DI 28030.020: Development of Medical Evidence

changes
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~~Effective Dates: 02/01/2018 - Present~~
Effective Dates: 02/02/2018 - Present
TN 38 (09-15)
DI 28030.020 Development of Medical Evidence
Citations: 20 CFR 404.1512, 404.1513, 404.1517, 404.1519a, 404.1519b, 404.1579, 404.1593, 404.1594, 416.912, 416.913, 416.917, 416.919a, 416.919b, 416.993, and 416.994
A. Medical evidence and the medical improvement review standard (MIRS)
Disability determination services (DDS) conducts a continuing disability review (CDR) periodically after an individual has been receiving disability benefits. The CDR will determine whether the individual continues to be disabled. The time frame and method (e.g., full CDR, deferment review, mailer process) for processing CDRs is based on the specific circumstances of each case. The goal of the CDR is to make the correct determination of continuance or cessation in a timely, accurate, and cost effective manner.
To adjudicate CDRs, the disability examiner (DE) does not use the 5-step sequential evaluation process used for initial and reconsideration claims. DEs use an 8-step evaluation process for CDRs based on MIRS. MIRS compares the individual’s symptoms, signs, and laboratory findings at the time of the most recent favorable medical determination, which we call the comparison point decision (CPD), to the current symptoms, signs, and laboratory findings of the same condition(s). If the individual’s condition(s) has improved or if an exception to medical improvement applies, we then proceed through the later steps of the CDR evaluation process. To review the CDR evaluation process charts, see DI 28005.010B and DI 28005.025.
REMEMBER:
* When a medically determinable impairment (MDI) is established at any point in time by evidence from an acceptable medical source (usually in the CPD file), do not develop to establish that same MDI again during the CDR.
* DEs may use other medical sources that are not acceptable medical sources to evaluate the current severity of the impairment(s) and how it affects an adult’s ability to work or a child’s ability to function.
* DEs may use only non-medical evidence to continue a case in certain medical improvement not expected (MINE) and MINE-equivalent cases. For more information on MINE cases, see DI 28040.125.
* The currency of medical evidence depends on the nature of each impairment(s). Therefore, the level of effort for development in a CDR may be different from that in an initial claim.
* DEs will make every reasonable effort to obtain necessary medical evidence from the individual’s medical sources prior to ordering a consultative examination (CE). For further discussion on reasonable effort, see DI 22505.001A.2.
* DEs may stop development and process a continuance whenever the evidence received is sufficient to make a continuance determination. However, the DE develops for all impairments and vocational issues prior to making a cessation determination.
B. What medical evidence is needed for a CDR determination
DEs will usually have the CPD case file with the medical evidence used to establish, or continue, the individual’s disability. Therefore, for the CDR, the DE needs to obtain current medical evidence to make a determination as defined under the MIRS.
C. Obtaining evidence from the individual’s medical sources
If requested by the DDS, the individual must provide reports from his or her physician, psychologist, or others who have treated or evaluated him or her, as well as any other evidence that will help the DE determine if he or she is still disabled. The individual must have a good reason for not providing this information or the DE may find that his or her disability has ended.
The DE will make reasonable efforts to obtain evidence from the individual’s medical sources when the individual gives us permission to request them. When asked, the individual must contact his or her medical sources to help the DDS get the medical reports.
The DE may order a consultative examination (CE) while awaiting receipt of medical source evidence if the source is unable to provide certain tests or procedures, or the source has previously been non-productive or uncooperative.
The DE develops a complete medical history covering at least the 12 months preceding the date the individual signs a report about his or her continuing disability status before deciding that the individual’s disability has ended.
D. When to purchase a CE
When the DDS needs additional evidence to determine whether the individual’s disability continues, the DE may ask the individual, upon request and reasonable notice, to undergo CEs or tests. The DE will decide whether to purchase a CE in accordance with the guidelines in DI 22510.005 and DI 22510.006.
E. Developing evidence
1. Developing medical and other evidence
Develop a complete medical history for the 12 months prior to the date that the SSA-454-BK (Continuing Disability Review Report) is completed. Use judgment in developing evidence outside the 12-month period. For information on electronic processes, see DI 81020.060.
During case development, consider:
* The individual’s current impairment(s), and
* The status of the impairment(s) present at the time of the CPD.
Resolve any conflict between evidence provided by the individual and medical source(s). For more information on specific evidence evaluations instructions, see DI 24515.001.
Some individuals may not have any current medical source(s). Actions required in these cases depend on the nature of the impairment(s) or the availability of knowledgeable third parties who can verify the individual’s statements. For source requirements in MINE, or MINE-equivalent cases, see DI 28040.125.
2. Development of evidence from an acceptable medical source
Evidence from an acceptable medical source is required to establish any new or previously existing (but not established) medical impairment(s), whenever consideration of that impairment(s) is relevant to the current CDR determination.
NOTE: Any medically determinable impairment(s) established previously, such as at the CPD, does not need to be re-established.
3. Development of evidence from a non-acceptable medical source
Current medical evidence from an acceptable medical source is not always necessary in CDR cases. Once an MDI has been established in a CDR case, evidence from sources who are not acceptable medical sources may be used to show the current severity of the impairment(s) and how it affects an adult’s ability to work or a child’s ability to function. For more information, see DI 22505.003 - Evidence from an Acceptable Medical Source (AMS)
Current medical evidence from an acceptable medical source is not always necessary in CDR cases. Once an MDI has been established in a CDR case, evidence from sources who are not acceptable medical sources may be used to show the current severity of the impairment(s) and how it affects an adult’s ability to work or a child’s ability to function. For more information, see DI 22505.003 - Evidence from an Acceptable Medical Source (AMS).
EXAMPLE: At CPD, an acceptable medical source established a diagnosis of osteoarthritis of the lumbar spine. On current CDR, the individual reports ongoing arthritis in the low back. It is not necessary to reestablish the existence of this impairment by current evidence from an acceptable medical source. DEs may use evidence from other sources, such as a physical therapist or chiropractor, to establish current severity and functioning.
NOTE: Stop development and process a continuance at any time during development when sufficient evidence supports a continuance.
4. Development of non-medical evidence
When an MDI is established, use non-medical evidence in appropriate cases to assist in determining the current severity of the impairment(s), and to show how the impairment(s) affects an adult’s ability to work or a child’s ability to function. Non-medical evidence may give important information about how the individual functions in his or her daily life. Activities of daily living (ADLs) offer valuable insight into an individual’s daily function. DEs may use ADLs in conjunction with medical evidence for a determination. Examples of non-medical evidence include (but are not limited to) information from educational personnel, public and private social welfare agency personnel, spouses, parents, other relatives, and friends.
NOTE: In certain MINE or MINE-equivalent cases, non-medical evidence maybe the only evidence needed for a determination. Medical evidence is required in all other situations. For more information on MINE case development, see DI 28040.125B.3.
5. Development of CPD evidence
Do not develop additional CPD evidence, except in unusual situations (e.g., CPD evidence was clearly inadequate and more evidence relevant to the CPD is known to be readily available). Do not obtain additional evidence just to consider the error exceptions. However, for development for Group II exceptions see DI 28020.900.
NOTE: For procedures applicable to lost folder cases, see DI 28035.000.
6. Development of CE evidence
Make every reasonable effort to obtain all medical evidence necessary to make a determination from the individual’s medical source(s). After receiving initial evidence from the source(s), if you still need additional evidence for a determination, consider whether it is readily available from these sources. If so, re-contact the source(s) for the additional evidence. A CE is only necessary when the evidence as a whole, both medical and non-medical, is not sufficient to support a determination. For guidelines on purchasing CEs, see DI 22510.001 through DI 22510.006. Do not order a CE if:
* The impairment(s) meets a listing and will always meet it. For examples of these obsolete listings, see DI 28015.055B.3.b.
* The impairment(s) meets the requirement(s) for certain MINE or MINE-equivalent cases. For additional information on MINE cases, see DI 28040.005 and DI 28040.125B.1.
7. Currency of evidence
DEs must have some current evidence for a CDR medical determination. To determine whether the individual’s impairment(s) shows medical improvement, the DE needs current medical evidence to compare the symptoms, signs, and laboratory findings of the impairment(s) at the time of the CPD to the symptoms, signs, and laboratory findings of the same impairment(s) at the time of the current review. In CDRs, the DDS generally develops a medical history for the 12 months preceding the completion of the SSA-454.
The nature of each impairment determines how current the medical evidence must be. Therefore, DEs must resolve this issue on a case-by-case basis. For example, if the impairment(s) is acute or of an exacerbating and remitting nature, the DE may need recent medical evidence for a determination. However, if the impairment(s) is chronic or progressive then non-medical evidence, which may not be as recent, may be the only evidence needed for determination. For further information on currency of evidence, see DI 22505.010.
F. Vocational rehabilitation (VR) agency
When an individual is known to a State, or other accredited, VR agency at the time of the CDR, contact the agency for a full report about the individual, including medical reports relating to the individual’s current medical status and other data pertinent to a determination. If data previously obtained from the agency (e.g., in connection with the initial adjudication) indicated the case was closed and the individual states the case has not been reopened, do not make further contact with the VR agency. Evidence obtained from the individual’s medical sources, together with evidence available through the VR agency, may be sufficient to permit a sound determination as to whether disability continues. For procedures on VR involvement “301” cases, refer to DI 28001.040.
NOTE: If an individual is actively involved in VR type services, clarify through the FO whether a “ticket to work” is in use. If so, this may negate the current CDR action.
Do not make a clear-cut cessation (cessation without current medical development, on the basis that medical recovery is indicated by return to full-time work without medical restrictions) when VR services are continuing because participation in VR constitutes “evidence to the contrary.” When current medical evidence establishes medical improvement and a present capacity for doing substantial gainful activity, find that disability ceases despite the fact that the individual may be an active participant in a State-sponsored VR program.
EXAMPLE: The individual was found disabled based on multiple fractures and complications that indicated the disabling condition would meet the 12-month duration requirement. When the medical diary came due, the CDR established that the individual was enrolled in a two-year bookkeeping course under a State-sponsored VR program. The DDS obtained evidence, from the VR agency, that stated one year of schooling remained. The DDS then obtained current medical evidence that clearly established medical recovery. Therefore, the DDS made a cessation determination.
G. References
* DI 22505.001 Medical and Nonmedical Evidence
* DI 22505.003 Evidence from an Acceptable Medical Source (AMS)
* DI 22505.006 Requesting Evidence – General
* DI 22505.030 Obtaining Medical Evidence by Telephone
* DI 28010.015 Comparison of Symptoms, Signs, and Laboratory Findings
* DI 28030.035 Cessation Without Full Medical Development (Clear-Cut Cessations)
* DI 28040.130 Development Guidelines for MINE or MINE-Equivalent Impairments
* DI 28060.001 General - VR or Similar Program Participation
* DI 81020.020 Electronic Case Development
* DI 81020.065 Electronic Case Documentation

POMS Reference

DI 28030.020: Development of Medical Evidence