SSA - POMS: DI 24505.030 - Identifying, Developing Evidence of, and Evaluating a Potential Impairment

A. What is a potential impairment?

A potential impairment is a medical condition the claimant did not allege when they filed an initial claim or requested a reconsideration, but is discovered in the medical or other evidence, on forms, or as a new allegation when in conversation with the claimant or one of the required contacts (see DI 22505.014). When adjudicators discover a potential impairment during case development, they must determine whether that impairment is medically determinable and severe at step two and, if so,whether it meets the duration requirement.

A potential impairment could also be:

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A medically determinable impairment (MDI) that does not meet the duration requirement (see DI 25505.025); or
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A non-severe impairment (see DI 24505.001).

NOTE: A symptom or condition that does not appear to be related to any of the alleged impairments might indicate the presence of an impairment the claimant did not allege.

B. What is an alleged impairment?

An alleged impairment is a medical condition the claimant asserts they have or is a description of a medical condition in the claimant’s own words. Generally, an alleged impairment is documented in Section 3 – “Medical Information” or Section 11 – “Remarks” on the SSA-3368-BK (Disability Report – Adult) when filing an initial claim; or in Section 3 “Medical Information” or Section 10 “Remarks” on the SSA-3441-BK (Disability Report – Appeal)when filing a reconsideration.

For information on identifying a new impairment, potential or alleged, during a continuing disability review, see DI 28005.210.

C. Developing evidence of an impairment

When a claimant alleges an impairment, as explained in DI 24505.030B in this subsection, you must use existing procedures to develop all relevant evidence, as explained in DI 22501.001 and DI 22505.008.

When you discover a symptom, condition, or impairment during case development that was not alleged, you must resolve whether:

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Treatment (such as a procedure, therapy, or medication) for the condition was recommended or received;
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Evidence from a medical source, including evidence obtained in a telephone contact, suggests the potential impairment is an MDI, as explained in DI 24501.020; or
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Evidence from, or contact with, a medical source, the claimant, or a third party who knows the claimant and is familiar with their condition(s) supports limitations in basic work activities (or functional limitations for children) resulting from the potential impairment.

If you contact the claimant or one of the required contacts by telephone to resolve the issues listed above, verify their identity prior to discussing any details of the case, see DI 39567.210, DI 22505.014, and GN 00203.020.

If you attempt to reach the claimant or third party by telephone, but you reach someone else instead, see DI 22505.014.

Ask the claimant or required contact focused questions that help us determine (or rule out) whether the potential impairment:

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Is reasonably related to another MDI;
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Is a side effect of medication used to treat another MDI;
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Resulted in medical evaluation or treatment;
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Resulted in limitations in basic work activities (or functional limitations for children); or
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Lasted or is expected to last 12 continuous months, or to result in death.

If a member of the adjudicative team contacts a medical source to help resolve whether the potential impairment is an MDI, use the relevant procedures explained in DI 22505.008B.1. When obtaining evidence from a medical source by telephone, follow the instructions in DI 22505.030.

If development efforts produce information that the claimant received treatment for the condition at issue, expedite steps to obtain the medical evidence (e.g., telephone, FAX, electronic evidence requests, or claimant assistance) to determine whether (1) the potential impairment is an MDI, and (2) the evidence could be relevant to the determination, as directed by DI 22505.006B.2.

NOTE: Before making any attempt to contact someone other than the claimant about the potential impairment confirm that there is a valid SSA-827 (Authorization to Disclose Information to the Social Security Administration (SSA)) in the file. If there is no valid SSA-827 in file, development should pause until disclosure is authorized by a new SSA-827. For information on what constitutes a valid SSA-827, see DI 11005.055.

Document all development efforts following DI 24505.030E in this subsection.

D. When to discontinue development

Whether potential or alleged, discontinue developing evidence of the impairment when the evidence:

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Is sufficient to make a fully favorable determination, see DI 24515.020;
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Indicates that the condition is actually a symptom or a side effect of another established MDI, see DI 24501.021;
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Shows the impairment did not last or is not expected to last 12 continuous months, or to result in death, see DI 25505.025; or
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Does not establish the existence of an MDI.

Document the reason(s) to discontinue development of the evidence, as discussed in DI 24505.030E in this section.

E. Document all development efforts

When the evidence does not establish the existence of a severe MDI that meets the duration requirement, do one of the following, as applicable:

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Explain why no further development is needed on a Case Note in the Disability Case Processing System (DCPS) and "write to" the Disability Determination Explanation (DDE). For example, state “the presence of [impairment] alone, or in combination with the claimant’s other MDI(s), does not significantly limit their ability to do basic work activities for 12 continuous months;” or
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Complete the appropriate medical assessment form (e.g., SSA-416 (Medical Evaluation) or SSA-2506-BK (Psychiatric Review Technique)).

When development efforts establish that the potential impairment is an MDI that is severe and meets the duration requirement, use the sequential evaluation process to further evaluate the MDI as discussed in DI 22001.001.

For information on what constitutes a properly documented DDE, see DI 26515.001.

For information on completing the SSA-416, see DI 24501.006.

For information on completing the SSA-2506-BK, see 24583.005.

F. Examples of when to develop and when to discontinue developing evidence of a potential impairment

1. Example of when to develop evidence of a potential impairment

While reviewing the medical evidence for a 52-year-old claimant alleging vascular insufficiency, hypertension, and diabetes, the adjudicator discovered a reference to a potential cognitive impairment as a result of recent transient ischemic attacks (TIA), which the claimant did not allege. The claims representative (CR) documented on the SSA-3367 (Disability Report – Field Office) that the claimant was pleasant and cooperative but struggled to understand certain questions during the disability interview and slurred their words.

The medical evidence from the claimant’s primary care physician included a record from an emergency room visit for a TIA, resulting in mild weakness on the right side and mildly slurred speech. In follow up visits with the primary care physician, the evidence indicates the right-sided weakness resolved and the claimant’s speech was improving. The source did not document any cognitive findings; however, the claimant complained of residual headaches and confusion. The medical source referred the claimant to a neurologist to follow up.

The adjudicator contacted the claimant to ask whether they sought treatment from a neurologist for the TIA, headaches, and confusion. Since the weakness resolved, the claimant did not seek further treatment and continues to see their primary care physician. The adjudicator noticed the claimant’s speech was slow and they paused frequently while answering questions about whether their symptom of “confusion” affected their ability to work. The claimant indicated that, before they stopped working, their employer removed them from certain job duties requiring them to operate a forklift to unload trucks and had them pack and unpack boxes instead.

In addition, the adjudicator verified that the SSA-827 in file was current before asking the claimant’s third-party contact (a long-time neighbor) to complete the SSA-3380-BK (Function Report Adult – Third Party). The third party completed the form and noted that the claimant has difficulty following instructions and sometimes asks for help understanding medical bills. The third party also stated the claimant sometimes forgets to turn off the stove when cooking.

While the physical effects of the TIA (weakness) were once severe but did not last 12 continuous months, the adjudicator appropriately pursued development of the symptom of “confusion” to resolve whether:

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Treatment (such as a procedure, a therapy, or a medication) for a condition was recommended or received;
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Evidence or contact with a medical source suggests that the potential impairment is an MDI, as explained in DI 24501.020; or
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Evidence or contact with a medical source, the claimant, or a third party who knows the claimant and is familiar with their condition(s) supports limitations in basic work activities (or functional limitations for children) resulting from the potential impairment.

While the claimant’s symptom of “confusion” is reasonably related to the MDI of the TIA, further evaluation is needed to determine whether the potential impairment is severe and is expected to last 12 continuous months. The adjudicator ordered a consultative examination, including a mental status evaluation and psychological testing, to help assess the claimant’s mental functioning.

2. Example of when to discontinue developing evidence of a potential impairment

Consider the same example, above, where the adjudicator discovered the potential impairment of a TIA in the medical evidence resulting in mild right-sided weakness and mildly slurred speech, but with different case facts.

In follow up visits, the evidence shows the right-sided weakness resolved the claimant’s speech was improving and they did not report any symptoms of headaches or confusion. The primary care physician recommended the claimant stop smoking cigarettes.

The adjudicator contacted the claimant to resolve the issues listed in DI 24505.030C, specifically whether: additional treatment was recommended; the potential impairment is an MDI; or the potential impairment affects the claimant’s ability to perform basic work activities.

The claimant confirmed they were following their doctor's advice to quit smoking, and they continue to follow up with their primary care physician for all their medical conditions, but they did not receive any treatment for the TIA. Further, the claimant did not believe the TIA prevented them from working since the weakness resolved.

Although the TIA is medically determinable, the case evidence did not support a finding that the impairment has lasted or is expected to last for 12 continuous months, because the right-sided weakness, headaches, and confusion had all resolved, and the claimant's speech, which was only mildly slurred because of the TIA, was improving. As such, no further development of the MDI is needed.

The adjudicator documented the content of their conversation with the claimant in a Case Note, concluding “the presence of the claimant’s TIA alone, or in combination with the claimant’s other MDI(s), does not significantly limit their ability to do basic work activities for 12 continuous months.” The adjudicator also documented their findings on an SSA-416, in accordance with DI 24505.030E in this section, which the MC signed in accordance with DI 24501.006B.

Social Security

Program Operations Manual System (POMS)

DI 24505.030 Identifying, Developing Evidence of, and Evaluating a Potential Impairment