The CPD date propagates from the electronic disability collect system (EDCS). The DDS will review and correct any error in the CPD date, see DI 28010.020.

The allegations of why disability continues propagate from EDCS. The DDS will add any new allegation(s) or impairment(s) identified during case development.

The DDS will review the case to see if there is any work activity since the CPD. If there is evidence of work and there is no work activity report in file (SSA-820 or SSA-821), the DDS will follow DI 28030.025 or DI 28050.010.

The DDS will review the case file and see if any of the issues listed below apply. The DDS will document how they considered, applied, and resolved any of the listed issues so it is clear to a subsequent reviewer.

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  Potential 301 case-DI 28060.001 and DI 14510.010

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  Section 1619 case or 1619 CDR concurrent T2-DI 28075.610

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  Extended period of eligibility (EPE)-DI 28055.000

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  Fraud or similar fault-DI 23027.015

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  Lost CPD folder-DI 28035.000

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  Court case readjudication-DI 32502.001

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  DDS deferral-DI 28003.010

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  T2 prisoner case-DI 28065.001

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  Other

The adjudicator develops a complete medical history covering at least 12-months preceding the date the individual completes the SSA-454.

The DDS generally needs to obtain current medical evidence to make a determination under MIRS; however, depending on the impairment in MINE or MINE equivalent cases the adjudicator may not need current medical evidence, see DI 28040.125.

The DDS will follow policy for development of medical evidence in DI 28030.020.

The DDS will review the evidence received for any medical opinions. Consideration of medical opinions depends on the filing date of the case.

For claims with a filing date on or after March 27, 2017, follow the guidance in DI 24503.030.

For claims filed before March 27, 2017, follow guidance in DI 24503.035.

To determine the filing date of the claim for a CDR, see DI 24503.050D.7.

This section notes the CPD date and the CPD basis along with the primary and secondary diagnosis.

The DDS will select if a side-by-side comparison needs to be completed.

If selected, the DDS will note the CPD signs, symptoms, and lab findings and compare them to current symptoms, signs, and laboratory findings related to the impairments that were established at the time of the CPD.

The DDS will consider MI, which is any decrease in the medical severity of the impairment(s) that was present at the time of the most favorable medical determination that the individual was disabled or continued to be disabled as evidenced by changes in symptoms, signs, or laboratory findings. Although the decrease in severity may be of any quantity or degree to find MI has occurred, disregard minor changes in signs, symptoms, or laboratory findings that do not represent MI and could not result in a finding that disability has ended.

The adjudicator will compare the severity of only the impairment(s) considered at the CPD with the current severity of the same impairment(s) to determine if there has been any MI.

When multiple impairments were present at the CPD, the rationale must show that the combined effect of all those impairments has been considered in the current determination and indicate whether there has been a change in such combined effect since the date of the CPD. For further information regarding MI, see DI 28010.000.

The DDS must determine if the side-by side analysis is sufficient. If the side-by -side is sufficient the DDS will select "Analysis of CPD impairments is sufficient; no additional analysis of impairments is necessary. If further information is needed the adjudicator can add additional analysis and further explanation of the MIRS process in the FOFAE."

Other issues addressed in the FOFAE include:

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  Documenting the rationale for disregarding evidence and the fraud or similar fault (FSF) redetermination per DI 23027.015C.4.

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  Documenting prisoner felony related cases DI 28065.040.

The DDS must:

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  Document the alleged symptom(s) which can reasonably be supported by one or more MDI(s); and

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  Analyze and explain the extent to which the symptoms are consistent, or inconsistent, with all the case evidence.

Do not use canned phrases or single, conclusory statements such as, "the individual's symptoms have been considered," or "the statements about the individual's symptoms are (or are not) supported or consistent, " in the narrative symptom's evaluation explanation.

For more information on the two-step symptom evaluation process and how to document finding, see DI 24501.021.

The DDS documents all medically determinable impairments and indicates the appropriate body system, impairment diagnosis, type (CPD or new), priority, and severity. Remember for CDRs the MDI is established in the CPD. The adjudicator does not need to develop the same MDI again during the CDR, see DI 28005.005B.1. However, prior to making a cessation determination, the adjudicator must develop all impairments and vocational issues, including establishing any new MDIs supported by the medical evidence.

The DDS will select the most appropriate listing that correspond(s) to the documented MDI(s). For information on the Listing of Impairments, see DI 34001.000.

The DDS will complete the appropriate medical evaluation(s) and identify whether the assessment(s) cover just the CPD impairment(s) or all impairments. There are times with a CDR that more than one assessment is necessary, see DI 28010.050B.2.

Appropriate medical assessments include:

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  416 Medical Evaluation, see DI 24501.006

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  Residual Functional Capacity (RFC), see DI 24510.050

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  Psychiatric Review Technique (PRT), see DI 24583.005

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  Mental Residual Functional Capacity (MRFC), see DI 24510.060

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  Medical Advisor (MA) 416, see DI 24501.006

Using the flexible approach is a way to facilitate appropriate continuances. If the evidence received in a particular case clearly establishes continuing disability, without following every step in the CDR evaluation process, the flexible approach may be used. Adjudicators will note if the flexible approach was applied and select if clearly no MI or RFC clearly shows inability to perform relevant or other work, or the no work profile applies, see DI 28005.005C.

The DDS will discuss whether the claimant meets or equals a listing including the specific findings that support the meets or equals determination.

1. 1. 

   Meets a listing

   Identify the listing that is met including the supporting findings that meet the listing’s requirements, see DI 24508.005.

2. 2. 

   Medically equals listing

   Provide a rationale explaining which of the three ways of finding medical equivalence is supported and provide the required rationale requirements per DI 24508.010.

3. 3. 

   Current impairment does not meet or medically equal the listing

   When the impairment or combination of impairment(s) does not meet or equal the listing, select: Impairment or combination of impairments does not meet or medically equal a current listing.

The DDS will address if there has been MI since CPD and if it is related to the ability to work.

If there is a decrease in severity in the symptoms, signs, and laboratory findings, the DDS must determine if it relates to the ability to do work using the two mechanisms:

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  Prior listing mechanism

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  RFC comparison mechanism

If the CPD was based on no MI (related) or exception use either mechanism as appropriate.

For further information see DI 28015.005.

For a Group 1 exception, the rationale must indicate whether there is no MI, or MI is not related to the ability to work. The rationale must also reflect consideration of the ability to engage in SGA.

If the evidence raises a significant question as to whether a particular exception applies, but the requirement(s) of that exception is not satisfied, include a brief explanation in the rationale stating why that exception did not apply.

Whenever the exceptions(s) to MI is applied, the rationale must reflect the evidence that establishes the criteria for a particular exception(s). If more than one exception (or an exception(s) and MI) applies in a case, state this explanation in the rationale.

For further information on Group 1 Exceptions, see DI 28020.000.

Apply the appropriate medical signature. For further information on who is responsible for the overall medical signature, see DI 24501.001.

The DDS documents all work activity including job title, start and end date, whether the work activity is PRW or is during the current period of disability, and the Dictionary of Occupational Titles (DOT) information. For more information about the development and capacity to do PRW, see DI 25005.000, DI 28005.015A.7, and DI 28030.030.

Based on the assessed RFC, indicate whether the individual has the RFC to perform PRW. If the individual cannot perform their PRW provide an explanation.

Based on age, education, and work experience select the appropriate profile if one applies, see DI 25010.001.

Based on the MRFC, indicate if the individual is limited to unskilled work and select the maximum sustained work capability level based on the RFC.

The adjudicator applies the appropriate vocational rule from DI 25025.035 based on the RFC and MRFC, education, and work history.

Cite three occupations or cite an exception and provide a vocational explanation, see DI 28005.015A.8, and DI 25025.030.

If applicable, create a vocational analysis or vocational specialist case note that supports the vocational assessment, including a transferability of skills assessment if applicable, see DI 25015.017.

If one of the following Group II exceptions applies, and the evidence does not permit adjudication under another basis, select the appropriate exception and provide the supporting explanation in the box:

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  Fraud or similar fault

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  Failure to cooperate

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  Whereabouts unknown

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  Failure to follow prescribed treatment

For further information see DI 28020.000.

Apply the reason for why the review was made per DI 28084.030.

The DDS will verify this date is correct and make necessary edits if incorrect.

The adjudicator will select one of the appropriate determinations.

The adjudicator will select the appropriate code per DI 28084.015 or DI 28084.020.

The adjudicator will select the appropriate cessation month per DI 28005.205.

Adjudicators will consider the individual facts of the case and the likelihood of improvement by the next CDR and schedule the diary accordingly, see DI 26525.001.

The adjudicator will assess the individual's capability and select the appropriate option, see DI 23001.005B and DI 28075.030.

If an AR applies DDS will select the appropriate AR and provide any required explanation in the explanation box.

An individual is not considered disabled if DAA is a contributing factor to the determination that the individual is disabled. If DAA is involved the adjudicator will follow the 7 step DAA CDR sequential evaluation process after following the 8 step CDR process. For this process see DI 28005.035 and DI 28005.045.

The DDS will select the appropriate notice and if applicable the appropriate paragraph files, see DI 26530.010 and DI 28095.001.

Apply any applicable list codes to the case, see DI 33530.001 and DI 33530.005.

Apply any applicable remarks to the case, see DI 26510.095.

The DDS determination governs case routing. The destination defaults depending on if the case is a continuance or cessation. If an alternate destination is chosen, the DDS will select the appropriate location. For further information regarding routing, see DI 32010.000.