PROGRAM OPERATIONS MANUAL SYSTEMPart DI – Disability InsuranceChapter 280 – Continuing Disability Review CasesSubchapter 10 – Medical Improvement and Related Medical IssuesTransmittal No. 14, 08/12/2024
Audience
Originating Component
ODP
Effective Date
Upon Receipt
Background
This transmittal coincides with the collateral estoppel policy updates. We provide updated information, clarification of policy, and reinforce existing policies when the CPD is unclear.
Summary of Changes
DI 28010.020 Comparison Point Decision (CPD)
Subsection A: Added clarification about the CPD date from the SSA-831, SSA-832/833
Subsection B :
B1, Clarified information
B2, Added note that collateral estoppel determinations cannot be CPDs if they were adoptions completed by the FO
B5, New subsection to reinforce existing policy when the CPD is unclear; added cross-reference to related policy; created a table for examples of query fields helpful in identifying CPD information
Subsection C: Added a cross-reference
CITATIONS:
The CPD is the most recent favorable medical decision that the individual was disabled or continued to be disabled.
The most recent favorable medical decision is the latest final determination or decision involving a consideration of the medical evidence and whether the individual was disabled or continued to be disabled.
The CPD date is the date that the adjudicator, Administrative Law Judge (ALJ), or Administrative Appeals Judge (AAJ) signed on the most recent favorable SSA-831, SSA-832/833, or decision.
Decisions (based on medical evidence that was current at the time of the decision) that the individual continues to have a disabling impairment are CPDs.
When collateral estoppel was the basis for the most recent favorable determination, the CPD is the most recent favorable medical decision that involved a usual level of development and current medical evidence that included consideration of medical, functional, or medical/vocational issues. This may be the earlier medical decision (usually under a different title) that was used as the basis for the collateral estoppel adoption determination.
NOTE: If the collateral estoppel determination was applied and did not include development and consideration of medical evidence at the time of adoption (i.e., without a usual level of development or supporting evidence), do not use the collateral estoppel determination as the CPD.
The following types of decisions do not involve development of current medical evidence or consideration of medical issues. They are not appropriate CPDs because the supporting evidence for the decision does not provide a suitable basis for medical improvement review standard (MIRS) comparisons. Therefore, do not use the following types of decisions as CPDs:
Collateral estoppel determinations without medical development completed. Use the decision that was the basis for collateral estoppel, such as the most recent prior favorable determination or decision based on meeting or equaling a listing (or functionally equaling a listing), an allowance based on medical-vocational rules, or a CDR related decision (such as a decision finding no MI) that included full medical development. This includes collateral estoppel adoptions completed by the field office (FO).
SSA-899-U2's (Continuing Disability Review) categorizing individuals as permanently impaired, without evaluation of then-current medical evidence
Reinstatement under a CDR moratorium
Decisions based solely on work
Decisions not involving consideration of the issue of current disability (e.g., most decisions on appeals requesting an earlier onset)
Use the established onset date as the comparison point. For further information on closed period cases, see DI 25510.001.
Use the prior medical decision on the previously adjudicated claim that resulted in a favorable medical decision as the CPD, when adopting a prior decision results in:
a closed period decision on a new claim, and
simultaneous cessation of benefits on a previously adjudicated claim.
Two comparison points may apply:
DI 28001.045 explains when cases must be evaluated under the State plan, and
DI 28035.025F discusses additional considerations related to comparison points in non-rollback conversion cases where evidence from the prior State decision is not available and cannot be reconstructed.
Use the most recent favorable decision under the Federal criteria as the CPD, as discussed in this section.
Use the most recent medical decision granting or affirming entitlement under the State criteria as the CPD if there is no prior favorable Federal decision.
Use the most recent medical decision granting or affirming entitlement under the State criteria as the CPD in considering State criteria.
If the CPD is unclear, the adjudicator should review any available documents from the prior favorable medical determination. For example, the SSA-831, SSA-832, or SSA-833 may contain the regulation basis code or vocational rule that was used to support the favorable determination if the medical assessments cannot be located.
Queries may also be a useful tool to help determine the basis for the CPD, see DI 28035.015.
The table contains some examples of useful data that may be found within common queries, such as the Supplemental Security Income Display (SSID), Full Account Query (FACT - Master Beneficiary Record or MBR display), or the Disability Determination Services Query (DDSQ) :
Examples of useful data in common queries
Field Indicator
Query Type
Query Line
Query Field Code
Reference(s)
Date of Disability Onset
DDSQ (accessed through PCOM - Query Master- DDSQ; or via PCOM - Option 18 (NDDSS Master File Menu), then Option 1 (DDS Query))
FACT or SSID
Case data
DISB
OND
DDO
SM 06002.200
SM 01601.595
State Closure Date (date the case cleared Disability Determination Services (DDS))
DDSQ
SCD
CPD date
ESD (examiner signature date)
Disability Diagnosis Code
DSI (Disability Identification Data – Permanent disability code, primary diagnosis code, medical diary reason code)
DIG
Medical Diary Date
DIAR
DIA (displays diary type and diary maturity date)
MR (diary code of "MR" is a medical reexamination diary, the date is the diary maturity date)
SM 016002.200
SM 01301.235,
SM 01601.580
Medical Diary Reason
SSID
MDR
* If not viewable, select PCACS through Query Master to view MDR
DI 22501.001 Disability Case Development for Evidence
DI 28001.045 Rollback and Non-rollback Conversion Cases
DI 28030.020 Development of Medical Evidence
DI 28035.025 Disability Determination Services (DDS) Reconstruction of Prior Folder Not Possible
DI 28055.045 Model Language: Impairment Severity Continuance Notice – Exhibit
DI 28075.010 Non-rollback Conversion Cases
DI 81010.215 The Comparison Point Decision (CPD) Date and Folder