The Social Security review of eligibility for benefits or CDR

Preparing for a Social Security review of disability benefit.

The U.S. Congress passed a law that requires that people receiving Social Security disability benefits have their eligibility reviewed every 3 years or less. When a case is granted, SSA places cases in a specific category such as "medical improvement expected" or "medical improvement not expected." This is an administrative categorization only and is used to assist in handling the large volume of cases scheduled for review. If SSA categorizes a case as "medical improvement not expected", a cursory review is performed only. Other claims are reviewed more thoroughly to determine if the claimant is still qualified to receive monthly benefits.

· Disability Review and the “Medical Improvement Standard”

The review is called a Continuing Disability Review or CDR. When SSA reviews a claim, the regulations require that the benefits be continued unless SSA finds that there was a “medical improvement” in the disabling condition that would allow for a return to “substantial gainful activity” or full-time work.

The regulation concerning termination of benefits indicates that “medical improvement” is required. The regulation states:

Sections 223(f) and 1614(a)(4) of the Act provide that, in general,

if you receive disability benefits under titles II and/or XVI of the

Act, we may find that you are no longer disabled if substantial

evidence shows that there has been medical improvement in your

impairment or combination of impairments, and you are now able to do

substantial gainful activity.

If the case is decided by an Administrative Law Judge, the process is described in the Office of Hearings and Appeals Handbook or HALLEX. It states:

In deciding the issue of medical improvement, I will apply the standard stated in section 223(f) of the Act, and consider:

· whether there has been any medical improvement in your original or related impairment(s) since we last found you disabled and, if so, whether the improvement relates to your ability to work; and

· Whether one of the exceptions to medical improvement stated in the Act and our regulations applies.

If no medical improvement in your original or related impairments relating to your ability to work has occurred and no exception applies, I will find that your disability continues.

· Be wary of the exceptions

The regulations have exceptions that reduce the restrictions on SSA to establish a medical improvement or continue benefits.

Although in a majority of the cases the medical improvement standard is applied, there are a number of exceptions to the requirement.

The first of these exceptions requires a finding that, even though the medical condition still exists, it “no longer results in marked and severe functional limitations. ….or evidence shows that the person should no longer be considered disabled or never should have been considered disabled.” (20 CFR §416.994a) This leaves the medical records open to interpretation. This may be very similar to the file review originally perform and would lift the requirement that the record show a medical improvement.

Exception number two

This exception deals with technological advances in medicine providing the ability to show that the medical condition was not as severe as prior, older and out-dated medical tests could show.

“Substantial evidence shows that, based on new or improved diagnostic techniques or evaluations, your impairment(s) is not as disabling as it was considered to be at the time of the most recent favorable decision.” (20 CFR §416.994a)

Exception number three

This covers benefits obtained fraudulently.

A prior determination or decision was fraudulently obtained. If we find that any prior favorable determination or decision was obtained by fraud, we may find that you are not disabled.

Exception number four

The claimant fails to cooperate with the review.

Exception number five

SSA cannot locate the claimant.

SSA does place an emphasis on the “medical improvement” standard when performing a CDR. Make sure your doctors know that SSA needs a statement from them that indicates the diagnoses and whether there has been a medical improvement sufficient to allow a return to full-time work.

The truth of the matter is only a small percentage of CDR’s result in loss of benefits. It’s important to keep the above information in mind.

Paul Proto