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