PROGRAM OPERATIONS MANUAL SYSTEMPart DI – Disability InsuranceChapter 280 – Continuing Disability Review CasesSubchapter 10 – Medical Improvement and Related Medical IssuesTransmittal No. 5, 07/07/2021
This is a Quick Action Transmittal. These revisions do not change or introduce new policy or procedure. Reference section titles updated to reflect recent revisions to DI 28020 sections published 07/01/2021.
Summary of Changes
DI 28010.130 Role of Exercise Tolerance Tests (ETTs) in Medical Improvement Review Standard (MIRS) Comparisons
DI 28020 reference titles updated in subsection D.
DI 28010.150 Intelligence Quotient (IQ) Scores in Medical Improvement Review Standard (MIRS) Comparisons
DI 28020 reference titles updated in subsection C.
Listing 4.00 provides for use of the ETT as primary evidence in cases involving ischemic heart disease. However, the listing also provides for use of other types of evidence as the basis for decisions when available evidence does not include acceptable ETT results.
Obviously, the evidence-to-evidence comparisons needed under the MIRS become more difficult when evidence from one point (but not both) includes 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 findings show MI.
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
changes in symptoms connected with the ETTs may provide a basis for finding MI.
Consider such changes in the context of other findings in deciding whether MI occurred.
DI 33535.010 lists ETTs as a possible basis for applying the “new or improved” exception to MI. Consider that exception where appropriate.
DI 28020.001 General - Groups I and II of Exceptions to Medical Improvement (MI)
DI 28020.250 Group I Exception - New or Improved Diagnostic or Evaluative Techniques
DI 33535.010 Cardiovascular
DI 34001.016 Cardiovascular System
IQ scores generally tend to stabilize by age 16.
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.
If the CPD and current evidence include IQ scores from the same test (e.g., the WISC-R) find medical improvement (MI) if:
Improvement in IQ scores exceeds one standard error of measurement (SEM), and
The medical or psychological consultant (MC/PC) finds the remaining evidence (including evidence related to adaptive functioning) consistent with such a determination.
The SEM cannot be used as above to determine MI if the CPD and current evidence include IQ scores from different tests (e.g., the WISC-R and the WISC-III). The MC/PC must use clinical judgment to determine whether any IQ score change represents MI. They must make a finding of 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.
DI 33535.035 lists IQ tests where the “new or improved” exception may apply. For an explanation of this exception, see DI 28020.250.
DI 24583.055 Using Intelligence Tests to Evaluate Cognitive Disorders, Including Intellectual Disorder
DI 28010.020 Nature and Quantity of Change Needed to Find Medical Improvement (MI)
DI 28020.350 Group I Exception - Prior Error Overview