Effective Dates: 8/22/2024 - Present

Identification Number:
DI 28035 TN 7
Intended Audience:
Originating Office:ORDP ODP
Title:Processing of Lost Folders/Medical Evidence
Type:POMS Full Transmittals
Program:Disability
Link To Reference:
 

PROGRAM OPERATIONS MANUAL SYSTEM

Part DI – Disability Insurance

Chapter 280 – Continuing Disability Review Cases

Subchapter 35 – Processing of Lost Folders/Medical Evidence

Transmittal No. 7, 08/22/2024

Originating Component

ODP

Effective Date

Upon Receipt

Background

This is a Quick Action Transmittal. These revisions do not change or introduce new policy or procedure.

Summary of Changes

DI 28035.010 Disability Determination Services (DDS) Review of Current Evidence to Determine Continuing Disability

We changed existing Section D to new Section D with a new title. Then we added Section E, titled it References, and included the information from existing Section D.. D. Continuing disability review (CDR) processing instructions involving a CPD with a lost folder and a subsequently filed claim in which the field office (FO) applied collateral estoppel

For the first CDR involving a scenario where: • The last favorable medical decision (i.e., the comparison point decision (CPD)) is a lost folder case, and

• A subsequent claim was filed after the CPD and the FO processed a collateral estoppel adoption determination (i.e., the decision involving the lost folder was adopted by the FO):

At CDR, the adjudicator must follow the instructions in DI 28035.000. This includes attempting to reconstruct the lost folder for the CPD, if appropriate, per the policy guidance in DI 28035.020. If reconstruction is not possible (see DI 28035.025), medical improvement cannot be found. The adjudicator will assess and document the severity of the current impairment(s).

In the absence of a Group II exception, benefits will continue. Example: A Title XVI recipient was allowed at the initial level due to the severity of their medical impairments. After the initial-level Title XVI allowance, the Title XVI folder was lost. The FO processed a collateral estoppel determination on a subsequent Title II claim, establishing that the individual was entitled to Title II benefits based on the Title XVI disability determination, and the rules for collateral estoppel were met as outlined in DI 11011.001A.

A CDR was initiated when the diary matured. At CDR, the adjudicator followed the instructions in DI 28035.001. The adjudicator was unable to reconstruct the lost folder and determined that a Group II exception did not apply. The adjudicator assessed the severity of the current impairments and ,following the guidance in DI 28035.010 and DI 28035.025, processed a continuance. The adjudicator processed a continuance because the evidence from the most recent medical determination was insufficient to determine medical improvement. The ratings and evaluation of the current impairments will serve as the CPD basis for future reviews. For any subsequent CDRs, the normal CDR sequential evaluation process will apply, as the CPD (being a continuance in the absence of a Group II exception) contains evaluation of impairment severity. The adjudicator will then follow the MIRS process for subsequent CDRs in DI 28005.015 and DI 28005.030.

DI 28035.010 Disability Determination Services (DDS) Review of Current Evidence to Determine Continuing Disability

IMPORTANT: These instructions incorporate policy and procedure for both electronic continuing disability review (eCDR) and eCDR exclusion (paper) cases when there is a lost or destroyed folder involved.

A. Medical improvement review standard (MIRS)

The DDS cannot determine medical improvement without the comparison point decision (CPD) folder or medical evidence. If DDS is unable to locate the appropriate CPD folder or medical evidence, the adjudicator will bypass MIRS temporarily.

When the adjudicator receives current medical evidence covering at least the last 12 months, he or she will evaluate the evidence using the initial sequential evaluation process (subject to the trial work period (TWP), extended period of eligibility (EPE), and 1619 provisions, if the individual is working).

B. DDS procedures for adult CDRs

1. Individual does not have a severe impairment(s)

If the individual does not have a severe impairment(s), the adjudicator will follow the instructions on DDS prior folder reconstruction in DI 28035.020.

2. Individual has a severe impairment(s)

The adjudicator will determine if the impairment(s) meets or medically equals the severity of a listed impairment, according to the instructions in DI 22001.001D.3

3. Impairment(s) meets or medically equals a listing

If the current impairment(s) meets or medically equals the severity of an impairment in the current Listing of Impairments, disability continues. The adjudicator will:

  • •

    Prepare a determination with the appropriate reexamination diary;

  • •

    Use appropriate meets or equals continuance code; and

  • •

    Show listing code 256 (Lost Folder Case) in item 34 of the SSA-832/833-U5 (Cessation or Continuance of Disability or Blindness Determination and Transmittal – Title XVI/Cessation or Continuance of Disability or Blindness Determination and Transmittal - Title II).

NOTE: 

The adjudicator should not use "Disability Continues – Data From Most Recent Prior Favorable Medical Determination Insufficient to Assess Medical Improvement."

4. Impairment(s) does not meet or medically equal a listing

If the current impairment(s) does not meet or medically equal the severity of an impairment in the current Listing of Impairments, the adjudicator will determine if the individual can perform past relevant work or other work.

5. Individual cannot perform past relevant work or other work

The adjudicator will prepare a determination to continue disability by following these instructions:

  • •

    Use appropriate impairment plus vocational factors continuance code;

  • •

    Enter list code 256 (Lost Folder Case) in item 34 of the SSA-832/833-U5 (Cessation of Continuance of Disability or Blindness Determination and Transmittal – Title XVI/Cessation or Continuance of Disability or Blindness Determination and Transmittal - Title II); and

  • •

    Document the file on Form SSA-5002 or similar document that the adjudicator did not formally consider MIRS.

NOTE: 

The adjudicator should not use "Disability Continues – Data From Most Recent Prior Favorable Medical Determination Insufficient to Assess Medical Improvement."

6. Individual can perform past relevant work or other work

If the individual can perform either past relevant work or other work, the adjudicator will not cease disability on this finding alone. The adjudicator will:

  • •

    Continue the sequential evaluation process to include consideration of the MIRS; and

  • •

    Attempt to reconstruct the prior medical evidence, provided they can determine the date of the CPD.

For information on reconstructing prior medical evidence, see:

  • •

    DI 28035.015 – Disability Determination Services (DDS) Identification of the Comparison Point Decision (CPD)Date;

  • •

    DI 28035.020 – Disability Determination Services (DDS) Reconstruction of Prior Folder.

7. Medical or medical-vocational allowances

If, based on current medical or medical-vocational evidence, disability continues, this determination becomes the CPD for the next CDR.

NOTE: Group II Exceptions to Medical Improvement may result in a cessation at any point during the evaluation process. They are not controlled by sequence.

For information on exceptions to medical improvement, see:

  • •

    DI 28020.001 – General - Groups I and II of Exceptions to Medical Improvement (MI);

  • •

    DI 28020.900 – Group II Exceptions.

C. DDS procedures for child CDR determinations

1. Child does not have a severe impairment(s)

If the child does not have a severe impairment(s), the adjudicator will determine if they can reconstruct the prior folder according to the procedures in DI 28035.020.

2. Child does have a severe impairment(s)

If the child has a severe impairment(s), the adjudicator will determine if the impairment(s) medically meets or functionally equals the listings for Title XVI child cases according to the instructions in DI 25201.005 How We Determine Disability for Children and DI 25225.001 Functional Equivalence – Policy (Section 416.926a(a)).

3. Child’s impairment(s) medically meets or functionally equals the listing(s)

The adjudicator will prepare a determination to continue disability and follow these instructions.

  • •

    Prepare a determination with the appropriate reexamination diary;

  • •

    Use appropriate meets or equals continuance code for disabled child (DC) or blind child (BC).

  • •

    Show listing code 256 (Lost Folder Case) in item 34 of the SSA-832/833-U5 (Cessation or Continuance of Disability or Blindness Determination and Transmittal – Title XVI/Cessation or Continuance of Disability or Blindness Determination and Transmittal - Title II).

NOTE: 

The adjudicator will not use "Disability Continues - Data from Most Recent Prior Favorable Medical Determination Insufficient to Assess Medical Improvement."

REMINDER: The adjudicator must complete an SSA-538-F6 (Childhood Disability Evaluation Form) for all Title XVI child CDRs.

4. Child’s impairment(s) does not medically meet or functionally equal the listing(s)

If the child’s current impairment(s) does not medically meet or functionally equal the severity of the listings, the adjudicator will determine whether to reconstruct the prior folder according to the instructions in DI 28035.020.

 

D. Continuing disability review (CDR) processing instructions involving a CPD with a lost folder and a subsequently filed claim in which the field office (FO) applied collateral estoppel  

For the first CDR involving a scenario where:

• The last favorable medical decision (i.e., the comparison point decision (CPD)) is a lost folder case, and

• A subsequent claim was filed after the CPD and the FO processed a collateral estoppel adoption determination (i.e., the decision involving the lost folder was adopted by the FO):

At CDR, the adjudicator must follow the instructions in DI 28035.000. This includes attempting to reconstruct the lost folder for the CPD, if appropriate, per the policy guidance in DI 28035.020.

NOTE: A decision adopted through collateral estoppel with no medical evidence or development is not the CPD.

If reconstruction is not possible (see DI 28035.025), medical improvement cannot be found. The adjudicator will assess and document the severity of the current impairment(s). In the absence of a Group II exception, benefits will continue.

Example: A Title XVI recipient was allowed at the initial level due to the severity of their medical impairments. After the initial-level Title XVI allowance, the Title XVI folder was lost. The FO processed a collateral estoppel determination on a subsequent Title II claim, establishing that the individual was entitled to Title II benefits based on the Title XVI disability determination, and the rules for collateral estoppel were met as outlined in DI 11011.001A.

A CDR was initiated when the diary matured. At CDR, the adjudicator followed the instructions in DI 28035.001. The adjudicator was unable to reconstruct the lost folder and determined that a Group II exception did not apply. The adjudicator assessed the severity of the current impairments and, following the guidance in DI 28035.010 and DI 28035.025, processed a continuance for both Title II and Title XVI claims. The adjudicator processed a continuance because the evidence from the most recent medical determination was insufficient to determine medical improvement. The ratings and evaluation of the current impairments will serve as the CPD basis for future reviews.

For any subsequent CDRs, the normal CDR sequential evaluation process will apply, as the CPD (being a continuance in the absence of a Group II exception) contains evaluation of impairment severity. The adjudicator will then follow the MIRS process for subsequent CDRs in DI 28005.015 and DI 28005.030.

E. References

  • •

    DI 22001.001 Sequential Evaluation of Title II and Title XVI Adult Disability Claims

  • •

    DI 25201.005 How We Determine Disability for Children

  • •

    DI 25220.005 Determining if a Child Has a Severe Impairment(s)

  • •

    DI 25220.010 Meets or Medical Equals

  • •

    DI 25225.001 Functional Equivalence – Policy (Section 416.926a(a))

  • •

    DI 28020.001 General - Groups I and II of Exceptions to Medical Improvement (MI)

  • •

    DI 28020.900 Group II Exceptions

  • •

    DI 28035.015 Disability Determination Services (DDS) Identification of the Comparison Point Decision Date

  • •

    DI 28035.020 Disability Determination Services (DDS) Reconstruction of Prior Folder

  • •

    DI 28035.025 Disability Determination Services Reconstruction of Prior Folder Not Possible

 


DI 28035 TN 7 - Processing of Lost Folders/Medical Evidence - 8/22/2024