DI 28010: Medical Improvement and Related Medical Issues
TN 2 (06-15)
Citations:
A. Introduction to PRTFs in CDRs
A PRTF(s) is required any time severity of a mental impairment(s) is formally assessed using the adult mental disorders listing criteria. Due to the flexible nature of the CDR evaluation process, a few CDR continuances may not involve consideration of any step (or situation) that requires a SSA-2506-BK (PRTF). Because of the wide variety of situations that may occur, it is impractical to list each case situation where a PRTF(s) is (or is not) required. However, for each case situation, a decision as to whether a PRTF(s) is needed can be made by:
Determining which steps in the appropriate CDR sequential evaluation process (DI 28005.010) are involved, and then
Considering the discussion in DI 28010.140C., in this section, related to all of the steps/situations used in arriving at the decision.
It may be necessary to apply the above process more than once to decide whether a PRTF(s) is needed in a particular CDR.
B. When to use the PRTF
Use the PRTF to evaluate the severity of a mental impairment(s) when the adult mental disorders listing criteria apply.
C. Using the PRTF
1. Meets, equals, or non-severe
Use the PRTF at these CDR evaluation steps per DI 28005.005. Consider all mental impairments.
2. Medical improvement (MI)
a. PRTF already in file
A medical/psychological consultant (MC/PC) usually completes a current PRTF before reaching this step. They may reach this step before completing a PRTF (occasionally) when skipping the “meets or equals” step.
b. PRTF usually not needed
MC/PCs do not formally assess severity at the “MI” step but, rather, compare symptoms, signs, and laboratory findings. Therefore, MC/PCs usually do not prepare a PRTF(s) for purposes of this step.
c. When a PRTF is needed at this step
In unusual close-call situations, an MC/PC may wish to use the PRTF as an aid in making the MI decision. When using the PRTF to aid in assessing MI, use two forms:
one for the CPD (may be in file from the CPD), and
one showing current status of (only) the mental impairment(s) present at the time of the CPD (may be in file from the meets/equals step).
While the PRTF may be used as an aid, the MI decision must be based on actual changes (or absence of change) in symptoms, signs, or laboratory findings.
3. Relating MI to ability to work
a. CPD used August 1985 adult mental disorders listings
Use the PRTF to decide whether the impairment(s) present at the time of the CPD continues to meet the August 1985 listing.
b. CPD used pre-August 1985 adult mental disorders listings or the childhood mental disorders listings
Do not use the PRTF for this step.
c. Medical/vocational CPD
As noted in DI 28010.140C.2. in this section, a PRTF(s) is usually completed before this step is reached. If the CPD used a residual functional capacity (RFC) assessment form different from the form used now, the MC/PC may use current and prior PRTFs (especially Section IV, Consultant’s notes) as an aid in judging whether RFC increased.
4. Medical improvement not expected (MINE) continuances
The MINE procedures assume continuing disability under the CPD's basis. Therefore, a PRTF is not needed.
5. Completion of medical disposition (Section I.A)
In situations where there is no appropriate pre-printed block on the PRTF to reflect the CDR disposition (e.g., “no MI”), leave this section blank. Record the CDR medical disposition elsewhere in file (on whatever form the Disability Determination Services (DDS) customarily uses for providing medical comments).
D. References
DI 28005.005 The Continuing Disability Review (CDR) Evaluation Process for Title II and Adult Title XVI Individuals
DI 28010.015 Comparison of Symptoms, Signs, and Laboratory Findings
DI 28040.001 MINE or MINE-Equivalent Cases -- Background