DI 28005.015: Step-by-Step Discussion of the Adult Continuing Disability Review (CDR) Evaluation Process

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Effective Dates: 09/05/2017 - Present
TN 6 (09-16)
DI 28005.015 Step-by-Step Discussion of the Adult Continuing Disability Review (CDR) Evaluation Process
A. Discussion of the 8-Step CDR evaluation process
This subsection corresponds with the numbered steps in the chart located in DI 28005.010. For Title XVI adults originally allowed as Title XVI children, see DI 28005.003. During the CDR evaluation process, consider the Group II exceptions at any point.
On case receipt, thoroughly review the comparison point decision (CPD) and the CPD evidence that supports the CPD determination. During the CPD review, the CDR adjudicator must notsubstitute his or her judgment for that of the prior adjudicator by:
* re-adjudicating the case, or
* reviewing the CPD evidence with the intent to find error in the CPD medical determination.
For additional guidance on substitution of judgment during a CDR, see DI 28005.007.
NOTE: Reviewing only the assessment summary from the CPD determination is not a thorough review of the CPD evidence. The CDR adjudicator must review all of the CPD evidence that supports the CPD determination including the signs, symptoms, and laboratory findings.
1. Step 1 substantial gainful activity (SGA)
The first step in the CDR evaluation process is to determine if the individual is performing SGA. This is a field office (FO) responsibility. These CDRs may involve a trial work period (TWP), extended period of eligibility (EPE), Section 301, or Section 1619, and may require a medical review. When appropriate, the disability determination services (DDS) incorporates SGA determinations into the decision. When this step applies, disability ceases based on performance of SGA. Do not apply Step 1 in:
* Title XVI cases for work performed after June 30, 1987. For additional information on this issue, see DI 28075.600.
NOTE 1: In concurrent Title II and Title XVI cases, an individual whose Title II benefit ends due to performance of SGA may retain Title XVI eligibility:
* during the TWP, or
* when deciding whether an individual continues to have a disabling impairment for purposes of an EPE or other work incentive benefits.
Once the FO has resolved any work issues for SGA, the disability adjudicator must identify the most recent favorable medical disability decision date, which is the CPD. After identifying the CPD, the adjudicator can continue to Step 2 of the CDR evaluation process. For additional information on identifying the CPD, see DI 28010.105.
NOTE 2: Although the SGA determination is primarily the FO responsibility, sometimes work issues may arise during the CDR at the DDS level. For details on DDS work activity development responsibilities, see DI 24001.005.
2. Step 2 meets or equals
Review the evidence in the file and document the individual’s current alleged impairment(s). Then, determine if any impairment(s) meet or equal a listing in the current Listing of Impairments:
* If yes, find that disability continues.
* If no, go to Step 3.
3. Step 3 medical improvement (MI) (decreased severity)
Review the CPD evidence and identify relevant medical signs, symptoms, and laboratory findings at the CPD. Then, compare them to the current CDR for medical signs, symptoms, and laboratory findings to the same impairment(s). For additional information relating to MI, see DI 28010.000. Decide whether MI occurs:
* If there is MI, go to Step 4.
* If there is no MI, go to Step 5.
4. Step 4 relating MI to the ability to work
When determining if MI relates to the ability to work, consider only the CPD impairment(s) and, if applicable, consider age and time on the rolls instructions in DI 28015.310.
Remember:
* If the CPD was based on meets or equals, and the individual still meets or equals that prior listing or any of the subsections of that listing, then MI does not relate to the ability to work. For consideration of prior listings, see DI 28015.050 and DI 28015.055.
* If the CPD was based on a residual functional capacity (RFC) assessment, compare the “CPD RFC” with a “MIRS RFC”. For additional information on RFC assessments, see DI 28015.300 and DI 28015.855). If there is no improvement, then MI does not relate to the ability to work.
Decide whether MI relates to the ability to work:
* If MI does not relate to the ability to work, go to Step 5.
* If MI relates to the ability to work, go to Step 6.
5. Step 5 exceptions
Group I and Group II exceptions permit a finding that disability ceases in situations where no MI occurred, but evidence clearly shows that the person should no longer be considered disabled or never should have been considered disabled. For general information on Group I exceptions, see DI 28020.001. For information on Group II exceptions, see DI 28020.900. Decide whether an exception to MI applies:
* If no exception applies, find that disability continues.
* If one of the Group I exceptions applies, go to Step 6.
* If one of the Group II exceptions applies, then adjudicators may cease immediately at any point in the 8-Step CDR evaluation process without a medical determination.
6. Step 6 severity
Decide whether the individual has any severe impairment(s) and assess the current RFC considering all current impairment(s). For more information on the RFC assessment, see DI 28015.850A.3. If applicable, consider age and time on the rolls instructions, see DI 28015.310. Determine if the individual has any severe impairment(s):
* If yes, go to Step 7.
* If no, find that disability ceases.
7. Step 7 past work
If the individual's combined medical conditions impose limitations on his or her current RFC, consider the individual's capacity to do his or her past relevant work (PRW). Do not consider work during the current period of disability (or current period of extended Medicare) as relevant work experience, see DI 25001.001A.64. For expedited reinstatement (EXR) cases, do not consider work since the established onset date (EOD) in the prior allowance was the PRW. Decide whether the individual has the ability to do past work:
* If yes, find that disability ceases.
* If no, go to Step 8.
8. Step 8 other work
If the individual's current medical condition precludes performing PRW, consider whether the individual retains an RFC to adjust to other work existing in the national economy. Do not consider work during the current period of disability (or current period of extended Medicare) as relevant work experience, see DI 25001.001B.65. Decide whether the individual has the ability to do other work:
* If yes, find that disability ceases.
* If no, find that disability continues.
NOTE: Consider borderline age situations if appropriate, when an individual is disabled for an extended time period. This may represent a vocational adversity. For additional information on PRW considerations for borderline age, see DI 25015.006.
B. References
* DI 10501.001 Meaning of SGA and Scope of Subchapter
* DI 24505.000 Impairment Severity
* DI 24505.015 Finding Disability Based on the Listing of Impairments
* DI 24505.015 Finding Disability Based on the Listing of Impairments
* DI 25001.001 Medical -Vocational Quick Reference Guide
* DI 25005.050 Making the Past Relevant Work (PRW) Determination
* DI 25015.001 General - Ability to Perform Other Work
* DI 28010.000 Medical Improvement and Related Medical Issues
* DI 28015.000 Relating Medical Improvement to the Ability to Work – Title II and Adult Title XVI Beneficiaries
* DI 28015.005 Two Mechanisms to Relate Medical Improvement (MI) to the Ability to Work
* DI 28015.310 Consider Age and Time on the Rolls When Assessing Residual Functional Capacity (RFC) in Continuing Disability Reviews (CDRs)DI 28050.001 The Trial Work Period
* DI 28020.000 Exceptions to Medical Improvement
* DI 28055.001 Extended Period of Eligibility (EPE) and Related Medicare Provisions – General
* DI 28075.000 Special CDR Issues
* DI 34001.001 Listing of Impairments -- Purpose, Parts and Use

POMS Reference

DI 28005.015: Step-by-Step Discussion of the Adult Continuing Disability Review (CDR) Evaluation Process