Identification Number:
DI 28090 TN 3
Intended Audience:See Transmittal Sheet
Originating Office:ORDP ODP
Title:CDR Rationale Preparation
Type:POMS Transmittals
Program:All Programs
Link To Reference:
 

PROGRAM OPERATIONS MANUAL SYSTEM
Part DI – Disability Insurance
Chapter 280 – Continuing Disability Review Cases
Subchapter 90 – CDR Rationale Preparation
Transmittal No. 3, 09/22/2021

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

We did not change policy for this chapter DI 28090. We rewrote the text to follow plain language guidelines. When possible, we wrote the text in third person.

Summary of Changes

DI 28090.001 Cessation or Continuance of Disability or Blindness Determination and Transmittal (SSA-832/833) Rationale

In DI 28090.001A.,, we changed the title from "Types of Rationales" to "Technical rationales".

In DI 28090.001A. and B., we made the following changes:

  • We moved the first paragraph of B. to the location for the first paragraph of A.

  • We combined the text in the "NOTE" in A., with the text in the existing first paragraph of A to explain the existing different types of rationales.

In DI 28090.001A., we kept the bulleted list but changed its heading to "The technical rationale for CDR determinations must:"

In DI 28090.001B., we deleted the paragraph above the "NOTE".

In DI 28090.001B, we changed "NOTE" to a regular paragraph. We expanded the text to more clearly discuss the Disability Case Processing System (DCPS).

 

DI 28090.005 Overview of Rationales

We capitalized the first word in each of the bullets.

 

DI 28090.010 Continuing Disability Review (CDR) Rationale Content

In DI 28090.010A., we added "whether the determination is a continuance or cessation" to the first sentence.

In DI 28090.010A., we deleted the "NOTE".

In DI 28090.010A.4., we changed "of" to "regarding"

In DI 28090.010B., 2nd paragraph, we made minor word changes and additions.

 

DI 28090.015 Rationale Content - Evidence Sources

In DI 28090.015A, 1st paragraph and A.4., we made minor word changes and additions.

 

 

DI 28090.020 Rationale Content - Basis for the Most Recent Prior Favorable Determination and Reason for Current Medical Review

In DI 28090.020, we capitalized the first word in every bullet.

 

 

DI 28090.025 Rationale Content - The Individual’s Reason(s) for Continued Entitlement or Eligibility

We added "or Eligibility" to the title.

 

DI 28090.030 Rationale Content - Statement of Non-medical Issues

 

We added a hyphen to "Non-medical" in the title.

 

DI 28090.035 Rationale Content - Medical Findings

 

In DI 28090.035A., we capitalized the first word in every bullet.

In DI 28090.035B., we changed the title to "Medical Opinions"

In DI 28090.035B., we added a first paragraph defining medical opinions before and after March 27, 1917.

In DI 28090.035C., we added "DI 24503.030, Articulation Requirements for Medical Opinions and Prior Administrative Medical Findings - Claims filed on or before March 27, 1917."

 

DI 28090.040 Rationale Content - Meets or Equals

We wrote the text in third person.

 

 

DI 28090.045 Rationale Content - Medical Improvement (MI)

We wrote the text in third person.

In DI 28090.045B., we added "(MI)" to the end of DI 28020.001.

 

 

DI 28090.050 Rationale Content - Whether Medical Improvement (MI) is Related to the Ability to Work

We did not make changes to this section.

 

 

DI 28090.055 Rationale Content – Groups I and II Exceptions

We wrote the text in third person.

 

 

DI 28090.060 Rationale Content – Non-severe Impairment(s)

In DI 28090.060A, second paragraph, we changed "DDS" to "Disability Determination Services (DDS)".

 

 

DI 28090.065 Rationale Content - Ability to Do Substantial Gainful Activity (SGA)

In DI 28090.065, first paragraph, we wrote the text in third person.

 

DI 28090.070 Rationale Content - Statement of Residual Functional Capacity (RFC)

 

We did not make any changes to this section.

 

DI 28090.075 Rationale Content - Ability to Perform Past Relevant Work (PRW) - Cessation
We added "Cessation" to the title.

We wrote the text in third person.

 

 

DI 28090.080 Rationale Content - Ability to Perform Other Work - Cessation

 

We capitalized the first word in every bullet.

 

DI 28090.085 Rationale Content - Ability to Perform Other Work - Continuance

 

We capitalized the first word in every bullet.

We wrote the text in third person.

 

DI 28090.150 Rationale Content – Basis for the Disability Determination (All Cases)

 

In DI 28090.150A., first sentence, we changed "DDS" to "the adjudicator".

We capitalized the first word in every bullet.

We wrote the text in third person.

In DI 280909.150C., we deleted the phrase "as the determination is a supplemental one" in the first sentence.

 

 

DI 28090.200 Rationale Content - Special Situations

 

We wrote the text in third person.

We capitalized the first work in every bullet.

 

DI 28090.300 Sample Rationales - Continuances and Cessations

 

We revised the dates in the examples to use more current dates.

We made minor changes, if needed, in each rationale.

 

DI 28090.001 Cessation or Continuance of Disability or Blindness Determination and Transmittal (SSA-832/833) Rationale

A. Technical Rationale

Adjudicators must prepare a rationale of the evaluation process used in adjudicating continuing disability review (CDR) cases whether the determination is a continuance or cessation. The rationale documents application of the medical improvement review standard (MIRS) required on all CDRs. When disability continues, the rationale establishes a basis for comparison in the subsequent CDR.

A technical rationale explains the complete documentation of the evaluation process used in CDR case adjudication. Previously, Disability Determinations Services (DDS) has used terms such as "technical," "supplemental," "modified ," and "summary" to describe types of rationales. Using these different terms sometimes caused confusion. Therefore, to avoid unnecessary confusion and with the implementation of DCPS, SSA decided that adjudicators use only "technical" to describe a rationale. The technical rationale should include all aspects of the CDR case, including the step-by-step evaluation process.

The technical rationale for CDR determinations must:

  • Clearly reflect all applicable steps in the CDR evaluation process;

  • Present an explicit explanation of the decision, including the documentation used to support the decision, and

  • Incorporate legislative requirements.

 

B. Content of rationales

The CDR rationale discusses the following, as needed:

  1. 1. 

    Evidence sources;

  2. 2. 

    Basis for the comparison point decision (CPD) and reason for current medical review;

  3. 3. 

    Individual's reason(s) for continued entitlement and eligibility (impairment allegation(s));

  4. 4. 

    Non-medical issues;

  5. 5. 

    Medical findings;

  6. 6. 

    Meets or equals determinations;

  7. 7. 

    Medical improvement (MI);

  8. 8. 

    Whether medical improvement is related to ability to work;

  9. 9. 

    Exceptions;

  10. 10. 

    Non-severe impairment(s);

  11. 11. 

    Ability to do substantial gainful activity (SGA);

  12. 12. 

    Residual functional capacity (RFC);

  13. 13. 

    Ability to perform past relevant work (PRW);

  14. 14. 

    Ability to perform other work;

  15. 15. 

    Basis for the disability determination; and

  16. 16. 

    Special situations.

DDS will discuss the rationale content for these 16 topics in DI 28090.015 through DI 28090.200.

NOTE: Some DDSs are still using the Electronic Claims Analysis Tool (eCAT) for documenting electronic CDR (eCDR) case analysis. However, DDSs are moving to the Disability Case Processing System (DCPS) to document each step of the adjudicative evaluation process. DCPS provides a complete claim explanation in one document, the Disability Determination Explanation (DDE), which is imaged to the electronic folder case documents (A. Payment Documents/Decisions (Yellow Front)). Adjudicators will follow the DCPS instructions and their site’s business process to document information. For additional guidance on eCDR rationales, see DI 81020.230.

 

DI 28090.005 Overview of Rationales

A. Character of a rationale

The purposes of the rationale are to:

  • Identify all of the medical and non-medical factors that have been considered (e.g., evidence requested and evidence used);

  • Explain the thought process used to make the determination;

  • Provide a permanent evidentiary record of the reasoning for the conclusion; and

  • Inform subsequent reviewers, including quality assessment components, of the basis for the determination.

Rationales must:

  • Be complete, accurate, logical, and legally supportable;

  • Be based on substantial evidence;

  • Show clearly and persuasively how substantial evidence leads to the conclusion(s);

  • Address and resolve all allegations made by the individual and other reporting sources that may be in conflict with determination conclusions; and

  • Describe in a complete and concise manner the importance attributed to each of the various factors of the case.

A sound rationale can result only from a well-developed and well-documented case file. It is essential to show all information pertinent to the relevant medical and non-medical issues and demonstrate that the adjudicator followed the continuing disability review (CDR) evaluation process.

B. References

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

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

  • DI 81020.230 Documenting Comparison Point Decision (CPD) Evidence and Preparing the Electronic Continuing Disability Review (eCDR) Rationale

 

DI 28090.010 Continuing Disability Review (CDR) Rationale Content

A. Complete rationales

A rationale is required in all CDR determinations, whether the determination is a continuance or cessation.

The technical rationale must contain six elements:

  1. 1. 

    Citation of the evidence sources;

  2. 2. 

    Basis for most recent favorable medical determination (comparison point decision (CPD)) and the reason for current medical review;

  3. 3. 

    Summary of individual's reason(s) that he or she is still disabled;

  4. 4. 

    Statement regarding non-medical issues (e.g., substantial gainful activity (SGA), work activity, vocational rehabilitation involvement (Section 301 cases), extended period of eligibility (EPE) cases);

  5. 5. 

    Discussion of the findings produced by the CDR evaluation process; and

  6. 6. 

    Basis for the disability decision, the reason the individual's disability continues (e.g., meets a listing)), or has ceased (e.g., medical improvement related to the ability to work has occurred and the individual has the ability to perform SGA).

The rationale will include an accurate discussion of the medical findings. To ensure clarity and conciseness, avoid using highly technical medical terminology unless rephrasing would be misleading or would result in an incorrect medical conclusion.

NOTE: 

NOTE: It is appropriate to use accepted medical abbreviations such as FEVl for “forced expiratory volume in 1 second,” ECG for “electrocardiogram,” and terms common to the medical improvement review standard (MIRS) and the CDR process, e.g., MI (medical improvement), comparison point decision (CPD), and SGA . However, avoid excessive use of acronyms and abbreviations.

 

B. Preparation of the technical rationale

In Disability Determination Services (DDSs) where the Disability Case Processing System (DCPS) is used, the adjudicator will follow instructions per their legacy systems.

In DDSs where the Electronic Claims Analysis Tool (eCAT) is still used, the adjudicator may prepare the rationale in the location of the Disability Determination Explanation (DDE) or on an SSA-4268 (Explanation of Determination). The State or Federal agency medical or psychological consultant (MC/PC) and adjudicator will sign and date the SSA-4268 in the appropriate blocks. The adjudicator can sign the rationale singly if the MC/PC has otherwise completed a separate medical assessment using any of these forms:

C. 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

  • DI 81020.230 Documenting and Copying Comparison Point Decision (CPD) Relevant Evidence and Preparing the Electronic Continuing Disability Review (eCDR) Rationale

DI 28090.015 Rationale Content - Evidence Sources

A. Documentation of evidence sources on the rationale

The rationale will list the evidence considered in making the comparison point decision (CPD) and the current evidence obtained for the continuing disability review (CDR).

However, if the CPD includes a list of the evidence considered then, the adjudicator may incorporate that list by reference (e.g., “in making the determination on the issue of continuing disability, all of the evidence listed on the CPD dated (MM/DD/YYYY) has been considered, as well as the following additional evidence:”).

If disability continues without consideration of the medical improvement review standard (MIRS) (i.e., based on meeting or equaling a listing or consideration of medical-vocational factors without formal consideration of the MIRS), there is no need to list the evidence from the CPD. This is not to circumvent the MIRS but to expedite action when a continuance is obvious. Always list the evidence obtained during the CDR process.

If an error exception applies to a decision other than the CPD, cite all of the evidence considered in that decision.

Identify any medical and non-medical sources of evidence considered:

  1. 1. 

    Medical source reports - Cite the source's name, including specialty if known, and the date the source signed the report. If undated, cite the last date of treatment. If no other date is available, cite the date of receipt. When teledictation is used, cite the date of dictation.

  2. 2. 

    Hospitals, clinics, or mental health centers - Identify the hospital, clinic, or mental health center for:

    • inpatient treatment, cite admission and discharge dates; and

    • outpatient treatment, give specific dates of treatment unless three or more treatments are listed. For three or more treatments, give the first through last date.

  3. 3. 

    Consultative examination (CE) reports - Indicate “consultative examination” and then cite consultant's name, specialty, and the date of the CE. When DDS purchased a CE in connection with the CDR, the discussion of medical evidence must contain a statement to explain why the available evidence was not sufficient and why a CE was necessary.

  4. 4. 

    N on-medical sources (school guidance counselors, welfare departments, vocational rehabilitation agencies, day treatment facilities, sheltered workshops, social workers, etc.) - List non-medical sources as evidence sources but do not identify those sources by a specific name. Identify non-medical sources by position and organization (e.g., “Vocational Rehabilitation Counselor, Department of Rehabilitation Services, report received XX/XX/XXXX”). For a rationale example, see DI 28090.300J or DI 28090.300O.

  5. 5. 

    Third- party lay evidence (family members, neighbors, coworkers, etc.) - Identify third-party evidence only by the generic category; i.e., “Third-party report received XX/XX/XXXX.”

NOTE: 

Generally, information from any non-medical or third-party source will be signed and dated. If the report is undated, cite the date of receipt.

B. References

  • DI 22505.003 Evidence from an Acceptable Medical Source (AMS)

  • DI 22510.001 Introduction to Consultative Examinations (CE)

  • DI 28030.020 Development of Medical Evidence

  • DI 28090.300 Sample Rationales - Continuances and Cessations

DI 28090.020 Rationale Content - Basis for the Most Recent Prior Favorable Determination and Reason for Current Medical Review

The rationale will include a brief statement indicating the:

  • Established onset date (EOD);

  • Basis for the most recent prior favorable determination; and

  • Reason for the current medical review.

NOTE: 

Do not provide a discussion of the medical findings of the most recent favorable decision. See DI 28090.035 for discussion of medical findings.

DI 28090.025 Rationale Content - The Individual’s Reason(s) for Continued Entitlement or Eligibility

A. Documentation of subjective complaints in the rationale

The rationale will include a brief statement outlining the physical and/or mental conditions and symptoms that the individual said limited his or her ability to work. The adjudicator will include all medical conditions and complaints reported by the individual during the field office (FO) interview, as well as any additional conditions, complaints, allegations, or observations subsequently reported by the FO, by medical sources or other sources, or to the Disability Determination Services directly. The adjudicator must specifically address any allegations of pain and any subjective symptoms.

B. References

  • DI 24501.020 Establishing a Medically Determinable Impairment (MDI)

  • DI 25210.005 Factors We Consider When We Evaluate The Effects Of Your Impairment(s) On Your Functioning (Section 416.924a(b)(1)-(2)

  • Social Security Ruling (SSR) 16-3p, “Titles II and XVI: Evaluation of Symptoms in Disability Claims”

DI 28090.030 Rationale Content - Statement of Non-medical Issues

The rationale will include a statement regarding whether the individual is working, and if so, discuss whether this work activity is substantial gainful activity. Identify any other non-medical issues material to the disability determination, e.g., vocational rehabilitation involvement (Section 301 cases) or extended period of eligibility (EPE) cases. For a rationale example, see DI 28090.300F.

DI 28090.035 Rationale Content - Medical Findings

A. Discussion of medical findings

The rationale must discuss all the medical and non-medical evidence used in the adjudicative process. Present the relevant symptoms, signs, and laboratory findings. For example, if there is a cardiac problem, discuss interpretation of available ECGs. Discuss both negative and positive findings. Do not discuss ECGs when there is no allegation or indication of a cardiac condition.

Adjudicators must give special attention to the evidentiary requirements of the listings related to the impairment(s). Use clear language; however, technical language may be required to document laboratory findings specified in a listing.

The discussion of the medical evidence in the rationale represents the core of the disability evaluation process. This section of the rationale will contain a discussion and summarization of the evidence including, as applicable:

  • Description of the findings with special attention to the evidentiary requirements of listings related to the impairment(s);

  • Discussion and resolution of any conflicts in the evidence;

  • Discussion of all allegations, including pain, and of all opinions to assess whether the evidence supports them; and

  • Explanation as to why a consultative examination (CE) was purchased.

B. Medical opinions

Consideration of medical opinions depends on the filing date of the case. For claims with a filing date on or after March 27, 2017, follow the guidance in DI 24503.030, "Articulation Requirements for Medical Opinions and Prior Administrative Medical Findings – Claims filed on or after March 27, 2017." For claims filed before March 27, 2017, follow guidance in DI 24503.035, "Evaluation and Articulation Requirements for Medical Opinions, Opinions, and Prior Administrative Medical Findings – Claims filed before March 27, 2017."

Physicians and other acceptable medical sources (AMSs) are qualified as experts in matters pertaining to medicine and the evaluation of impairments. However, “disability,” as defined by the Social Security Act, encompasses not only the medical factors of impairment, but also the consideration of such non-medical factors as age, education, past work experience, and daily activities.

Occasionally, a physician or other AMS may include conclusions or opinions in the medical records regarding the individual's abilities. When medical sources make statements about issues that are reserved to the Commissioner, regarding an individual’s abilities, such as “totally and permanently disabled,” “unable to work,” or “cannot return to any work,” the rationale must explain whether medical and non-medical evidence substantiates these opinions. This explanation must describe any relevant program provisions, such as work incentives, and relate them directly to the adjudicator’s conclusions.

C. References

  • DI 24503.030 Articulation Requirements for Medical Opinions and Prior Administrative Medical Findings – Claims file on or after March 27, 2017

  • DI 24503.035 Evaluation and Articulation Requirements about Medical Opinions, Opinions, and Prior Administrative Medical Findings — Claims Filed before March 27, 2017

  • DI 24503.040 Evaluating Statements on Issues Reserved to the Commissioner (IRC)

DI 28090.040 Rationale Content - Meets or Equals

A. Meets a listing

The rationale must reflect the specific listing, including any subsection identification (for example, Listing 14.02A or B) in the rationale if a listing is met. Include the specific findings that meet the listing’s requirements. For a rationale example, see DI 28090.300A.

B. Equals a listing

When the impairment(s) is medically equivalent to a listed impairment in the Listing of Impairments, the rationale must identify the elements that support this finding and identify the listed impairment number, including any subsection identification that is equaled. The adjudicator must explain why the signed statement of the reviewing medical or psychological consultant (MC/PC) concluded that severity and duration equivalent to a listed impairment is present. The adjudicator must incorporate the entire analysis, as to equivalency provided by the reviewing MC/PC, into the rationale. The rationale must also document medical equivalency in the following situations:

1. Specified medical finding(s) missing

When an impairment is listed, and one or more of the specified medical findings is missing from the evidence (but other medical findings of greater or equal significance that relate to the same impairment are present in the evidence), the MC/PC or adjudicator should identify the equivalent finding (or finding of greater or equal significance).The MC/PC or adjudicator should explain the basis(es) for the equivalency.

2. Unlisted impairment

When there is an unlisted impairment, identify the most closely analogous listed impairment. The analysis must identify those medical findings of the unlisted impairment and explain why the findings or manifestations are equivalent to the severity reflected in the identified listed impairment.

3. Combination of impairments

When the MC/PC or adjudicatorbases equivalency on a combination of impairments, the MC/PC or adjudicator will cite the listed impairment number most closely related to the most severe impairment. In these situations, the MC or PC will provide a medical explanation to show how the interaction of the combined impairments equates with the intended severity of a listed impairment(s).

For more information on medical equivalence, see DI 24508.010. For a rationale example, see DI 28090.300B.

C. Impairment does not meet or equal

When the individual's impairment(s) does not meet or equal the Listings, the adjudicator will include the statement: “The individual's impairment(s) does not meet or equal the level of severity described in, or intended by, the Listing of Impairments.”

DI 28090.045 Rationale Content - Medical Improvement (MI)

A. Documenting MI in the rationale

MI is any decrease in the medical severity of the impairment(s) that was present at the time of the most favorable medical determination that the individual was disabled or continued to be disabled as evidenced by changes in symptoms, signs, or laboratory findings.

The adjudicator will compare the severity of only the impairment(s) considered at the comparison point decision (CPD) with the current severity of the same impairment(s) to determine if there has been any medical improvement. He or she will document the conclusion in the rationale. For a rationale example, see DI 28090.300G, DI 28090.300M, or DI 28090.300P. The adjudicator will consider any additional or new impairment(s) at a later step in the continuing disability review (CDR) evaluation process.

The adjudicator will discuss MI or the exceptions to MI in the rationale unless evidence received in a particular case clearly establishes continuing disability, without following every step in the CDR evaluation process. For more information on this flexible approach, see DI 28005.005B.2.

NOTE: If the adjudicator did not formally consider the medical improvement review standard (MIRS) because benefits are continued based on consideration of residual functional capacity and vocational factors, the rationale must include an explanation why MI and the exceptions to MI have not been formally considered. No statement regarding MI and the exceptions is necessary if a listing is met or equaled.

B. References

  • DI 28005.001 Legal Standard for Determining if Disability Continues

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

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

DI 28090.050 Rationale Content - Whether Medical Improvement (MI) is Related to the Ability to Work

A. MI found

When the findings demonstrate MI (a decrease in the medical severity of an impairment), the rationale will:

  • List the impairment(s) that was present at the comparison point decision (CPD); and

  • Include a discussion of whether MI is related to the ability to work.

B. Impairment met or equaled at CPD

The rationale must indicate that if the CPD impairment(s) met or equaled a listed impairment but the impairment(s) no longer meets or equals that same listing, then the adjudicator must determine and discuss whether MI is related to the ability to work.

C. CPD was a medical-vocational decision

If the CPD was a medical-vocational decision, the rationale must include an explanation of the functional limitations (e.g., the ability to lift and carry, sit, stand, and walk) based on the medical findings and a statement of residual functional capacity (RFC). The adjudicator will compare this explanation with an assessment of the “MIRS RFC” (current functional capacity considering only the impairment(s) that was present at the CPD). For more information on the “MIRS RFC," see DI 28015.300.

D. Multiple impairments

When multiple impairments were present at the CPD, the rationale must show that the combined effect of all those impairments has been considered in the current determination and indicate whether there has been a change in such combined effect since the date of the CPD.

E. References

  • DI 24510.001 Residual Functional Capacity (RFC) Assessment – Introduction

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

  • DI 28015.850 Types of Residual Functional Capacity (RFC) Assessment(s) Needed

  • DI 28090.070 Rationale Content - Statement of Residual Functional Capacity (RFC)

DI 28090.055 Rationale Content – Groups I and II Exceptions

A. Exceptions in the rationale

Consider Group I exceptions when there is:

  • No medical improvement (MI); or

  • MI, but it is not related to the ability to work.

Consider Group II exceptions at any point they occur in the process.

B. Discussion of exceptions

For a Group I exception, the rationale must indicate whether there is no MI, or MI is not related to the ability to work. The rationale must also reflect consideration of the ability to engage in substantial gainful activity (SGA). For more discussion on SGA, see DI 28090.065.

If a Group II exception applies, and the evidence does not permit adjudication under another basis, discuss the relevant Group II exception(s). For a rationale example, see DI 28090.300R.

If the evidence raises a significant question as to whether a particular exception applies, but the requirement(s) of that exception is not satisfied, include a brief explanation in the rationale stating why that exception did not apply.

Whenever the exception(s) to MI is applied, the rationale must reflect the evidence that establishes the criteria for a particular exception(s). If more than one exception (or an exception(s) and MI) applies in a case, state this explanation in the rationale. For a rationale example, see DI 28090.300J.

If no exception applies at this point in the continuing disability review (CDR) evaluation process, include a statement that no exception to MI applies and that disability continues.

C. References

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

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

  • DI 28020.900 Group II Exceptions

  • DI 28090.065 Rationale Content - Ability to Do Substantial Gainful Activity (SGA)

DI 28090.060 Rationale Content – Non-severe Impairment(s)

A. Discussion of non-severe impairment(s) in the rationale

For Title II and adult Title XVI cases, an impairment is not severe if it has no more than a minimal effect on an individual's physical or mental ability(ies) to do basic work activities. For a Title XVI child case, an impairment is not severe if it is only a slight abnormality or a combination of slight abnormalities that causes no more than minimal functional limitations.

It is possible that several non-severe impairments could combine to produce a severe impairment. Disability Determination Services (DDS) must consider the combined effect of all the individual's impairments in determining whether the impairments are severe. The adjudicative team will assess the impact of the combination of those impairments on the person's ability to function, rather than assess separately the contribution of each impairment to the restriction of his or her activity as if each impairment existed alone. When there is a combination of non-severe impairments, the rationale must show consideration the impact of the combination of those impairments on the person's ability to function.

If the impairment(s), when considered singly or in combination, is determined to be non-severe, the rationale will state this fact. For a rationale example, see DI 28090.300D or DI 28090.300Q.

NOTE: The concept of a non-severe impairment(s) does not apply if it has been determined at an earlier step in the continuing disability review (CDR) evaluation process that the current impairment(s) imposes a significant restriction on the ability to perform basic work activities. In this case, the rationale must state that the impairment is severe.

B. References

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

  • DI 24505.001 Individual Must Have a Medically Determinable Severe Impairment

  • DI 24505.005 Evaluation of Medical Impairments that are Not Severe

  • DI 25220.005 Determining If a Child Has a Severe Impairment(s)

DI 28090.065 Rationale Content - Ability to Do Substantial Gainful Activity (SGA)

Before a cessation based on either medical improvement (MI) or a Group I exception to MI can be made, the adjudicator must consider the individual’s ability to engage in SGA.

The rationale must explain the functional limitations (e.g., the ability to lift and carry, sit, stand, and walk) imposed by the current impairment(s) and include a statement of residual functional capacity (RFC) at this point, if not previously included in the rationale. The rationale must reflect the individual's ability to do any past relevant work or other work. For a rationale example, see DI 28090.300C, DI 28090.300F, DI 28090.300G, DI 28090.300K, or DI 28090.300O.

DI 28090.070 Rationale Content - Statement of Residual Functional Capacity (RFC)

When medical considerations alone are not the basis for the determination on Title II and adult Title XVI cases, the rationale must summarize the RFC findings as recorded on the assessment form(s): SSA-4734-BK (Physical Residual Functional Capacity Assessment) or SSA-4734-F4-SUP (Mental Residual Functional Capacity Assessment). This statement must include specific citations of the evidence supporting the RFC.

For physical impairments and limitations, the specific work-related findings must establish the capacity to meet the strength and non-strength requirements of the various ranges of work: sedentary, light, medium, heavy, and very heavy work.

For mental impairments and limitations, the specific work-related findings must establish the capacity to meet the mental demands of different types of work.

DI 28090.075 Rationale Content - Ability to Perform Past Relevant Work (PRW) - Cessation

A. Discussion of PRW in the rationale

If the individual has performed PRW, the rationale must contain the following findings of fact:

  • Vocational relevancy of the PRW; and

  • Physical and mental demands of the PRW.

B. Unable to perform PRW

If the continuing disability review (CDR) shows the individual has no PRW, or does not have the ability to perform PRW based on the individual's physical or mental residual functional capacity (RFC or MRFC), include a statement to that effect.

C. Able to perform PRW

If the individual retains the capacity for PRW, the rationale’s discussion must describe the specific job(s) and explain the evidence supporting that finding of fact. The adjudicator must include the findings of fact into a concluding statement of “not disabled” based on the individual's RFC or MRFC being compatible with the performance of a vocationally relevant past job. For a rationale example, see DI 28090.300F.

DI 28090.080 Rationale Content - Ability to Perform Other Work - Cessation

Citation: 20 CFR 404, Subpart P, Appendix 2.

A. Discussion of other work in the rationale (cessation)

The rationale’s medical-vocational discussion must contain the following findings of fact:

  1. 1. 

    The individual's age. This fact is usually the alleged age, although the field office (FO) may develop proof of age. If other evidence, such as medical records, raised questions about the individual’s age, the adjudicator will address how any material discrepancy was resolved.

  2. 2. 

    The individual's education. This fact is usually the individual's allegation, absent evidence to the contrary.

  3. 3. 

    The physical and mental demands of the individual's past relevant work (PRW) experience.

  4. 4. 

    A statement indicating the individual’s residual functional capacity (RFC) or mental residual functional capacity (MRFC) does not permit performing any PRW.

  5. 5. 

    Consideration of the special medical-vocational profiles discussed in DI 25010.001.

  6. 6. 

    How the findings relate to an appendix 2 rule (commonly known as the “vocational rule(s),” “voc-rule(s),” or “grids”):

    • That directs a conclusion of “not disabled,” or

    • When used as a framework: The adjudicator will discuss the vocational implications of RFC, age, education, work experience, and the remaining occupational base. He or she will provide an explanation of why these factors show the ability to engage in other substantial gainful activity (SGA).

    In addition to the findings of fact, when a finding of “not disabled” is based on:

    • Transferable skills, the rationale must provide an assessment of those skills;

    • Education that provides direct entry into skilled work, the adjudicator will discuss the education that provides for direct entry; and

    • Ability to do unskilled work, the adjudicator will not discuss transferable skills or education that provides for direct entry into skilled work. Transferability and education that provide for entry into skilled work do not apply to unskilled work.

B. Meeting a vocational rule

When a voc-rule providing for a finding of “not disabled” is met, the adjudicator must cite the specific rule in the rationale, but need not cite examples of jobs the individual can do, unless the determination is based on transferable skills or education that provides for direct entry into skilled work. For a rationale example, see DI 28090.300I.

C. Vocational rule used as a framework

When the voc-rules provide a “framework” to determine a finding of “not disabled,” the rationale must contain either:

  • Examples of jobs (usually three) the individual can do functionally and vocationally, and provide a statement of the incidence of such work in the region in which the individual resides or in several regions of the country, or

  • The Social Security Ruling (SSR) that supports finding a minimal or no effect on the occupational base.

For more information on using the voc-rules as a framework, see DI 25025.005C.

D. References

DI 28090.085 Rationale Content - Inability to Perform Past Relevant Work (PRW) or Other Work - Continuance

Citation: 20 CFR 404, Subpart P, Appendix 2

A. Discussion of PRW or other work in the rationale (continuance)

The rationale’s medical-vocational discussion should contain, when appropriate, the following findings of fact:

  1. 1. 

    The individual's age. This fact is usually the alleged age, although the field office may develop proof of age. If other evidence, such as medical records, raised questions about the individual’s age, address how any material discrepancy was resolved.

  2. 2. 

    The individual's education. This fact is usually the individual's allegation, absent evidence to the contrary.

  3. 3. 

    The physical and mental demands of the individual's past relevant work (PRW) experience.

  4. 4. 

    A statement indicating the individual’s residual functional capacity (RFC) or mental residual functional capacity (MRFC) does not permit performing any PRW.

  5. 5. 

    Consideration of the special medical-vocational profiles discussed in DI 25010.001.

If the special medical-vocational profiles are not the basis for the determination, then the adjudicator will discuss how the findings support an appendix 2 rule (commonly known as the ”vocational rule(s),” “voc-rule(s),” or “grids”):

  • That directs a conclusion of “disabled,” or

  • That is used as a “framework” for the conclusion, with a discussion of the vocational implications of RFC, age, education, work experience, and the remaining occupational base. The adjudicator will explain why these factors show the inability to adapt to other work. For more information on using the voc-rule(s) as a framework, see DI 25025.005C.

When disability continues based on medical-vocational factors, and at least one of the individual’s past relevant jobs was skilled or semiskilled, the adjudicator will indicate that DDS considered transferability of skills. Similarly, when the individual has recently completed educational courses, there must be a statement showing that DDS considered if education would provide for direct entry into skilled work.

In applying the voc-rules, the adjudicator will not consider the age factor mechanically in borderline situations. In addition, an individual's numerical educational grade level is not controlling in the presence of evidence to the contrary. When age or education grade level does not exactly match the cited voc-rule (for example: citing a rule applicable to an individual of advanced age (55+), when his or her chronological age is 54 years, 11 months (approaching advanced age)) explain why the cited rule is appropriate to the case.

B. References

DI 28090.150 Rationale Content – Basis for the Disability Determination (All Cases)

A. Concluding statement

In the concluding statement in the rationale, DDS must clearly indicate:

  • The current determination (disability continues or no longer disabled);

  • The basis(es) on which the determination was made (meets, equals, med-voc, capable of substantial gainful activity (SGA), etc.);

  • Whether more than one exception applies, or both medical improvement and an exception apply; the rationale acknowledges all bases for cessation documented in the file. For a rationale example, see DI 28090.300J;

  • The basis(es) code(s) from block 11 or 12 of the SSA-832 or SSA-833 (Cessation or Continuance of Disability or Blindness Determination and Transmittal); and

  • For a cessation determination, the month disability ceases and the month of disability termination. For a rationale example, see DI 28090.300H or DI 28090.300I.

B. Cessation date in the past

If disability ceased in the past, the adjudicator will explain the reason for the selected date. For a rationale example, see DI 28090.300R.

C. Extended period of eligibility (EPE) cases

In extended period of eligibility (EPE) cases, the adjudicator will specify only the cessation date. The disability termination date is related to work activity and is SSA's jurisdiction. For a rationale example, see DI 28090.300F.

DI 28090.200 Rationale Content - Special Situations

A. Discussion of special situations in the rationale

The following situations have specific issues that must be addressed where specified.

NOTE: When a “one-time-only” (e.g., an audit or study) category of cases requires special processing, the POMS will provide additional instructions. If necessary, the instructions will include a sample rationale to reflect the specific issues and any special modifications unique to the situation.

1. Clear-cut cessation rationales

Cite current sources in “clear-cut” medical cessations, but do not list the comparison point decision (CPD) sources.

Provide a concise statement of the pertinent evidence sufficient to make the conclusion clear. The rationale must include the following items:

  • Nature of the impairment;

  • Established onset date (EOD);

  • Fact that it was a medical improvement expected (MIE) case;

  • Statement that the individual has returned to full-time work with no significant restrictions;

  • Statement that the individual has acknowledged that medical improvement occurred in or before the month he or she returned to work, and that he or she expects to be able to continue working;

  • Statement that the individual does not want medical evidence for the previous l2 months to be obtained before a decision is made;

  • Statement that the individual’s medical source has released him or her to return to full-time unrestricted work; and

  • Explanation that disability ended in the past, in the first month the individual returned to full-time unrestricted work.

2. Lost folder case rationales

In continuing disability review (CDR) cases where the prior medical folder cannot be located, the rationale reflects the procedures described in DI 28035.001 regarding lost folder cases.

NOTE: If DDS reconstructs the prior folder, the case would no longer be considered a lost folder case and DDS will follow the usual CDR evaluation process in the rationale.

Modify rationales as follows when the prior folder is not available:

a. Meets or equals a listing

If current evidence indicates the individual meets or equals a listing, disability continues without further development. Follow the procedures for rationales in DI 28090.040.

b. Unable to perform past or other work

If the individual is obviously unable to perform past or other work based on medical-vocational factors (a residual functional capacity (RFC) assessment was prepared), none of the exceptions apply, and it is determined that disability continues, the rationale will state that “disability continues and medical improvement (MI) was not formally considered.”

c. Cessation likely or the determination is not clear

If review of the current evidence indicates a determination is unclear or cessation would be likely, the rationale must contain a summary of:

  • Attempts to identify the CPD; and

  • Efforts to reconstruct the prior folder.

The adjudicator will ensure that current documentation is complete and continues disability in the absence of current substantial gainful activity or a group II exception. For a rationale example, see DI 28090.300L.

3. Non-rollback conversion case rationales

If an individual, who was originally found disabled under a State plan, continues to be disabled based on the current Federal CDR evaluation process, the adjudicator will follow the usual rationale procedures. If the individual is found “not disabled” after the CDR evaluation process, the adjudicator will evaluate the individual under the appropriate State plan, using the medical improvement review standard. Provide a discussion supporting this conclusion as part of the rationale.

NOTE: In concurrent Title II/Title XVI cases that need a decision under the State plan for the Title XVI case, in eCAT prepare two Forms SSA-4268 (Explanation of Determination). The Title XVI rationale can incorporate the Title II rationale before including the evaluation of the case under the appropriate State plan. For cases in DCPS, follow current instructions. For more information on conversion cases, see DI 28075.010.

4. Medical improvement not expected (MINE) case rationales

The adjudicator will prepare an abbreviated rationale. He or she will include the first four elements of the rationale, from DI 28090.015 through DI 28090.030:

  1. a. 

    Evidence sources;

  2. b. 

    Basis for CPD and reason for review;

  3. c. 

    Individual’s reason(s) for continued entitlement and eligibility; and

  4. d. 

    Statement of non-medical issues.

MINE cases do not need an extensive discussion of medical findings. The adjudicator will provide findings of fact showing the existence of the MINE impairment, and how current development verifies those findings. For a rationale example, see DI 28090.300S.

B. References

  • DI 28001.045 Rollback and Non-rollback Conversion Cases

  • DI 28010.105 Comparison Point Decision (CPD)

  • DI 28015.315 Comparison Point Decision (CPD) Residual Functional Capacity (RFC)

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

  • DI 28030.035 Cessation Without Full Medical Development (Clear-Cut Cessations)

  • DI 28035.000 Processing of Lost or Destroyed Folders/Medical Evidence

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

  • DI 28040.001 Background of Medical Improvement Not Expected (MINE) or MINE-Equivalent Cases

DI 28090.300 Sample Rationales - Continuances and Cessations

This section contains examples of rationales. Every rationale must include the factors covered in the decision-making process in order of continuing disability review (CDR) evaluation.

Decision Type

Sample

Impairment Meets Listing Requirements - Continuance

A

Impairments Equal Listing - Continuance

B

MI Occurred, RFC Shows the W/E Cannot Do SGA – Continuance

C

MI Occurred, Not Severe - Cessation

D

MI Occurred – Cessation

E

MI Occurred, Can Perform Past Work - Cessation

F

MI Occurred, Cannot Perform Past/Other Work - Continuance

G

MI Occurred, Can Perform Other Work - Cessation

H

MI Occurred, Multiple Not Severe Impairments Combined Effect is Severe, but One Impairment Is a Subsequent Impairment, Can Perform Other Work - Cessation

I

MI Occurred, and It Is Obvious that the Vocational Exception Also Applies, Can Perform Other Work - Cessation

J

No MI, but Error Exception Applies, Cannot Perform Past or Other Work – Continuance

K

Unable to Determine if MI Occurred, Folder Lost – Continuance

L

No MI or Exception - Continuance

M

No MI or Exception - Continuance

N

MI is not Related to Ability to Do Work, but Vocational Therapy Exception Applies, Can Perform Other Work – Cessation

O

No MI or Exception, Unchanged Medical Findings – Continuance

P

No MI, Not Severe Impairment(s), but Error Exception Applies – Cessation

Q

Failure to Cooperate – Cessation

R

MINE Case – Continuance

S

NOTE: 

These samples are intended to show the proper format and the sequence of the various elements following the medical improvement review standards (MIRS). They are not intended to serve as policy statements nor as examples of how medical findings are to be evaluated.

A. Sample rationale - Impairment meets listing requirements - continuance

The following reports were used at the comparison point decision (CPD) dated 10/05/2014 to determine disability:

  • Charles Hall, Jr., M.D. , report of 06/15/2014; and

  • Mark James, M.D., report of 06/05/2014.

The following reports were used to decide if disability continues:

  • Alfred Sandman, M.D., Internist, report dated 02/16/2018;

  • Charles Hall, Jr., M.D., report of 03/01/2018; and

  • Frederick James, M.D., Orthopedist, consultative examination of 03/08/2018.

The individual was found to be disabled beginning 01/05/2014 because of a combination of obesity and osteoarthritis of both knees. These impairments limited the individual to the performance of sedentary work and Vocational Rule 201.09 directed a finding of disabled. A current evaluation is necessary as medical improvement is possible. The individual has not engaged in substantial gainful activity since onset and maintains he is unable to perform any work activity because of arthritis. He stated he seldom goes to his doctor as it's difficult for him to get around.

The individual's treating internist reported on 02/16/2018 that the individual continues to suffer from knee pain and limitation of motion in spite of a physical therapy program and medication. He noted that the individual weighed 331 pounds at the last examination on 12/04/17. Because the medical evidence of record was not complete enough to permit evaluation of current severity, DDS arranged a consultative examination.

The consulting orthopedist reported on 03/08/2018 that the disabled individual was 70 inches in height and weighed 325 pounds and used a manual wheelchair for mobility. He had difficulty getting on and off the examining table and complained of constant knee pain. Range of motion studies revealed that flexion of the right knee was 80 degrees. Flexion of the left knee was limited to 75 degrees. He could not stand or walk unassisted due to severity of his knee pain with weight-bearing. X-rays were consistent with advanced osteoarthritic changes of both knees. The consulting orthopedist opined that the individual's wheelchair was medically necessary.

Since the record shows that the disabled individual's osteoarthritis of the knees meets the requirements of Listing 1.02A, he continues to be disabled.

B. Sample rationale - Impairments equal listing - continuance

The following reports were used at the comparison point decision (CPD) dated 01/27/2017 to determine disability:

  • Hillary Watson, M.D., Women's Hospital, inpatient treatment of 08/17/2016 to 09/02/2016;

  • William Green, M.D., report dated 10/05/2016; and

  • Grace Monafo, M.D., report dated 12/07/2016.

The following reports were used to determine whether disability continues:

  • Hillary Watson, M.D. , Women's Hospital , inpatient 08/17/2019 to 09/01/2019; outpatient 12/04/2019 and 12/18/2019;

  • William Green, M.D., report dated 03/20/2019; and

  • Grace Monafo, M.D., reports dated 03/29/2019 and 04/10/2019.

The individual was found to be disabled beginning 8/17/16 due to obesity, heart disease, and arthritis. Medical records document a myocardial infarction in August 2016. Also, the individual had pain in both knees with limitation of motion bilaterally. Due to obesity and limitation of knee motion, the individual had difficulty walking. The impairments were determined to be equivalent to the severity reflected in Listing 1.02. Current evidence is needed because medical improvement is possible. The disabled individual states that she is still disabled because of a heart condition and arthritis. She has not worked since her established onset date.

An examination on April 10, 2019 shows she had no recurrence of angina, but complained of shortness of breath on walking 1 1/2 blocks and dependent edema at night. Her persistent knee joint pain was exacerbated by walking or prolonged standing. She also complained of generalized joint pain and morning stiffness. Her height was 62 inches, weight 249 pounds. Blood pressure with a large cuff was 150/95. She was in no acute distress. There was mild ankle edema. The knees were enlarged and crepitant, but without heat or inflammation. Range of motion of the knees was moderately decreased bilaterally. There was no jugular vein distention and the liver was not palpable. The lungs were clear, but breath sounds were somewhat distant. Heart rhythm was markedly irregular and the apical pulse was 120, with a radial pulse of 100. There was a soft systolic aortic ejection murmur. Chest film shows clear lungs. CT ratio is 53 percent, with mild left ventricular prominence. ECG tracing shows multifocal PVCs and QS complexes through lead V5. Fasting blood sugar is 130. Serum creatinine is 1.4. X-ray films show moderate osteoarthritic changes in the knees.

The DDS medical consultant's review indicates that the individual does not meet the disability criteria for Listing 1.02. However, her mobility continues to be severely limited by impairment-related shortness of breath and by joint pain. It is determined that the combination of heart disease, obesity, and osteoarthritis of the knees continues to be equivalent to the severity reflected in the criteria for Listing 1.02. Therefore, she is disabled within the meaning of the Social Security Act and disability is continued.

 

C. Sample rationale – medical improvement (MI) occurred, residual functional capacity (RFC) shows the individual cannot do substantial gainful activity (SGA) - continuance

The following reports were used at the comparison point decision (CPD) of 01/10/15 to determine disability:

  • Philip Smith, M.D., report of 11/07/2014 and

  • St. John's Hospital, inpatient treatment 10/07/2014 to 10/27/2014.

The following reports were used to determine whether disability continues:

  • Philip Smith, M.D., report dated 02/25/2018;

  • Khalil Kashir, M.D., report dated 03/10/2018; and

  • Charles White, M.D., Internist, consultative examination of 03/20/2018 and Pulmonary Function Studies (PFS) of 03/26/2018.

The individual was determined to be disabled from 10/07/2014 because of multiple injuries sustained in an automobile accident. At the time of the CPD, the individual was recuperating from multiple rib fractures, internal injuries, and a compound, comminuted fracture of the left ankle. These injuries limited him to the performance of light work and Vocational Rule 202.06 directed a finding of disabled. Current evidence is needed because medical improvement is possible. The disabled individual states that he is still unable to work due to a leg condition and shortness of breath. He is not engaging in SGA.

Current medical evidence shows complete healing of the rib and ankle fractures and healed internal injuries. The only current residual of the accident is a mild restriction of movement of his left ankle; however, he has normal gait and station. An x-ray of his left ankle reveals a healed fracture with degenerative changes. He has good range of motion of his hips and knees. There are no sensory, motor, or reflex abnormalities. Abnormal breath sounds and labored breathing were noted. A diagnosis of chronic obstructive pulmonary disease has been made.

A consultative examination was obtained since a chest x-ray and Pulmonary Function Studies (PFS) were needed to evaluate this additional impairment. PFS performed on 03/26/2018 revealed that the pulmonary disorder has resulted in reduced breathing capacity with an FEV1 of 1.6 and MVV of 67. His height is 6 feet without shoes. The impairments do not meet or equal the Listings.

Therefore, medical improvement has occurred. This individual previously had an RFC for light work at the CPD. Considering only the impairment present at the CPD, there is currently no significant restriction of function. Therefore, the medical improvement is related to the ability to work. The disabled individual's respiratory impairment is severe as he is limited in his ability to lift more than 20 pounds occasionally or 10 pounds frequently. He should not work in polluted environments. Therefore, based on all the current impairments, he is found to be restricted to a limited range of light work.

The disabled individual is 58 years of age with a high school education and a 25-year work history as a rigger in the shipbuilding industry (skilled work at a heavy exertional level). This work involved maintaining the weight-handling gear on ships, arranging the weight distribution of the load and organizing the movement of the gear. He cannot perform this past relevant work because of the heavy exertional requirement, as he can only do a limited range of light work. His skills are not transferable to light work. In view of his remaining occupational base translated from his RFC and considered in conjunction with his advanced age, education, and work experience, he would be unable to make the adjustment to other skilled work. Accordingly, he continues to be disabled within the framework of Vocational Rule 202.06. Therefore, although medical improvement related to ability to work has occurred in the original impairment, the current impairment is severe and precludes the individual from performing SGA, so disability continues.

D. Sample rationale – medical improvement (MI) occurred, not severe - cessation

The following reports were used at the comparison point decision (CPD) of 05/12/2015 to determine disability:

  • Hudson Memorial Hospital, report of admission of 08/10/2014 to 09/6/2014 and outpatient records covering 10/03/2014 to 01/17/2015; and

  • John Masters, M.D., report of 02/05/2015.

The following reports were used to determine whether disability continues:

  • Daniel Jones, M.D., report dated 02/24/2018;

  • Thomas Doucette, M.D., report dated 03/27/2018; and

  • Albert Cohen, M.D., Orthopedic Surgeon, consultative exam of 04/02/2018.

The individual was found to be disabled beginning 08/10/2014 because of a fractured left femur with slow healing. At the CPD, the individual was unable to walk without crutches and x-rays did not show the expected amount of healing. The impairment met the requirements of Listing 1.06. Current evaluation is necessary since medical improvement is expected. He indicates that he is still unable to perform work activity due to a left leg problem. He has not engaged in any substantial gainful activity (SGA) since onset.

Current medical evidence reveals that the disabled individual had full weight-bearing status at an examination in February 2018. X-rays interpreted at that time revealed that the fracture was well-healed. A consultative orthopedic evaluation was secured since a current physical exam and range of motion data were needed. The consulting orthopedic surgeon reported that the individual had good range of motion of both lower extremities. He walked with a normal gait and experienced no difficulty getting on and off the examining table. His impairment does not meet or equal listing severity.

His impairment has decreased in severity since he is fully weight-bearing and an x-ray shows solid union; therefore, medical improvement has occurred. Since the individual met a listing at the CPD but currently no longer meets that listing, the medical improvement is related to the ability to work. Although he alleges a left leg problem, his current impairment is not severe as he now has good range of motion of both lower extremities and no significant restrictions on standing, walking, lifting or other work activities.

As medical improvement has occurred and the individual is able to engage in SGA, disability ceases as of 04/02/2018 and benefits will terminate 06/30/2018.

E. Sample rationale - medical improvement (MI) occurred - cessation

The following reports were used on 08/15/2015, the date of the comparison point decision (CPD), to determine disability:

  • Oak Ridge Hospital, reports covering admissions of 08/24/2014 to 09/15/2014 and 05/30/2015 to 06/17/2015;

  • Marvin Henry, M.D., report of 07/10/2015; and

  • Keven R. Connolly, O.D., report of 07/12/2015.

The following reports were used to determine if disability continues:

  • University Hospital, reports covering admission of 10/07/2018 to 10/20/2018;

  • Michael Wilson, M.D., report of 02/28/2019;

  • Marvin Henry, M.D., report of 03/04/2019; and

  • Keven R. Connolly, O.D., report of 03/10/2019.

The individual has been disabled since 08/24/2014. Her impairment met Listing 1.04C. as a result of a back injury with spinal stenosis. A physical exam at the time of the CPD showed the individual had markedly decreased range of motion of the spine. Muscle spasm was present. There was L5 motor weakness and hypothesia to pin prick. She was unable to heel or toe walk. Current evaluation is necessary since medical improvement was expected. The individual states she is still unable to work because of back and right leg pain. She has not worked since onset.

In October 2018, a myelogram revealed an L4-5 extradural defect. The individual underwent a right L4-5 laminectomy and excision of the nucleus pulposus. Current evidence shows that the back impairment has decreased in severity. Office notes show that her symptoms improved although she continued to experience periodic back and right foot pain. She has good range of motion of her lumbosacral spine with 80 degree forward flexion and normal lateral bending. Motor exam reveals normal mass and tone. Deep tendon reflexes and sensation are normal. She is able to heel and toe walk normally. An x-ray shows evidence of a past laminectomy and degenerative arthritis. Therefore, medical improvement has occurred. Since the individual met a listing at CPD and now no longer meets or equals that listing, the medical improvement is related to the ability to work. Current medical findings do not establish an impairment that produces pain of such severity as to preclude the individual from engaging in any gainful work. Therefore, disability is ceased as of March 2019 and benefits will be terminated on 05/31/2019.

F. Sample rationale - medical improvement (MI) occurred, can perform past work - cessation

The following reports were used in the comparison point decision (CPD) of 12/10/2015 to determine disability:

  • Concord Hospital, inpatient records from 06/22/2014 to 07/04/2014 and 08/17/2015 to 08/31/2015;

  • Cliff Adams, M.D., report of 09/01/2015; and

  • Frederick Thompson, M.D., Cardiologist, consultative examination of 09/13/2015.

The following reports were used to determine if disability continues:

  • Concord Hospital, inpatient records from 04/04/2018 to 04/15/2018;

  • Cliff Adams, M.D., report dated 06/09/2018; and

  • Elsie Friehold, M.D., Cardiologist, report dated 04/15/2018.

This individual was found to be disabled beginning 06/22/2014 because of coronary artery disease. At the time of the CPD, medical evidence indicates the individual underwent cardiac bypass surgery in June 2014. Although she initially progressed well, she subsequently began to complain of chest pain and shortness of breath. She underwent a second bypass surgery in August 2015. The impairment equaled Listing 4.04C.

The individual has completed a 9-month trial work period. She continues to work as a telephone solicitor with earnings indicative of substantial gainful activity (SGA). Benefits have been stopped on 11/13/2018 as indicated on SSA-833. She feels she still has a severe heart condition which limits activity. A current medical decision is needed to determine impairment severity and thus, entitlement for an extended period of eligibility (EPE).

She has coronary artery disease and ischemic heart disease. Current examination revealed normal heart sounds with only occasional premature ventricular contractions. The individual experiences chest pain infrequently and only with heavy exertion. The pain is relieved with nitroglycerin or rest. The second bypass (August 2015) improved circulation to the heart and symptoms have decreased. The treating physician stated that the patient would not be able to return to work activity. The treating cardiologist hospitalized the individual in April 2018 for chest pain. The individual performed a stress test which was negative at 5 METS and showed abnormalities at 7 METS. A chest x-ray revealed only mild cardiomegaly. The treating cardiologist assessed that because of the individual's history of heart disorder, she should avoid lifting in excess of 20 pounds.

The evidence does not show current findings that meet or equal the listed impairments; therefore, MI has occurred. Since the impairment no longer meets or equals the listings, the MI is related to the ability to work.

The record reveals the individual continues to have a severe cardiovascular impairment which limits her ability to perform basic work activities. There is a current capacity to lift a maximum of 20 pounds occasionally and 10 pounds frequently.

Although the individual's treating physician stated she would not be able to return to work activity, this issue is reserved for the Commissioner. The weight given such statements depends upon the extent to which they are supported by specific and complete clinical findings and are consistent with other evidence in the individual's case. The clinical findings and other evidence do not support the conclusion that the individual is disabled from any gainful work.

Since MI has been demonstrated by a decrease in medical severity related to the ability to work and since the individual is able to engage in SGA, disability ceased in 04/2018 and benefits are terminated as of 06/30/2018.

 

G. Sample rationale - medical improvement (MI) occurred, cannot perform past/other work - continuance

The following report was used at the comparison point decision (CPD) of 10/19/2014 to determine disability:

  • Joseph Anderson, M.D., report of 07/05/2014.

The following reports were used to determine whether disability continues:

  • St. John's Hospital, reports covering admission of 04/8/2018 to 04/17/2018;

  • Joseph Anderson, M.D., report dated 2/9/18; and

  • Janice Urban, M.D., Cardiologist, report of 05/25/2018.

The individual was found to be disabled beginning 05/17/2014 because of coronary artery disease and thrombophlebitis. The individual had severe inflammation of the leg veins which was persistent despite treatment. The individual had chest pain with exertion. The impairment limited the individual to the performance of sedentary work and Vocational Rule 201.10 directed a finding of disabled. New medical evidence is needed because medical improvement is considered possible. The individual alleges that he is still disabled due to a heart condition. He has not performed substantial gainful activity (SGA) since 05/17/2014, his date of onset.

Current medical evidence from the individual's treating cardiologist indicates that the individual underwent cardiac bypass surgery in April 2018. Examination revealed normal heart sounds with only occasional premature ventricular contractions. There are infrequent episodes of angina. The treating cardiologist reported in May 2018 that the individual performed a stress test to 7 METS with no angina. A chest x-ray revealed only mild cardiomegaly. The individual has a history of thrombophlebitis, but the lower extremities show no abnormalities. The medical findings do not document an impairment that meets or equals the listings.

The evidence shows a decrease in the medical severity of his impairment; therefore, medical improvement has occurred. Based on the individual's current impairment, he has the capacity to lift 20 pounds occasionally and 10 pounds frequently with no further restrictions. Therefore, the medical improvement is related to the ability to work.

The individual is 58 years old and has 10 years of education. He has 5 years of relevant work history as a nurse's aide which is a medium, semiskilled job. Since the individual is limited to light work, he would be unable to perform his past work due to the exertional demands involved. His skills are not transferable to jobs of a light or sedentary type of work. The individual satisfies the criteria for Vocational Rule 202.02, which directs a decision of disabled. Since the individual does not have the ability to do SGA, even though MI has occurred, disability is found to continue.

 

H. Sample rationale - medical improvement (MI) occurred, can do other work - cessation

The following evidence was used at the comparison point decision (CPD) of 06/12/2014 to determine disability:

  • St. John's Hospital, inpatient 02/06/2014 to 03/01/2014;

  • Lakeside Rehabilitation Center, outpatient 03/01/2014 to 03/27/2014; and

  • Claude Arakari, M.D., report of 04/01/2014.

The following reports were used to determine whether disability continues:

  • Lakeside Rehabilitation Center, outpatient 04/05/2017 to 08/21/2017;

  • Robert Franklin, M.D., report dated 02/08/2018; and

  • Samuel Glassner, M.D., Orthopedist, consultative examination of 03/01/2018.

The individual has been disabled since 02/06/2014 because of musculoskeletal injuries sustained in a motorcycle accident. He was able to ambulate for only short distances due to his right knee impairment. X-rays of his right knee showed incomplete healing. He was found to be limited to sedentary work and Vocational Rule 201.09 directed a finding of disabled. He has not worked since his established onset date. The individual alleges he remains unable to return to any work activity because he still has knee pain. Current evaluation is needed because medical improvement was expected.

Currently, the treating physician reported that he continued treating the individual for complaints of pain to the lower extremities. He states that he treated the individual with medication and advised him to exercise. X-rays taken at the examination on 02/08/2018 revealed only spurring in the right knee in addition to old healed fractures. A consultative examination was arranged to obtain a physical exam and range of motion. Evidence from the consulting orthopedist dated 03/01/2018 reveals the individual continues to walk with an abnormal gait. Flexion of the right knee is limited to 120 degrees. The left knee can be fully flexed. Range of motion of the hips and ankles is normal. The impairment does not meet or equal the requirements of the Listings.

Therefore, medical improvement has occurred as there is a decrease in medical severity. He now has the ability to stand and walk 6 out of 8 hours and to lift 20 pounds occasionally and 10 pounds frequently, which is a wide range of light work. The medical improvement that has occurred is related to his ability to work, since he could only do sedentary work activity at the CPD.

Although the individual alleges pain in the right knee, the fracture is well-healed with minimal spurring and mild limitation of motion. He is restricted to light work but the clinical findings do not establish an impairment that produces pain of such severity as to prevent the individual from performing any substantial gainful activity (SGA).

The disabled individual is 53 years old, has a limited education, and has a 20-year work history as a general laborer in a foundry which is unskilled work involving heavy lifting and carrying. Since the individual is limited to light work, he would be unable to perform his past work due to the exertional demands involved. The special medical-vocational characteristics pertaining to those cases involving arduous, unskilled work or no work are not present. The facts in this case correspond exactly with the criteria of Vocational Rule 202.10 which directs a finding of not disabled. Since there is medical improvement and the individual has the ability to do SGA, disability is ceased in 03/2018 and benefits will be terminated as of 05/31/2018.

I. Sample rationale - medical improvement (MI) occurred, multiple not severe impairments combined effect is severe, but one impairment is a subsequent impairment, can perform other work - cessation

The following reports were used at the comparison point decision (CPD) of 04/13/2015 to determine disability:

  • Meadeville Medical Center, inpatient treatment of 11/12/2014 to 11/21/2014; outpatient treatment of 10/19/2014 and 12/02/2014; and

  • Alexander Doone, M.D., report of 01/17/2015.

The following reports were used to determine if disability continues:

  • Renee Legere, M.D., report of 02/28/2019;

  • Alexander Doone, M.D., report of 03/10/2019; and

  • Consultative examination, John R. Smith, M.D., Internist, 03/26/2019.

The individual has been under a disability since 10/19/2014 due to rheumatic heart disease with mitral stenosis and peptic ulcer which led to an allowance in the framework of Vocational Rule 201.10. Currently the case is being evaluated as medical improvement is possible. The individual believes he is still disabled because of his heart condition plus recent pulmonary disease. He attempted working a few years ago but had to stop after three weeks. There is no substantial gainful activity (SGA) issue.

Current medical evidence reveals a history of rheumatic heart disease that required hospitalization for congestive heart failure. According to his physician, this impairment has responded to treatment. Currently there is no chest pain and no evidence of pulmonary or peripheral edema. There are no symptoms related to peptic ulcer disease since his diet has been adjusted. Recently, shortness of breath has been increasing. He had been smoking two packs of cigarettes per day for 20 years, but has stopped because of respiratory problems. A consultative examination dated 03/26/2019 was performed for evaluation of his respiratory impairment with pulmonary function studies (PFS).

On physical examination, height was 69" and weight was 180 pounds. Breath sounds were diminished with prolonged expiration and an expiratory wheeze. The chest was otherwise clear. On examination of the heart, a diastolic rumble at the apex was noted. An ECG showed a prominent wide P-wave suggestive of left atrial enlargement, which was confirmed on the chest x-ray. The heart size otherwise was within normal limits. The lung fields were hyperaerated and diaphragms were somewhat flattened. PFS done by the consultant revealed post-bronchodilator FEV1 was 1.9 liters and MVV 76 liters per minute.

Current medical findings do not meet or equal the findings described in any listed impairment. There is no current evidence of congestive heart failure and no active peptic ulcer disease. This individual's impairment shows medical improvement as there is a decrease in the medical severity of impairments present at the CPD. At that time the residual functional capacity (RFC) was for light work activity. The current RFC, considering only the rheumatic heart disease and peptic ulcer disease, shows full capacity to do all work activities and these impairments are now not severe. Therefore, medical improvement is related to the ability to do work.

Although the heart and digestive impairments are not severe when considered alone, considering their effect on the ability to perform work activities in combination with a respiratory impairment, the individual would be restricted to lifting up to 50 pounds occasionally and 25 pounds frequently. The individual now has the capacity to perform a full range of medium work. He cannot perform his prior work as baker helper (heavy, unskilled work). It involved much lifting of things, such as bags of flour (up to 100 pounds), racks of baked items, and piles of unfolded boxes. Although his most recent work was arduous and unskilled, it lasted only 17 years and he previously did semiskilled work. Therefore, the special medical-vocational characteristics pertaining to arduous, unskilled work, or no work, are not present. He is of advanced age (56) with limited education (grade 6) and meets Vocational Rule 203.11, which indicates the ability to do SGA. Since there is medical improvement demonstrated by decreased medical severity, it is related to the ability to work. Because the individual has the ability to do SGA, disability is ceased as of 03/2019. Benefits will be terminated 05/31/2019.

J. Sample rationale - medical improvement (MI) occurred, the vocational exception also applies, can perform other work - cessation

In making the determination on the issue of continuing disability, all of the evidence listed on the decision dated 12/31/2014 has been considered, as well as the following additional evidence:

  • Vocational Rehabilitation Counselor, Department of Vocational Rehabilitation, reports covering 03/10/2017 to 03/15/2018;

  • T. Weston, M.D., report dated 04/19/2018;

  • L. Lehman, M.D., report dated 04/21/2018; and

  • G. Robertson, M.D., report dated 05/01/2018.

The individual was allowed disability benefits from 06/07/2014 because of injuries received in a motorcycle accident. At the time of the CPD, he had a traumatic left above the knee amputation with persistent stump complications, inability to use a prosthesis, and a right recurrent shoulder dislocation. The impairment was found to meet Listing 1.05B. A current evaluation is necessary as medical improvement was expected. The individual states he is still disabled because of a left above the knee amputation and difficulty walking with his prosthesis. He has not worked since the onset date.

The medical evidence reveals that following his left above the knee amputation in 06/14 the individual experienced persistent pain and tenderness about the stump. He underwent three stump revisions. The most recent revision was 12/2014 for excision of a bony spur and painful scar. Office notes from the individual's treating physician show that following the latest stump revision, the individual was able to wear his prosthesis over an extended period of time without much discomfort. Recent examination of the stump revealed no neuromatous changes or other abnormalities. An x-ray did not demonstrate any bony spurs or complications. Furthermore, the individual has had no recent problems with right shoulder dislocation. He had full range of motion of his shoulder without pain or instability. The individual no longer has an impairment that meets or equals the level of severity described in the Listings.

Therefore, medical improvement has occurred. Although he alleges difficulty walking with his prosthesis, the individual has the residual functional capacity to stand and walk for 2 hours and to sit for six hours with no further restrictions. Since his current condition no longer meets or equals Listing 1.05B, his medical improvement is related to the ability to work.

The individual received evaluation and counseling through the Department of Vocational Rehabilitation. He obtained funds to attend a 2-year program at Central University. In December 2017 he received an associate degree in computer science. The combination of education and counseling constitute vocational therapy.

The individual has a severe impairment that limits him to the performance of sedentary work. The individual is 30 years old with 16 years of education. He has 4 years of relevant work experience as a painter. This job involved standing and walking at least 6 out of 8 hours. The individual is unable to perform his past work because of limitations on standing and walking. The special medical-vocational characteristics pertaining to arduous, unskilled work or no work are not present. Additionally, his ability to perform sedentary work has been enhanced by vocational therapy; therefore, the vocational therapy exception applies. The individual meets Vocational Rule 201.28 which directs a decision of not disabled. Medical improvement is established, the vocational therapy exception applies, and the individual is able to engage in substantial gainful activity (SGA). Therefore, the individual is no longer disabled and benefits are ceased as of May 2018 and benefits are terminated as of July 31, 2018.

K. Sample rationale - No medical improvement (MI), but error exception applies, cannot perform past or other work - continuance

In making the determination of continuing disability, all the evidence cited in the comparison point decision (CPD) of 02/23/2015 has been considered, as well as the following:

  • Ervin Medical Center, outpatient treatment 12/07/2018, 12/19/2018, and 04 /12/2019;

  • Commonwealth Hospital, outpatient report of 09/23/2018;

  • Georgia Ebenezer, M.D., report of 03/02/2019;

  • William A. Bell, M.D., office notes from 01/03/2014 to 03/01/2018; and

  • Edward Burgin, M.D., report of 03/17/2019.

The individual has been under a disability since 07/29/2014 because of ischemic heart disease which met Listing 4.04C. based on the angiogram done 12/07/2014. A narrative report of the results of a treadmill exercise test done 10/12/2014 were negative at 7 METS when it was stopped due to fatigue. Actual tracings were not obtained. Cardiac bypass surgery was considered but was not done due to obesity (197 pounds). Current evaluation is needed as medical improvement is possible. The individual says she is still as bad off as she was when she applied and she still gets bad chest pain. She also has arthritis in her hands. There is no substantial gainful activity (SGA) issue.

Current medical evidence shows that the individual continues to have crushing chest pain on exertion, such as lifting her grandson, which stops with rest or medication. Her doctor has told her to avoid strenuous activity. When she limits exercise, she rarely has angina. She has stiffness in her finger joints and a 12/19/2018 x-ray shows degenerative arthritis of her hands and wrists, greater than normal for her age. There is also evidence of an old healed fracture of her left wrist, which is her dominant hand. Limitation of motion is noted in the left wrist and thumb. Her blood pressure is 110/70 and heart sounds are normal. There is infrequent angina for which nitroglycerin has been prescribed. Current weight is 165 pounds and height is 67-1/2 inches. She still does not want to risk surgery. Further weight reduction is planned. A treadmill exercise test done 09/23/2018 was stopped due to chest discomfort at 7 METS with no ECG abnormalities present as described in the listings.

There is no evidence of decreased medical severity in relation to the individual's cardiac impairment. Therefore, no medical improvement has been demonstrated. The evidence now shows that a treadmill exercise test, done around the time of the initial allowance but not obtained then and not considered in making that decision, was negative at 7 METS. Had the test been considered at the time of the initial decision, the case would not have met the listing since the treadmill results have precedence over the angiogram. There would have been an residual functional capacity (RFC) light work. The individual's past relevant work involved mounting tissue specimens on glass plates, doing blood and urine tests, keeping laboratory test tubes and other equipment clean and in order, and other duties, a job classified as light work in the Dictionary of Occupational Titles (DOT). Therefore, a denial based on the ability to perform her past work as a medical-laboratory assistant would have been the appropriate decision. If the treadmill results had been considered at the time of the prior determination, disability would not have been found. Therefore, the error exception applies.

Currently there is an additional impairment, arthritis of the hands, which was not present at the CPD. Current RFC permits lifting 20 pounds occasionally and 10 pounds frequently based on the cardiac impairment. However, because of the limitation of the use of the left wrist and the dominant left hand, constant handling would be precluded. The current impairments are severe and restrict the individual to light work with additional non-exertional restrictions. Since constant handling was an integral part of her past work as a medical-laboratory assistant, she could not perform this work now.

The individual is 56 years old. She is a high school graduate with a background of skilled work. She no longer has full use of her hands required in her type of work and thus has no transferable skills. The framework of Vocational Rule 202.06 and 201.06 indicates she is not able to do SGA. Therefore, although the error exception applies for the time of the CPD, the individual currently has a new impairment which limits her ability to work. Therefore, disability is found to continue because the individual is not able to do SGA.

 

 

L. Sample rationale - Unable to determine if medical improvement (MI) occurred, folder lost - continuance

The following reports were used to determine if disability continues:

  • Wharton Hospital, outpatient 05/12/2018 to 01/05/2019;

  • Fred Josephs, M.D., report of 02/20/2018; and

  • Consultative examination, Constance A. Binns, M.D., Otologist, report dated 02/28/2018.

The prior folder cannot be located. The available evidence (via query) indicates the claim was allowed as equaling a listing with an onset of 09/06/2014. Current evaluation is necessary because the diary date has been reached and indicates medical improvement was considered possible. The individual states that he continues to be disabled due to his heart condition. He also has some trouble hearing. He has not worked since he first became disabled. It is unclear whether a decision has been made since then. He remembers going for an examination set up by the DDS which he thinks was more recent than 2014.

Medical evidence reveals a history of a myocardial infarction 09/06/2014 and cardiac arrhythmia which was due to digitalis. His medication was changed and his heart symptoms decreased. A treadmill exercise test done 05/12/2015 was positive at 10 METS according to the cover sheet describing the results of the test. The tracings are not available. The individual no longer has any chest pain. A consultative examination was arranged to evaluate the severity of his hearing impairment. He has a 40 decibel loss in the right ear and 60 decibel loss in the left ear. A hearing aid was recommended. The individual's impairments do not meet or equal any listed impairment.

A current assessment of functional capacity shows the ability to lift up to 20 pounds occasionally and 10 pounds frequently with no limit on walking and standing. He should not work in a very noisy atmosphere or in a job that requires hearing perfectly. Since the individual's past relevant work was accounting, a sedentary skilled job, he would be able to perform this past work. Therefore, he is currently able to engage in substantial gainful activity (SGA) and reconstruction of the prior folder is required if the date of the comparison point decision (CPD) can be established. Attempts to reconstruct prior medical evidence have not been made because the CPD date is not clear. Therefore, neither medical improvement nor any of the exceptions to medical improvement have been demonstrated and disability must be continued.

 

M. Sample rationale - No medical improvement (MI) or exception - continuance

The following reports were used at the comparison point decision (CPD) of 12/22/2015 to determine disability:

  • St. Anthony Hospital, inpatient treatment 06/14/2015 to 06/27/2015; outpatient treatment 07/15/2015 to 10/16/2015; and

  • James Gregory, M.D., report dated 11/02/2015.

The following reports were used to decide whether disability continues:

  • St. Anthony Hospital, inpatient treatment 09/13/2018 to 09/19/2018 and 09/27/2018 to 10/14/2018;

  • Vincent Moberg, M.D., Cardiologist report dated 03/05/2019; and

  • James Gregory, M.D., reports dated 02/19/2019 and 03/15/2019.

The individual has been disabled since 06/14/2015 because of coronary artery disease. He had angina and an abnormal treadmill exercise test positive at 6 METS. A medical-vocational allowance was made because of a residual functional capacity (RFC) for light work. He has not engaged in substantial gainful activity (SGA) since onset. Current review is necessary since medical improvement was expected. The individual states he continues to be unable to work because of a bad heart.

Current medical records reveal that the individual was hospitalized on 09/13/2018 with complaints of chest pain and shortness of breath. He was treated conservatively and released on 09/19/2018 but again hospitalized on 09/27/2018 to undergo further evaluation. At that time, angiography revealed significant blockage of the left anterior descending artery and the right coronary artery. The individual underwent cardiac bypass surgery and although his recovery was uneventful, he continued to complain of chest pain and shortness of breath with any exertion. An electrocardiogram was interpreted as abnormal and an echocardiogram showed a decreased ejection fraction. The treating cardiologist indicated that further surgery was not anticipated and the individual would continue to be treated with conservative therapy including medication, rest, and an exercise program. The cardiologist indicated the individual would be limited in his ability to perform any strenuous activities because of the continued chest pain, shortness of breath, and easy fatigability. The cardiologist noted the possibility of further cardiac damage.

The individual's coronary artery disease does not meet or equal the requirements of the Listings. The medical record reveals that the individual has coronary artery disease for which he has undergone surgical procedure. In spite of surgery, he has shortness of breath, chest pain on exertion, and easy fatigability. He has not had a treadmill exercise test since then because of his chest pain post-surgery. The individual has not had a decrease in severity of his coronary artery disease as evidenced by the medical findings. Medical improvement has not occurred and no exception to MI applies; therefore, disability continues.

 

N. Sample rationale - No medical improvement (MI) or exception - continuance

  1. 1. 

    The following reports were used at the comparison point decision (CPD) of 04/22/2015 to determine disability:

  • Veterans Administration Hospital, admissions of 06/14/2014 to 06/22/2014 and 10/27/2014 to 11/05/2014; and

  • Herbert Roberts, M.D. report of 12/15/2014.

The following reports were used to determine whether disability continues:

  • Veterans Administration Hospital, admission of 02/25/2018 to 03/03/2018 and outpatient records covering 01/21/2016 to 03/17/2018;

  • John Albrecht, M.D., report of 03/27/2018; and

  • George Baylis, M.D., report of 04/02/2018.

The individual was initially determined to be disabled from 06/14/2014 because of uncontrollable diabetes, peripheral neuropathy, and decreased vision. He had diabetic neuropathy with mild sensory changes of his legs and feet. The left eye had a cataract with decreased vision to 20/100 best correction. The right eye had normal vision. His impairment was considered to be equivalent to Listing 9.08. Current medical evidence was obtained as medical improvement was possible. The individual alleges that he is still disabled because of “sugar diabetes, pins and needles in his legs, and cataracts.” He has not worked since onset.

Current medical reports show that the individual's diabetes has not been well controlled by diet and insulin. He had a hospitalization in 02/2018 to assist with control of his diabetes. Subsequent office visits revealed some elevated blood sugars. The individual has never had hypoglycemic reaction or acidosis. An ECG and chest x-ray were normal. Eye grounds exam showed no retinopathy. Visual exam revealed the presence of a cataract in the left eye. Best corrected visual acuities were 20/100 OS and 20/25 OD. The individual had good peripheral pulses throughout. However, exam indicated that there was bilateral hypalgesia to pinprick and diminished vibratory sense in both lower extremities. Deep tendon reflexes (DTRs) were diminished bilaterally at the ankles. The individual was ambulatory with a normal gait. The individual does not have an impairment or combination of impairments that meets or equals the Listings.

There has been no change in the medical findings to show medical improvement. Since medical improvement has not occurred, and none of the exceptions to MI applies, disability continues.

 

O. Sample rationale - Medical improvement (MI) is not related to the ability to do work, but vocational therapy exception applies, can perform other work - cessation

The following reports were used at the comparison point decision (CPD) of 09/25/2015 to determine disability:

  • Mark Green, Jr., M.D., report of 10/02/2014 and

  • Washington Community Hospital, inpatient 08/03/2014 to 09 /04/2014.

The following reports were used to determine whether disability continues:

  • Washington Community Hospital, inpatient 09/13/2018 to 09/23/2018;

  • Vocational Rehabilitation Counselor, Department of Rehabilitation Services, report of 12/17/2018;

  • William Jacobs, M.D., report of 02/27/2019; and

  • Howard Goodman, M.D., Orthopedist, consultative exam of 03/11/2019.

The individual was found to be disabled beginning 08/03/2014 due to a crush injury with fracture of his left ankle. After discharge from the hospital, the individual followed up with his treating physician. He continued to have pain and numbness in his left foot. He was restricted to the performance of light work and thereby met the requirements of Vocational Rule 202.06, which directed a decision of disabled. Current medical evidence was obtained because medical improvement was expected. The individual states that he continues to be disabled because of left ankle pain and difficulty standing and walking. He has not worked since onset of his disability.

Recent medical information from the individual's physician shows that an ankle fusion was done in 09/2018 to provide a stable joint and to permit weight bearing. Currently, he is fully weight bearing, but walks with a prominent limp. In order to further document severity and obtain a current x-ray, the individual was examined by a consulting orthopedic physician. Clinical examination of the left ankle revealed some thickening of the heel but the fusion was stable. Ankle movements are limited to 10 degrees dorsiflexion and 20 degrees plantar-flexion. An x-ray was consistent with a healed subtalar arthrodesis and moderate traumatic degenerative changes. Neurological evaluation revealed an absent left ankle jerk and inability to walk on heels and toes. There was decreased sensation over the lateral and dorsal aspects of the left foot and decreased strength of the left extensor hallucis longus.

The individual's impairments do not meet or equal the level of severity described in the Listings. An x-ray shows that arthritis has developed at the fracture site. The individual continues to experience left ankle pain. Further, he has an abnormal gait and limitation of motion of his left ankle. However, since the ankle fusion the individual has been full weight-bearing, which is medical improvement since the CPD. His left ankle impairment continues to restrict his ability to stand and walk to 6 hours during an 8-hour day. The individual remains limited to the performance of a wide range of light work, lifting 20 pounds occasionally and 10 pounds frequently. This residual functional capacity (RFC) is the same as that at the CPD. Therefore, medical improvement is not related to his ability to work.

Since the CPD, the individual underwent vocational counseling through the Department of Rehabilitation Services and enrolled in an 18-month training program on small appliance repair. He completed the course on 11/30/2018 after working on appliances such as radios, electrical tools and a variety of small household appliances.

The recent completion of this specialized training course in conjunction with counseling constitutes vocational therapy. This therapy has enhanced the individual's ability to perform work since he has acquired a skill that provides for direct entry into light work.

Although the individual continues to experience left ankle pain, he is fully weight-bearing and is able to perform light work. The clinical findings do not establish an impairment that results in pain of such severity as to preclude him from engaging in any substantial gainful activity.

The individual has a severe impairment that restricts him to light work. He is 57 years old with 12 years of education. He has 6 years of relevant work experience as a truck driver that is a medium semiskilled job. The individual is unable to perform work as a truck driver because of the exertional demands of the job and there are no transferable skills. The special medical-vocational characteristics pertaining to arduous, unskilled work or no work are not present. However, as a result of vocational therapy since the CPD, the individual has obtained job skills which are useful in the performance of light work. Therefore, he meets Vocational Rule 202.08 which directs a decision of not disabled. He can do such occupations as an Electrical-Appliance Repairer (DOT 723.381-010), a Radio Repairer (DOT 720.281-010) or as an Electrical Tool Repairer (DOT 729.281-022), all skilled light work in the electrical equipment industry. According to the Labor Market Trends Bulletin and the Virginia Department of Labor and Industry, over 30,000 individuals are employed in the electrical equipment industry in Virginia; and the cited occupations are well represented throughout that industry. It can be inferred that the occupations exist as individual jobs in significant numbers in the region where the individual lives and throughout the national economy.

While there has been no medical improvement related to the ability to work in the individual's impairment, the vocational therapy exception to medical improvement applies and the individual is able to engage in SGA. Therefore, the individual is no longer disabled as of 11/30/2018 and benefits are terminated as of 01/31/2019.

P. Sample rationale - No medical improvement (MI) or exception, unchanged medical findings - continuance

The following reports were used at the comparison point decision (CPD) of 07/18/2015 to determine disability:

  • George Washington Hospital, admission of 10/22/2014 to 10/27/2014;

  • Nicholas Lawrence, M.D., report of 11/29/2014; and

  • John Webster, M.D., Cardiologist, consultative exam of 12/12/2014.

The following reports were considered to determine whether disability continues:

  • Nicholas Lawrence, M.D., report of 02/13/2018;

  • Paul Bush, M.D., report of 02/15/2018;

  • Richard Wilson, M.D., report of 02/21/2018; and

  • Bernard Parker, M.D., Vascular Surgeon, consultative exam of 03/10/2018.

The individual was previously determined to be disabled beginning 10/22/2014 by peripheral vascular disease, hypertension, and obesity. The individual had a recent history of vein ligation and stripping on the left leg. Physical findings revealed a weight of 214 pounds and a blood pressure of 180/118. There was induration and edema of the right leg and recently healed stasis ulcers. The combination of impairments was determined to be equivalent to the severity reflected in Listing 11.14. Current evaluation is necessary because medical improvement was possible. The individual reports that she is still disabled because of poor circulation of blood in her legs and high blood pressure. She has not engaged in substantial gainful activity (SGA) since she became disabled.

The individual's treating physician reported that the individual continues to be overweight (232 pounds) despite adherence to a strict diet and continues to complain of left leg swelling with necessity for using an elastic stocking. A consultative exam was obtained for specific findings regarding any peripheral vascular disease. The physical exam was remarkable for weight of 232 pounds, height of 5 feet 4 inches, and blood pressure of 190/110 with an appropriate size cuff. A chest x-ray showed the heart to be at the upper limits of normal size but otherwise unremarkable. An ECG showed left axis deviation. The left leg showed evidence of prior surgery and pigmentary changes from venous stasis. There were scars over the right ankle compatible with old healed ulcers.

A comparison with present findings show that the individual's weight has increased 18 pounds, her diastolic blood pressure remains elevated to excess of 100, and there is still evidence of vascular disease.

The current physical findings do not demonstrate a decrease in severity of the impairments from those at the CPD; therefore, medical improvement has not occurred. Exceptions to medical improvement have been considered and do not apply in this case. The individual continues to be disabled.

 

Q. Sample rationale -- No medical improvement (MI), not severe impairment(s), but error exception applies - cessation

The following reports were used at the comparison point decision (CPD) of 04/26/2015 to determine disability:

  • Thomas Noonan, M.D., report of 11/25/2014; and

  • University Hospital, admission of 10/22/2014 to 10/27/2014; and outpatient report of 12/20/2014 - received after CPD as trailer mail.

The following reports were used to decide whether disability continues:

  • Charles Miller, M.D., report of 03/15/2018 and

  • David Morehead, M.D., Internist Pulmonary consultative exam of 04/02/2018.

The individual was initially allowed disability benefits effective 10/22/2014 because of chronic obstructive pulmonary disease and asthma. At the CPD, she was receiving treatment from her treating physician for asthma and COPD. In October 2014 she was hospitalized for an asthma attack. Pulmonary Function Studies (PFS) were done during the hospitalization. Based on the results of the PFS, she was restricted to light work, which resulted in an allowance. Current findings were obtained because medical improvement is possible. The individual alleges that she is still unable to work because of emphysema and has not worked since her onset.

Re-review of the October 2014 records demonstrates that PFS were done while the individual was in an acute phase of asthma. Wheezes and rales were noted but no bronchodilator was administered prior to testing. Documentation guidelines in effect at the CPD prohibit the use of PFS performed in the presence of bronchospasm. Outpatient records of 12/20/2014 sent after the CPD as trailer mail reveal that PFS were repeated. These studies show an FEV1 of 1.9 and MVV of 84. Medical improvement has not occurred. However, the error exception applies since the individual was allowed using PFS performed in the presence of bronchospasm without the administration of bronchodilators. Additional evidence that relates to the CPD shows that if that 12/20/2014 evidence had been considered in making the CPD, disability would not have been established.

 

Currently, a report from the individual's treating physician states that the individual has chronic obstructive pulmonary disease and complains of shortness of breath. She also has been diagnosed with asthma, allergic sinusitis, and hay fever. These conditions are controlled with medications. A consultative exam was scheduled 04/02/2018 to obtain a current physical exam and PFS. A chest x-ray revealed mild chronic obstructive pulmonary disease. PFS showed FEV1 of 1.7 and MVV of 75. A physical exam showed a height of 5 feet 2 inches and weight of 120 pounds. There were decreased breath sounds; otherwise, the chest was clear to percussion and ausculation. The impairment does not meet or equal the level of severity described in the Listings.

The individual does not have any restrictions on standing, walking, or lifting due to her breathing impairment. Her impairment is not severe. Therefore, the individual retains the capacity to do SGA.

The error exception of the medical improvement review standard (MIRS) applies, and the individual has the ability to perform SGA. Disability ceases April 2, 2018 and benefits will terminate as of June 30, 2018.

 

 

R. Sample rationale - Failure to cooperate - cessation

The following reports were used at the comparison point decision (CPD) of 08/07/2014 to determine disability:

  • Wadsworth Memorial Hospital, inpatient treatment 05/21/2014 to 06/12/2014; and

  • Gene Keller, M.D., report of 07/12/2014.

  • The following evidence was used to determine if disability continues:

  • Wadsworth Memorial Hospital, outpatient treatment 08/18/2017 to 12/08/2017.

The individual has been under a disability since 05/21/2014 due to histiocytic lymphoma of the ileum with metastasis that equaled the Listings. Current evaluation is needed as medical improvement is possible. There has been no work since onset. The individual says he is still disabled because of stomach problems. He had chemotherapy and radiation therapy after his operation. Because he has ulcers, he must avoid certain foods.

The only current treatment source given by the individual was Wadsworth Memorial Hospital. The Oncology Clinic notes indicate he had completed chemotherapy. He was last seen 12/08/2017 at which time he was progressing satisfactorily. He weighed 170 with height of 6 feet. Lymph nodes were shotty and the liver was enlarged. Since no current medical evidence was available, a consultative examination (CE) was scheduled for 02/10/2018.

The individual failed to keep the CE. He was contacted and another appointment was scheduled which he again failed to keep. On 03/01/2018, the Field Office made contact with the individual. The FO explained the need for current medical evidence and for his cooperation in going for a CE. There was no indication of any mental impairment or other condition that would make him unable to cooperate. Since he again agreed to keep a CE, DDS scheduled another appointment for 03/18/2018. The individual did not keep the CE and the DDS was unable to contact him by telephone. On 03/18/2018 DDS sent to the individual written notice that failure to cooperate could result in termination. He did not respond.

There is no current medical evidence available to determine if medical improvement has occurred. The individual has repeatedly failed to cooperate in efforts to obtain current medical evidence. Therefore, since there is failure to cooperate, which is a group II exception to medical improvement, disability is ceased 03/01/2018. This month is when the individual was first notified that failure to cooperate could result in termination of benefits. Disability benefits will terminate 05/31/2018.

S. Sample rationale - MINE case - continuance

The following reports were used at the comparison point decision (CPD) dated 06/30/2014 to determine disability:

  • John Smith, M.D., report of 03/25/2014; and

  • General Hospital, inpatient 02/03/2014 to 03/15/2014.

The following report was used to decide if disability continues:

  • John Smith, M.D., report of 04/30/2018.

The individual was found to be disabled beginning 02/03/2014 due to Huntington's Chorea which met Listing 11.17. Medical improvement was not expected, but current review is required by law. The individual advises that he has not worked since he was found disabled and there is no improvement in his impairment.

Contact with the current medical source reveals that the individual is under the care of a physician. The treating physician confirmed the individual's statements and further stated that the individual's condition continues to deteriorate. He has not had recent treatment and none is planned.

The individual's impairment has shown no medical improvement and no exception applies; therefore, disability continues.

 


DI 28090 TN 3 - CDR Rationale Preparation - 9/22/2021