505.025D).

                  IMPORTANT: We do not include in the RFC any prophylactic limitations or restrictions intended to limit possible exposure to COVID-19 or any other infectious disease (e.g., face covering, telework, etc.). For example, a recommendation that a person must telework due to high medical risk for COVID-19 is not a functional limitation resulting from an MDI or impairment-related symptom (DI 24510.001A.1).
                  8. Established onset date (EOD) – medical evaluation and related factors
                      Follow existing policy for evaluating evidence (DI 24501.016), including determining the EOD (SSR 18-01p). The EOD is the first date that a person meets the definition of disability and all the relevant entitlement or eligibility factors (DI 25501.200). We may need to infer the EOD when medical evidence from the acute COVID-19 infection is not available (DI 25501.450).

                      a. Death in the waiting period

                        COVID-19 may result in death in a short period of time, which means that some people with title II Disability Insurance Benefits (DIB) and Disabled Widow(er)’s Benefits (DWB) claims may die during the 5-month waiting period. It is critical in these cases to consider whether an underlying MDI(s) met the definition of disability before to the COVID-19 infection when determining EOD.

                      b. EOD before COVID-19 infection

                        If one or more underlying MDIs was disabling before the COVID-19 infection, we may be able to establish the EOD as the earliest date any underlying disabling MDI(s) first prevented SGA.
                        EXAMPLE: A person with history of chronic heart failure (CHF) applied for disability benefits with an alleged onset date (AOD) of 01/01/2020 (the date he or she stopped working due to the condition). The person was diagnosed with COVID-19 on 03/18/2020. Prior to contracting COVID-19, the person demonstrated persistent shortness of breath and difficulty completing activities of daily living (ADLs), with an ejection fraction of 29% during a period of stability on 12/15/2019. The person was hospitalized on 06/20/2019 and again on 01/13/2020 with peripheral edema and a reduced ejection fraction. The person was hospitalized a third time on 03/22/2020 due to exacerbation of respiratory and cardiac symptoms due to COVID-19, demonstrating an ejection fraction of 27%, decreased lung volume, and significant edema in both legs and feet. The person’s MDI of CHF meets the criteria for listing 4.02 (DI 34001.016) with an EOD of 01/01/2020. Given the persistent symptoms and significant severity demonstrated prior to the COVID-19, it is reasonable to establish the EOD prior to the COVID-19 infection.

                      c. EOD not before COVID-19 infection

                        If one or more underlying MDIs was not disabling before the COVID-19 infection, we cannot establish the EOD before to the COVID-19 infection.
                        EXAMPLE: A person has a history of chronic kidney disease that did not meet listing level severity and remained under good control prior to the COVID-19 infection on 04/01/2020. After contraction of COVID 19, the person’s serum creatinine increased from a pre-COVID-19 average of 2 mg/dL to 4.5 mg/dL on 04/01/2020, 4.8 mg/dL on 06/18/2020, and 4.9 mg/dL on 08/24/2020 with persistent anasarca demonstrated on these dates despite treatment. The person’s MDI meets the criteria for listing 6.06 (DI 34001.020) with an EOD as of 04/01/2020. Prior to the COVID-19 infection, the person’s impairment did not demonstrate listing level severity and the claimant’s RFC, age, education, and past work experience were consistent with a finding of not disabled. Therefore, we cannot establish the EOD prior to the COVID-19 infection.
                    9. Diaries
                        COVID-19 is a new disease and the trajectory of improvement may be difficult to predict in some cases. Follow existing policy when scheduling the diary (DI 26525.001). Remember to consider the probability that the Medical Improvement Review Standard (MIRS) applies, including all MDIs and the individual case facts. Do not apply criteria mechanically; use judgement and establish a shorter or longer diary based on the facts of each case.

                    Direct all program-related and technical questions to your Regional Office (RO) support staff or Processing Service Center (PSC) Operations Analysis (OA) staff. RO support staff or PSC OA staff may refer questions or problems to their Central Office contacts.

                    OQR personnel should direct questions to their local management.

                    OHO personnel should direct questions to local management. OHO managers may seek guidance from the RO. RO managers may refer questions or unresolved issues to the Division of Field Procedures in the Office of the Chief Administrative Law Judge.

                    OAO personnel should direct any program-related or technical questions to the Executive Director’s Office.

                    References:

                    DI 22001.001 Sequential Evaluation of Title II and Title XVI Adult Disability Claims
                    DI 22505.001 Medical and Nonmedical Evidence
                    DI 22505.006 Requesting Evidence – General
                    DI 23510.000 Death Cases - Table of Contents
                    DI 23510.001 Cases Involving Death - Title II and Title XVI
                    DI 24501.016 Evidence Evaluation
                    DI 24501.020 Establishing a Medically Determinable Impairment (MDI)
                    DI 24501.021 Evaluating Symptoms
                    DI 24505.001 Individual Must Have a Medically Determinable Severe Impairment
                    DI 24505.005 Evaluation of Medical Impairments that are Not Severe
                    DI 24508.005 Impairment Meets a Listing
                    DI 24508.010 Impairment or Combination of Impairments Equaling a Listing - Medical Equivalence
                    DI 24510.001 Residual Functional Capacity (RFC) Assessment - Introduction
                    DI 24510.005 General Guidelines for Residual Functional Capacity (RFC) Assessment
                    DI 24510.020 Projecting the RFC
                    DI 24510.057 Sustainability and the Residual Functional Capacity (RFC) Assessment
                    DI 24515.020 Curtailing Development of Fully Favorable Claims
                    DI 25501.200 Overview of Onset Policy
                    DI 25501.450 Inferring Onset for the Established Onset Date (EOD)
                    DI 25505.025 Duration Requirement for Disability
                    DI 25505.030 Evaluation of the Duration Requirement for Disability
                    DI 25505.035 Medical Deferment Involving the Duration Requirement
                    DI 26510.015 Completing Item 16A and 16B (Primary and Secondary Diagnosis, Body System Code, and Impairment Code) on the SSA-831 Disability Determination and Transmittal
                    DI 26525.001 Scheduling Continuing Disability Reviews (CDRs) - General Policies
                    DI 28005.015 Step-by-Step Discussion of the Adult Continuing Disability Review (CDR) Evaluation Process
                    DI 28010.015 Comparison of Symptoms, Signs, and Laboratory Findings
                    DI 28084.035 Diagnosis Codes (Items 21 and 22)
                    DI 34001.014 Respiratory Disorders
                    DI 34001.016 Cardiovascular System
                    DI 34001.020 Genitourinary Impairments
                    EM-20060 Disability Cases with an Allegation of Coronavirus Disease (COVID-19) as a Medical Condition
                    SSR 18-01p Title II and XVI: Determining the Established Onset Date (EOD) in Disability Claims
                    SSR 82-52 Titles II and XVI: Duration of the Impairment
                    EM 21032 - Evaluating Cases with Coronavirus Disease 2019 (COVID-19) - 04/16/2021