TN 39 (07-21)

DI 28020.001 General - Groups I and II of Exceptions to Medical Improvement (MI)

CITATIONS:

20 CFR §404.1594(d) and (e),
20 CFR §416.994(b)(3) and (b)(4).

A. Intent of Group I and Group II exceptions to MI

The exceptions to MI permit finding that disability ceased in limited situations where, even though there has been no MI or MI is not related to the ability to work, evidence shows that the person should no longer be considered disabled or never should have been considered disabled.

 

B. Introduction to the Group I and Group II exceptions to MI

There are two groups of exceptions to MI:

1. Group I exceptions

Generally, Group I exceptions apply at:

  • step 5 of the continuing disability review (CDR) sequential evaluation process for Title II and adult Title XVI CDRs; and

  • step 2 of the CDR sequential evaluation process for Title XVI children.

Group I exceptions may result in a finding that the individual is not currently disabled. Group I exceptions by themselves do not result in automatic cessation of benefits. If a Group I exception applies, the adjudicator must continue the sequential evaluation process to determine whether the individual is currently disabled.

The Group I exceptions are:

  • substantial gainful activity (SGA) (for field office use only and does not apply to Title XVI children), see DI 28020.050;

  • advances in medical or vocational therapy or technology (does not apply to Title XVI children), see DI 28020.100;

  • vocational therapy (does not apply to Title XVI children), see DI 28020.150;

  • new or improved diagnostic or evaluative techniques, see DI 28020.250; and

  • prior error, see DI 28020.350, which includes:

    • error on the face of the record; see DI 28020.355;

    • required and material evidence was missing, see DI 28020.360; or

    • new evidence related to the prior determination or decision, see DI 28020.365.

2. Group II exceptions

Group II exceptions apply at any step of the CDR sequential evaluation process for adults or children. A Group II exception may result in a determination that an individual is no longer disabled. See DI 28020.900, for further information.

The Group II exceptions are:

  • fraud or similar fault;

  • failure or refusal to cooperate;

  • whereabouts unknown; and

  • failure to follow prescribed treatment.

C. How to apply the Group I and Group II exceptions to MI

1. Development of exceptions

Develop only when there is strong indication that an exception may apply. Avoid routine development only to pursue an exception(s).

2. Caution in applying exceptions

The intent of the Group I exceptions is to provide a way of finding that a person is no longer disabled in those limited situations where there has been no decrease in severity of the impairment(s) and the evidence shows that the person should no longer be considered disabled or never should have been considered disabled. Do not apply any exception to MI if you have reasonable doubt about whether the exception applies.

D. Exclusions for Group I exceptions to MI

  • The SGA exception is a field office determination and does not apply to certain claims, see DI 28020.050C.

  • The advances in medical or vocational therapy or technology exception does not apply to certain claims, see DI 28020.100D.

  • The vocational therapy exception does not apply to certain claims, see DI 28020.150E.

 

E. Additional considerations when more than one exception applies

In the rare situation when more than one exception applies (or one exception applies and there is MI related to the ability to work), discuss this in a rationale. For additional discussion of exception CDR rationale and required content, see DI 28090.055.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0428020001
DI 28020.001 - General - Groups I and II of Exceptions to Medical Improvement (MI) - 08/11/2015
Batch run: 09/09/2021
Rev:08/11/2015