DI 24501.002:
Introduction to Medical Evaluation
Effective Dates: 03/24/2016 - Present- Effective Dates: 03/08/2018 - Present
TN 4 (09-15)- TN 11 (03-18)
- DI 24501.002 Introduction to Medical Evaluation
Citations: 42 U.S.C. 421(h); 42 U.S.C. 1382c(a)(3)(H) and (I);- Citations:
20 CFR 404.1503(e)/ 416.903(e) and (f); 404.1520a(d)(1)/416.920a(d)(1); 404.1526/416.926; 416.926a(c); 404.1527(f)(1)/416.927(f)(1); 404.1614/416.1014; 404.1615(c) and (d)/416.1015(c), (d), and (e); and 404.1616/416.1016- 20 CFR §§ 404.1520a(d)(1); 404.1526,404.1527(f)(1),404.1614, 404.1615(c), 404.1616, 416.903(e), 416.920a(d)(1), 416.926, 416.926a(c), 416.927(f)(1), 416.1014, 416.1015(c) (d),, 416.1016
- A. Policy for medical evaluation
- The medical evaluation is the agency explanation of the medical determination.
Every disability determination must contain a medical evaluation unless the case contains no medical evidence. This medical evaluation must be contained on one or more medical assessment forms and should address the alleged impairments for the full assessment period depending on the nature of the impairments.- Every disability determination must contain a medical evaluation unless the case contains no medical evidence or collateral estoppel applies.
- For more information on when collateral estoppel applies, see DI 27515.001.
- The medical evaluation must address the alleged and discovered impairments for the full assessment period on one or more medical assessment forms.
- B. Requirements for medical evaluation
1. Assessment period covered- 1. Period covered
- The medical evaluation should cover the time from potential onset date (POD) through the date of adjudication.
- a. Exceptions to evaluating from the POD to the date of adjudication
- * Unfavorable cases—entitlement period ended in the past
- In the instances listed if the determination is unfavorable, the period assessed ends at the date the entitlement ended.
- * A denial with date last insured (DLI) in the past for Disability Insurance Benefits (DIB) claims.
- * A denial with prescribed period (PP) that ended in the past for Disabled Widow Benefit (DWB) claims.
- * A denial in which Childhood Disability Benefits (CDB) claimant filed after age 22 or a re-entitlement claim with a re-entitlement period that ended in the past.
- For additional information about period adjudicated see DI 27510.001B.
- EXAMPLE: The claimant’s DLI was 12/31/2016. The POD is 1/1/2016. He alleged fatigue due to the early stages of renal failure beginning 1/1/2016. He did not begin chronic dialysis until 6/1/2017. His impairment did not meet or equal a listing until that time and he was a younger individual with a college education who was capable of performing his past relevant work at his DLI of 12/31/2016. Because the determination is unfavorable, the medical evaluation will be through the DLI of 12/31/2016. The period adjudicated is through 12/1/2016.
- IMPORTANT: A favorable determination for a claimant with an entitlement period that ended in the past requires a medical evaluation from POD to the date of adjudication unless you are finding a closed period of disability.
- * Closed period cases
- For a closed period case, the medical evaluation must be from POD until the date the period of disability ended.
- You must find medical improvement related to the ability to work or a Group I or Group II exception to finding medical improvement in order to close a period of disability.
- For additional information about the medical improvement review standard, see DI 28005.001.
- Although the medical evaluation is from the POD until the date the period of disability ended, the period adjudicated for a closed period case is through the date of the determination or decision.
- For additional information see:
- * DI 27510.001 Period Covered by a Final Determination or Decision: “Period Adjudicated”
- * DI 25510.001 Closed Periods of Disability
- EXAMPLE: The claimant is awarded a closed period of disability from 1/1/2015 to 6/1/2016. The Disability Determination Services (DDS) awards the closed period on 9/1/2016. The claimant files a new claim in January 2017 alleging an onset of 6/1/2016. The earliest onset the DDS can consider without reopening is 9/2/2016 the day after they awarded the closed period of disability.
- * Duration Issues
Generally, the medical evaluation should cover the time from potential onset date (POD) or alleged onset date (AOD) through the date of adjudication. You may have to evaluate more than one period to document changes over time or to establish whether a disabling level of severity is expected to last 12 months.- For cases in which the claimant has not met the duration requirements for disability at the time of the determination, you may need a medical evaluation that project severity past the date of adjudication to address the duration issue. For these cases, the period adjudicated is through the date of the determination.
Factors that could impact the assessment period include:* A date last insured (DLI) in the past* A closed period of disability* A prescribed period or controlling date for Disabled Widow Benefit claims* Establishing disability onset prior to the attainment of age 22 for TII Childhood Disability Benefits (CDB)- For additional information, see
- * DI 25505.025 Duration Requirement for Disability
- * DI 25505.030 Evaluation of the Duration Requirement for Disability
2. Issues addressed- EXAMPLE: The claimant alleges disability due to a fracture of the femur, which occurred 1/1/2017. You adjudicate the case on 6/1/2017. To address the duration issue, you must project your medical evaluation through the 12 month duration period, which ends 12/31/2017. The period adjudicated will be through the date of your determination, 6/1/2017.
- b. More than one assessment needed
- In some cases, you may need to make more than one assessment to reflect varying levels of severity throughout the period covered.
- EXAMPLE: From the POD of 10/1/2016 to the established onset date (EOD) of 12/1/2016, the claimant had a medium residual functional capacity (RFC) due to poorly controlled blood pressure and reduced renal function. On 12/1/2016, the claimant had a stroke. By March 2017, the claimant’s right lower extremity had 4/5 strength. He required a hand held assistive device to walk for even short distances. Based on the objective medical and clinical findings, a sedentary RFC applied from 12/1/2016 to the date of adjudication.
- Claims requiring multiple evaluations typically involve a material change in the claimant’s medical condition during the period adjudicated. For example:
- * Severity lessens materially over the period evaluated;
- * Severity worsens materially over the period evaluated; or
- * Successive unrelated impairments.
- IMPORTANT: In initial claims, never combine successive, unrelated severe impairments each lasting less than 12 months to meet the 12 month duration period, see DI 25505.030.
- C. Issues addressed
- The medical evaluation is the agency explanation of the medical determination.
a. Medical evaluation(s) must:- 1. Medical evaluation(s) must:
- * address all allegation(s)
* address all medically determinable impairment(s) (MDI(s))* discuss signs, symptoms, and laboratory findings- * address all medically determinable impairments (MDI)
- * discuss signs and laboratory findings
- * contain an analysis of the medical evidence and how it was used in the evaluation
b. If applicable, discuss:* medical opinions* collateral source evidence about function* evaluation of symptoms* duration or expected duration* adherence to or failure to follow prescribed treatment* drug addiction and alcoholism (DA and A)- 2. If applicable, discuss:
- * collateral source evidence about function, see DI 24515.012
- * drug addiction and alcoholism (DAA), see DI 28005.045
- * duration or expected duration, see DI 25505.025
- * evaluation of symptoms, see DI 24501.021
- * failure to follow prescribed treatment, see DI 23010.005
- * medical opinions and administrative findings, see DI 24503.025
- * sufficiency of evidence, see DI 24501.001
- * resolution of conflicts in the evidence, see DI 24501.016
- NOTE: Adjudicators may process a fully favorable allowance determination without addressing all of these issues.
NOTE: Adjudicators may process a fully favorable allowance determination without addressing all of these issues if the claimant meets the medical or medical and vocational criteria for disability, including duration, and the Established Onset Date (EOD) is fully favorable.- For detailed information, see Curtailing Development of Fully Favorable Claims DI 24515.020.
C. Documenting the medical evaluation- D. Documenting the medical evaluation
- Complete the medical evaluation on SSA-approved medical assessment form(s).
Disability Determination Services (DDS) adjudicators, including medical consultants (MCs) and psychological consultants (PCs), generally complete medical assessment forms in the electronic Claims Analysis Tool (eCAT). For additional guidance on completing medical assessment forms in eCAT, see the most recent eCAT User Guide. These forms are also available for stand-alone use as an eform in the form selector application.- The DDS adjudicators, including medical consultants (MC) and psychological consultants (PC), complete medical assessment forms in the electronic Claims Analysis Tool (eCAT).
- For guidance on completing medical assessment forms, see eCAT User Guide.
- Forms are available for stand-alone use as an eform in the inForm library.
- 1. SSA-approved medical assessment forms
- * SSA-2506-BK (Psychiatric Review Technique)
- * SSA-4734-BK (Physical Residual Functional Capacity Assessment)
- * SSA-4734-F4-SUP (Mental Residual Functional Capacity Assessment)
- * SSA-538-F6 (Childhood Disability Evaluation Form)
- * SSA-416 (Medical Evaluation)
- 2. Signature Requirements
Each medical assessment form must be signed by the proper individual with an acceptable physical signature or an SSA-approved electronic signature. Only the following individuals may sign medical assessment forms:* Medical Consultant (MC),* Psychological Consultant (PC),* Single Decision-Maker (SDM), or* Disability Examiner(DE) with authority for compassionate allowance and quick disability determination (CAL/QDD) to make a fully favorable quick disability determination (QDD) or compassionate allowance initiative (CAL) determination.For a detailed explanation of MC and PC roles, see DI 24501.001.- On 11/11/2016, we implemented a staged phase out of the single decision maker (SDM) and disability examiner (DE) authority to make a fully favorable quick disability determination (QDD) or compassionate allowance (CAL) determination.
For a detailed explanation of SDM authority, see DI 12015.100.- On 12/28/2018, the SDM and DE authority to make a QDD and CAL determination ends.
For an explanation of DE authority for CAL and QDD cases, see DI 23023.001.- The proper individual with an acceptable physical signature or an SSA-approved electronic signature must sign each medical assessment form. Only the following individuals may sign medical assessment forms:
- * MC,
- * PC,
- * SDM (until phase out in December 2018), or
- * DE with authority to make a fully favorable QDD or CAL determination (until phase out in December 2018).
- See Also:
- * DI 24501.001 The Disability Determination Services (DDS) Disability Examiner (DE), Medical Consultant (MC), and Psychological Consultant (PC) Team, and the Role of the Medical Advisor (MA)
- * DI 12015.100 Disability Redesign Prototype Model
- * DI 23023.001 Disability Examiner Authority for Quick Disability Determinations and Compassionate Allowance Initiative Cases
- * DI 26510.090 Completing SSA-831(Disability Determination and Transmittal) Signature Information, Items 30-33
- * DI 24510.066 Options to Simplify Case Processing
- 3. Medical assessment form(s) retention
a. Retain- Never remove any medical assessment form(s) from previous levels of adjudication.
- a. Retain in file
- Retain any medical assessment(s) in the file that:
* Complete(s) the medical portion of the claim or* Support(s) the determination.- * completes the medical portion of the claim, or
- * supports the determination.
- b. Delete at case closure
- Move other medical assessments that do not reflect the final determination (i.e., partial or preliminary forms) to the temporary (green) section of the certified electronic (CEF) or paper folder.
NOTE: Never remove any medical assessment form(s) from previous levels of adjudication.- System automatically deletes the forms from the CEF at case closure.
b. Delete- You must remove and destroy paper folder forms at case closure.
Move other medical assessments that do not reflect the final determination (for example, forms that are partial or preliminary) to the temporary (green) section of the certified electronic (CEF) or paper folder. The system will automatically delete these forms from the file at case closure for CEFs. If the case is paper, remove and destroy these at case closure.- c. Correcting forms
c. Correct- Cases involving federal quality assurance review may require the creation of corrected medical assessment forms.
Cases involving federal quality assurance review may require the creation of corrected medical assessment forms. Follow instructions in DI 30005.236 Correcting Incorrect Psychiatric Review Technique Forms and Residual Functional Capacity Assessment Forms.- For details on correcting forms, see DI 30005.236.
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