PROGRAM OPERATIONS MANUAL SYSTEMPart DI – Disability InsuranceChapter 230 – Special IssuesSubchapter 20 – Priority CasesTransmittal No. 9, 12/07/2020
This is a Quick Action Transmittal. These revisions do not change or introduce new policy or procedure.
Summary of Changes
DI 23020.045 Terminal Illness (TERI) Cases
Subsection A - The third bullet was deleted to remove any confusion concerning Military Casualty/Wounded Warrior case processing and TERI case processing.
Subsection E.1 - Updated the name of Office of Quality Performance to its current name of Office of Quality Review.
Subsection E.2 - Removed reference to MC/WW cases.
Do not use the words terminal or terminal illness on any material in the case folder that is available to the claimant.
The DDS tracks and expedites TERI case processing.
Only the DDS may remove the TERI case flag when the medical evidence of record (MER) establishes that the claimant’s impairment does not meet the definition of a TERI case, as described in DI 23020.045F in this section.
The Social Security Administration defines terminal illness as “a medical condition that is untreatable and expected to result in death.” We make every effort to identify a potential TERI case as early as possible. We identify potential TERI cases either directly through the claimant’s allegation(s) or indirectly through TERI case descriptors.
Flag TERI cases eligible for Electronic Disability Collect System (EDCS) processing for expedited processing using an electronic TERI flag as described in DI 81020.085. Flag EDCS exclusion cases using a paper SSA-2200 TERI Case Flag. For an exhibit of the paper TERI case flag see OS 15020.301.
We expedite TERI cases at each step in the disability process. Unlike Compassionate Allowances (CAL) and Quick Disability Determination (QDD) cases, TERI applies to both electronic and paper cases. TERI cases may share common traits with other types of cases but are distinct, as they are indicative of a terminal illness. Other types of cases involve a high probability of allowance, but DO NOT necessarily meet the TERI criteria (e.g. CAL, QDD).
DDS management is responsible for tracking TERI cases during the DDS review process. Management should ensure quality assurance or supervisory follow up every 10 days until the DDS completes its actions.
Field offices (FO) also track TERI cases. If the DDS does not complete its actions within 30 days, the FO contacts the disability examiner (DE). If the DDS does not complete its actions within 60 days, the FO contacts the DDS management. FO tracking procedures are described in DI 11005.601.D.3.d.
Be alert to potential TERI cases. Flag the case for TERI processing whenever the claimant alleges or medical records indicate that an impairment is untreatable, cannot be reversed, and is expected to end in death.
Use the following descriptors to identify potential TERI cases.
An allegation from the claimant or third party that the illness is terminal.
An allegation or diagnosis of amyotrophic lateral sclerosis (ALS), known as Lou Gehrig’s Disease.
An allegation or diagnosis of acquired immune deficiency syndrome or acquired immunodeficiency syndrome (AIDS).
Receiving inpatient hospice care or is receiving home hospice care – e.g., in-home end of life counseling or palliative nursing care.
Chronic dependence on a cardiopulmonary life-sustaining device.
Awaiting a heart, heart and lung, lung, liver, or bone marrow transplant (excludes kidney and corneal transplants).
Chronic pulmonary or heart failure requiring continuous home oxygen and an inability to care for personal needs.
Any malignant neoplasm (cancer) which is:
Metastatic (has spread);
Defined as Stage IV;
Persistent or recurrent following initial therapy; or
Inoperable or unresectable.
An allegation or diagnosis of:
Cancer of the esophagus;
Cancer of the liver;
Cancer of the pancreas;
Cancer of the gallbladder;
Small Cell or Oat Cell lung cancer;
Cancer of the brain; or
Acute myelogenous leukemia (AML) or acute lymphocytic leukemia (ALL).
Comatose for 30 days or more.
Newborn with a lethal genetic or congenital defect.
NOTE: The above list, shown on the back of the paper TERI Flag (i.e., SSA-2200 (TERI Case)), is not intended to be all-inclusive. It should be used to provide general guidance in the identification of TERI cases. The category Other (Identify): allows for cases that are not identified in the list of descriptors, to be included as well, as long as the medical condition is untreatable and is expected to end in death.
Upon receipt of TERI cases from the FO:
Record the case for special control and processing as a TERI case. (Controls are manual or automated.) Use study list code (SLC) U to identify TERI cases. See “How to Complete the Receipt (DREC) Data Input Screen” (SM 06001.120B (item 20)). Include the name of the assigned examiner on the control.
Expedite assignment of the case for review no later than the next business day.
Hand-carry TERI EDCS exclusion cases to the assigned DE.
Take the following steps when you identify a TERI after transfer from the FO:
Flag the case as TERI.
Ensure that DDS controls show the name of the assigned examiner.
Notify the FO by telephone or other electronic means, to initiate simultaneous development and to begin tracking the case.
The assigned DE:
Develops and adjudicates as a priority. Handles any development or follow-up actions by telephone, fax, or other electronic means. Expedite the SSA-448 (Request for Medical Advice) or other locally used form, if Medical Consultant (MC) review is required.
Retains the TERI designation throughout the process, unless the MER shows the designation is incorrect. For TERI removal instructions see, DI 23020.045F in this section.
Lists all TERI cases using disability-related list code 153 per “Completion of Item 26 (List Number)” (DI 26510.070) and “Disability-Related List Codes (Active)” (DI 33530.005).
NOTE: Medical deferment to assess response to treatment or level of residual impairment is rarely applicable to a TERI case. In many TERI cases, a favorable determination can be immediately made based on an equals or medical-vocational basis. Should an examiner feel that medical deferment is warranted, obtain documented approval from an MC using an SSA-416 (Medical Evaluation) for inclusion in the medical record.
When the DDS processes an allowance on an EDCS exclusion TERI case, send the case folder to the FO by priority mail with a TERI designation on the envelope. If the case is selected for Office of Quality Review, send the case in a specially marked envelope by priority mail to the designated office.
The DDS Quality Assurance (QA) Unit or the unit supervisor will conduct a special review of the determination when a denial or reconsideration affirmation is made on a TERI case.
Do not remove the TERI flag when denial is based upon:
Dates first or last insured (DFI or DLI).
Failure to cooperate (FTC).
Any other non-medical eligibility or entitlement factor.
DDS may remove the TERI case flag when the MER establishes that the claimant’s impairment does not meet the definition of a TERI case.
Inform the FO via telephone, or place an electronic alert in eView, that the case was removed from TERI processing. This allows the FO to cease tracking the claim for follow up.
NOTE: For complete instructions on adding, viewing, and removing the electronic TERI case flag, see DI 81020.085.
The DDS may remove the TERI designation only when the evidence clearly supports either:
An obvious error in designating the claim for TERI processing. For example, the claimant alleges disability due to an ACL injury. However, the allegation was incorrectly keyed as ALS.
The absence of a TERI condition. For example, the claimant or a third party alleges the impairment is terminal. However, for example, the medical evidence indicates the claimant’s neoplastic disease is responding to multimodal therapy.
DDS administrators determine if supervisory or QA concurrence is required for DEs to remove the TERI designation.
Clearly document the reason for removing the TERI designation in the official case file. Use the term, TERI processing. Do not use the words terminal, or terminal illness, on any material in the case folder. For example, “The medical evidence clearly supports removal from TERI processing. The claimant’s neoplastic disease is responding to multimodal therapy.”
Document the rationale for removing the TERI designation in one of the following areas:
eCAT Claim Communication,
SSA-416 Case Analysis
SSA-5002 Report of Contact,
Case worksheet summary.
NOTE: When using the electronic case analysis tool (eCAT), you must apply the documentation in your claims communication to the disability determination explanation (DDE) to ensure it shows up on the final document.