TN 6 (03-04)

A. Policy

When a determination of SGA or SSI countable earned income depends on the deduction of alleged IRWE, the FO must first confirm that:

• the IRWE items or services correlate with the DDS' established medical basis of disability; or

• the IRWE items or services correlate with any medically established impairment(s) being treated by a physician or health care provider. (See DI 10520.010B for the definition of a health care provider.)

In addition, the IRWE must be needed to enable the person to work.

This check on the relationship between the alleged IRWE and the person's impairment(s) should be conducted in both initial and continuing cases.

B. Procedure — Initial Title II, Title XVI, and Concurrent Case

When the deduction of IRWE will affect either the determination of SGA or SSI countable earned income, follow these procedures :

1. Record Alleged IRWE on SSA-821-BK

Complete question 12, Interviewer/Reviewer Checklist by answering yes to question E. for IRWE. In the discussion field record the following items:

• The item or service alleged as IRWE;

• The alleged impairment(s) to which each item or service applies; and

• The cost of each alleged item or service.

2. Complete SSA-831 or Disability Transmittal Screens

Follow established procedures by either entering “IRWE Case” in the SSA-831 remarks section or completing the disability transmittal screens. Forward the case to the DDS for disability determination.

C. Procedure - DDS Approves Disability

If the DDS finds the person disabled, it will complete the disability determination, and will update the case control using the SSA-4648, but will not enter the decisional input on that form. The DDS will return the case to the FO, indicating on the route slip that it is an allowed but untriggered IRWE case.

Compare the alleged IRWE item or service with the diagnosis(es) entered by the DDS on the SSA-831-U5 (see DI 26510.015G for diagnosis codes),

1. DDS Diagnosis correlates with IRWE

• If the alleged IRWE correlates with the person’s impairment(s), establish the need for the item or service and proof of payment per DI 10520.025.

• If correlation, need, and proof of payment are established, make a determination on non-SGA level work and trigger payment for the case by making the proper allowance inputs.

• After payment is triggered, code the VERN screen on the DCF with monthly wages and IRWE amounts.

2. IRWE does not correlate with DDS diagnosis

If the alleged IRWE does not correlate with DDS established diagnosis(es), determine if the person has another impairment that is being treated by a physician or health care provider per DI 10520.020E.

D. Procedure for Continuing Title II, Title XVI, and Concurrent Cases

The procedure for comparing the alleged IRWE with the person's impairment(s) in continuing disability review (CDR) cases is basically the same as that for initial cases.

• Compare the IRWE item or service with the DDS established medical diagnosis(es); see the most recent QMMD screen of the DCF for the primary and secondary diagnosis codes (DI 26510.015G).

• If the alleged IRWE correlates with the DDS established medical diagnosis(es), establish the need for the item or service and proof of payment per DI 10520.025.

• If the alleged IRWE does not correlate with the DDS established diagnosis(es), determine of the person has another impairment that is being treated by a physician or health care provider per DI 10520.020E.

E. Procedure - IRWE Does Not Correlate With DDS Established Diagnosis

If the beneficiary/claimant alleges IRWE for an impairment that has not been established by DDS as a primary or secondary diagnosis, a correlation issue can still be established if:

• the person is being treated by a physician or health care provider for the alleged impairment; and

• the alleged IRWE is needed to enable the person to work.

1. Correlation established by medical file

Obtain and review the medical file for any medical records or statements from a treating physician or health care provider that will confirm:

• the existence of the alleged impairment; and

• the person is being treated by a physician or health care provider for the impairment; and

• the identity of the physician or health care provider.

If correlation is found, follow procedures in DI 10520.020B and DI 10520.020C for adjudicating initial claims. For continuing disability reviews, follow procedure in DI 10520.020D.

2. No correlation established by medical records

When the beneficiary’s or claimant’s alleged IRWE does not correlate with either the DDS diagnosis or medical records in the medical file, ask the beneficiary to provide medical records or a statement from the treating physician or health care provider that establishes correlation.

If the beneficiary is unable to provide documentation, contact the physician or health care provider directly to determine if the person is being treated for the alleged impairment and that the alleged IRWE is needed due to the impairment.

• Obtain a signed SSA-827 from the beneficiary.

• Use a request for information form SSA-L732.

• Include customized language that fits the person’s case.

For example: “(Beneficiary name) has reported that he/she (takes/uses item or service) due to (impairment(s)) in order to work. We need your assistance to determine if we can deduct the cost of these items from his/her countable earnings. Attached is a signed release of information.

1) Are you currently treating (beneficiary name) for (impairment(s)? (Yes or no checkbox.)

2) Are you prescribing or providing the following due to this/these impairment(s)? List items or services. (Yes or no checkbox.)”

If no medical records or statements are provided to establish correlation, consult the regional office before disallowing the IRWE. If the regional office should require any assistance in making the IRWE determination, it may contact DCRDP, OPDR, Employment Policy Team.