BASIC (08-04)

A. Operating Procedure

1. No SGA Cessation

Prepare a medical improvement review standard (MIRS) “medical” determination of cessation or continuance in the usual manner , when the FO determines the work activity does not warrant a finding of SGA cessation and ODIO/PSC-DRS can not screen out as meeting the currently disabled criteria in DI 28055.020B.

2. SGA Cessation

Prepare a MIRS “impairment severity” determination for EPE and other work incentive benefits, e.g., extended Medicare, when the FO refers the case because work activity was found to be SGA and a SGA cessation (SSA-833-U5) was made, but ODIO/PSC-DRS could not screen out as meeting the currently disabled criteria in DI 28055.020B.

3. Review Standard

1. Use MIRS in any decision to determine whether the individual continues to have a disabling impairment for purposes of continuing entitlement under the work incentive provisions.

2. Do not apply the SGA exception to MIRS in a determination of “impairment severity” during the EPE.

4. New Work Activity Found

If the TWP has not been completed, and work activity is discovered in a MIP or MINE case after medical development has been initiated but before a final decision has been rendered, discontinue the medical development and route the case to the FO via a SSA-408 with remark “Develop work activity and establish TWP if appropriate-Medical CDR for periodic review not necessary at this time, input necessary.”

EXCEPTION: If sufficient medical evidence is currently available to render a final MIRS cessation decision, do so; do not return the case to the FO just to develop for work activity.

If, during medical development of an MIE case, work activity is discovered which is not likely to result in cessation, retain the folder and continue medical development while referring the work issue to the FO for resolution.

B. Related Procedure

1. Application of MIRS

The MIRS applies to any decision that an impairment is no longer disabling.

1. SGA Exception

   When work activity continues at the SGA level following completion of the TWP, the FO applies the SGA exception to medical improvement (MI) to permit a finding that disability ceased. Eligibility for the EPE must also be considered.

   Application of the SGA exception to MIRS requires that the individual must have engaged in SGA in the month for which disability is found to have ceased.

   For Group I or Group II exceptions to MIRS see DI 28020.001.

2. Consider MIRS in making any medical decision that the TWP ends because disability has ceased for any reason other than work.

2. Possible Medical Recovery

Resolve the issue of medical recovery. Evaluate the pertinent medical and vocational evidence, and prepare a determination regarding the continuance or cessation of disability based on applicable statute and regulations. Disability ceases when medical recovery occurs even though the individual may not have used the full 9 months of a TWP.

1. Medical recovery occurs when the medical and vocational evidence establish that the individual's functional capacity is sufficient to enable the individual to engage in SGA and the individual's impairment has medically improved or one of the exceptions to MI is met regardless of whether there has been an actual return to work.

2. Complete promptly any CDR involving a possibility of medical recovery. Document fully your decision and instruct the FO to take any timely suspension action to prevent an overpayment.

3. The following may raise a continuing disability medical issue:

   • Matured Medical Improvement Expected (MIE) Diary, Matured Medical Improvement Possible (MIP) Diary, or Matured Medical Improvement Not Expected (MINE) Diary

   • Additional work and medical evidence required or received which affects entitlement

   • Matured Trial Work Period Diary-Title II only

   • Earnings Reports, Voluntary Reports, or Third Party Reports indicating work activity or possible medical improvement

   • Vocational Rehabilitation Notices

   • Reimbursement for Expenses Incurred During Rehabilitation

3. MIE/MIP/MINE Diaries and Relationship to Work Activity

• Establish MIE diaries in cases based on anticipated medical improvement that will likely result in termination of entitlement after completion of a medical CDR.

• Initiate a medical/work CDR when work activity is reported in a MIE case because medical improvement was expected, unless the beneficiary is eligible for CDR protection (See DI 13010.012)

• Note exception to full medical development in MIE diaried cases for a “clear-cut” cessation per DI 28030.035.

  NOTE: If an MIE diaried case has designated duration requirement (e.g., Listing 6.02B or 7.11), a return to work during this period will not automatically raise a medical issue. A TWP will be granted if otherwise applicable.

• Do not initiate a medical review in MIP or MINE cases when the individual is working until completion of the TWP, unless the individual is eligible for CDR protection. (See DI 13010.012)

  EXCEPTION: If sufficient medical evidence is available to render a final MIRS cessation decision, do so; do not return the case to the FO just to develop work activity.

• If the FO returns a MIP or MINE case at end of TWP because ODIO/PSC-DRS can not screen out, prepare an “impairment severity” medical decision.

4. Miscellaneous Procedure

• Complete the Form SSA-833-U5 in EPE Medical Review Cases per DI 28055.030.

• If the TWP is completed and the FO or ODIO/PSC-DRS did not complete an SGA determination (SSA-833-U5), after your “impairment severity” medical decision, return the folder to the FO for their necessary action on the SGA determination per DI 13010.170.

• Due process instructions are contained in DI 28080.110 through DI 28080.115 and DI 28055.035.

• The FO and ODIO/PSC-DRS evaluate work activity and determine whether it is SGA. FO instructions are contained in DI 13010.000, and ODIO/PSC-DRS instructions are in DI 40510.000.

• Instructions for cessation without full medical development (clear-cut cessations) are contained in DI 28005.205B and DI 28030.035.