There may be scenarios involving both physical and mental impairments that were “present”
(i.e., “established” per DI 28010.001B.1.) at the CPD, and at CDR, there is medical improvement in one impairment but not the
other (e.g., improvement in a physical impairment but no MI in mental impairment).
If physical and mental impairments were established at the CPD and there is medical
improvement in only one impairment (e.g., improvement in a mental impairment) at the
CDR, a finding of no MI is not supported (unless the flexible approach is supported
– see DI 28005.005C). When both physical and mental impairments are involved, there must be no MI in
BOTH physical and mental impairments to support a continuance at step 3. The MC and
PC must complete their assessments based on the supported findings in medical evidence.
If the medical disposition is no MI, an MC/PC should complete a medical assessment
form, see in this section B.2.
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If no MI is found for both physical and mental impairments, the MC will complete an
SSA-416 and the PC will complete an SSA-416 (or PRT).
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If no MI is found for one impairment, the MC and PC will complete the appropriate
assessment(s) form, and the adjudicator will continue with the sequential evaluation
process.
EXAMPLE:
CPD Information: The CPD allowance involved mental and physical impairments and was
continued on the basis of no MI. At CPD, the MC completed an SSA-416 no MI assessment
and the PC completed a no MI PRT. The CPD no MI assessment was based on the initial
allowance. The initial allowance was completed by an Administrative Law Judge (ALJ)
resulting in the inability to perform other work. For physical, the ALJ assessment
was an RFC (limiting the individual to standing and walking 4 hours, avoiding unprotected
heights), and a PRT/MRFC (indicating moderate limitations in understanding, remembering
and applying information and in concentration persistence and pace, mild limitation
in interacting with others and in adaptation).
CDR Information: At the CDR, the PC determines there is MI for mental impairments
and the MC determines there is no MI for the physical impairments. The PC completes
a PRT and MRFC (indicating mild limitations in understanding, remembering and applying
information and in concentration persistence and pace, no limitation in interacting
with others and in adaptation), and the MC completes a SSA-416 citing evidence to
support no MI, stating that the prior RFC still applies. Noting that the prior RFC
still applies is policy compliant per DI 28015.005A. No other assessment needs to be created by the MC because there is no MI in the physical
impairments. The adjudicator finds MI at step 3 because of the MI in the mental impairment
and continues to Step 4 to evaluate if the MI relates to the ability to work.