CPD evidence: The individual’s impairment(s) met listing 13.10E at the CPD due to breast cancer
with secondary lymphedema to an upper extremity. The listing directs that the individual
should be considered under a disability for at least 12 months from the date of the
surgery that treated the secondary lymphedema. The individual had surgery on the upper
extremity on 06/12/2021 and the examiner set the medical re-examination diary for
12 months after the date of this surgery.
CDR evidence: Conducted in 08/2022. The individual continued chemotherapy treatment after the CPD
and the surgery to the upper extremity. At a follow-up visit on 06/18/2022, the individual
still complained of tenderness and swelling in the upper extremity. Since the surgery,
the individual has had difficulty with range of motion due to scar tissue and has
persistent numbness and tingling in the hands. She has not had additional surgery
to the upper extremity since the last surgery performed 06/12/2021. A PET scan performed
in 06/2022 shows the breast cancer has responded to treatment and has reduced in grade,
but the cancer is still present. The oncologist notes from 06/2022 indicate that the
individual will take a break from chemotherapy for two months to allow her body time
to recover, as she has not been tolerating the continuous treatment well and has significant
fatigue and weakness.
There is a plan to start at least 6 more cycles of treatment, beginning in 09/2022.
At a follow-up in 07/2022, her surgeon notes that an additional surgery to her upper
extremity will likely be scheduled after she completes the additional rounds of chemotherapy.
The surgeon remarks that another surgery is necessary to reduce scar tissue and try
to improve function but feels that given the claimant’s fatigue and difficulty tolerating
treatment, an additional surgical recovery period is not ideal while she is enduring
Discussion: The adjudicator processes a continuance at step 2 of the Title II and adult Title
XVI CDR sequential evaluation process and meets listing 13.10E.” The adjudicator sets
a medical re-examination diary for 09/2025. MI and the CPD listing are not considered
in this example because the impairment meets a current listing earlier in the sequential
The adjudicator reasons that the individual’s impairment persists and determines that
a 3-year diary is appropriate given the ongoing treatment and residual limitations
in the upper extremity. The adjudicator further reasons that the 3-year diary is appropriate
in this situation as the individual continues to exhibit a listing level impairment,
has additional chemotherapy and surgery planned, and already received an MIE diary
at the CPD. The determination is also consistent with instructions in DI 26525.020B.2.