TN 9 (05-23)

DI 28010.050 Adjudicator and Medical or Psychological Consultant (MC/PC) Roles in Considering Medical Improvement (MI)

A. Review by the adjudicator

The adjudicator must review the medical and non-medical evidence to determine whether MI has occurred, following the basic procedures outlined in DI 28010.015A.2.

The adjudicator must document pertinent findings including a comparison of signs, symptoms, and laboratory findings between the comparison point decision (CPD) impairment(s) and the signs, symptoms, and laboratory findings for the same impairment(s) at the continuing disability review (CDR). The adjudicator may document the comparison in the side-by-side comparison section of the disability determination explanation (DDE) or Findings of Facts and Analysis of Evidence (FOFAE) sections of the DDE.

It may be useful to use the side-by-side comparison section of the DDE as a tool to help determine whether there is MI. Use the Finding of Fact and Analysis of Evidence (FOFAE) section of the DDE to document analysis of the medical and other evidence and show how the evidence leads to the adjudicator's findings of fact about whether there is MI.

NOTE: When MI is not material to the determination (i.e., when an impairment(s) meets or equals a current listing or when the flexible approach applies to facilitate a continuance), adjudicators are not required to discuss a comparison of the CPD findings and current findings related to the CPD impairment(s).

For additional information on the flexible approach and consideration of the medical improvement review standard (MIRS) related steps see DI 28005.005C.3.

B. Review by the MC/PC

1. Referral to the MC/PC

Although the adjudicator determines whether MI has occurred, the MC/PC must review the relevant evidence and the adjudicator's analysis of MI to evaluate:

  • Changes in symptoms, signs, or laboratory findings in relationship to medical severity, and

  • Their opinion on the issue of MI.

Consistent with the policy in DI 24501.002A, a disability determination must contain a medical evaluation unless the case does not contain medical evidence or collateral estoppel applies. Policy requires that the medical evaluation address the impairment(s) on one or more medical forms, see DI 24501.002D.1.

  • The Residual Functional Capacity (RFC) is an administrative determination of an individual's capacity to perform work-related physical and mental activities despite limitations and restrictions resulting from a medically determinable impairment(s), see DI 24510.001.

  • The Psychiatric Review Technique (PRT) (SSA-2506-BK) is an assessment to evaluate mental impairments in adults under Part A of the Listing of Impairments, see DI 24583.005. For specific CDR instructions on use of the PRT, see DI 28010.140. The Mental Residual Functional Capacity (MRFC) is used in addition to the PRT when MI is demonstrated in the individual's impairment(s) and the individual's impairment(s) does not meet or equal a current listing, see DI 24510.060. For specific CDR instructions on use of the MRFC, see DI 28010.145.

  • The SSA-416-UF is an assessment form used to evaluate a number of different medical finding scenarios, see DI 24501.006. For CDRs, the SSA-416-UF may only be used to compare symptoms, signs, and laboratory findings where there is no MI, scenarios when the impairment meets or equals a physical (not mental) listing, or if there is no severe physical impairment(s).

    For additional information about when to use the SSA-416-UF, see DI 24501.006.

  • The SSA-538 (Childhood Disability Evaluation Form) or "CDE" is an administrative determination of whether a title XVI child’s impairment is severe, meets or medically equals a listing, or does or does not functionally equal the listings, see DI 25230.001.

No MI:

If the MC/PC finds that there is no MI, they will prepare the SSA-416-UF, see DI 28010.050B.2.

NOTE: For CDR cases involving evaluation of a mental impairment(s), a SSA-416-UF or PRT may be used, see DI 28010.140C.2.

MI has occurred:

If the MC/PC finds that MI has occurred, they will continue to the next step in the sequential evaluation process and prepare the appropriate assessment form (e.g., an RFC or a PRT and MRFC) to address their findings. see DI 28010.050B.2.

For Title II and adult Title XVI individuals, the medical improvement review standard (MIRS) RFC assessment must include a discussion of changes in the signs, symptoms or laboratory findings in the individual's CPD RFC to determine if MI relates to the ability to work or if the individual's impairment(s) continues to meet or equal the CPD listing, see DI 28015.060 and DI 28015.300.

For Title XVI child CDR cases, the assessment must include a discussion of the changes in signs, symptoms or laboratory findings that support a finding of MI and relevant evaluation of evidence in subsequent steps in the Title XVI child CDR sequential evaluation process, see DI 28005.030C.

Scenarios where MI is not material to the determination:

If the MC/PC finds that MI is not material to the determination (i.e., a Title II or adult Title XVI individual meets or equals a current listing, or the flexible approach applies and is used to facilitate a continuance as discussed in DI 28005.005C), they are not required to discuss a comparison of the CPD findings and current findings related to the CPD impairment(s) in their assessment.

2. MC/PC evaluation of MI

Title II and Adult Title XVI Assessment Forms to Evaluate MI

Finding

Physical Assessment (for MC completion)

Psychological Assessment (for PC completion)

No MI

SSA-416-UF

SSA-416-UF or PRT (SSA-2506-BK)

MI

NOTE: More than one assessment may be necessary, see DI 28005.015A for a detailed discussion of the steps and associated assessment forms at each step.

SSA-416-UF (see below)

or RFC, depending on the basis for the CPD.

If MI is demonstrated at Step 3 and the individual met or medically equaled a listing at the CPD, the MC will use an SSA-416-UF to document if the impairment continues to meet or medically equal the CPD listing in determining if MI relates to the ability to work at Step 4, see DI 28015.050 and DI 28015.055.

If MI is demonstrated at Step 3 and the CPD determination was based on medical-vocational factors using an RFC assessment (see DI 28015.005), the MC will evaluate impairment severity and medical improvement in the RFC(s) in determining if MI relates to the ability to work at Step 4, see DI 28015.300 and DI 28015.850.

PRT (and MRFC if impairment(s) is severe)

If MI is demonstrated at Step 3 of the Title II or adult Title XVI sequential evaluation process, the PC will evaluate impairment severity and medical improvement in the PRT/MRFC to determine if MI related to the ability to work at Step 4, see DI 28015.005.

Title XVI Child Assessment Forms to Evaluate MI

Finding

Assessment for MC/PC Completion

No MI

SSA-416-UF , or the SSA-538/CDE, see DI 28005.030C.4.b.

MI, no current severe impairments

SSA-416-UF , see DI 28005.030C.4.b.

MI, severe impairments

Complete the SSA-538 or CDE (DI 25230.001).

NOTE: A second SSA-538 or CDE may be necessary, see DI 28005.030C.4.c.

 


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http://policy.ssa.gov/poms.nsf/lnx/0428010050
DI 28010.050 - Adjudicator and Medical or Psychological Consultant (MC/PC) Roles in Considering Medical Improvement (MI) - 05/08/2023
Batch run: 05/08/2023
Rev:05/08/2023