Identification Number:
DI 25230 TN 3
Intended Audience:See Transmittal Sheet
Originating Office:ORDP ODP
Title:Childhood Disability Evaluation Form (SSA-538)
Type:POMS Transmittals
Program:All Programs
Link To Reference:
 

PROGRAM OPERATIONS MANUAL SYSTEM
Part DI – Disability Insurance
Chapter 252 – Title XVI Child Claims Based on Disability
Subchapter 30 – Childhood Disability Evaluation Form (SSA-538)
Transmittal No. 3, 08/11/2021

Audience

PSC: DE, DEC;
OCO-OEIO: CR, ERE, FDE, RECONE;
OCO-ODO: DE, DEC, DS, RECONE;
ODD-DDS: ADJ, DHU;

Originating Component

ODP

Effective Date

Upon Receipt

Background

The Bipartisan Budget Act of 2015 Section 832 authorizes only qualified physicians to be Medical Consultants (MC) (in physical impairment cases) and qualified psychiatrists or psychologists (in mental impairment cases) beginning on November 2, 2016. This change affected who can provide signatures for the medical evaluation of title XVI disabled child determinations. Social Security published the final rules “Revisions to Rules Regarding the Evaluation of Medical Evidence” in the Federal Register (82 FR 5844), effective March 27, 2017. This regulation updated the terminology for the evaluation of medical evidence.

Summary of Changes

DI 25230.005 Documenting Disabled Child (DC) Determinations on Prescribed Forms

We updated this section to reflect the requirement only qualified physicians (in physical impairment cases) and qualified psychiatrists or psychologists (in mental impairment cases) can provide signatures on prescribed forms for documenting the medical evaluation in title XVI disabled child determinations. We updated this section to refer to “considering” and not “weighing” medical evidence, consistent with our rules for the evaluation of medical evidence. Additionally, for clarity we added grammatical edits and a direct citation to the POMS for functional equivalence examples in children.

DI 25230.005 Documenting Disabled Child (DC) Determinations on Prescribed Forms

A. Impairments

List all established impairments considered in reaching a finding. Also list any condition(s) or impairment(s) recorded in the case record but not established. State clearly which impairments were actually established and which were not.

NOTE: The established impairments must be the same impairments shown on the SSA-831 or SSA-832.

B. Case Disposition

The consultant having overall responsibility for the findings must ensure that the disposition checked is the one that best describes the disability case findings, and that any required explanation is entered on the form. The dispositions are:

1. Not Severe

(Step 2 of Initial and Reconsideration claims, and Step 3 for CDR claims)

Complete this disposition for all cases in which the evidence shows no medically determinable impairment or an impairment or combination of impairments that is a slight abnormality or a combination of slight abnormalities that results in no more than minimal functional limitations.

Use the appropriate section on the prescribed form to explain the factors and evidence that support this finding.

2. Meets Listing

(Step 3 of Initial, Reconsideration, and CDR claims)

Complete this disposition if a child's impairment(s) meets the severity of a listing. Record the complete listing number and subsection. When applicable, complete additional sections on the prescribed form to show how a medical opinion(s) or inconsistent evidence was considered, or to make clear any issue related to the finding. Although no explanation is required, the adjudicative team may use additional sections on the prescribed form to explain a finding of “meets.”

3. Medically Equals Listing

(At Step 3 of Initial, Reconsideration and CDR claims)

Complete this disposition if a child’s impairment(s) medically equals the severity of a listing. Document the complete listing number and subsection. Cite the medical findings that are at least equal to the significance of the findings specified in a listing. If the impairment is not a listed impairment, or the child has a combination of impairments, none of which meets or is medically equivalent to a listing, cite the medical findings that compare to findings in closely analogous listed impairments.

4. Functionally Equals the Listing

(At Step 3 of Initial, Reconsideration and CDR claims)

Complete this disposition if a child's impairment(s) results in marked limitations in two domains or an extreme limitation in one domain.

NOTE: A functional equals determination based on an example in DI 25225.060 does not require a CDE in eCAT.

5. Impairment or Combination of Impairments is Severe, But Does Not Meet, Medically Equal, or Functionally Equal the Listings

(At Step 3 of Initial, Reconsideration, and CDR claims)

Complete this disposition if a child's impairment(s) is severe, but is not of listing-level severity. Make this finding only after considering the factors and evidence, and evaluating and rating the domains.

6. Does Not Meet the Duration Requirement

Complete this disposition if an impairment of listing-level severity is not expected to (or did not) last 12 continuous months, or result in death. Explain in the appropriate section of the prescribed form the relevant factors and evidence that support the finding.

7. Other Disposition

Complete this disposition in all other case dispositions, e.g., whereabouts unknown, failure to cooperate, or continuing disability reviews.

Explain the relevant factors and evidence in the case record that support the finding in the appropriate section of the prescribed form.

C. Assessment of functioning throughout sequential evaluation

Consider the factors outlined in the prescribed form in evaluating a child's functioning, and determine the kinds of evidentiary issues that you must explain. The medical consultant (MC) or psychological consultant (PC) having overall responsibility for the findings affirms that all relevant factors were considered. Any additional MC or PC who provides input on the case must also sign and date the form.

D. Signature responsibilities for DC cases

1. Who can be the consultant with overall responsibility

The medical or psychological consultant who decides the disposition of the case can be:

2. Who can decide the disposition of a case

PCs are limited in the types of impairments that they may assess. This limitation affects who can be the consultant with overall responsibility in deciding the disposition of the case.

a. If impairment (or combination of impairments) is a mental disorder

A PCcan be the consultant with overall responsibility for cases in which the only impairment(s) is a mental disorder, whether the determination is favorable or unfavorable.

b. If the impairments are within multiple disciplines

A PC can be the consultant with overall responsibility for fully favorable determinations based solely on a mental disorder. For example, the child has intellectual disability (ID) and asthma. The ID meets listing 112.05A. The PC signs as the consultant with overall responsibility.

In all other cases, the MC must be the consultant with overall responsibility.

3. The role of medical advisors

Medical advisors (MA) can provide analysis of medical issues related to impairments for which they are qualified to evaluate. For example, a qualified speech-language pathologist can provide an analysis of a language impairment. An MA will use a SSA-416 (Medical Evaluation) to provide the analysis.

4. The role of MCs

An MC must be the consultant with overall responsibility for:

  • fully favorable determinations in which there are impairments in multiple disciplines if the case cannot be allowed based solely on an impairment(s) within a PC's discipline;

  • all unfavorable and partially favorable determinations involving impairments in multiple disciplines.

NOTE: An MC can also be the consultant with overall responsibility for determinations involving non-physician disciplines.

E. References

  • DI 24501.001 The Disability Determination Services (DDS) Disability Examiner (DE), Medical Consultant (MC), and Psychological Consultant (PC) Team, and the Role of the Medical Advisor (MA)

  • DI 24501.001 Introduction to Medical Evaluation

  • DI 26510.090 Completing SSA-831 Signature Information, Items 30-33

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


DI 25230 TN 3 - Childhood Disability Evaluation Form (SSA-538) - 8/11/2021