DI 28057.015: Expedited Reinstatement (EXR) Medical Determination Criteria
Effective Dates: 06/25/2015 - Present TN 1 (02-06) DI 28057.015 Medical Determination Criteria A. Introduction The expedited reinstatement (EXR) medical determination process is a two-step process. The individual requesting EXR must be under a disability and meet both of the following criteria to be entitled to reinstatement: * the current impairment(s) must be the “same as or related” to that which formed the basis of the most recent disability entitlement; and * must be under a disability using the medical improvement review standards (MIRS) normally used in a continuing disability review (CDR) to determine this. (See DI 28005.005.) If the final evidence clearly establishes that the individual's current impairment(s) is not the same as or related to the prior impairment(s), a determination regarding medical improvement is not needed. The EXR request should be denied per DI 28057.020B. Unless the evidence clearly establishes that the current impairment(s) is not the “same as or related” to the prior impairment(s), determine that the current impairment is the “same as or related” to the prior impairment. Conduct a medical review using the same medical improvement review standards (MIRS) applicable to continuing disability reviews per DI 28005.001. Standard procedures relative to whereabouts unknown and failure to cooperate will be followed (see DI 28075.005), as necessary. Prepare the necessary personalized language for the notice the FO will issue. B. Policy - Comparison Point Decision (CPD) The most recent favorable medical decision should be used as the CPD when making EXR medical determinations. An intervening medical determination that the individual had medically improved does not prevent an individual from requesting EXR, as long as their previous entitlement was terminated due to SGA (title II) or earned/unearned income (title XVI). The DDS must determine that the individual is disabled under MIRS in the month of the EXR request in order for the individual to qualify for EXR (see DI 28057.015D). Likewise, an individual can request EXR even if a previous EXR request was denied. In cases where a previous EXR medical denial exists, the DDS should use the most recent favorable medical determination as the CPD for making the current EXR medical determination. C. Policy - “Same As or Related” Determination The first criteria is that the current impairment(s) must be determined to be the “same as or related” to that which formed the basis of the most recent disability entitlement. Unless the evidence clearly indicates otherwise, determine that the alleged impairment(s) is the same as or related to the CPD impairment(s). NOTE: While the initial indications in file may be that the current impairment(s) is the same as or related to the prior entitlement impairment(s), the determination in this regard is made when all necessary medical development has been completed. 1. Basis for CPD Determination In an EXR “same as or related” finding, it is irrelevant whether the basis of the CPD determination (i.e., the most recent disability entitlement) was a listing or a residual functional capacity assessment that resulted in a medical-vocational evaluation. Impairments that were material to a medical-vocational allowance, as well as listing level impairments, should be considered. 2. Current Impairment Severity For EXR “same as or related” findings, the current impairment must be the same as or related to the CPD impairment in terms of the anatomy or the type of disease involved, but not necessarily in terms of severity. Severity is assessed after a “same as or related” finding is made. The “same as or related” finding is made first so that SSA can apply the correct standard of review for the case. As the “same as or related” finding is made before the case receives a full medical evaluation, it does not involve a severity determination. 3. Obsolete CPD Listing The relationship between the CPD impairment(s) and the alleged current impairment(s) is relevant; however, the fact that the listing at the CPD is now obsolete is not. An obsolete listing in effect at the CPD can be applied to EXR cases when considering whether the impairment(s) is the “same as or related.” For example, the fact that the obesity listing (9.09) became obsolete in 1999 is irrelevant to the finding that a current impairment could be related to it. 4. Unable to Locate CPD Folder If the individual's prior medical file is missing, accept the individual's allegation that the impairment is the same as or related to the CPD impairment(s). To conduct the EXR medical review, refer to DI 28035.000 for lost folder procedures. 5. Case Examples a. Examples - When a Determination that Current Impairment is the “same as or related” is Appropriate The following are examples of when a determination that the current impairment is the “same as or related” is appropriate: * Ms. Wolf Facts: In 1992, Ms. Wolf began receiving title II disability benefits based on obesity (that met listing 9.09, weight table II) with signs of arthritis in her spine. In June 1999, SSA terminated her benefits because her earnings exceeded SGA. In May 2001, Ms. Wolf requests EXR, alleging that severe pain and deformity in her left hip due to arthritis prevents her from working. She acknowledges that she has been able to lose over 100 pounds and her weight is now in the normal range for her height. Rationale: Arthritic conditions, especially arthritis of weight-bearing joints, are frequently associated with longstanding obesity. Arthritis (or gross anatomical deformity) of the hip would be a plausible long-term result of obesity, even if the obesity were subsequently mitigated by substantial weight loss. Therefore, Ms. Wolf's alleged impairment is considered to be the same as or related to her CPD impairment. The DDS should evaluate the case under the MIRS (DI 28005.000) to determine if she is under a disability and entitled to have benefits reinstated. * Mr. Stone Facts: Mr. Stone requests EXR in March 2001, alleging that complications resulting from a prosthesis for his left leg prevent him from walking well enough to continue working. The prior medical file reveals that in May 1995 Mr. Stone underwent an amputation of the left leg (just below the knee) and received a prosthesis that fit well at the time. In November 1995, Mr. Stone applied for and became entitled to disability benefits. Because of moderate lumbar spinal stenosis, with some intermittent pseudoclaudication in the right leg, Mr. Stone frequently needed to use a cane, especially on rough terrain or distances of one to two blocks. The file shows that lumbar spinal stenosis and the residual effects of the prosthesis contributed to the finding of disability. The DDS had used vocational rule 201.14 to determine that the 51-year-old Mr. Stone was unable to perform other work and was, therefore, disabled. In February 1998, Mr. Stone returned to work after surgical correction of the lumbar stenosis that had essentially eliminated his need to use a cane. In December 1999, his disability benefits were terminated due to SGA. The evidence from his current physician indicates that over the last year, Mr. Stone has developed significant complications in the residual stump from trauma and progressive irritation due to the prosthesis. The physician states that Mr. Stone requires bilateral assistive devices to walk. Rationale: The progressive complications of the prosthesis can be easily traced to the medical impairments involved in the CPD determination. Mr. Stone's current impairments are the same as or related to the CPD impairments. b. Example - When a Determination that Current Impairment is not the “same as or related” is Appropriate The following is an example of when a determination that the current impairment is not the “same as or related” is appropriate: Facts: Ms. Green requests EXR, alleging that she can no longer work because she sustained traumatic brain injury in a recent car accident. The prior medical file indicates that her most recent entitlement to disability benefits ended 18 months ago due to work. The basis for her entitlement (CPD impairment) was thyroid cancer. Rationale: The disability resulting from a traumatic brain injury sustained in a car accident is not associated with the CPD impairment, thyroid cancer. Ms. Green's circumstances, therefore, do not meet the criteria for EXR requests. D. Procedure – Medical Evaluation Determination After determining that the alleged impairment(s) is the same as or related to the CPD impairment, conduct a medical evaluation by applying the same medical improvement review standards (MIRS) and procedures used in continuing disability reviews, including consideration of new impairments at step 6–8, see DI 28010.001 - DI 28010.150. NOTE: In cases involving HIV infection awarded in 1991 or later, continuing disability review (CDR) screen-out policy normally applies. However, CDR screen-out policies do not apply to EXR cases; therefore, the DDS must make a medical determination. For cases that would have been screened-out under DI 28003.005C, the DDS will follow DI 28057.015C to make a “same as or related” determination. If the DDS determines the individual has a same as or related impairment, the DDS will then determine the individual is under a disability, and process the award accordingly (see DI 28057.020D Procedure – Favorable Decision Under MIRS). * Determine an individual is disabled when there is no medical improvement related to the ability to work, no exceptions to MI apply, and the individual is not capable of performing SGA. Establish the proper month of entitlement to determine when benefit payments may begin for title II cases. See DI 28057.015E and DI 28057.015F. * When an individual has experienced medical improvement related to the ability to work and is capable of engaging in SGA, or an exception to MI applies, determine the individual is ineligible for EXR. Group I exceptions to MI require a finding that the individual is capable of engaging in SGA before an unfavorable determination can be made. * To establish retroactive entitlement to title II disability benefits, follow the same procedures used to establish an onset date for initial disability claims. Use: * the same medical evidence used to determine that the impairment(s) is the same as or related to the CPD impairment(s) and that the individual is under a disability; AND * the individual’s allegation that he or she stopped performing SGA (the FO will indicate the month and year the individual requested EXR on the 454, document the SGA/nonSGA months during the 12 month EXR retroactive period on the SSA-820 or SSA-821, and record the SGA determination on the SSA-823 per DI 13050.045B.2.). Document approval and denial determinations per DI 28057.020. Prepare personalized language to be attached to the formal denial notice. The FO and OCO/PC will prepare and issue all award and denial notices related to EXR determinations. E. Policy - Determining Month of Entitlement - Title II Cases When the medical determination is favorable, determine the appropriate month of entitlement: * If it is found that the individual is under a disability and entitled to EXR in the month they file for EXR, benefits may be reinstated retroactively for up to 12 months before the EXR request date, provided all factors of entitlement are met. This includes the requirement that the individual is disabled based on the MIRS standard. * Review the “Remarks” section of the SSA-454 for the month and year of the EXR request. In addition, the FO should indicate in the remarks, “possible retroactivity exists prior to the month of filing-see SSA-823.” Review the SGA determination on the SSA-823 for the earliest month of non-SGA in the 12-month retroactive period. * Establish the month of entitlement to reinstated benefits. Consider the same evidence used to determine that the individual under a disability based on the application of MIRS. The month of entitlement will be: * the month in which the individual requests EXR, or * the first month in the 12-month retroactive period that all factors of entitlement are met, whichever is earliest. NOTE: Retroactive title II disability benefits in EXR cases cannot be paid for any month before January 1, 2001, the effective date of the EXR provisions. * The month of entitlement can be no later than the month of the EXR request. * The individual cannot be engaging in SGA in the month of entitlement. * The individual must meet the MIRS requirements in the month of entitlement. * The month of entitlement cannot be before the benefit termination month (BTM) of the previous entitlement. EXAMPLE: Mr. Smith was previously entitled to SSDI for back problem and his earlier entitlement terminated due to work on 11/03 (BTM Month). In 6/04, Mr. Smith has an accident that reinjures his back and he is unable to work. In 9/04, he decides to file for EXR. When the FO develops the case to send to DDS, they provide a filing date of 9/04 and note the following SGA and non-SGA months in the 12-month retroactive period: SGA Months: 9/03, 10/3, 11/03, 12/03, 1/04, 2/04, 3/04, 5/04 Non-SGA Months: 4/04, 6/04, 7/04, 8/04 The DDS decides that Mr. Smith meets the medical requirements of EXR in the month of filing (9/04). They then look at the first non-SGA month in the retroactive period, which is 4/04. They determine that though Mr. Smith did not perform SGA, he did not meet the MIRS criteria in 4/04. They then look at the next non-SGA month (6/04) and determine that Mr. Smith did meet the MIRS criteria in that month. Therefore, the month of entitlement for EXR is 6/04. F. Policy - Determining Month of Eligibility - Title XVI Cases
- When the medical determination is favorable, determine the appropriate month of eligibility:
* Eligibility for reinstated benefits in Title XVI EXR cases begins with the month following the month in which the individual requests EXR. There is no retroactive eligibility to title XVI payments under EXR. * Title XVI disability benefits in EXR cases cannot be paid for any month before February 2001, the month after the first possible filing month for EXR. G. Policy - Return to Work When an individual returns to work during the processing of the EXR request, contact the FO. Returning to SGA during the provisional payment period will result in termination of title II provisional payments and adjustment of title XVI provisional payments. Normally, an EXR medical determination will still be necessary if the individual did not engage in SGA in the month the EXR request was filed. If the individual engaged in SGA in the month the EXR request was filed, return the case file to the FO. The FO will issue a technical denial, per DI 13050.005A.2.
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