PROGRAM OPERATIONS MANUAL SYSTEMPart DI – Disability InsuranceChapter 280 – Continuing Disability Review CasesSubchapter 10 – Medical Improvement and Related Medical IssuesTransmittal No. 18, 05/14/2025
Audience
Originating Component
ODP
Effective Date
Upon Receipt
Background
This new POMS section highlights considerations for calculating and evaluating SSA Chronic Liver Disease (CLD) scores in the continuing disability review (CDR) sequential evaluation process. The October 6, 2023 revisions to the digestive disorders listings impacted the use of the CLD scores and calculators to evaluate CDR claims for individuals with CLD and a comparison point decision prior to October 6, 2023. This transmittal received a full IRD from 12/11/24-1/23/25.
Summary of Changes
DI 28010.155 Using the SSA Chronic Liver Disease (SSA CLD) and SSA Chronic Liver Disease – Pediatric (SSA CLD-P) Scores in Continuing Disability Review (CDR) Cases
We added this new section to highlight considerations for calculating and evaluating SSA Chronic Liver Disease (CLD) scores in the continuing disability review (CDR) sequential evaluation process.
Citations : 20 CFR 404.1594, 416.994, and 416.994a
We evaluate chronic liver disease (CLD) under listing 5.05 for adults and listing 105.05 for children in the Digestive Disorders body system. On October 6, 2023, we revised the digestive disorders listings for both adults and children. Additionally, we updated the SSA Chronic Liver Disease (SSA CLD) Calculator and SSA Chronic Liver Disease – Pediatric (CLD-P) Calculator to reflect the new criteria in listing subsections 5.05G and 105.05G, which impacts the use of these calculators to evaluate CDR claims for individuals with CLD and a comparison point decision (CPD) prior to October 6, 2023. The calculation and evaluation of the SSA CLD and SSA CLD-P scores in CDR cases is determined by the date of the CPD.
Below, we highlight some considerations for calculating and evaluating SSA CLD scores in the CDR sequential evaluation process. Steps which are not discussed below do not involve the use of the SSA CLD or SSA CLD-P calculators. As discussed in DI 28010.001, a finding of medical improvement (MI) must be based on improvements in the symptoms, signs, or laboratory findings associated with the CPD impairment(s). The individual laboratory findings that are used for calculation of the SSA CLD and SSA CLD-P scores may be used in the evaluation of whether MI has occurred, but the actual SSA CLD or SSA CLD-P calculated scores should not be considered at the MI step (i.e., step 3 for adults or step 1 for children in the CDR sequential evaluation processes outlined in DI 28005.015 and DI 28005.030). The SSA CLD and SSA CLD-P calculated scores are only considered when determining if a current or prior listing is met or equaled.
There are no special considerations for calculating SSA CLD or SSA CLD-P scores in the CDR sequential evaluation process for individuals whose impairments met or equaled listings 5.05 or 105.05 on or after October 6, 2023. Use the calculators normally to calculate SSA CLD or SSA CLD-P scores.
Follow the CDR sequential evaluation process outlined in DI 28005.015 to evaluate Title II beneficiaries and adult Title XVI recipients. Use the flexible approach described in DI 28005.005C when conducting the CDR when appropriate. If evidence in a particular case clearly documents a continuance at a later step in the process, earlier steps may be skipped. The steps discussed below are those that require the use of the SSA CLD calculator.
1. Step 2 – Does the impairment(s) meet or equal a current listing?
Use the SSA CLD calculator normally to calculate the SSA CLD scores and determine if the individual’s impairment(s) meets or equals current 5.05G.
Continue with sequential evaluation if the individual’s impairment(s) does not meet or equal a current listing.
2. Step 4 –Is medical improvement related to the ability to work?
If the individual’s impairment(s) met or equaled listing 5.05 at the CPD, and the evidence does not support that disability continues at an earlier step in the CDR sequential evaluation process, consider whether the individual’s impairment(s) continues to meet or equal listing 5.05 as it appeared at the time of the CPD. In deciding whether the individual’s impairment(s) continues to meet or equal listing 5.05 as it appeared at the time of the CPD, follow the guidance in DI 28005.015A.4 to consider all subsections, such as 5.05A or 5.05B, and not just the specific subsection used at the CPD.
The current SSA CLD calculator produces a CLDi score, which is mathematically equivalent to the SSA CLD score used for prior 5.05G and can be used to determine whether the SSA CLD scores at the CDR continue to meet 5.05G, as it appeared prior to October 6, 2023.
SSA CLD Calculator Instructions
How to Use the SSA CLD Calculator to Determine Whether Chronic Liver Disease Continues to Meet 5.05G as it Appeared Prior to October 6, 2023
1
Input the CDR lab values in the SSA CLD calculator to calculate the SSA CLDi scores. The serum sodium entry may be left blank.
2
Find that prior 5.05G continues to be met if there are two SSA CLDi scores of 22 or greater.
3
Confirm that all of the required laboratory values were obtained within the required 6-month period and disregard any messages about the required 12-month period.
If the individual’s impairment(s) no longer meets or equals the CPD listing, determine that the MI is related to the ability to work and continue to the next step of the CDR sequential evaluation process.
The listing criteria for considering SSA CLD scores due to a child’s chronic liver disease (105.05G) contains two subsections with age-based criteria; evaluating children who are age 12 or older (105.05G1) and evaluating children who have not attained age 12 (105.05G2).
Identify the child’s age and the listing subsection that was used at the time of the CPD, and the child’s age at the time of the CDR. If the child has passed the age designated in the listing subsection, the impairment no longer meets or equals the CPD listing subsection with the age criteria. For example:
If the child's impairment met listing subsection 105.05G2 (less than 12 years of age) at the CPD, and the child has attained age 12 (or older) at the CDR, do not use 105.05G2 to determine if the prior listing continues to be met. The adjudicator must use listing subsection 105.05G1 and all other subsections of 105.05 (except 105.05G2) as they appeared at the time of the CPD when considering if the prior listing continues to be met or equaled.
If the child was less than 12 years of age and met listing subsection 105.05G2 at the CPD, and remains under age 12 at the CDR, use 105.05G2 and all other subsections of 105.05 (except 105.05G1) as they appeared at the time of the CPD to evaluate if the prior listing continues to be met or equaled.
Changes to the listings on October 6, 2023 made 105.05G1 and 105.05G2 less restrictive. It is therefore possible to find that the impairment(s) does not meet the CPD listing as it was written at step 2 but find that the impairment meets the current listing at step 3. Specific changes include:
Reduction in the SSA CLD scores required to meet 105.05G1 (from a value of 22 to 20);
Addition of serum sodium to the SSA CLD formula for 105.05G1;
Extension of the timeframe for the presence of the criteria in 105.05G1 (from a 6-month period to a 12-month period); and
Requirement for one listing-level SSA CLD-P score rather than two in 105.05G2.
For evaluating Title XVI child recipients, follow the CDR sequential evaluation process outlined in DI 28005.030. Use the flexible approach described in DI 28005.005C when conducting the CDR when appropriate. If evidence in a particular case clearly documents a continuance at a later step in the process, earlier steps may be skipped. The steps discussed below are those that require the use of the SSA CLD calculator.
1. Step 2 – Does the impairment(s) continue to meet or equal the severity of the listing it met or medically equaled at the CPD?
a. For children age 12 or older at CDR
If a continuance is not supported at step 1 considering the age criteria discussed above, determine whether the child’s impairment(s) continues to meet or medically equal listing 105.05 as it appeared at the time of the CPD. In deciding whether the child's impairment(s) continues to meet or medically equal listing 105.05 as it appeared at the time of the CPD, consider all subsections (except 105.05G2) such as 105.05A, 105.05B, etc., not just the specific subsection used in the CPD.
The current SSA CLD calculator produces a CLDi score, which is mathematically equivalent to the SSA CLD score used for prior 105.05G and can be used to determine whether the SSA CLD scores at the CDR continue to meet 105.05G1, as it appeared prior to October 6, 2023.
How to Use the SSA CLD Calculator for Children Age 12 or Older at CDR to Determine Whether Chronic Liver Disease Continues to Meet 105.05G1 as it Appeared Prior to October 6, 2023
Find that prior 105.05G1 continues to be met if there are two SSA CLDi scores of 22 or greater.
NOTE: If there are not two SSA CLDi scores of 22 or greater, or the required lab values were not obtained within the required 6-month period, but a message appears on the calculator page stating that the listing is met, determine if the flexible approach is appropriate to support a continuance at step 3 in the child CDR sequential evaluation process based on a finding that the child’s SSA CLD score meets the current listing criteria.
If the child’s impairment(s) no longer meets or equals the CPD listing, the adjudicator must proceed through sequential evaluation.
b. For children who have not attained age 12 years at CDR
If a continuance is not supported at step 1 considering the age criteria discussed above, determine whether the child’s impairment(s) continues to meet or medically equal listing 105.05 as it appeared at the time of the CPD. In deciding whether the child's impairment(s) continues to meet or medically equal listing 105.05 as it appeared at the time of the CPD, consider all subsections (except 105.05G1) such as 105.05A, 105.05B, etc., not just the specific subsection used in the CPD.
The current digestive disorders listings did not change the CLD-P formula. Therefore, if the child’s impairment met or medically equaled any subsection of listing 105.05 at the CPD prior to October 6, 2023, the adjudicator or medical consultant (MC) can use the new SSA CLD-P calculator to determine whether the SSA CLD-P scores at the CDR continue to meet prior 105.05G2.
SSA CLD-P Calculator Instructions
How to Use the SSA CLD-P Calculator for Children Who Have Not Attained Age 12 Years at CDR to Determine Whether Chronic Liver Disease Continues to Meet 105.05G2 as it Appeared Prior to October 6, 2023
Input the CDR lab values in the SSA CLD-P calculator to calculate the SSA CLD-P scores. Calculate the SSA CLD-P score twice, using two separate sets of lab values, because two scores are required under the prior listing.
Find that prior 105.05G2 continues to be met if there are two SSA CLD-P scores of 11 or greater.
Confirm that all of the required laboratory values for the second SSA CLD-P score were obtained at least 60 days after the latest laboratory value for the first SSA CLD-P score and within the required 6-month period.
NOTE: If there are not two SSA CLD-P scores of 11 or greater, or the required lab values were not obtained within the required 6-month period, but a message appears on the calculator page stating that the listing is met, determine if the flexible approach is appropriate to support a continuance at step 3 in the child CDR sequential evaluation process based on a finding that the child’s SSA CLD-P score meets the current listing criteria.
If the child’s impairment(s) does not meet or equal the CPD listing, the adjudicator must proceed to step 3.
2. Step 3 – Is the child currently disabled?
Consider whether the child’s impairment(s) meets or equals a current listing at step 3 of the CDR sequential evaluation process for children. To determine whether a child’s chronic liver disease meets 105.05G, use the SSA CLD calculator normally to calculate the two SSA CLD scores for children age 12 or older (105.05G1), and the SSA CLD-P calculator normally to calculate the SSA CLD-P score for children who have not attained age 12 (105.05G2).
If the child’s impairment(s) does not meet or equal a current listing, the adjudicator must determine whether the impairment(s) functionally equals the listings.
If the individual has undergone a liver transplant since the CPD, use post-transplant laboratory values to calculate the SSA CLD or SSA CLD-P scores.
DI 28010.015 Comparison of Symptoms, Signs, and Laboratory Findings When Evaluating Medical Improvement (MI)
DI 28015.050 Consideration of Prior Listing
DI 28015.055 What is a Listing?
DI 34001.018 Digestive Disorders
DI 34005.105 Digestive Disorders
DI 34125.009 Digestive Listings from 12/18/07 to 1/16/17
DI 34125.011 Digestive Listings from 01/17/17 to 10/05/23
DI 34225.007 Digestive Listings from 12/18/07 to 06/11/15
DI 34225.009 Digestive Listings from 6/12/15 to 1/16/17
DI 34225.011 Digestive Listings from 01/17/17 to 10/05/23