Identification Number:
DI 28005 TN 11
Intended Audience:See Transmittal Sheet
Originating Office:ORDP ODP
Title:The CDR Evaluation Process
Type:POMS Transmittals
Program:Disability
Link To Reference:
 

PROGRAM OPERATIONS MANUAL SYSTEM
Part DI – Disability Insurance
Chapter 280 – Continuing Disability Review Cases
Subchapter 05 – The CDR Evaluation Process
Transmittal No. 11, 08/08/2022

Audience

PSC: CS, DE, DEC, DTE, IES, RECONR, SCPS, TSA, TST;
OCO-OEIO: CR, ERE, FDE, RECONE;
OCO-ODO: BET, CR, CTE, CTE TE, DE, DEC, DS, PETE, PETL, RECONE;
ODD-DDS: ADJ, DHU;

Originating Component

ODP

Effective Date

Upon Receipt

Background

Updates made to multiple sections in DI 28005 for consistency with current regulations and related subregulatory policies, clarifications to multiple sections, updated references and hyperlinks, and expanded instructions, where applicable.

Summary of Changes

DI 28005.001 Legal Standard for Determining if Disability Continues

  • Added pertinent regulatory citations to the beginning of the section.

  • A- revised title from “Background of the medical improvement revise standard (MIRS)” to “Introduction to the medical improvement review standard (MIRS)”

  • B- revised title from “Definition of MIRS” to “Definition of the MIRS”

  • C- revised title from “Basic MIRS requirements” to “When the MIRS applies.” Related content was moved from subsection D1 to C.

  • D- revised title from “Application of MIRS” to “How to apply the MIRS.” Included pertinent references to the sequential evaluation process.

  • E- revised title from “References” to “When the MIRS leads to a cessation.” This section now includes information about scenarios when the MIRS leads to a cessation, breaking out information in E1 about the sequential evaluation steps leading to this scenario for Title II or adult Title XVI individuals or Title XVI child CDRs. Some of this information was previously in subsection C1, expanded text. Created E2, to include a discussions of the exceptions to medical improvement.

  • F – created new subsection about when the MIRS does not apply. This content was previously in D2, now has own subsection.

  • G – references updated and expanded, previously in subsection E.

DI 28005.003 Disability Redeterminations Required in Certain Cases Instead of a CDR

  • Revised section title from “Disability Redeterminations Required in Certain Cases Instead of a CDR” to “When to Complete an Age-18 Redetermination Instead of a Continuing Disability Review (CDR).”

  • Added pertinent regulatory citations to the beginning of the section

  • A- Expanded background content for additional information, including new pertinent references.

  • B- revised title from “Procedure – Adult Originally Allowed as Title XVI Child” to “When to perform an age-18 disability redetermination.” Fixed hyperlinks and added additional clarifying text.

  • C- Removed content in subsection C that was previously title “Procedure – Title XVI Child With Comparison Point Decisions (CPD) Based on IFA or Maladaptive Behaviors.” There are very few cases this content would still apply to, which describes these scenarios and the procedures in the revised background in subsection A, and subsection B not contains a sentence about evaluating these cases prior to the establishment of age-18 redetermination policy, including a link to pertinent POMS that contain detailed information and instructions for processing these claims. Subsection C is not titled “How to evaluate age-18 disability redeterminations” and contains instructions about the appropriate sequential evaluation process to follow.

 

DI 28005.005 The Continuing Disability Review (CDR) Evaluation Process for Title II and Adult Title XVI Individuals

  • Revised the section title from “The Continuing Disability Review (CDR) Evaluation Process for Title II and Adult Title XVI Individuals” to “Overview of Development in the Continuing Disability Review (CDR) Sequential Evaluation Process.”

  • A- expanded bulleted information and included hyperlinks to the different sequential evaluation processes for Title II and adult Title XVI individuals and Title XVI child CDR cases. Also referenced the different process for evaluating age-18 redeterminations to differentiate between CDR and redetermination processing.

  • B- revised title from “Basic CDR evaluation” to “Overview of evidence development for CDRs. B1 content expanded for development of evidence, included additional information and pertinent references. Previous B3 section titled “After the determination” contained information regarding handling evidence received after the determination, this is now in B2. The content in previous B2 titled “The CDR determination” is now discussed in different categorized areas within the section, with expanded instructions and references.

  • C- revised title from “Skipping CDR evaluation steps” to “The flexible approach in the CDR sequential evaluation process – when skipping steps may be appropriate.” Elaborated on content in this section and organized content. Included additional references and instructions.

  • D- revised title from “When not to skip steps” to “When the flexible approach is not appropriate.” Expanded content and instructions in this section.

 

DI 28005.007 Substitution of Judgment (SOJ) During a Medical Continuing Disability Review (CDR)

  • Retained subsection content and titles (with the exception of D, see below), included additional instructions and clarified information where appropriate.

  • Subsection D “References” is now Subsection E. Condensed and updated references for those not included in the previous subsections. Subsection D is now “Examples.” Included two examples in this section, applying the prior error exception without substitution of judgment and applying the prior exception with substitution of judgment.

 

DI 28005.009 Evidence and Basis for a Continuing Disability Review (CDR) Decision by a Disability Determination Services (DDS) Team

This is a new POMS section that contains content which is moved from DI 28005.215, currently titled "Evidence and Basis for Determination by a Disability Determination Services (DDS) Team." DI 28005.215 will be archived, as the content in this section is chronologically more appropriate earlier in the DI 28005 sub chapter. General enhancements, additional clarification, and references added.

  • The title for the new section in DI 28005.009 will be "Evidence and Basis for a Continuing Disability Review (CDR) Decision by a Disability Determination Services (DDS) Adjudicative Team."

  • Added additional content to subsection B for evidence requirements and development. Included additional policy information about developing evidence in MINE and MINE-equivalent cases.

  • Created new subsection B5 to address which medical evidence rules to use to evaluate CDR references. This is added due to the medical evidence rule change from 2017. A reference to the instructions in DI 24503.050D7 was added to this subsection.

DI 28005.010 The Continuing Disability Review (CDR) Evaluation Process Summary Chart for Title II and Adult Title XVI Individuals

  • Revised title from "The Continuing Disability Review (CDR) Evaluation Process Summary Chart for Title II and Adult Title XVI Individuals" to "Summary Chart of The Continuing Disability Review (CDR) Sequential Evaluation Process for Title II and Adult Title XVI Individuals." This identifies the summary chart at the beginning of the title so the user can easily distinguish between the related step-by-step instructions and the summary chart content.

  • Added "sequential" to the term CDR evaluation process for consistency with terminology in other recently revised policy sections. Removed the term "using the medical improvement review standard (MIRS) in the first sentence in subsection A because the chart provides an overview of the entire CDR sequential evaluation process, not only the MIRS-related steps.

 

DI 28005.015 Step-by-Step Discussion of the Adult Continuing Disability Review (CDR) Evaluation Process

  • Revised title from "Step-by-Step Discussion of the Adult Continuing Disability Review (CDR) Evaluation Process" to "Step-by-Step Discussion of the Title II and Adult Title XVI Continuing Disability Review (CDR) Sequential Evaluation Process." The revised title more accurately reflect to whom the sequential evaluation process applies, eliminating the term "adult" to cover scenarios for Title II CDR reviews.

  • A- Revised content in subsection A to include additional clarifying text for evaluating step 2 (title of subsection A2 now includes "a current listing" proceeding "meets or equals" to distinguish between what listings are evaluated between step 2 and the consideration of prior listings at step 4) and included clarifying text about the evaluation of any impairment meeting or equaling a current listing at this step. Expanded policy related information in subsection A3 for evaluating medical improvement, and revised content in subsection A4 to differentiate between the two mechanisms used to determine if medical improvement relates to the ability to work.

  • Revised use of terminology in related subsections when discussing the evaluation of signs, symptoms, "and" or "and/or" laboratory findings. Language revised to "signs, symptoms, or laboratory findings" where appropriate for accuracy, as 'and' implies changes are necessary to all three related terms to determine if medical improvement has occurred. Revised for consistency with regulatory terminology. No change in existing policy, correction to terminology.

  • B- Revised and condensed references in subsection B.

DI 28005.020 The CDR Evaluation Process – Title XVI Child – General

SECTION ARCHIVED

Content in this section is repetitive with content in DI 28005.021, DI 28005.025, and DI 28005.030. Pertinent content condensed within other aforementioned sections.

DI 28005.021 Title XVI: Determining Continuing Disability at Step 2 of the Medical Improvement Review Standard Sequential Evaluation Process for Children Under Age 18 - - Functional Equivalence

Removed extra hyphen in title and added hyperlink to SSR 05-03p.

DI 28005.025 The CDR Sequential Evaluation Process - Title XVI Child - Summary Chart

  • Revised title from "The CDR Evaluation Process - Title XVI Child" to "Summary Chart of the Continuing Disability Review (CDR) Sequential Evaluation Process for Title XVI Child CDR Cases." Revision to title of section made to easily identify at the beginning of the title the content contains the summary chart vs the step-by-step detailed discussion section.

  • Expanded text in subsection A to include a reference to detailed step-by-step instructions.

DI 28005.030 The CDR Evaluation Process - Title XVI Child - Step-by-Step Discussion

  • Revised title of section from The CDR Sequential Evaluation Process - Title XVI Child - Step-by-Step Discussion" to "Step-by-Step Discussion of the Title XVI Child Continuing Disability Review (CDR) Sequential Evaluation Process". Revision to title of section made to easily identify at the beginning of the title the content contains the step-by-step instructions as opposed to the less detailed summary chart.

  • • Added related regulatory references before section content.

  • B- Revised the title from "Policy -Things To Keep In Mind" to "Overview of Title XVI child assessment at CDR." The previous title was non-specific, revised title to reflect the content of this subsection provides an overview. B1 content retained. B2 title revised from “For Title XVI Children, Equals Includes Medical and Functional Equals” to “Development.” B2 now provides development guidelines, and content about medical and functional equals is now in B3. B3 title revised from “Some Group I Exceptions Do Not Apply to Title XVI Children” to “For Title XVI child CDRs, “equals” includes medically equals and functionally equals.” Included the term "medical improvement review standard" prior to acronym use "MIRS" in subsection B3.Content that was in B3 is now in B4. Content in B4 is now in B5.

  • C- Revised the title of subsection C from "Procedure" to "The Sequential Evaluation Steps for Title XVI Child CDR Cases." This revision provides a more accurate description of the subsection content than the previous title. Expanded content in subsection C 2 to include content to distinguish between listings with a non-specific period of disability and how those are evaluated at the time of a CDR. Included pertinent policy reference and instructions pertaining to evaluation of this content and included two examples. Also added new bullet in subsection C2 (bullet "c") to include instructions if there is MI in the impairments and the child did not meet or equal a listing at CPD. This content did not exist in prior version, completes possible scenarios. Revised content inC4 to include the childhood disability evaluation (CDE) and childhood disability evaluation forms (CDEF) for cases processed in eCAT and DCPS. Organized content for clarification of when a 538, CDE, or CDE is or is not necessary, and when a second assessment for is necessary. Previous content revised as this was outdated and not consistent with current electronic processing procedures. Revised to provide pertinent directions for adjudicators and medical and psychological consultants.

DI 28005.035 General Drug Addiction or Alcoholism (DAA) Material Continuing Disability Review (CDR) Evaluation Process for Title II and Adult Title XVI Cases

  • Revised the title from "General Drug Addiction or Alcoholism (DAA) Material Continuing Disability Review (CDR) Evaluation Processes for Title II and Adult Title XVI Cases" to "Drug Addiction or Alcoholism (DAA) In a Title II or Adult Title XVI Continuing Disability Review (CDR) - Overview of the CDR Sequential Evaluation Process for Considering DAA." Revised this title as content in this section does NOT just discuss when DAA is material.

  • A- Revised title of subsection A from “Introduction to the DAA CDR evaluation process” to “Overview – DAA condition in CDRs. A1 contains the definition of a DAA condition, and A2 includes general development instructions, content was previously in B1. A2 contains information about the definition of MI and when to find MI under the DAA material CDR evaluation process. Revised content in subsection A to provide a definition of DAA and moved general development of cases with DAA involvement and content involving defining a DAA condition from subsection C to subsection A.

  • B- Revised title from “Development of cases with DAA involvement” to “Introduction to the DAA CDR sequential evaluation process.” Expanded text in subsection B to include more detailed instructions for evaluating DAA in the CDR sequential evaluation process. B2 previously contained information about skipping evaluation steps, this content is now in section C. Subsection B focuses on general scenarios we consider DAA involvement and includes references to “material” and “not material” related policy. Section B includes a discussion of when the additional steps in the DAA sequential evaluation process are used.

  • C- New subsection titled “Skipping evaluation steps with DAA involvement.” Content was previously in B2, now contained in specific subsection

DI 28005.040 Drug Addiction or Alcoholism (DAA) Material Continuing Disability Review (CDR) Evaluation Process for Title II and Adult Title XVI Individuals

  • Revised the title from "Drug Addiction or Alcoholism (DAA) Material Continuing Disability Review (CDR) Evaluation Process for Title II and Adult Title XVI Individuals" to "Drug Addiction or Alcoholism (DAA) In a Title II or Adult Title XVI Continuing Disability Review (CDR) - Summary Chart for the CDR Sequential Evaluation Process When DAA is Present in a CDR." Revised title to distinguish this section provides a summary chart for the sequential evaluation process.

  • B- Included "sequential" and "adult Title XVI individuals" in subsection B title for consistency in terminology. Revised subsection B title from “DAA material CDR evaluation process summary chart for Title II and Title XVI individual age 18 and over” to “DAA material CDR sequential evaluation process summary chart for Title II and adult Title XVI individuals”

DI 28005.045 Step-by-Step Discussion of the 7-Step Drug Addiction or Alcoholism (DAA) Material Continuing Disability Review (CDR) Evaluation Process for Title II and Adult Title XVI Individuals

  • Revised the section title from "Step-by-Step Discussion of the 7-Step Drug Addiction or Alcoholism (DAA) Material Continuing Disability Review (CDR) Evaluation Process for Title II and Adult Title XVI Individuals" to "Drug Addiction or Alcoholism (DAA) In a Title II or Adult Title XVI Continuing Disability Review (CDR) - Step-by-Step Discussion of the 7-Step DAA Material CDR Evaluation Process."

  • • B- revised title from “Step-by-step discussion” to “Procedure to determine if DAA is material to Title II or adult Title XVI CDR determination. Expanded content in subsection B1 for additional clarification, and included references.

 

DI 28005.050 DAA Material CDR Evaluation Process for Title XVI Child

  • Revised the section title from "DAA Material CDR Evaluation Process for Title XVI Child" to "Drug Addiction or Alcoholism (DAA) In a Title XVI Child Continuing Disability Review (CDR) - Step-by-Step Discussion of the 7-Step DAA Material CDR Sequential Evaluation process.

  • A- Added additional instructions in subsection A regarding consideration of DAA in the child CDR sequential evaluation process.

  • B- Revised title from “Procedure to determine if DAA is material to the child CDR determination” to “Procedure to determine if DAA is material to the Title XVI child CDR determination.”

  • C- Revised title from “Summary exhibit for making DAA materiality determination” to “Summary exhibit for making a DAA materiality determination”

DI 28005.090 Continuing Disability Review (CDR) Evaluation Process in Cases Involving Statutory Blindness

  • Revised the section title from "Continuing Disability Review (CDR) Evaluation Process in Cases Involving Statutory Blindness" to "Evaluating Continuing Disability Review (CDR) Cases Involving Blindness."

  • A- Subsection A1 – revised text to provide blindness listings as opposed to previous content that was not direct. A2- revised title from MIRS and Title XVI blindness” to “Medical improvement review standard (MIRS) evaluation of blindness. Expanded content and created A2a, which provides an overview of Title II blindness evaluation issues, and A2b, which is content specific to Title XVI evaluation. A3- created subsection titled “Diary considerations and development,” which provides information about MINE diary considerations when evaluating blindness. Included pertinent listings and hyperlinks.

  • B- Revised title from “Step-by-step CDR evaluation of statutory blindness” to “Introduction to evaluation of statutory blindness in CDRs. Expanded text in subsection B to provide discussion of statutory blindness evaluation issues and how they impact a CDR. Step-by-step instructions moved to subsection C.

  • C- Subsection C titled “Step-by-step discussion of the sequential evaluation process for statutory blindness in CDRs.” Expanded instructions and clarified information in subsection C, which provides the step-by-step evaluation process for evaluating blindness issues in CDRs.

  • D- Revised subsection title and content. Subsection entitled “Overview of the sequential evaluation process when statutory blindness is established or alleged.” This section includes a new table, that provides evaluation instructions for different scenarios, including blind status at CPD, alleged impairments at CDR, and the evaluation process used. Previous content was related to allegations of blindness, this is now in E.

  • E –This was previously the references section, which is now in F. Revised title from “Allegations of blindness” to “New allegations of blindness at CDR.” Content retained, references updated.

  • F- revised references as appropriate to reflect appropriate related content.

 

DI 28005.205 Determining the Cessation Month in Continuing Disability Review (CDR) Cases

  • Added a note and updated references in subsection C6

  • Added reference to subsection D2.

 

DI 28005.210 New Impairments or Subsequent Disability

  • Revised section title from "New Impairments or Subsequent Disability" to "New Impairments or Subsequent Disability in Continuing Disability Review (CDR) Cases"

  • A- Inserted additional content in subsection A1 to provide a detailed breakdown of when to consider CPD impairments only, original related content was moved from subsection B1. Expanded text as well in subsection A2 to include more detailed instructions about considering current impairments in CDRs.

  • C- Revised title from “The role of new impairments after cessation month” to “How we evaluate subsequent disability after the cessation month.” Created C1 and C2, providing additional detail about procedures when evaluating a subsequent period of disability and the adjudicator determines the appropriate cessation month was chosen, and also explanation for when the incorrect cessation month is chosen. Added additional detail and note in section C about evaluating subsequent disability, including a reference to SSR 13-3p.

 

DI 28005.215 Evidence and Basis for Determination by a Disability Determination Services (DDS) Team

ARCHIVED-

The content in this section will be moved to a new POMS section, DI 28005.009. Existing POMS section DI 28005.215 will be archived. The information in this section discusses how evidence is assessed in CDRs and chronologically, should be present earlier in the DI 28005 sub chapter.

See content revision summary below for new section DI 28005.009.

  • The title for the new section in DI 28005.009 will be "Evidence and Basis for a Continuing Disability Review (CDR) Decision by a Disability Determination Services (DDS)."

  • Revised section title from "Evidence and Basis for Determination by a Disability Determination Services (DDS) Team" to "Evidence and Basis for a Continuing Disability Review (CDR) Decision or Determination by a Disability Determination Services (DDS) Team."

  • Added additional content to subsection B for evidence requirements and development. Included additional policy information about developing evidence in MINE and MINE-equivalent cases.

  • Created new subsection B5 to address which medical evidence rules to use to evaluate CDR references. This is added due to the medical evidence rule change from 2017. A reference to the instructions in DI 24503.050D7 was added to this subsection.

 

Conversion Table
Old POMS ReferenceNew POMS Reference
DI 28005.215DI 28005.009

DI 28005.001 Legal Standard for Determining if Disability Continues

A. Introduction to the medical improvement review standard (MIRS)

Under the continuing disability review (CDR) instructions in effect before October 9, 1984, adjudicators only considered the individual's current ability to engage in substantial gainful activity (SGA) and did not consider medical improvement (MI) in deciding if disability continued. The “Social Security Disability Benefits Reform Act of 1984” (P.L. 98-460), provided the MIRS in CDR cases. The MIRS is a series of steps in the CDR sequential evaluation process.

B. Definition of the MIRS

The MIRS refers to the legal standard for determining if disability continues in a CDR. The MIRS includes consideration of both MI and the exceptions to MI.

For policy on when the MIRS applies, see DI 28005.001C.

C. When the MIRS applies

MIRS applies in the following cases:

  • All CDRs after October 8, 1984.

  • Any determination or decision with an adjudicative date on or after December 6, 1985, apply MIRS to establish that a closed period of disability ended. See DI 25510.001C for additional information.

  • Reopenings to a cessation or denial with an adjudicative date of October 8, 1984, or later, based on a revised determination or decision concerning the individual's disability, except as noted in DI 28005.001F below.

D. How to apply the MIRS

The adjudicator will consider the MIRS at different steps in the CDR sequential evaluation process depending on whether an adjudicator is evaluating a Title II or adult Title XVI CDR case or a Title XVI child CDR case.

For an overview of the steps in the Title II or adult Title XVI CDR sequential evaluation process, see DI 28005.010.

For an overview of the steps in the Title XVI child CDR sequential evaluation process, see DI 28005.025.

E. When the MIRS leads to a cessation

1. When an individual (adult or child) is no longer disabled under the MIRS

a. Title II or adult Title XVI individual

We will determine that individuals receiving Title II and adult Title XVI benefits are no longer disabled only if the evidence demonstrates either:

  • MI related to the ability to work and the ability to engage in SGA, or

  • a Group I exception to MI applies and results in a finding of the ability to engage in SGA, or

  • a Group II exception applies.

b. Title XVI child

We will determine that a Title XVI child is no longer disabled only if the evidence demonstrates either:

  • MI and the child has no medically determinable severe impairment(s) that meet, medically equal, or functionally equal the severity of any listed impairment (see DI 25220.010 and DI 25225.001), or

  • a Group I exception to MI applies and results in a finding of no longer disabled (no marked and severe functional limitations), or

  • a Group II exception applies.

2. MIRS exceptions discussion

Our regulations provide exceptions to MI, see 20 CFR 404.1594(d) and (e), 20 CFR 416.994(b)(3)and(b)(4), 20 CFR 416.994a(e) and (f), and DI 28020.001. There are two groups of exceptions to MI, Group I and Group II exceptions. The MIRS includes evaluation of the exceptions.

If a Group I exception applies, the adjudicator will apply the exception and continue with the sequential evaluation process. If a Group I exception applies, it may lead to a finding that disability has ceased. The Group I exceptions are discussed in DI 28020.100 through DI 28020.365.

The Group II exceptions do not require a finding of the ability to engage in SGA for Title II or adult Title XVI individuals, or that the impairment(s) no longer results in marked and severe functional limitations for a Title XVI child. The Group II exceptions also do not require a finding of MI. The Group II exceptions are discussed in DI 28020.900.

F. When MIRS does not apply

MIRS does not apply in the following cases:

  • Initial claims where the requirements for a closed period of disability are not met.

  • Appeals of partially favorable disability determinations. For example, the individual files for reconsideration, requesting an earlier onset date and, on reconsideration, the claim is denied.

  • Adverse reopenings to a later onset based on medical or non-medical issues, whether status as a recipient of disability benefits is preserved or not. For example, revised medical onset after date last insured may result in revision to a denial.

  • Adverse reopenings based on a revised determination or decision concerning insured status or other non-disability issues.

  • Title XVI Age-18 Redeterminations, which are processed like CDRs, but evaluated using the 5-step sequential evaluation process for new applicants (except for the rules related to performance of SGA). See DI 22001.001 for the 5-step sequential evaluation process for new applicants.

G. References

Public Law 98-460 – Social Security Disability Benefits Reform Act of 1984

DI 23570.020 Disability Determination Services (DDS) Procedures for Processing an Age-18 Redetermination

DI 25510.001 Closed Period of Disability

DI 28005.003 When to Complete an Age-18 Redetermination Instead of a Continuing Disability Review (CDR)

DI 28005.010 The Continuing Disability Review (CDR) Evaluation Process Summary Chart for Title II and Adult Title XVI Individuals

DI 28005.003 When to Complete an Age-18 Redetermination Instead of a Continuing Disability Review (CDR)

A. Background

P.L. 104-193, enacted August 22, 1996, changed the title XVI childhood definition of disability and the sequential evaluation process for children under title XVI. It required a disability redetermination for certain Title XVI childhood cases, for children allowed title XVI disability based on an individualized functional assessment or maladaptive behaviors. The change also requires redeterminations of individuals who were children when found disabled under title XVI and attained age 18 August 22, 1996 or later (see DI 23570.006). The age-18 redetermination is necessary because the title XVI childhood definition of disability does not apply to an adult.

P.L. 105-33, enacted August 5, 1997, modified the disability redetermination provisions to change certain time limitations, so that an age-18 disability redetermination may be initiated after the individual attains age 19, and childhood disability redeterminations may be initiated after August 22, 1996.

References:

DI 11070.001 Public Law (P.L.) 104-193--General

DI 23570.000 Title XVI Childhood and Age 18 Disability Redetermination Cases (Public Law (P.L.) 104-193 as Modified by P.L. 105-33) - DDS

DI 28005.016 The Continuing Disability Review (CDR) Evaluation Process for Title XVI Adults Originally Allowed as Children Who Attained Age 18 before August 22, 1996

DI 28005.017 Preparation of Comparison Point Decision (CPD) Residual Functional Capacity Assessments for Title XVI Adults Found Disabled before Age 18 Based on an Individualized Functional Assessment (IFA)

B. When to perform an age-18 disability redetermination

An age-18 disability redetermination is required for Title XVI recipients receiving disabled child (DC) benefits who are attaining age 18 on August 22, 1996 or later. See DI 23570.006 and DI 23570.010. If an age-18 disability redetermination has already been done, conduct a CDR following the sequential evaluation process in DI 28005.015.

A CDR will be performed for Title XVI adults who were originally allowed as children who attained age 18 before August 22, 1996. See DI 28005.016 and DI 28005.017.

C. How to evaluate age-18 disability redeterminations

The medical improvement review standard (MIRS) does not apply to an age-18 disability redetermination. Age-18 disability redeterminations follow the sequential evaluation process for Title II and adult Title XVI initial claims as outlined in DI 22001.001; however, the substantial gainful activity (SGA) step of the sequential evaluation process does not apply. For additional information about the development and evaluation of age-18 disability redeterminations, see DI 23570.020.

DI 28005.005 Overview of Development in the Continuing Disability Review (CDR) Sequential Evaluation Process

A. Introduction to the CDR sequential evaluation process

Regulations require the use of the- 8-step evaluation process for Title II and adult Title XVI CDRs and a 3-step evaluation process for Title XVI child CDRs. For additional information on this process, see DI 28005.015 for Title II and adult Title XVI individuals, or DI 28005.030 for Title XVI child CDR cases. Do not use the 5-step initial claims sequential evaluation process discussed in DI 22001.001.

The 5-step initial claims sequential evaluation processed is used to evaluate age 18 redeterminations, see DI 28005.003.

NOTE: Although we refer to an 8-step evaluation process for Title II and adult Title XVI CDRs, the first step of this evaluation process (evaluation of substantial gainful activity) does not apply to Title XVI adult CDRs.

It would be rare to encounter a CDR for adults who:

  • were originally allowed as children, and

  • attained age 18 before August 22, 1996 (which prevents an age-18 redetermination), and

  • were previously evaluated based on an individualized functional assessment.

For those rare cases, refer to DI 28005.016 and DI 28005.017.

B. Overview of evidence development for CDRs

1. Development of evidence

For CDRs, the medically determinable impairment (MDI) is generally established in the comparison point decision (CPD). Do not develop solely to establish the same MDI again during the CDR. Follow the development guides for evidence in DI 28030.020. The disability examiner must consider all evidence the individual submits, including all evidence obtained from medical and non-medical sources.

Do not focus development on a particular impairment(s), develop evidence for all alleged impairments. Although the medical improvement review standard (MIRS) sequence for Title XVI child CDR cases first considers the CPD impairment(s) and the current impairment(s) later in the sequential evaluation process, initiate development of all current evidence simultaneously. Additional development may be curtailed once evidence clearly supports a finding that disability continues; see DI 28005.005C below.

  • For guidelines on developing vocational evidence in Title II and adult Title XVI CDR cases, see DI 28030.030.

  • For guidelines on developing functional evidence in Title XVI child CDR cases, see DI 28030.031.

  • For a more detailed discussion of evidence development and assessment for CDRs, see DI 28005.009.

2. Evidence received after the determination

When handling any additional evidence (trailer material, or “trailer mail”) the disability determination services (DDS) receives after processing the determination, follow instructions in DI 22520.001.

C. The flexible approach in the CDR sequential evaluation process - when skipping steps may be appropriate

1. Overview of the flexible approach in the CDR sequential evaluation process

Follow the CDR sequential evaluation process in the order shown, in most cases. However, use a flexible approach as a way to facilitate appropriate continuances.

If the DDS receives evidence that clearly establishes continuing disability, stop development and process a continuance. Skip the sequential evaluation process steps as appropriate and discussed in this section to process a continuance, but do not skip steps in a cessation.

Develop all impairments and vocational issues before making a cessation determination (except for Group II exceptions). If a Group II exception applies, find that disability ceases without proceeding to steps that determine whether the individual can engage in SGA, or for a Title XVI child, that the child's impairment(s) no longer results in marked and severe functional limitations. Do not skip consideration and development of a Group II exception to support a continuance in the sequential evaluation process if evidence suggests a Group II exception may apply. For information about Group II exceptions, see DI 28020.900.

Do not skip any step that could affect the outcome, and do not use this flexibility as a way to routinely consider steps out of order. Exclusions to using the flexible approach are discussed in DI 28005.005D.

2. Skipping the "meets or equals" step - Title II or adult Title XVI individuals

We consider if an individual's impairment(s) meets or equals a medical listing at two steps in the Title II or adult Title XVI CDR sequential evaluation process. We consider if the individual's impairment(s) meets or equals the severity of a current listing at step 2, and we consider if the individual's impairment(s) still meets or equals the severity of the listing that was met or equaled at CPD at step 4. See DI 28005.015A for a detailed explanation of the Title II or adult Title XVI CDR sequential evaluation process steps.

If evidence does not show whether an impairment(s) meets or equals the listing requirements, but clearly shows:

  • No medical improvement (MI) related to the ability to work,and

  • No exception to MI applies, then:

Find that disability continues on that basis, the skipped step does not affect the outcome.

NOTE: If the evidence demonstrates that the impairment(s) still meets or equals the prior listing criteria that was met at the CPD but the adjudicator cannot determine whether the impairment(s) meets or equals a current listing at step 2 or determine if MI has occurred at step 3, consider whether using the flexible approach would be appropriate to facilitate a continuance.

References for evaluating the medical listings:

  • For the current listing of impairments, see DI 34001.000.

  • For obsolete versions of the listing of impairments, see DI 34100.000.

3. Skipping MIRS related steps

a. Title II or adult Title XVI individuals - skipping MIRS evaluation steps to support a continuance

If a residual functional capacity (RFC) assessment or mental residual functional capacity (MRFC) assessment evaluating current impairments clearly shows the individual cannot do past relevant work or other work and no exception to MI applies, but the DDS cannot resolve issues of:

  • MI, or

  • MI related to the ability to work, then

Find that disability continues due to the inability to perform other work (referred to as "impairment plus vocational factors" in the continuance coding instructions for the SSA-832 and SSA-833 in DI 28084.020C), because development of the above steps will not affect the outcome of the decision or determination.

b. Title XVI child CDR cases - skipping MIRS evaluation steps to support a continuance

If the child's medically determinable severe impairment(s) clearly meets, medically equals, or functionally equals the severity of a current listing and no exception to MI applies but the DDS cannot resolve issues of the following:

  • MI, or

  • Determining if the impairment(s) meets/equals the severity of the listing it met at the CPD; then

Find that disability continues on the basis of meeting, medically equaling, or functionally equaling the severity of a current listing, whichever applies, because the development of the above steps will not affect the outcome of the determination.

D. When the flexible approach is not appropriate

1. Title II or adult Title XVI individuals

If the DDS receives evidence that shows MI related to the ability to work and shows that the individual cannot do other work, do not skip the past relevant work step. Doing so could affect the CDR outcome. Obtain any additional evidence needed and consider whether disability ceases based on the ability to do past relevant work. The same principles in DI 25005.005 apply to CDRs when considering expedited vocational assessment.

2. Evaluation of statutory blindness

Since there are special considerations for blindness, the adjudicator should use caution in using the flexible approach. This is due to higher substantial gainful activity (SGA) limits that may benefit the Title II beneficiary if they are able to work, and for possible payment advantages of Title XVI recipients. If an issue of blindness exists, the examiner should ensure appropriate development and evaluation of a blindness or vision impairment instead of using the flexible approach to facilitate evaluation of a non-blind individual’s impairment(s).

For additional information on evaluating statutory blindness in CDRs, see DI 28005.090.

3. Group II exceptions

Do not use the flexible approach if criteria for a Group II exception applies or there is evidence that a Group II exception may apply, see DI 28005.005C1.

DI 28005.007 Substitution of Judgment (SOJ) During a Medical Continuing Disability Review (CDR)

During a CDR, the current adjudicator may arrive at a different determination than the adjudicator, administrative law judge, or appeals council who made the determination at the comparison point decision (CPD). This may occur even when the previous determination is fully documented and rationalized.

A. What is SOJ?

SOJ occurs when an adjudicator conducting a CDR comes to a different determination than a prior DE after reviewing the same evidence and:

  • The determinations are equally supportable based on the evidence in the folder, and

  • The previous adjudicator has fully documented the folder.

The term “determination” means medical assessment (including severity and residual functional capacity (RFC)), vocational assessment, medical-vocational assessment, or determination of disabled or not disabled.

The term “support” or “supportable” means conforming to the Social Security Administration (SSA) disability program policy and procedures.

When reviewing the CPD evidence during the CDR, the current adjudicator must be aware of the SOJ concept as a review principle and must not substitute their own judgment by attempting to re-adjudicate the case or intentionally search for a Group I prior error exception.

When the CPD folder has complete and accurate documentation, the evidence in the folder supports the determination, and the determination complies with SSA policy; but the CDR adjudicator arrives at an opposite yet equally supportable conclusion, the CDR adjudicator must not substitute their judgment for that of the CPD adjudicator.

B. Identifying SOJ

Substitution of judgment may occur when:

  • The CPD adjudicator fully developed and documented the case with evidence supporting the CPD determination based on policy guidance;

  • The CPD adjudicator considered all the facts in making the determination;

  • The CDR adjudicator, after considering all the facts, believes the evidence directs a different determination than the CPD adjudicator; and

  • Determinations from both the CPD and CDR are equally supportable, then

SOJ occurs if the CDR adjudicator applied an error exception.

NOTE: Do not apply the prior error exception if it is unclear as to whether the CPD determination was made in error. See DI 28020.350 for additional information about the linited scenarios where the prior error exception applies.

C. SOJ and Group I prior error exceptions

1. Identifying prior error without SOJ

When reviewing the CPD evidence, the CDR adjudicator must determine if medical improvement (MI) occurred without substituting judgment on the CPD determination. The case does not involve SOJ if any of the following exists and an exception applies in accordance with DI 28020.001:

  1. a) 

    The CPD determination clearly contradicts the evidence present during the CPD (for example, the CPD adjudicator bases their determination on an incorrect interpretation of an electrocardiogram, contrary to accepted medical knowledge); or

  2. b) 

    The CPD determination is clearly contrary to specific disability program policy in effect at the time of the CPD; or

  3. c) 

    The CPD adjudicator has clearly misinterpreted or misrepresented the evidence in their determination rationale; or

  4. d) 

    All of the following exist:

  • The CPD adjudicator’s determination does not explain the application of the medical improvement review standard (MIRS),

  • The CDR adjudicator reaches a different conclusion, and

  • The CPD adjudicator’s determination is not supportable.

Do not apply a prior error exception simply because the prior determination explanation is inadequate or missing. There must be disagreement based on a reasonable interpretation of the evidence in file, and the current DE’s determination must clearly be more supportable.

If the CPD determination is not supportable, then the CDR adjudicator's different determination does not represent SOJ and the adjudicator may apply an error exception when appropriate. For additional information on the Group I exceptions, see DI 28020.001B.1.

2. Documenting a prior error finding

When applying the Group I prior error exception, thoroughly document the finding of prior error. Include a supportive rationale that explains how the evidence shows the prior determination was erroneous. This includes evidence on the record at the time of any prior determination and any newly obtained evidence that relates to a prior determination. For additional information on applying a prior error exception and the rationale content, see DI 28020.350 through DI 28020.365 and DI 28090.055. When documenting the prior error exception, explain:

  • What substantial evidence shows a prior determination was in error, 

  • The specific available evidence that does not show a reasonable alternate basis for the prior determination (meaning the decision outcome was not correct, not that the claim could have been allowed under an alternate basis that does not impact benefits), and 

  • One of the three types of prior error is found in DI 28020.350 through DI 28020.365 apply. 

The error exception will not be applied retroactively under the conditions described below unless the conditions for reopening the prior decision are met (see DI 27501.001, DI 27501.005, and DI 27505.000. Do not apply a prior error exception simply because the prior determination explanation is inadequate, lost, or missing.

3. Addressing prior error during a CDR

If the CDR adjudicator determines that prior error exists in the CPD determination, and this determination does not constitute SOJ, then the CDR adjudicator must determine which error exception applies according to DI 28020.001B.1 and then follow the procedures to apply the prior error exception according to DI 28020.375.

D. Examples

1. Applying the prior error exception without SOJ

At CPD: The individual alleges she cannot walk due to numbness in her legs. She uses a cane when walking and must sit down to relieve tingling in her legs. Examinations shows she maintains good strength but is diagnosed with peripheral arterial disease (PAD) and was prescribed a four prong cane. The impairment did not meet or equal listing 4.12, so the adjudicator prepared a less-than-sedentary RFC assessment. limiting standing and walking to one hour out of an 8-hour workday. This precluded the individual's past relevant work due to the ambulatory limitations. Functional evidence was in the file at CPD that discusses standing and walking, but this was not addressed in the RFC assessment. The examiner only cited the PAD and ambulation with a cane.

At CDR: Current evidence shows unchanged symptoms and signs. However, review of the CPD evidence showed an ankle-brachial index (ABI) of .95, indicating mild PAD. A detailed review of the CPD activities of daily living (ADLs) indicate the individual reported an estimate of standing and walking approximately 4 hours in an 8-hour period during the day, using her cane as needed. The current DE feels that at CPD the individual should have been capable of at least sedentary activity. The current DE applies a Group I prior error exception.

Discussion: The current adjudicator applied a Group I prior error exception correctly. The results of the ABI clearly indicates that the impairment is not as severe as proposed at CPD and the individual's ability to stand and walk more than a total of one hour out of an 8-hour workday is supported. SOJ did not occur because the evidence clearly contradicted the restrictions in the prior RFC that was the basis of the allowance at the CPD.

2. Applying the prior error exception with SOJ

At CPD: The individual reported difficulty standing and walking and was taking medicine prescribed by his pain management doctor. X-rays showed mild to moderate spinal stenosis. The CPD adjudicator prepared an allowance based on a sedentary RFC due to back impairment.

At CDR: The individual currently reports back pain and is taking over-the-counter medications because he no longer sees a doctor on a regular basis. He reports difficulty standing due to the pain but he is able to perform some light household chores. Examinations show he walks 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 cease because the medical-vocational rules indicate “not disabled.”

Discussion: In the example provided, the individual currently reports back pain with difficulty standing and walking, and is taking pain medications (symptoms), he 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 significantly changed since the CPD. The current adjudicator failed to evaluate MI and, instead, re-adjudicated the CPD evidence, arriving at a different RFC based on the same evidence without demonstration of an error. The current adjudicator should have prepared a “No MI” determination.

E. References

  • DI 28005.005 Overview of Development in the Continuing Disability Review (CDR) Sequential Evaluation Process

  • DI 28010.015 Comparison of Symptoms, Signs and Laboratory Findings

  • DI 28020.355 Group I Exception - Prior Error, Error on the Face of the Record

  • DI 28020.360 Group I Exception - Prior Error, Required and Material Evidence Was Missing

  • DI 28020.365 Group I Exception - Prior Error, New Evidence Related to the Prior Determination or Decision

  • DI 28020.375 Error, Reopening, and the Medical Improvement Review Standard (MIRS)

DI 28005.009 Evidence and Basis for a Continuing Disability Review (CDR) Decision by a Disability Determination Services (DDS) Adjudicative Team

A. Role of DDS adjudicative teams

The DDS adjudicative teams evaluate medical improvement review standard (MIRS) issues when conducting a CDR. These teams consist of a medical or psychological consultant and adjudicator, trained in the disability evaluation process. In deciding MIRS issues, the team members have the same responsibilities as when making initial determinations.

B. Development of evidence in a CDR

1. Evidence requirements to assess medical improvement (MI)

Consider evidence submitted from medical and nonmedical sources when determining if MI has occurred. This includes evidence of function. The sufficiency of the evidence at the CDR must allow the adjudicative team to determine if there has been any decrease in the current medical severity of the impairment(s) which was present at the time of the most recent favorable medical decision, known as the comparison point decision (CPD).

For additional information on the development of evidence at the CDR, see DI 28030.020.

2. Evidence development for medical improvement not expected (MINE) or MINE-equivalent impairments at CDR

Extensive current medical development at CDR may not be needed in MINE or MINE-equivalent impairments because they are considered permanent. While medical development in MINE and MINE-equivalent cases may not require extensive current evidence, the DDS must contact a current medical source when possible. If no medical source is available, see DI 28040.125.

For additional development guidelines, see DI 28040.120 and DI 28040.125.

3. Basis for a determination and analysis of the evidence

DDS adjudicative teams:

  1. a. 

    Make CDR determinations considering all available evidence.

  2. b. 

    Do not draw any initial inference as to the presence or absence of disability from the fact that:

    • The individual was previously found disabled, or

    • A CDR is being conducted.

  3. c. 

    Determine if disability continues based on the supportability and consistency of the evidence.

  4. d. 

    Do not:

    • Substitute current judgment for that of the prior adjudicator (see DI 28005.007),

    • Re-adjudicate the prior determination or decision, or

    • Re-establish a medically determinable impairment that has already been established.

4. Consider all evidence

Consider all evidence concerning the individual's CPD and current impairment(s) (and vocational profile where applicable). Consider:

  • All evidence already in file, and

  • Any new evidence presented by the individual or secured by the Commissioner. For information on the development of medical evidence, see DI 28030.020.

5. Determining which medical evidence rules to use to evaluate the CDR evidence

a. Background on the medical evidence rules

The medical evidence rules were revised effective March 27, 2017. The changes in the medical evidence rules impacted the evaluation of different aspects of medical evidence evaluation, including who is concisdered to be an acceptable medical sources and how we consider medical opinions and prior administrative medical findings. A detailed list of specific evidence rules that were revised can be found in DI 24503.050A.2.

b. Which medical evidence rules to use

At CDR, we might have to use the “prior rules,” or the “current rules,” as described in DI 24503.050.

Initial claim filed before March 27, 2017

  1. 1) 

    If there has not been a prior CDR, use the prior rules.

  2. 2) 

    If there has been a prior CDR:

    • Use the prior rules if the comparison point decision (CPD) is before March 27, 2017, see DI 24503.035.

    • Use the current rules if the CPD is on or after March 27, 2017, see DI 24503.025 and DI 24503.035.

Initial claim filed on or after March 27, 2017

To determine which medical evidence rules to apply, we must look at the filing date of the initial claim associated with the CDR. The same rules will apply throughout the entire CDR determination or decision, including the appeals process. Detailed instructions can be found in DI 24503.050D.7.

C. The cessation or continuance determination

To determine whether a continuance or cessation is appropriate, follow the applicable continuing disability review sequential evaluation procedures in DI 28005.015 or DI 28005.030.

DI 28005.010 Summary Chart of The Continuing Disability Review (CDR) Sequential Evaluation Process for Title II and Adult Title XVI Individuals

A. Introduction to the process summary chart

This chart outlines the CDR sequential evaluation process for all Title II beneficiaries and Title XVI recipients age 18 or older. For Title XVI adults originally allowed as Title XVI children, see DI 28005.003.

B. Exhibit of the evaluation process summary chart

Adult CDR Evaluation Process Summary Chart. For a more detailed discussion of these steps, see DI 28005.015A.

DI 28005.015 Step-by-Step Discussion of the Title II and Adult Title XVI Continuing Disability Review (CDR) Sequential Evaluation Process

A. Discussion of the 8-Step Title II and adult Title XVI CDR sequential evaluation process

This subsection corresponds with the numbered steps in the chart located in DI 28005.010. For adults originally allowed as children under Title XVI, see DI 28005.003. Consider the Group II exceptions at any point during the CDR sequential evaluation process.

On case receipt, thoroughly review the comparison point decision (CPD) and the CPD evidence that supports the CPD determination. The CPD is the most recent favorable decision, see DI 28010.105. The CDR adjudicator must not substitute their own judgment for that of the prior adjudicator when reviewing CPD evidence, see DI 28005.007.

NOTE: Reviewing only the assessment summary from the CPD determination is not a thorough review of the CPD evidence. The CDR adjudicator must review all of the CPD evidence that supports the CPD determination including the signs, symptoms, and laboratory findings.

1. Step 1 - substantial gainful activity (SGA)

The first step in the CDR evaluation process is to determine whether the individual is performing SGA. This is a field office (FO) responsibility and determination. The FO determines if disability ceases based on performance of SGA.

SGA cessation determinations are not applicable to Title XVI cases for work performed after June 30, 1987. For additional information on this issue, see DI 28075.600. Since SGA is not a consideration in the sequential evaluation process for Title XVI disability recipients, proceed directly to step 2 below.

In concurrent Title II and Title XVI cases, an individual whose Title II benefit ends due to performance of SGA may retain Title XVI eligibility:

  • during the trial work period (TWP), or

  • when deciding whether an individual continues to have a disabling impairment for purposes of an extended period of elgibility (EPE) or other work incentive benefits.

In concurrent case scenarios that contain documentation of a work incentive program such as a TWP or EPE, do not send the case to the FO for development of SGA.

Once the FO has resolved any work issues for SGA, the disability determination services (DDS) adjudicator must identify the CPD. After identifying the CPD, the adjudicator can continue to Step 2 of the CDR sequential evaluation process. For additional information on identifying the CPD, see DI 28010.105.

Although the SGA determination is primarily the FO responsibility, sometimes work issues may arise during the CDR at the DDS level. For details on DDS work activity development responsibilities, see DI 24001.005C.

2. Step 2 - meets or equals a current listing

Review the evidence in the file and document the individual’s current alleged impairment(s). Then, determine whether any impairment(s) meet or equal a listing in the current Listing of Impairments:

  • If yes, find that disability continues.

  • If no, go to Step 3.

NOTE: At step 2, we are not concerned with what the individual’s impairment(s) was at the time he or she was last found disabled, nor are we concerned with the basis for having found the individual disabled previously. We consider if any impairment(s) the individual currently has meets or equals a current listing.

3. Step 3 - medical improvement (MI)

Review the CPD evidence and identify relevant medical signs, symptoms, or laboratory findings for the same impairment(s) that were present at the CPD. Then, compare the signs, symptoms, or laboratory findings for the same impairment(s) at the CDR to determine whether there is a decrease in the medical severity of the impairment(s) at the CDR. For MI to occur, there must be a decrease in the medical severity of any of the impairments present at the time of the CPD. Minor changes in any CPD impairment do not demonstrate MI. For additional information relating to MI, see DI 28010.000.

Decide whether MI occurs:

  • If there is MI, go to Step 4.

  • If there is no MI, go to Step 5.

4. Step 4 - relating MI to the ability to work

When determining if MI relates to the ability to work, consider only the CPD impairment(s) and, if applicable, consider age and time on the rolls instructions in DI 28015.310. For detailed instructions on relating MI to the ability to work, see DI 28015.000

Two mechanisms to determine if MI relates to the ability to work:

  • Prior listing mechanism: If the basis of the CPD was meeting or equaling a listing and the individual still meets or equals that prior listing or any of the subsections of that listing as it appeared at the time of the CPD (including a listing that has since been revised or is now obsolete), then MI does not relate to the ability to work. For consideration of prior listings, see DI 28015.050 and DI 28015.055.A summary list of changes to the Listing of Impairments, and the effective date of the changes, is located in DI 27516.010F. Obsolete versions of the adult listings may be located at DI 34100.000 and DI 34200.000.

  • Residual functional capacity (RFC) comparison mechanism: If the CPD was based on medical and vocational factors, compare the findings in the evidence used to support the “CPD RFC” with the findings in the evidence for the same impairments evaluated in the “medical improvement review standard (MIRS) RFC” or other assessment document (such as a SSA-416 UF if the CPD impairment(s) is not severe at the CDR). Do not attempt to reassess the "CPD RFC." If there is no improvement in the individual's ability to perform work related tasks, then MI does not relate to the ability to work. For additional information on RFC assessments, see DI 28015.300 and DI 28015.855).

To consider age and time on the rolls when assessing the current RFC, see DI 28015.310.

Decide whether MI relates to the ability to work:

  • If MI does not relate to the ability to work, go to Step 5.

  • If MI relates to the ability to work, go to Step 6.

5. Step 5 - exceptions

Group I and Group II exceptions to MI permit a finding that disability ceased in situations where even though there has been no MI or MI is not related to the ability to work, evidence clearly shows that the person should not longer be considered disabled or never should have been considered disabled.

If there is doubt as to whether the exception applies, decide in the individual’s favor. For Group I exceptions, that means that disability would continue because we have already found that there has been no medical improvement. For the Group II exceptions, we would continue the evaluation.

The Group I exceptions apply at step 5 of this sequential evaluation process and may result in a finding that an individual is no longer disabled. For information on Group I exceptions, see DI 28020.001B1.

Group II exceptions can apply at any step of the CDR sequential evaluation process and do not require a determination that an individual has medically improved or can engage in SGA. For information on Group II exceptions, see DI 28020.900.

Decide whether an exception to MI applies:

  • If no exception applies, find that disability continues.

  • If one of the Group I exceptions applies, go to Step 6.

  • If one of the Group II exceptions applies, then the adjudicator may find that disability ceases at any point in the 8-Step CDR evaluation process without a medical determination.

6. Step 6 - severity of current impairment(s)

Decide whether the individual has any severe impairment(s) and assess the current RFC considering all current impairments. Our policy defines a “severe” impairment as an impairment that causes limitations having more than a minimal effect on an individual’s capacity to perform basic work activities, see DI 24505.001. For more information on the RFC assessment, see DI 28015.850. If applicable, consider age and time on the rolls instructions, see DI 28015.310.

If the individual’s impairment(s) has medically improved but remains more than “not severe,” or a current impairment is more than “not severe,” the DE proceeds to step 7.

Conversely, if the individual’s CPD impairment(s) has medically improved and there is no evidence of a current severe impairment(s), a cessation is appropriate.

Determine if the individual currently has any severe impairment(s):

  • If yes, assess the impairment(s) on a RFC and go to Step 7.

  • If no, find that disability ceases.

7. Step 7 - past work

If the individual's combined medical conditions impose limitations on their current RFC, consider the individual's capacity to do their past relevant work (PRW). Do not consider work during the current period of disability (or current period of extended Medicare) as relevant work experience, see DI 25001.001A.64. For expedited reinstatement (EXR) cases, do not consider work that has occurred since the CPD; this will not be considered PRW.

If the vocational evidence is not sufficient to evaluate past work at step 7, adjudicators may consider use of a vocational expedient, see DI 25005.005 .

Decide whether the individual has the ability to perform past relevant work:

  • If yes, find that disability ceases.

  • If no, go to Step 8.

8. Step 8 - other work

If the individual's current medical condition precludes performing PRW or there is insufficient evidence regarding the individual’s PRW, consider the individual’s ability to adjust to other work existing in the national economy by considering the RFC and the vocational factors of age, education, and work experience, as appropriate in the case. Decide whether the individual has the ability to do other work:

  • If yes, find that disability ceases.

  • If no, find that disability continues.

NOTE: Consider borderline age situations if an individual is within a few days to a few months of reaching a higher age category and using the chronological age results in a cessation. Consider using the higher age category if it results in a continuance, after RFC, age, education, and work experience have all been evaluated. Specific criteria must be met, see DI 25015.006C for information on identifying a borderline age situation.

B. References

  • DI 24001.005 Work Activity Development Responsibilities

  • DI 25010.000 Special Medical-Vocational Profiles Showing an Inability to Adjust to Other Work

  • DI 25015.000 Ability to Perform Other Work

  • DI 28005.010 The Continuing Disability Review (CDR) Evaluation Process Summary Chart for Title II and Adult Title XVI Individuals

  • DI 28010.000 Medical Improvement and Related Medical Issues

  • DI 28015.000 Relating Medical Improvement to the Ability to Work – Title II and Adult Title XVI Beneficiaries

  • DI 28020.000 Exceptions to Medical Improvement

  • DI 28055.001 Extended Period of Eligibility (EPE) and Related Medicare Provisions – General

  • DI 28075.000 Special CDR Issues

  • DI 34001.001 Listing of Impairments -- Purpose, Parts and Use

DI 28005.021 Title XVI: Determining Continuing Disability at Step 2 of the Medical Improvement Review Standard Sequential Evaluation Process for Children Under Age 18 - Functional Equivalence

A. Background

On April 27, 2005, SSA published SSR 05-03p, “Title XVI: Determining Continuing Disability at Step 2 of the Medical Improvement Review Standard Sequential Evaluation Process for Children Under Age 18 – Functional Equivalence.” The entire SSR is in DI 28005.021B. Refer to the Policy Interpretation section of the SSR whenever functional equivalence must be considered at step 2 of the childhood CDR process.

B. Policy – SSR 05-03p

SSR 05-03p: Title XVI: Determining Continuing Disability at Step 2 of the Medical Improvement Review Standard Sequential Evaluation Process for Children Under Age 18 – Functional Equivalence

PURPOSE: To explain our policies for determining continuing disability at step 2 of the medical improvement review standard (MIRS) sequential evaluation process for children under 20 CFR 416.994a(b)(2) and to explain how we apply the functional equivalence rule at step 2.

CITATIONS (AUTHORITY):

Sections 1614(a)(3), 1614(a)(4), and 1614(c) of the Social Security Act; Regulations No. 16, subpart I, sections 416.924, 416.925, 416.926, 20 CFR 416.926a, and 416.994a.

 

INTRODUCTION:

When we conduct a continuing disability review, we use a three-step MIRS sequential evaluation process, outlined in 20 CFR 416.994a(b).

  1. 1. 

    At step 1, we determine whether there has been medical improvement in the impairment(s) that was present at the time of the most recent favorable determination or decision. (20 CFR 416.994a(b)(1)). We refer to the most recent favorable determination or decision as the “comparison point decision” (CPD), and we refer to the impairment(s) that was present at the time of the most recent favorable determination or decision as the “CPD impairment(s).” If there has been no medical improvement in the CPD impairment(s), we find that the child's disability continues. If there has been medical improvement, we proceed to step 2. [1]

  2. 2. 

    At step 2, we determine whether the CPD impairment(s) still meets or medically or functionally equals “the severity of the listed impairment” that it met or equaled at the time of the CPD. (20 CFR 416.994a(b)(2)). If the CPD impairment(s) still meets or medically or functionally equals the severity of the listing we considered at the CPD, we find that the child is still disabled. As long as we determine that the CPD impairment(s) currently meets or medically or functionally equals the listing we considered before, we do not have to make the same finding we made at the CPD. For example, if we found at the CPD that the child's impairment(s) met a listing, and now it no longer meets that listing but it medically equals that listing, we find that the child's disability continues. Likewise, if we found that the child's impairment(s) functionally equaled a listing, and now it meets that listing, we find that the child's disability continues. If the CPD impairment(s) does not still meet or equal the severity of that listed impairment, we proceed to step 3.

  3. 3. 

    At step 3, we determine whether the child is currently disabled, considering all current impairments. (20 CFR 416.994a(b)(3)). We determine if the child's current impairment(s) is severe, as defined in 20 CFR 416.924(c). If the impairment(s) is not severe, we find that the child's disability has ended. If the impairment(s) is severe, we consider whether it meets or medically equals a listing. (20 CFR 416.924(d), 416.925, 416.926). If it does, we find that the child's disability continues. If not, we consider whether it functionally equals the listings. (20 CFR 416.926a). If it does, we find that the child's disability continues. If not, we find that the child's disability has ended.

On September 11, 2000, we published final rules (the “2001 rules”) for evaluating disability in children under the Supplemental Security Income program. These rules became effective on January 2, 2001. [2] In section 416.926a of the 2001 rules, (20 CFR 416.926a), we clarified and simplified our prior rules for evaluating functional equivalence [3] in a number of ways. Under the functional equivalence policies that we applied prior to January 2, 2001, we required a comparison of the child's impairment(s) to a specific listing. [4] One way in which we clarified and simplified functional equivalence under the 2001 rules was to no longer refer to specific listed impairments. Instead, we determine whether a child's impairment functionally equals the listings. To functionally equal the listings, a child's impairment(s) must cause “marked” limitations in two domains of functioning, or “extreme” limitation in one such domain, as described in 20 CFR 416.926a.

Therefore, findings of functional equivalence made on or after January 2, 2001, are not based on a specific listing.

Because our current rules about step 2 of the MIRS sequential evaluation process refer only to the specific listed impairment(s) that we considered at the CPD, we are issuing this ruling to explain how we apply the functional equivalence rules at step 2. We also explain how we apply step 2 when the CPD was based on functional equivalence to the listings.

POLICY INTERPRETATION:

When we evaluate functional equivalence at step 2 of the MIRS sequential evaluation process for children in 20 CFR 416.994a(b), we use the current rules for evaluating functional equivalence.

How we apply step 2 of the MIRS sequential evaluation process for children depends on the date of and basis for the CPD. A chart that summarizes our policies on applying step 2 follows the text.

a. If the CPD was made before January 2, 2001.

If the CPD was made before January 2, 2001, it was based either on a finding that the child's impairment(s) met or medically equaled a specific listing, or functionally equaled a specific listing under the rules for functional equivalence that were in effect at the time of the CPD.

When we determine whether a child's disability continues at step 2, we first consider whether the CPD impairment(s) now either meets or medically equals the same listing that it met, medically equaled, or functionally equaled at the CPD, as that listing was written at that time. If the CPD impairment(s) now meets or medically equals the severity of that listed impairment as it was written at that time, we find that the child is still disabled.

If the CPD impairment(s) does not now meet or medically equal the CPD listing, we consider whether the CPD impairment(s) now functionally equals the listings under our current rules in 20 CFR 416.926a. If it does, we find that the child is still disabled. If it does not, we proceed to step 3.

b. If the CPD was made on or after January 2, 2001.

If the CPD was made on or after January 2, 2001, it was based either on a finding that the child's impairment(s) met or medically equaled a listing, or functionally equaled the listings under the current rules in 20 CFR 416.926a.

(1) If the CPD impairment(s) met or medically equaled a listing:

If our determination or decision at the time of the CPD was that the child's impairment(s) met or medically equaled a listing, we consider whether the CPD impairment(s) now either meets or medically equals that same listing, as it was written at that time. If it does, we find that the child is still disabled.

If the CPD impairment(s) does not now meet or medically equal the CPD listing, we consider whether the CPD impairment(s) now functionally equals the listings under our current rules in 20 CFR 416.926a. If it does, we find that the child is still disabled. If it does not, we proceed to step 3.

(2) If the CPD impairment(s) functionally equaled the listings:

When we determine whether a child's disability continues at step 2 and the CPD was based on functional equivalence to the listings, we consider only whether the CPD impairment(s) now functionally equals the listings. We do not consider whether the impairment(s) now meets or medically equals the CPD listing, because there is no specific CPD listing. If that impairment(s) now functionally equals the listings under our current rules in 20 CFR 416.926a, we find that the child is still disabled. If it does not, we proceed to step 3.

Chart: This chart summarizes the explanations above. Follow a. or b. as appropriate.

a. If the CPD was made before January 2, 2001:

b. If the CPD was made on or after January 2, 2001, follow (1) or (2) as appropriate:

(1) CPD impairment(s) met or medically equaled a listing:

(2) CPD impairment(s) functionally equaled the listings

C. EFFECTIVE DATE:

This SSR is effective upon publication in the Federal Register.

D. CROSS-REFERENCES:

Program Operations Manual System, sections DI 28005.020, DI 28005.025, and DI 28005.030.

[1] At each step of the process certain “exceptions to medical improvement” may apply, under which disability can be found to have ended even though medical improvement has not occurred. (20 CFR 416.994a(e)-(f)). Although we apply the exceptions when appropriate, further discussion of the exceptions is unnecessary in this Ruling.

[2] 65 FR 54747-54790 (2000).

[3] We have included the policy of functional equivalence in our childhood disability rules since 1991. See 56 FR 5534, 5543, 5561-5562 (1991).

[4] 20 CFR 416.926a(b) (1997); 20 CFR 416.926a(b) (1993); 20 CFR 416.926a(b) (1991).

[5] The conclusion that disability continues here and elsewhere on this chart is subject to any applicable exceptions to the MIRS standard. See footnote 1 above.

DI 28005.025 Summary Chart of the Continuing Disability Review (CDR) Sequential Evaluation Process for Title XVI Child CDR Cases

A. Introduction

The chart below outlines the CDR evaluation process for Title XVI child CDR cases. For detailed step-by-step instructions on the CDR sequential evaluation process for Title XVI child CDR cases, see DI 28005.030.

B. Exhibit - Title XVI Child CDR Process

DI 28005.030 Step-by-Step Discussion of the Title XVI Child Continuing Disability Review (CDR) Sequential Evaluation Process

CITATION

A. Introduction

The discussion in subsection DI 28005.030C is numbered to correspond to the summary chart in DI 28005.025.

B. Overview of Title XVI child assessment at CDR

1. For Title XVI disability purposes, a child is anyone under age 18

For Title XVI disability purposes, “ Adult means a person who is age 18 or older. Child means a person who has not attained age 18” (20 CFR 416.902(c) ).

For other Title XVI purposes, e.g., income and resources, some individuals age 18 or older are considered disabled children (“DCs” ), and some individuals under age 18 are considered disabled adults (“DIs”), but these categorizations have no bearing on whether an individual is a child or an adult for disability purposes.

2. Development

Follow the development guides in DI 28030.020. Do not focus development on a particular impairment(s). Although the medical improvement review standard (MIRS) sequence as it applies to title XVI children focuses first on the CPD impairment(s) and later on the current impairment(s), initiate development of all current evidence simultaneously.

See DI 28005.003 if the CPD was prior to August 22, 1996, and a disability redetermination may be required.

3. For Title XVI child CDRs, "equals" includes medically equals and functionally equals

For Title XVI child CDR cases, wherever the term “equals” (and related terms, e.g., “equaled”) appears without “medically” or “functionally” as a modifier, it includes both of those concepts.

For example: “does your impairment(s) still meet or equal the severity of the listed impairment that it met or equaled before?” must be read as “does your impairment(s) still meet or medically or functionally equal the severity of the listed impairment that it met or medically or functionally equaled before?”

4. Some Group I exceptions do not apply to Title XVI child CDRs

P.L. 104-193, enacted August 22, 1996, changed the medical improvement review standard (MIRS) exceptions that apply to Title XVI children.

The following Group I exceptions that are applicable to Title II CDR cases and adult Title XVI CDR cases do not apply to Title XVI child CDR cases:

  • Advances in Medical or Vocational Therapy or Technology (see DI 28020.100);

  • Substantial Gainful Activity (SGA) (applicable to Title II CDR cases only, see DI 28020.050); and

  • Vocational Therapy (see DI 28020.150).

5. 1619 Provisions Apply

SGA is not a reason for disability cessation for title XVI child CDR cases because of the 1619 provisions (see DI 28005.015B.)

C. The sequential evaluation steps for Title XVI child CDR cases

Follow the CDR evaluation process shown and summarized in the chart in DI 28005.025. There is a step-by-step discussion of the MIRS sequence for title XVI children in DI 28005.030. As with CDRs, and for other categories of claimants, use a flexible approach (DI 28005.005C) when appropriate. If evidence in a particular case clearly documents a continuance at a later step in the process, earlier steps may be skipped. Skip evaluation process steps as necessary to process a continuance (but not a cessation). Do not skip any step that could affect outcome, or routinely consider steps out of order.

1. Has there been medical improvement (MI)?

The first step in the sequential evaluation process for evaluating Title XVI child CDR cases is to determine whether MI has occurred, see DI 28010.015 for a definition of MI. If there has been no MI, we will find that disability continues unless one of the exceptions in DI 28020.250 through DI 28020.900. If there has been medical improvement, the adjudicator will go to the next step in the sequential evaluation process.

Determine whether there has been MI in any impairment(s) the child had at the time of the comparison point decision (CPD), see DI 28010.015.

  1. a. 

    If there is no MI, consider whether a Group I or Group II exception applies. See DI 28020.001.

    • If no exception applies, find that disability continues.

    • If a Group I exception applies (see DI 28020.001B1), go to step 3.

    • If a Group II exception applies (see DI 28020.900), find that disability has ended. Group II exceptions may apply at any point in the CDR sequential evaluation process.

  2. b. 

    If MI has occurred, go to step 2.

2. Does the impairment(s) meet/equal the severity of the listing met/equaled at the CPD?

If there has been MI, consider whether the impairment(s) that we considered at the CPD still meets or equals the listing it met or equaled at that time. Consider the current severity of that impairment(s), and the same listing section and any subsections of that listing used to make that determination or decision as it was written at that time, even if it has since been revised or removed from the Listing of Impairments.

  •  

    Example 1: At the CPD, a child was 4-years old, and their hearing impairment showed average air conduction hearing threshold of 60 decibels. The hearing impairment met listing 102.10A. If the average air conduction hearing threshold was still 60 decibels at the CDR three years later, the impairment would not meet listing 102.10A or B.1 because the child has surpassed the age in the listing criteria for 102.10A (which applies for children from birth to age 5) and listing 102.10B requires average air conduction hearing threshold of 70 decibels or greater in the better ear.

    For listings that indicate a non-specific period of disability (see DI 28010.030A2.), do not consider the same criteria at the CDR that were applicable at the CPD if the child has surpassed the age requirement in the designated listing.. For listings with different criteria for different ages, use the criteria applicable to the child’s age at the time of the CDR, not the CPD.

  •  

    Example 2: At the CPD, a child met listing 105.10, which indicates the need for supplemental daily enteral feeding via a gastrostomy for children who have not attained age 3. At CDR, the child is 4-years old and still requires daily enteral feeding via a gastrostomy. We would find the listing criteria for 105.10 is no longer met at CDR, as the child has surpassed the age requirement. Therefore, we find medical improvement has occurred at step 1 of Title XVI child CDR sequential evaluation, and we proceed to the next step in the evaluation process. We evaluate the residual impairment(s), considering criteria in 105.00H in the preamble criteria for the body system as the listing directs.

Does the impairment(s) meet/equal the severity of the listing met/equaled at the CPD?

  1. a. 

    If the impairment(s) still meets or equals the listing met or equaled at the CPD, consider whether a Group I or Group II exception applies, see DI 28020.001. Find that disability continues, UNLESS a Group I or Group II exception applies (see DI 28020.001).

    • If no exception applies, find that disability continues

    • If a Group I exception applies (see DI 28020.001B1), go to step 3.

    • If a Group II exception applies (see DI 28020.900), find that disability has ended. Group II exceptions may apply at any point in the CDR sequential evaluation process.

  2. b. 

    If the impairment(s) does not still meet or equal the listing met or equaled at the CPD, go to step 3.

  3. c. 

    If there is MI in the impairment(s) and the child did not meet or equal a listing at CPD, go to step 3.

NOTE: See Social Security Ruling (SSR) 05-03p (in DI 28005.021) for how we apply the functional equivalence rules at this step and how we apply this step when the CPD was based on functional equivalence to the listings.

3. Is the child currently disabled?

If there has been MI, and the impairment(s) no longer meets or equals the severity of the listing it met or equaled at the time of the CPD, or if a Group I exception applies, consider whether the child is currently disabled under the rules in DI 25220.010 and DI 25225.001, taking into account all factors relevant to assessing impairment severity -- e.g., basic consideration (DI 25210.001 through DI 25210.040) and pain and other symptoms (DI 24501.021). Consider all impairment(s) the child now has, including any impairment(s) that existed but was not considered at the time of the CPD. The steps in determining current disability are summarized as follows:

  1. a. 

    Is the current impairment(s) severe? (DI 25220.005)

    • If the impairment(s) is not severe, find that disability has ended.

    • If the impairment(s) is severe, go to b.

  2. b. 

    Does the current impairment(s) meet or medically equal any current listing? (DI 25220.010)

    • If theimpairment(s) meets or medically equals a current listing, find that disability continues.

    • If the impairment(s) does not meet or medically equal a current listing, go to c.

  3. c. 

    Does the current impairment(s) functionally equal the listings? (DI 25225.001)

    • If the impairment(s) functionally equals the listings, find that disability continues.

    • If the impairment(s) does not functionally equal the listings, find that disability has ended.

4. Complete SSA-538, the childhood disability evaluation form (CDEF), or the childhood disability evaluation (CDE)

a. Instructions for completing the SSA-538, CDEF, or CDE for Title XVI child CDR cases

Explain the CDR determination on an SSA-538, the CDEF for cases processed in the disability case processing system (DCPS), or the CDE for cases processed in the electronic Claims Analysis Tool (eCAT). For additional information on completing these forms, see DI 25230.001 and DI 25230.005.

There are certain scenarios where an SSA-416-UF may be used instead of the SSA-538, CDEF, or CDE, see DI 28005.030C4b below.

Conversely, there are times where two CDEF or CDE assessments may be necessary, see DI 28005.030C4c below for details.

b. When a SSA-538, CDEF or CDE is not necessary in a CDR

A CDEF or CDE is not necessary in all Title XVI child CDR cases processed in eCAT or DCPS. Consistent with the instructions in DI 25230.001B1, a CDE or CDEF is only required if the severe impairment(s) require a domain evaluation.

A CDEF or CDE is not necessary in CDRs in situations where a child’s impairment(s):

  • Meets, medically equals, or functionally equals a listing based on example (this may be for a current listing or if the CPD listing continues to be met), or

  • Demonstrates no MI, or

  • Are all considered not severe (i.e. no limitation) in all Domains.

If one of the three scenarios above are met and the CDE or CDEF are not completed, the medical consultant or psychological consultant must use the SSA-416-UF to document their full claim analysis in eCAT or DCPS.

c. When a second SSA-538, CDEF, or CDE is necessary

A second SSA-538, CDEF, or CDE is necessary when:

  • There is MI in the CPD impairment(s) and the impairment(s) does not meet, medically, or functionally equal the severity of the listing that was met or equaled at the CPD, and

  • There are new impairments that were not established at the CPD; then

Assess only the CPD impairments in the first SSA-538, CDEF, or CDE. This will be the "MIRS" version of the document. In the second SSA-538, CDEF, or CDE, assess the current severity of ALL impairments, not only comparing those that were established at the CPD.

If all current impairments were considered at the time of the CPD, a second CDEF or CDE is not necessary.

5. Subsequent Action

Follow DI 22520.001through DI 22520.020 for handling any additional evidence received after processing the decision.

DI 28005.035 Drug Addiction or Alcoholism (DAA) in a Title II or Adult Title XVI Continuing Disability Review (CDR) - Overview of the CDR Sequential Evaluation Process for Considering DAA

A. Overview - DAA condition in CDRs

1. Definition of DAA condition

When an individual has a medically determinable substance use disorder and DAA is not material, they will be found to have a “DAA condition,” see DI 90070.060. For claims filed on or after July 1, 1996, Public Law (P.L. 104-121) contains special treatment referral provisions for individuals with a DAA condition who are determined to be incapable of managing their benefits.

2. General development of cases with DAA involvement

Follow the general disability case development guides in DI 28030.020. Do not undertake further development on the issue of materiality if you can make a favorable disability determination regarding other impairments and you can make a reasonable inference that additional evidence on the impact of DAA would not result in a finding that DAA is material.

3. Medical improvement (MI) involving DAA

For the definition of MI, and when to find MI under the DAA material CDR evaluation process, see DI 28010.055.

B. Introduction to the DAA CDR sequential evaluation process

We do not consider an individual disabled if DAA is a contributing factor to the determination that the individual is disabled. The definition of DAA can be found in DI 90070.050B.

There are two scenarios we consider DAA involvement:

Such scenarios may be involved in Title II CDRs or in adult Title XVI CDRs. When DAA is involved in those categories of CDR, there is a 7-step DAA CDR sequential evaluation process to follow AFTER following the 8-step CDR sequential evaluation process in DI 28005.010.

We consider the additional steps in the DAA sequential evaluation process displayed in the chart in DI 28005.040 if the following criteria are both met:

  • There is medical evidence of DAA in the CDR, and

  • The 8-step Title II or adult Title XVI CDR sequential evaluation process yields a finding that disability continues, THEN

Follow the additional 7-step process outlined in DI 28005.040. Step 1 of the chart in DI 28005.040 represents the conclusions reached in applying the CDR sequential evaluation process shown in DI 28005.010.

For a detailed discussion of the 7 steps, see DI 28005.045.

C. Skipping evaluation steps with DAA involvement

After you have determined that disability continues under DI 28005.010, follow the DAA material CDR evaluation process in the order shown. However, you may skip an evaluation process step(s) if doing so would not affect the finding that DAA is or is not material; i.e., it would not affect the outcome of the CDR.

1. When to skip evaluation steps

We may skip CDR evaluation steps at several points in the process.

  • No medical improvement (MI) - If there is medical evidence of a substance use disorder but the substance use disorder currently imposes no limitations and does not impact the other impairment(s), find no MI at step 3. Find that DAA is not material and disability continues.

  • Other impairment(s) meets/equals - If there is medical evidence of a substabce use disorder, but a listing would still be met or equaled if the substance use stopped (e.g., listing 1.20A or 13.13B), skip step 3 and find no MI related to the ability to work at step 4. Find that DAA is not material and disability continues. The step skipped does not affect the outcome.

  • DAA only - If there is medical evidence of a substance use disorder, and it is the only impairment, find MI at step 3 and skip to step 5 (severe impairment(s)). If the individual were to stop using drugs/alcohol, the substance use disorder would no longer exist and there would be no direct effects or residuals. Find that there would be no severe impairment, DAA is material, and disability ceases. The step skipped does not affect the outcome.

2. When not to skip steps

If there would be MI related to the ability to work if DAA stopped and the individual would not be able to do other work (step 7), do not skip the past relevant work step (step 6). This could affect the DAA material finding and thus the CDR outcome. Obtain any additional evidence needed to determine whether the individual would retain the ability to do past relevant work. If so, find that DAA is material and disability ceases.

DI 28005.040 Drug Addiction or Alcoholism (DAA) In a Title II or Adult Title XVI Continuing Disability Review (CDR) - Summary Chart for the CDR Sequential Evaluation Process When DAA is Present in a CDR

A. Introduction to the DAA material chart

This chart outlines the DAA material CDR evaluation process (using the medical improvement review standard (MIRS)), effective upon enactment of Public Law (P.L. 104-121), for all Title II beneficiaries and Title XVI recipients age 18 or older.

B. DAA material CDR sequential evaluation process summary chart for Title II and adult Title XVI individuals

For a more detailed discussion of the DAA process see DI 28005.045B.

NOTE: Follow the CDR evaluation process shown in DI 28005.010 to determine if disability continues before proceeding to step 1 of the following chart.

DAA Material CDR Evaluation Process

DI 28005.045 Drug Addiction or Alcoholism (DAA) in a Title II or Adult Title XVI Continuing Disability Review (CDR) - Step-by-Step Discussion of the 7-Step DAA Material CDR Evaluation Process

A. Introduction to the step-by-step discussion

The discussion in DI 28005.045B in this section is numbered to correspond to the steps in the chart in DI 28005.040B. The chart and this discussion are applicable to CDR cases involving DAA.

B. Procedure to determine if DAA is material to Title II or adult Title XVI CDR determination

1. Disability continues after evaluation through the Title II and adult Title XVI CDR sequential evaluation process

Determine whether disability continues by following the CDR evaluation process outlined in DI 28005.010. Consider all the evidence, including any evidence of DAA.

  • If disability does not continue under the CDR sequential evaluation process outlined in DI 28005.010, it is not necessary to evaluate the additional DAA steps below.

  • If disability continues after evaluating all impairments by following the CDR sequential evaluation process outlined in DI 28005.010, follow the additional steps below to evaluate if DAA is material to the Title II or adult Title XVI CDR determination.

2. Medical evidence of DAA

Determine whether the medical evidence establishes the existence of a substance use disorder.

  • If not, find that disability continues.

  • If so, go to step 3.

3. Medical improvement (MI) if DAA stopped

Determine whether MI would occur in the comparison point decision (CPD) impairment(s) if the individual stopped using drugs or alcohol.

  • If not, find that DAA is not material and disability continues.

  • If so, go to step 4.

4. MI related to the ability to work

Decide whether MI would be related to the ability to work.

  • If not, find that DAA is not material and disability continues.

  • If so, go to step 5.

5. Severity of current impairment(s)

Determine whether the individual would have a severe impairment(s) if the individual stopped using drugs or alcohol.

  • If not, find that DAA is material and disability ceases.

  • If so, go to step 6.

6. Past relevant work

Determine whether the individual would be able to do past relevant work if the individual stopped using drugs or alcohol.

  • If so, find that DAA is material and cease disability.

  • If not, go to step 7.

7. Other work

Decide whether the individual would be able to do other work if the individual stopped using drugs or alcohol.

  • If so, find that DAA is material and disability ceases.

  • If not, find that DAA is not material and disability continues.

DI 28005.050 Drug Addiction or Alcoholism (DAA) In a Title XVI Child Continuing Disability Review (CDR) Case - Step-by-Step Discussion of the 7-Step DAA Material CDR Sequential Evaluation Process

A. Introduction to the DAA step-by-step evaluation process for Title XVI CDR cases

We cannot consider a Title XVI child to be disabled if drug addiction or alcoholism (DAA) is a contributing factor material to the determination that they continue to be disabled.

Decide whether disability continues by following the CDR evaluation process outlined in DI 28005.025. Consider all the evidence, including any evidence of DAA. If disability continues after evaluating all impairments by following the Title XVI CDR sequential evaluation process outlined in DI 28005.025, follow the additional steps outlined below to evaluate if DAA is material to the Title XVI child CDR determination.

If DAA may be material, but the evaluation through the CDR sequential evaluation process outlined in DI 28005.025 resulted in a finding of “not disabled” (and a continuance is not supported), it is not necessary to evaluate the additional DAA steps below.

B. Procedure to determine if DAA is material to the Title XVI child CDR determination

Follow the steps described in the chart to determine if DAA is material in a Title XVI child CDR case:

Steps to Determine DAA Material for Child CDR

If Yes

If No

1. Decide whether disability continues considering all the evidence, including any evidence of DAA.

Follow the CDR evaluation process outlined in DI 28005.025.

If the child is still disabled, go to Step 2.

If the child is no longer disabled, find that disability has ceased. No materiality determination is needed.

 

 

2. Decide whether there is medical evidence of DAA.

For the policy related to medical evidence of DAA, see DI 90070.050C.

If there is medical evidence of DAA, go to Step 3.

 

If there is no medical evidence of DAA, find that disability continues. No materiality determination is needed.

 

3. Decide whether medical improvement (MI) would occur if the child stopped using drugs or alcohol.

For the policy on MI if the child stopped using drugs or alcohol, see DI 28010.055.

If MI would occur, go to Step 4.

 

If MI would not occur, find that DAA is not material and disability continues.

NOTE: If a Group I exception applies, go to Step 5.

For the policy on Group I exceptions, see DI 28020.001 and DI 28020.250 - DI 28020.365.)

4. Decide whether the impairment(s) present at the comparison point decision (CPD) would still meet or equal the severity of the listed impairment that it met or equaled at the time of the most recent decision if the child stopped using drugs or alcohol.

NOTE: The application of this step depends on whether the CPD was before January 2, 2001, or on or after January 2, 2001. To apply this step, see DI 28005.020B.2. and DI 28005.021.

 

If yes, find that DAA is not material and disability continues.

NOTE: If a Group I exception applies, go to Step 5. To obtain additional instructions on Group I exceptions, see DI 28020.001 and DI 28020.250 - DI 28020.375.

 

 

 

If no, go to Step 5.

 

5. Decide whether the child's current impairment(s) would be severe if he or she stopped using drugs or alcohol.

If the impairment(s) is severe, go to Step 6.

If the impairment(s) would not be severe, find that DAA is material and disability ceases.

6. Decide whether the current impairment(s) would meet or medically equal a listed impairment if the child stopped using drugs or alcohol.

 

If yes, find that DAA is not material and disability continues.

 

If no, go to Step 7.

 

7. Decide whether the current impairment(s) would functionally equal the listings if the child stopped using drugs or alcohol.

 

If yes, find that DAA is not material and that disability continues.

 

If no, find that DAA is material and disability ceases.

 

C. Summary exhibit for making a DAA materiality determination

The exhibit below summarizes the steps for making a DAA materiality determination in a Title XVI child CDR case:

 

DI 28005.090 Evaluating Continuing Disability Review (CDR) Cases Involving Blindness

A. Statutory blindness background

1. Blindness listing

To establish statutory blindness, the impairment must meet listing 2.02, 2.03A. 102.02A, 102.02B, or 102.03A. For a comprehensive overview of statutory blindness evaluation for Title II and Title XVI individuals, see DI 26001.001.

2. Medical improvement review standard (MIRS) evaluation of blindness

a. Overview of Title II statutory blindness evaluation when the disabled insurance beneficiary's (DIB) entitlement or insured status has changed at the CDR

There are several considerations involving the evaluation of statutory blindness for Title II beneficiaries at CDR. The disability determination services (DDS) may encounter different scenarios for Title II blindness at CDR, including:

  • Title II individuals with fully insured status where the individual met a statutory blindness listing at the comparison point decision (CPD), or

  • Title II decisions for individuals allowed for a non-blind impairment(s) at the CPD alleging statutory blindness at CDR.

Please see DI 28005.090D for blindness evaluation directions for each of these scenarios.

b. Overview of Title XVI statutory blindness evaluation at CDR

If the CDR contains a new allegations of blindness that was not previously established at the CPD, it is important to develop the potential blindness at the CDR, even if the individual has established disability previously on the basis of a non-blind impairment.

Because of possible payment advantages to Title XVI recipients found “blind” rather than “disabled,” undertake development for blindness whenever there is a reasonable basis to believe the visual disorder may meet the statutory definition of blindness, even when the medical evidence of record already establishes disability.

EXCEPTION: A disabled claimant who is in a Federal living arrangement D (FLA/D) (i.e., lives in a medical treatment facility where Medicaid pays over 50 percent of the cost of care) is not eligible for any additional benefit amount based on blindness. Do not develop for statutory blindness in this situation, see DI 26005.005.

3. Diary considerations and development

Statutory blindness, as defined in DI 26001.001B, generally corresponds with setting a medical improvement not expected (MINE) diary, except blindness due to cataracts or detached retina not correctable by surgery or other treatment, as defined in DI 26525.045B.2c.

Development instructions for individuals who meet the statutory blindness requirements by meeting listings 2.02, 2.03A, 102.02, or 102.03A, is located in DI 28040.130B2.

B. Introduction to evaluation of statutory blindness in CDRs

The CDR sequential evaluation process applies the medical improvement review standard (MIRS) in determining whether an individual is still blind. For information on the CDR sequential evaluation process, see DI 28005.005. Where appropriate, the flexible approach in DI 28005.005C applies. Actions after a finding that blindness ended is discussed in DI 28005.090C.5. in this section.

Establishing statutory blindness or affirming that blindness continues is often an important consideration even when disability continues based on non-blind impairments. Higher substantial gainful activity (SGA) limits and other work incentive provisions are higher for blind individuals, this may benefit Title II beneficiaries if the individual attempts to return to work. For Title XVI recipients, additional possible payment advantages, as stated in DI 26005.005 may exist when statutory blindness is established or affirmed on CDR.

C. Step-by-step discussion of the sequential evaluation process for statutory blindness in CDRs

While an individual may continue to be found disabled based on other non-blind impairments, in certain scenarios we must first consider whether the individual is blind. For CDRs involving allegations of statutory blindness only, we follow an abbreviated medical improvement review standard (MIRS) process outlined below. For additional detailed information on different scenarios when we apply the abbreviated sequential evaluation process below, see DI 28005.090D.

1. Is there medical improvement (MI)?

Decide whether MI occurred in the individual's blindness.

  • If MI did occur, go to step 2.

  • If MI did not occur, go to step 3.

2. Is MI related to the ability to work?

Decide whether MI is related to the ability to work. For consideration of prior listings, see DI 28015.050.

  • If MI is not related to the ability to work, go to step 3.

  • If MI is related to the ability to work, go to step 4.

3. Is there an exception to MI?

Decide whether an exception to MI applies.

  • If one of the Group I exceptions applies, go to step 4.

  • If one of the Group II exceptions applies with respect to the individual's blindness, find that blindness has ended, and go to step 5.

  • If no exception applies, find that disability due to blindness continues.

4. Does the impairment meet a listing that indicates blindness?

Decide whether the impairment currently meets the statutory blindness requirements of the Listing of Impairments (Listing 2.02 , 2.03A, 102.02A, 102.02B, or 102.03A).

  • If yes, find that disability due to blindness continues.

  • If no, find that blindness has ended, and go to step 5 below.

5. Blindness has ended; are there any non-blind disabling impairments?

If blindness has ended, determine whether the individual continues to be disabled due to other non-blind impairments by applying the steps in DI 28005.005. Follow applicable procedures to determine if disability continues.

DIB entitlement will continue for statutorily blind beneficiaries who meet "Fully Insured" status for blindness only (i.e., do not meet 20/40 or Special Insured status), and are subsequently determined no longer statutorily blind, but still disabled (i.e., have a non-blind impairment). This also applies to the Title II portion of concurrent Title II and Title XVI cases involving "Fully Insured" status for blindness only.

D. Overview of the sequential evaluation process when statutory blindness is established or alleged

The table below outlines the sequential evaluation process to use for different scenarios based on allegations of statutory blindness.

Determining the Steps to Assess Blindness in CDRs

Blind Status at CPD

Alleged impairments at CDR

Evaluation Process

Statutorily blind at CPD (see DI 26001.001 for definition and criteria of blindness)

Established by either:

  • Meeting (or continuing to meet on CDR) Listing 2.02 or 2.03A for adults or Listing 102.02A, 102.02B or 102.03A for children; or

  • Primary diagnosis code of 3694 "statutory blindness" in Item 16A on SSA-831 or Item 21 on the SSA-832 or 833

  • For CPD before 01/14/2014, diagnosis code reflected the underlying cause of blindness- see DI 26510.015G.

Stat blind only, no other impairments

Follow steps to evaluate blindness in DI 28005.090C.

Stat blind at CPD (same criteria above to establish)

Stat blind and other impairments

  • Stat blind no longer alleged, but other non-blind impairments alleged; or

  • No disabling impairments.

First, consider if statutory blindness still applies. Follow instructions to evaluate blindness in DI 28005.090C. Even if the individual no longer alleges blindness, if the CPD basis was statutory blindness, the disability examiner still needs to determine whether medical improvement in the vision impairment has occurred.

Not stat blind at CPD, newly alleged vision impairment at CDR

Allowed at CPD for an impairment(s) other than statutory blindness, but is alleging statutory blindness at the time of the CDR

Follow appropriate steps in DI 28005.015 for Title II or adult Title XVI individuals or DI 28005.030 for Title XVI children

E. New allegations of blindness at CDR

To determine whether to develop the blindness issue in cases where blindness is alleged but is not established, and disability continues on a basis other than blindness, follow the instructions in DI 26005.001 and DI 26005.005.

F. References

  • DI 13010.135 Title II Continuing Disability Considerations in Blindness Cases

  • DI 26001.005 Evidence of Blindness

  • DI 26001.010 Title II Disability Freeze

  • DI 26005.001 Title II Statutory Blindness Evaluation Issues

  • DI 26005.005 Title XVI Statutory Blindness Evaluation Issues

  • DI 28010.010 Which Impairment(s) to Consider in Medical Improvement (MI)

  • DI 28040.210 Evaluation and Determination When Reviewing Medical Evidence in Medical Improvement Not Expected (MINE) or MINE-Equivalent Cases

  • DI 34001.012 Special Senses and Speech – Adult

DI 28005.205 Determining the Cessation Month in Continuing Disability Review (CDR) Cases

A. Setting the cessation month

To set the cessation month in cases where disability ended, use the table in DI 28005.205C. Do not use this table in reopenings.

B. Cessation month procedure

The cessation month generally coincides with the month of the notice. When applicable, find retroactive cessation only in the situations outlined in DI 28005.205C, items 2-9, in this section.

C. Cessation month table

Use the following table to determine the cessation month in CDR cases: 

 

If Cessation is Based On:

Find that Disability Ended in the Month:

Reference:

1.

MEDICAL CESSATION - ANY SITUATION NOT COVERED BY 2-8 BELOW (most cessations)

The cessation notice is mailed to the individual (general rule).

DI 28005.205B.

2.

REPORT OF EARLIER MEDICAL CESSATION

The treating physician told the individual of regained capacity to engage in substantial gainful activity (SGA), or, in a Title XVI child case, told the child's representative payee that the child could return to normal activities.

DI 28005.205D.1.

3.

INDIVIDUAL HAS RETURNED TO WORK IN A MEDICAL IMPROVEMENT EXPECTED (MIE) CASE (referred to as a "clear-cut cessation")

The individual returns to full-time work with no significant medical restrictions.

DI 28030.035

4.

FAILURE TO COOPERATE

The individual fails, without good cause, to do what the Social Security Administration (SSA) or the Disability Determination Services (DDS) has requested and the individual was aware that they had to cooperate and the repercussions of failing to do so.

DI 28075.005K; DI 25205.020 for Title XVI child cases

5.

WHEREABOUTS UNKNOWN

SSA first knew that the individual's whereabouts are unknown but not earlier than the month a continuing disability issue arose.

NOTE: Title XVI benefits are suspended rather than ceased.

DI 28075.005G.

6.

FAILURE TO FOLLOW PRESCRIBED TREATMENT (FTFPT)

The evidence clearly establishes the individual's unjustified failure to follow prescribed treatment.

NOTE: If FTFPT is the basis for the cessation, the cessation date cannot be earlier than 30 days after the predetermination notice is sent.

DI 23010.040C1, DI 23010.013D

7.

WORK ACTIVITY ONLY

The individual first engages in SGA following completion of any applicable trial work period. DDSs do not decide this issue. Do not cease Title XVI cases on this basis.

DI 28050.000
DI 28075.600
SI 02302.001

8.

RECOVERY PRIOR TO INITIAL ALLOWANCE DECISION (closed period cases)

Shown by the evidence.

DI 25510.001

9.

FRAUD OR SIMILAR FAULT

When the individual is no longer disabled, if applicable, after the fraudulent evidence is disregarded during the determination.  Base this determination on sequential evaluation for CDRs; also consider the information listed in the “Reference” column.

DI 23025.000

D. Determining cessation months

1. Report of earlier medical cessations

The following situations involve the setting a cessation month earlier than what would normally be supported solely by medical evidence that results in a cessation.

  1. a. 

    Find retroactive cessation in cases where there is no doubt that the individual was aware that they were able to work. Alternatively, in a Title XVI child CDR case, find retroactive cessation when there is no doubt that the child's representative payee (or the child, if the child is their own payee) was aware that the child could return to normal activities, but failed to report this change. That is, find retroactive cessation only if:

    • the individual (or Title XVI child's representative payee) reports that at an earlier date the treating source informed the individual that they had regained the capacity to return to work or, in a Title XVI child case, had informed the child's representative payee that the child could return to normal activities; or

    • the treating source voluntarily reports the individual was informed at an earlier date that they had the capacity to return to work or, in a Title XVI child case, the child's representative payee was informed that the child could return to normal activities.

  2. b. 

    Set cessation as of the month the individual was made aware they had regained capacity to engage in SGA or, in a Title XVI child case, the child's representative payee was made aware that the child could return to normal activities.

  3. c. 

    Do not set this type of retroactive cessation date if:

    • there is substantial conflict between statements from the medical source and the individual (or, in a Title XVI child case, the medical source and the child's representative payee) concerning the individual's awareness of capacity to work, or the child's ability to return to normal activities; or

    • inadequate (or no) objective medical evidence supports the statement from the medical source establishing the retroactive cessation date.

2. Cessation month in error exception cases

In cessations that rely on the error exception to medical improvement (MI), as described in DI 28020.350, do not find retroactive cessation unless the conditions for reopening the prior decision are met.

3. Cessation month in low birth weight (LBW) infant cases

For LBW infants who are found no longer disabled, establish the cessation month no earlier than the month the baby attains age 1.

E. References

  • DI 25225.060 Examples of Impairments That Functionally Equal The Listings (Section 416.926a(m))

  • DI 25235.005 Medical Diary Criteria for Certain Title XVI Disabled Infants

  • DI 25235.006 Medical Diary Criteria for Low Birth Weight (LBW) Infants under Title XVI

  • DI 27501.001 Reopenings and Revisions: Pertinent Definitions and Related Policy

  • DI 28020.350 Group I Exception - Prior Error Overview

  • DI 23025.000 Fraud or Similar Fault

DI 28005.210 New Impairments or Subsequent Disability in Continuing Disability Review (CDR) Cases

A. Role of comparison point decision (CPD) and new impairments in the continuing disability review CDR sequential evaluation process

1. When to consider CPD impairments only

For Title II and adult Title XVI cases, consider only the CPD impairment(s) at the following steps in the sequential evaluation process outlined in DI 28005.015:

  • Step 3, medical improvement (MI);

  • Step 4, MI related to the ability to work;

  • Step 5, exceptions to medical improvement.

For Title XVI child cases, consider only the CPD impairments at the following steps in the sequential evaluation process outlined in DI 28005.030:

  • Step 1, MI;

  • Step 2, CPD impairments still meet/equal prior listing.

Do not consider new impairments (impairments that began after the CPD) in deciding such steps in the CDR evaluation process.

2. When to consider all current impairments

For Title II and adult Title XVI cases, consider ALL impairments, including any new impairments that have occurred since the CPD, at the following steps in the sequential evaluation process outlined in DI 28005.015:

  • Step 2, meets/equals current listing;

  • Step 6, severe impairments;

  • Step 7, past work;

  • Step 8, other work.

For Title XVI child CDR cases, consider ALL impairments, including any new impairments that have occurred since the CPD, at the following steps in the sequential evaluation process outlined in DI 28005.030:

  • Step 3, severe impairments and meets or medically/functionally equals a current listing

B. Considering new impairments before cessation

1. Impairment duration

Consider new impairments even if they do not meet the duration requirements.

2. Possible period of non-disability

If the current impairment(s) (including any new impairment(s)) support that disability continues and there is no reason to support.

If the evidence shows a period of possible non-disability since the CPD but the current impairment(s) warrants a continuance, do not cease disability. Do not find that disability ceases in this instance, unless there is additional evidence to support a retroactive cessation, including reopening and revising a prior determination.

C. How we evaluate subsequent disability after the cessation month

1. Overview

If a new impairment(s) again disables the individual causes the individual to become disabled again after the cessation month (even within the 2-month period before benefits end), the original period of disability does not continue. The break in the continuity of disability requires establishing a new period of disability.

  • A new application is usually required for Title II individuals with subsequent disability after a disability cessation, unless the individual appeals the decision and the impairment(s) is found to be disabling through the date of the appeal decision or determination.

  • This does not apply to reinstatement during the extended period of eligibility due to earnings below the substantial gainful activity level.

  • For additional information on appeals of an initial medical disability cessation determination or decision, see SSR-13-3p

2. Evaluation of subsequent disability

a. Correct cessation month

If the adjudicator determines the initial medical cessation determination was correct during the appeal, the adjudicator will then:

  • Determine if the individual has again become disabled at any time through the date of their determination or decision because of a worsening of an existing impairment or the onset of a new impairment(s), if all other requirements for listing a period of disability, including the duration and insured status requirements are met.

  • Evaluate severity and duration requirements for the new impairment(s) under the initial disability sequential evaluation process discussed in DI 22001.001.

If the adjudicator determines that the medical cessation date in a Title II case (or the Title II portion of a concurrent medical disability cessation case) was appropriate, but evidence also shows that the beneficiary had again become disabled at any time through the date of his or her determination or decision due to worsening of an existing impairment or by the onset of a new impairment, the adjudicator will evaluate disability through the date of the appeal determination or decision.

This eliminates the need for filing a new application for reentitlement in Title II cases. In Title XVI cases, a new application is not required if a Title XVI recipient again becomes disabled while an appeal is pending. See SSR 13-3p.

b. Incorrect cessation month

If the adjudicator determines that the initial disability cessation determination was not correct during the appeal, the adjudicator will then:

  • Determine if the evidence establishes medical improvement as a basis for cessation of disability at any time through the date of final determination or decision.

  • Evaluate all impairment(s) using the medical improvement review standard (MIRS).

D. References

  • DI 28005.205 Determining the Cessation Month in Continuing Disability Review (CDR) Cases

  • DI 28010.001 Medical Improvement (MI)

  • DI 28015.001 Context and Scope — Relating MI to Ability to Work

  • DI 28020.001 General - Groups I and II of Exceptions to Medical Improvement


DI 28005 TN 11 - The CDR Evaluation Process - 8/09/2022