I-5-4-51.Schoolcraft v. Shalala

Table of Contents
I Purpose
II Background
III Guiding Principles for Identifying Individuals Entitled to Schoolcraft Relief
IV Processing and Adjudication
V Case Coding
VI Inquiries
Attachment 1 - Schoolcraft v. Sullivan Stipulation; Approved and Entered by the District Court on October 28, 1994.
Attachment 2 Published version of the Regional Program Circular, dated August 5, 1994.
Attachment 3 - Flag Attached to DDS-Identified SchoolcraftClaims to Be Coded Into the OHA Case Control System (OHA CCS).
Attachment 4 - Flag Attached to OHA-Associated Potential Schoolcraft Claims to be Forwarded to ODIO After Agency/Judicial Action is Completed.

ISSUED: November 30, 1995


I. Purpose


This Temporary Instruction (TI) is being issued to advise OHA adjudicators of the parties' stipulation and order for settlement of the Schoolcraft v. Shalala class action complaint. The TI distributes a copy of the parties' settlement agreement and a copy of the published version of the Regional Program Circular entitled Evaluation of Substance Addiction Disorder Cases; Explanation of Current Policy, which is also an attachment to the settlement agreement. With the program circular, the Office of Disability's Division of Medical and Vocational Policy has clarified, primarily for the benefit of the Minnesota Disability Determination Services (DDS), the Agency's standard for evaluating title II and title XVI disability claims involving allegations of alcoholism and drug addiction.


The settlement agreement affects only the claims of current Minnesota residents. However, all adjudicators should be familiar with the Agency's policy for evaluating title II and title XVI disability claims involving allegations of alcoholism and drug addiction, as set forth in the program circular.


OHA is issuing this TI pursuant to the Schoolcraft settlement. The TI is not a part of the Agency's implementation of the drug addiction and alcoholism (DAA) provisions of the Social Security Independence and Program Improvements Act of 1994 (Public Law 103-296). However, adjudicators are advised that the DAA provisions have full force and effect when implementing the Schoolcraft settlement.


II. Background


On January 25, 1990, plaintiffs filed a complaint alleging that, pursuant to Adams v. Weinberger, 548 F.2d 239 (8th Cir. 1977), at step three of the sequential evaluation, the Secretary of Health and Human Services (the Secretary) and the State of Minnesota (the State) are also or alternatively required to consider “whether the claimant is addicted to alcohol and has lost the voluntary ability to control its use.” Plaintiffs argued that Adams established an alternative to Listing section 12.09, which OHA adjudicators employed but the Minnesota DDS allegedly did not. Plaintiffs proposed that the court certify a class that would include all title II and title XVI disability claimants in Minnesota who had not received a hearing decision. For relief, plaintiffs requested that the Secretary and the State be compelled to apply the same disability evaluation standard at each stage of the administrative process.


On January 3, 1991, the district court entered summary judgment for the Secretary and the State, finding that it did not have subject matter jurisdiction because of the three named plaintiffs' failure to exhaust their administrative remedies (Schoolcraft v. Sullivan, 753 F. Supp. 1478 (1991)). The court refused to waive the exhaustion requirement because plaintiffs did not dispute the Secretary's argument that they would receive what they alleged to be the proper standard of review if they appealed their adverse DDS determinations to OHA. In dismissing plaintiffs' complaint, the court relied in part on the Third Circuit's similar decision in Petition of Sullivan (Wilkerson), 904 F.2d 826 (1990).


On July 2, 1992, the United States Court of Appeals for the Eighth Circuit held that the district court had erred in granting summary judgment in the Secretary's and the State's favor and dismissing the class action complaint for lack of subject matter jurisdiction (Schoolcraft v. Sullivan, 971 F.2d 81 (1992)). Determining that plaintiffs had met all the necessary requirements for the judicial waiver of the exhaustion of administrative remedies requirement, the circuit court held that the Federal courts did have subject matter jurisdiction to hear plaintiffs' complaint. In remanding the case to the district court for resolution of the merits, the court suggested that perhaps the parties could settle their dispute. The court further suggested that the Secretary consider entering into a consent judgment if “plaintiffs are correct in asserting that the Secretary has failed to properly instruct the state officials to do what the Secretary agrees should be done.” The court ordered the district court to rule on plaintiffs' motion for class certification and instructed that class certification should relate back to the class complaint filing date.


On October 9, 1992, the court of appeals denied the Secretary's and the State's petition for rehearing with suggestion for rehearing in banc. The parties subsequently commenced settlement negotiations regarding the merits of plaintiffs' complaint and, at the same time, jointly pursued Supreme Court review of the jurisdictional issues. On January 18, 1994, the Supreme Court denied the parties' joint petition for certiorari, which had requested the Court to: 1) vacate the July 2, 1992 court of appeals decision; 2) instruct the court of appeals to vacate the January 3, 1991 district court judgment; and 3) instruct the court of appeals to remand the case to the district court for consideration of the parties' January 5, 1994 settlement proposal (Shalala v. Schoolcraft, 62 U.S.L.W. (January 18, 1994)). As a result of the Supreme Court's action, the July 2, 1992 court of appeals decision and order, remanding Schoolcraft to the district court for resolution of the merits, remained in effect.


In April 1994, the parties agreed to seek the district court's approval of the January 5, 1994 settlement proposal that they had attached to their joint petition for certiorari.


While there was no evidence to support plaintiffs' allegations, in an effort to settle the case, SSA agreed to publish a Regional Program Circular entitled Evaluation of Substance Addiction Disorder Cases; Explanation of Current Policy. Paragraph 1.c. of the settlement agreement provided that SSA would distribute the program circular to all adjudicators, quality assurance personnel, and medical and psychological consultants at the Minnesota DDS, and to all SSA personnel who have any responsibility for reviewing determinations issued by the Minnesota DDS. Even though OHA adjudicators did not expressly fall within the list of distributees, OHA agreed that it would distribute the program circular to OHA adjudicators.


On June 30, 1994, the parties signed the proposed stipulation for settlement. On August 5, 1994, SSA issued the program circular in accordance with the parties' agreement. On October 12, 1994, OHA issued a memorandum to the OHA adjudicators of disability claims of Minnesota residents for the purpose of providing that limited group of adjudicators with an informational copy of the August 5, 1994 program circular. On October 28, 1994, the district court approved the parties' stipulation of settlement and entered a judgment dismissing the action, but reserving the question of plaintiffs' entitlement to attorneys' fees under 42 U.S.C. § 1988 and 28 U.S.C. § 2412(d)(1)(A).


The parties' June 30, 1994 stipulation, which attaches the program circular, is reproduced in Attachment 1. The August 5, 1994 published version of the program circular is reproduced in Attachment 2.


III. Guiding Principles for Identifying Individuals Entitled to Schoolcraft Relief


A class was not certified in Schoolcraft. Individuals who are entitled to a review of a prior claim pursuant to the settlement provisions are, therefore, referred to as "Schoolcraft claimants."


Under the Schoolcraft stipulation, individuals may be entitled to a review of a prior claim if:


  • they resided in the State of Minnesota at the time that they received an adverse determination on their title II or title XVI claim for disability benefits (including a claim for continuing benefits), and they currently reside in Minnesota; and

    
    

  • they received the adverse determination from the Minnesota DDS at the initial or reconsideration level on or after November 20, 1989, through and including August 4, 1994; and

    
    

  • their alleged or established disability was based, either in whole or in part, on a substance addiction disorder; and

    
    

  • the adverse determination by the Minnesota DDS became the final decision of the Secretary, i.e., their claim was not reviewed and decided by an Administrative Law Judge, the Appeals Council (or in Federal court) or under the terms of another court case; and

    
    

  • they file a subsequent claim under title II and/or title XVI of the Act alleging disability based in whole or in part on an allegation of substance addiction and are allowed on any ground or the claim is allowed and substance addiction is listed as a primary or secondary impairment and:

    
    

    • the subsequent claim was allowed on any ground on or after November 20, 1989, and the claimant contacts SSA to request review of the potential Schoolcraft claim within one year of SSA's April 20, 1995 poster notice (i.e., not later than April 19, 1996); or

      
      

    • the subsequent allowance claim is filed within one year of SSA's April 20, 1995 poster notice (from and including April 20, 1995, through and including April 19, 1996).

      
      

      NOTE:

      A claimant is still entitled to a Schoolcraft review if the claimant is no longer a Minnesota resident but resided in Minnesota at the time that ODIO or the DDS determined that he or she was entitled to review.

      
      

Individuals are not entitled to Schoolcraft relief, i.e., a redetermination, if:


  • they do not currently reside in the State of Minnesota (unless the above “NOTE” applies);

    
    

  • they did not reside in the State of Minnesota at the time their disability claim was denied or terminated;

    
    

  • their claim for disability benefits was not based on a substance addiction disorder;

    
    

  • they appealed their disability claim to OHA;

    
    

  • their title II or title XVI application for disability benefits was not denied or terminated on or after November 20, 1989, and before August 5, 1994; or

    
    

  • they cannot show good cause for failing to file an application for disability benefits or, if currently entitled, do not request Schoolcraft review before April 19, 1996, i.e., within one year of SSA's April 20, 1995 poster notice.

    
    

IV. Processing and Adjudication


A. Minnesota DDS Claims


Prior claims that were appealed to OHA are not entitled to Schoolcraft relief. The Minnesota DDS has exclusive jurisdiction for determining whether to reopen a prior determination (Schoolcraft claim). Once reopened, a revised determination will be issued and will be an initial determination under 20 CFR §§ 404.902 and 416.1402 and will be fully appealable (see Part IV. A. 3. below). If the DDS decides not to reopen the Schoolcraft claim, the claimant may ask the DDS to reconsider its decision but may not appeal further. The Office of Disability and International Operations (ODIO) will, based on computer-generated alerts, locate and retrieve inactive title II and title XVI claim files for the purpose of screening and determining entitlement to Schoolcraft review. The Minnesota DDS is responsible for screening all claims outside of ODIO's screening jurisdiction, e.g., reconstructed cases, res judicata denial cases and cases pending in the DDS. ODIO will forward inactive claims that are potential Schoolcraft reopenings to the DDS for processing and possible reopening. If there is a subsequent claim pending at OHA or in Federal court, ODIO will forward the prior Schoolcraft claim and alert package to OHA for association and possible consolidation with the pending subsequent claim.


1. Minnesota DDS Screening and Notices


  1. Although ODIO will screen cases for determining entitlement to Schoolcraft review under usual circumstances, the DDS will screen cases that are reconstructed, cases that involve res judicata considerations, and cases that involve a pending claim at the DDS level.

    
    
  2. The DDS will send notices to individuals whose prior determinations were not made in a manner consistent with the Schoolcraft program circular (and were not appealed to OHA).

    
    

  3. The DDS will also send notices to individuals who requested a Schoolcraft review of their prior claim(s) and are determined to be not entitled to such a review.

    
    

2. Minnesota DDS Flagging of Cases for Hearing Office (HO) Coding


If a claimant requests Schoolcraft review of a prior claim by the April 19, 1996 deadline, but is not currently receiving benefits and does not have a current claim pending at any level, an SSA field office will accept a new application for benefits and forward it to the Minnesota DDS for adjudication. If the claim results in a reconsideration-level denial, the DDS will attach a Schoolcraft Reconsideration Denial Flag to the front of the claims folder. The flag will serve as an alert to HO personnel that special OHA Case Control System (CCS) coding is necessary (as explained in Part V. below). The coding will allow SSA's Litigation Staff to computer-identify these claims if they are subsequently allowed at the OHA level. A copy of the Schoolcraft Reconsideration Denial Flag is reproduced in Attachment 3.


3. Schoolcraft Review Appeal Rights


If the DDS decides to reopen a Schoolcraft claim, it will issue a revised determination which will be an initial determination under 20 CFR §§ 404.902 and 416.1402. Such determinations are fully appealable through administrative and judicial levels of review. If the DDS decides not to reopen the Schoolcraft claim, the claimant may request the DDS to reconsider its decision, but the claimant may not appeal further; i.e., the DDS decision not to reopen is not appealable to OHA.


4. Administrative Finality of DDS Determinations


The Schoolcraft stipulation provides that if a claimant files a title II claim that would ordinarily be denied on the grounds of res judicata, based on a final medical or vocational denial or termination of benefits, and the result is that the claimant no longer meets the insured status requirement, the DDS will review the prior denial or termination as if the claimant's new application had been allowed. If the DDS determines that the prior denial or termination was in accordance with Schoolcraft, SSA will give the prior denial or termination its ordinary preclusive effect.


B. Consolidation of Schoolcraft Claim with Pending OHA Claim


As indicated above, the Minnesota DDS has exclusive jurisdiction for determining whether to reopen a prior determination on a Schoolcraft claim. However, if a current claim is pending or stored at OHA, and the issue of Schoolcraft relief is not yet ripe because of the lack of a final allowance on a subsequent claim, ODIO will forward the prior potential Schoolcraft claim and alert package to the Class Action Coordinator in the Office of Appellate Operations (OAO) at OHA Headquarters to coordinate association and possible consolidation with the current claim. ODIO will also forward the prior potential Schoolcraft claim and alert package to the OAO Class Action Coordinator if there is a current claim pending in Federal court. Because of the unique “subsequent allowance” requirements, the OHA association and consolidation instructions should involve only a very limited number of cases.


1. Alerts Sent to OHA for File Association


When a potential Schoolcraft claimant has a current claim pending or stored at OHA, ODIO will forward the alert to:

 

Office of Hearings and Appeals
Office of Appellate Operations
One Skyline Tower, Suite 701
5107 Leesburg Pike
Falls Church, VA 22041-3200

Attn: OAO Class Action Coordinator

The OAO Class Action Coordinator is responsible for controlling and reconciling the disposition of Schoolcraft alerts shipped to OHA for association with pending or stored claims. The OAO Class Action Coordinator will maintain a record of all alerts received and the location, if any, to which alerts are transferred. This information will be necessary to do the final case processing reconciliation.


  1. If the current claim is located in OHA Headquarters, the OAO Class Action Coordinator will forward the alert and prior claim file to the appropriate OAO branch for association with the current claim. (Part IV. B. 2. c. below provides instruction to the OAO branches regarding the action to be taken if they receive an alert package from the OAO Coordinator but no longer have a current claim pending.)

    
    

  2. If the current claim is located in an HO, the Coordinator will forward the alert and prior claim file to the HO for association with the current claim. (Part IV. B. 2. b. below provides instructions to HOs regarding the action to be taken if they receive an alert package from the OAO Coordinator but no longer have a current claim pending.)

    
    

  3. If the current claim is pending in court, the Coordinator will forward the alert and prior claim file to the appropriate OAO Court Case Preparation and Review Branch (CCPRB) for association with the claim file(s) (or court transcript).

    
    

  4. If the OAO Class Action Coordinator (or his designee) is unable to locate the current claim file within OHA and the current claim is not pending in court, the Coordinator (or his designee) will broaden the claim file search and arrange for alert transfer or folder reconstruction, as necessary.

    
    

2. Association


  1. General Instructions

    
    

    The receiving component will associate the alert and the potential Schoolcraft claim file with the current claim and attach a Schoolcraft flag (see Attachment 4).

    
    

    Because the issue of Schoolcraft relief may not ripen until administrative and/or judicial action on the current claim becomes final, OHA will not be involved in screening for entitlement to relief. Additionally, in most cases, OHA will not take any substantive action on the prior claim; i.e., will not consolidate the prior claim with the current claim and issue a decision on the combined claims. The only exception to this is the situation in which OHA is prepared to issue a decision on the current claim which would be fully favorable with respect to the prior claim, and if the prior claim could be reopened and adjudicated under the normal rules of administrative finality. If such action is possible, OHA will so act. Otherwise, OHA will take the association and flagging action with respect to the potential Schoolcraft claim and adjudicate the current claim only.

    
    

  2. If the receiving component is an HO and no longer has the current claim file, it will return the alert and the potential Schoolcraft claim file to the OAO Class Action Coordinator at the following address and advise the Coordinator of the action taken on the current claim and its destination.

     

    Office of Hearings and Appeals
    Office of Appellate Operations
    One Skyline Tower, Suite 701
    5107 Leesburg Pike
    Falls Church, VA 22041-3200

    Attn: OAO Class Action Coordinator

    The Coordinator will determine the current claim file location and forward the alert and the potential Schoolcraft claim file to that location for further processing action.

    
    

  3. If the receiving component is an OAO branch and no longer has the current claim file (and it is not located in mini-dockets or an OAO docket and files branch), it will determine the location of the current claim file. If the current claim is located within OHA, the OAO branch will forward the alert and any accompanying prior claim file(s) to the current OHA location. If the files are no longer in OHA, the OAO branch will forward the alert and any accompanying prior claim files(s) to the non-OHA location of the current claim and request that the file(s) be forwarded to ODIO for processing. The OAO branch will advise the OAO Class Action Coordinator of its actions.

    
    

3. Consolidation When a Favorable Decision on the Pending Claim Results In a Fully Favorable Decision with Respect to the Schoolcraft Claim


If an Administrative Law Judge (ALJ) or the Appeals Council consolidates the potential Schoolcraft claim with the current claim for the purpose of issuing a fully favorable decision with respect to the Schoolcraft claim, the ALJ or Appeals Council will:


  • notify the claimant, and representative, if any, that the decision on the current claim also resolves the Schoolcraft claim; and

    
    

  • forward a copy of the decision to:

     

    Office of Hearings and Appeals
    Office of Policy, Planning and Evaluation
    Division of Litigation Analysis and
    Implementation (DLAI)
    One Skyline Tower, Suite 702
    5107 Leesburg Pike
    Falls Church, VA 22041-3255

    Attention: Schoolcraft Coordinator

    DLAI will forward a copy of the decision to the OAO Class Action Coordinator and to Litigation Staff at SSA Central Office.

    
    

V. Case Coding


At the time DDS-identified Schoolcraft claims are received in OHA based on a claimant's request for a hearing, HO personnel will code them into the OHA Case Control System (OHA CCS) by entering the letter “A” into the “SPC” field. The DDS-identified claims will be “flagged” by the DDS with the attachment that is reproduced in these instructions as Attachment 3. It is not necessary, for purposes of complying with these instructions, to enter a special identification code into the Hearing Office Tracking System (HOTS).


VI. Inquiries


HO personnel should direct any questions to their Regional Office. Regional Office personnel should contact the Division of Field Practices and Procedures in the Office of the Chief Administrative Law Judge at (703) 305-0022. Headquarters personnel should direct questions to the Division of Litigation Analysis and Implementation at 305-0708.


Attachment 1. - Schoolcraft v. Sullivan Stipulation; Approved and Entered by the District Court on October 28, 1994.





UNITED STATES DISTRICT COURT
DISTRICT OF MINNESOTA
FOURTH JUDICIAL DISTRICT

Daniel J. Schoolcraft and Joseph L.  
Drumbeater, individually and on behalf of  
all others similarly situated,  
   

Plaintiffs

 
   
v. STIPULATION
   
Donna E. Shalala, Secretary of the Civil File No. 4-90-53
Department of Health & Human Services,  
and  
Walter Roers, in his official capacity  
as director of the Disability  
Determination Services,  
and  
R. Jane Brown, in her official capacity  
as Commissioner of the Minnesota  
Department of Jobs and Training  
   

Defendants

 
  1. Standards.

    
    

    1. The Social Security Administration (SSA) will issue a Program Circular (hereafter Circular) to clarify the evaluation of claims for disability benefits under Title II or Title XVI of the Social Security Act based in whole or in part on allegations of a substance addiction disorder.

      
      

    2. The Circular is reproduced as Attachment 1 and is hereby incorporated in this agreement.

      
      

    3. The purpose of the Circular is to clarify, not to supersede, existing regulations and provisions of the Program Operations Manual System (POMS) SSA will distribute the Circular to all adjudicators, quality assurance personnel, and medical and psychological consultants at the Minnesota Disability Determination Services (DDS). SSA will also distribute the Circular to all SSA personnel, including quality assurance personnel, who have any responsibility for overseeing or reviewing decisions made by the DDS. SSA will issue and distribute the circular to the DDS and SSA personnel no later than 45 days after the date on which the parties or their representatives have signed this agreement, and SSA will instruct the DDS to apply the Circular to all claims pending at the DDS on the date the Circular is issued.

      
      

    4. SSA represents that it has no present intention to revise the Circular.

      
      

    5. SSA agrees that the Circular will remain in effect with respect to the determination by the DDS of all claims filed in Minnesota for disability benefits under Title II or Title XVI of the Social Security Act based in whole or in part of allegations of a substance addiction disorder for a period of two years after the date on which the notice described below in paragraph 5 is posted, unless and until there is an intervening change in federal law or regulations that requires a revision of the Circular.

      
      

    6. Notwithstanding paragraph (e) above, SSA agrees that the Circular will be used by the DDS when determining the relief to which Schoolcraft claimants are entitled under paragraphs (2) (a) through (2) (g) below, unless and until there is an intervening change in federal law or regulations that requires revision of the Circular.

      
      

  2. Relief.

    
    

    1. The DDS will review, under the Circular, certain initial and reconsideration determinations denying or terminating disability benefits that were not appealed to the Office of Hearings and Appeals in SSA. This review will be available to all Minnesota residents, hereafter referred to as Schoolcraft claimants, who:

      
      

      1. (A)On or after November 20, 1989, and before March 1, 1990, received one or more binding determinations by the DDS denying or terminating disability benefits on medical or vocational grounds, as to which substance addiction was listed as a primary or secondary impairment; or (B) on or after March 1, 1990, and before the date of the issuance of the Circular, received one or more binding determinations by the DDS denying or terminating disability benefits on medical or vocational grounds, (1) as to which substance addiction was listed as a primary or secondary impairment, or (2) which, in accordance with SSA's teletype to DDSs dated February 28, 1990, received listing code 430 because of an allegation of substance addiction; and either

        
        

      2. Filed a claim for disability benefits under Title II or Title XVI of the Social Security Act (or both) within one year after the date on which the notice described below in paragraph 5 is posted in Social Security offices and copies made available to the Minnesota Department of Human Services and to counsel for plaintiffs, and are found disabled, if (A) the claim is based in whole or in part on an allegation of substance addiction and allowed on any ground or (B) the claim is allowed and substance addiction is listed as a primary or secondary impairment; or

        
        

      3. Filed a claim for disability benefits and were found disabled on or after November 20, 1989 -- if (A) the claim is based in whole or in part on an allegation of substance addiction and allowed on any ground or (B) the claim is allowed and substance addiction is listed as a primary or secondary impairment -- and contact SSA to request review of the prior denial within one year after the date on which the notice described below in paragraph 5 is posted in Social Security offices and copies provided to the Minnesota Department of Human Services and to counsel for the plaintiffs.

        
        

    2. The one-year period referred to in paragraphs (a) (ii) and (a) (iii) above is, for an additional period of one year, subject to waiver for good cause -- i.e., if the claimant shows that he or she was out of the State during the entire one-year period.

      
      

    3. If a Schoolcraft claimant files a Title II claim that would ordinarily have to be denied on grounds of administrative res judicata based on a final medical or vocational denial or benefit termination, as described in paragraph (a) (i) above, that resulted in the claimant's no longer meeting Title II insured-status requirements, the DDS will review the prior denial or benefit termination in accordance with paragraph (e) below as if the claimant's new application had been allowed. If the DDS determines that the prior denial or benefit termination was made in accordance with the Circular, that prior denial or benefit termination will be given its ordinary preclusive effect.

      
      

    4. SSA is not required, in reviewing prior determinations denying or terminating benefits under the Circular, to apply any future amendments to listing 12.09, (20 C.F.R. Subpart P, APP. 1).

      
      

    5. The DDS will review the prior determinations by the DDS denying or terminating the disability benefits of Schoolcraft claimants to determine whether the prior determinations were made in accord with the Circular. The DDS will consider whether the determination or the development of evidence did not comply with the requirements of the Circular. If a Schoolcraft claimant has received more than one final prior determination denying or terminating benefits within the relevant time frame, the DDS will review each prior determination.

      
      

    6. If the DDS determines that a prior determination denying or terminating benefits did not comply with the requirements of the Circular as specified in paragraph (e) above, it will reopen the prior determination. The DDS will notify the claimant that the prior determination has been reopened and that the claimant may submit new and additional evidence relating to the period for which the prior claim was made. The notice will take the form set forth in Attachment 2. The DDS will gather and develop new evidence in accord with the requirements of the Circular, and will issue a revised determination. The revised determination will be an initial determination under 20 C.F.R. §§ 404.902 and 416.1402 and will be fully appealable. DDS will provide notice of the revised determination to the claimant. The notice will be the standard notice of revised determinations provided by DDS, except that if the revised determination sustains the prior determination, the notice will advise the claimant of the identity and telephone number of counsel for plaintiffs, substantially in the manner set forth in Attachment 3.

      
      

    7. If the DDS decides not to reopen the prior determination under paragraph (f) above, it will give the claimant written notice of the decision not to reopen. The notice will take the form set forth in Attachment 3. The claimant may ask the DDS to reconsider its decision not to reopen a prior determination. If, on reconsideration, the decision not to reopen remains unchanged, the claimant may not appeal further.

      
      

  3. Instructions to DDS. SSA will issue instructions to the DDS to implement the terms of this agreement. SSA will provide counsel for the plaintiffs with a draft of these instructions within 120 days after the date on which the parties sign this agreement. SSA will make a good faith effort to issue final instructions within 45 days of receiving comments and suggestions from counsel for the plaintiffs. The issuance of the instructions, however, is contingent upon, and will occur only after, the District Court enters a judgment dismissing the action in accordance with this agreement. SSA will give counsel for the plaintiffs a copy of the instructions to the DDS, and any subsequent revisions to the instructions. The DDS will not review any prior determinations of Schoolcraft claimants until the instructions have been issued.

    
    

  4. Data. SSA will, to the extent allowed by privacy laws, provide counsel for plaintiffs with the following data on a quarterly basis, beginning with the first full quarter after the date on which the poster notice described in paragraph (5) below is made available to counsel for plaintiffs:

    
    

    1. SSA will provide the following data regarding Schoolcraft claimants for each quarter until DDS has completed review of all prior denials or terminations under paragraph (2) (e) above, not including review of any claims made after expiration of the one-year period pursuant to paragraph (2) (b) above:

      
      

      1. the number of persons who have been identified as Schoolcraft claimants pursuant to paragraph (2) (a) ;

        
        

      2. of the persons described in (i) above, the number of persons who do not, under paragraph (2) (e) above, require a review of the prior determination denying or terminating benefits described in paragraph (2) (a) (i) because that prior determination changed to an allowance or continuation of benefits in the course of adjudicating a subsequent claim that was allowed;

        
        

      3. of the persons described in (i) above, the number of persons who do, under paragraph (2) (e) above, require a review of the prior determination denying or terminating benefits described in paragraph (2) (a) (i);

        
        

      4. the number of persons for whom a prior determination denying or terminating benefits described in paragraph (2) (a) (i) has been reviewed under paragraph (2) (e) above;

        
        

      5. v. of the persons described in (iv) above, (A) the number of persons for whom the prior determination denying or terminating benefits was changed to an allowance or a continuance of benefits, and (B) the number of persons for whom the prior determination was not so changed;

        
        

      6. of the persons described in both paragraph (v) (A) and paragraph (v) (B) above, a further breakdown of the number of persons for whom substance addiction was coded as a primary impairment, the number of persons for whom substance addiction was coded as a secondary impairment, and the number of persons for whom substance addiction was coded as the only impairment;

        
        

      7. the number of persons with respect to whom DDS has reconsidered a decision not to change a prior determination denying or terminating benefits described in paragraph (2)(a)(i) to an allowance or continuation of benefits;

        
        

      8. of the persons described in paragraph (vii), (A) the number of persons with respect to whom, upon reconsideration, the prior determination was changed to an allowance or a continuance of benefits, and (B) the number of persons with respect to whom, upon reconsideration, the prior determination was not so changed;

        
        

      9. of the persons described in both paragraph (viii) (A) and paragraph (viii) (B) above, a further breakdown of the number of persons for whom substance addiction was coded as a primary impairment, the number of persons for whom substance addiction was coded as a secondary impairment, and the number of persons for whom substance addiction was coded as the only impairment.

        
        

    2. In addition to the data described in paragraph (a) above, SSA will provide the following data for eight quarters:

      
      

      1. the number of initial decisions and the number of reconsideration decisions by the DDS in which substance addiction was coded as a (A) primary or (B) secondary or (C) the only impairment, with a further breakdown indicating the number of initial decisions and the number of reconsideration decisions in categories (A), (B), and (C);

        
        

      2. of the number of initial decisions and the number of reconsideration decisions described in (i) above, and for each of the three categories described in (i) above, the number of decisions which allowed benefits and the number of decisions which denied benefits.

        
        

  5. Notice of Relief Available Under This Agreement.

    
    

    1. SSA will develop a poster to notify potential Schoolcraft claimants of their rights under this agreement. SSA will draft the poster, and give counsel for the plaintiffs an opportunity to provide input as to the content and design of the poster.

      
      

    2. SSA will display one or more posters in all SSA field and hearing offices and in the DDS offices in Minnesota.

      
      

    3. SSA will provide two hundred copies of the poster to counsel for the plaintiffs.

      
      

    4. SSA will provide two hundred copies of the poster to the Minnesota Department of Human Services and will ask the Department to distribute the posters to each local welfare office in the State of Minnesota for posting.

      
      

    5. SSA will complete the actions described in paragraphs (a) through (d) above within 10 days after the date on which it issues the instructions described in paragraph (3) above.

      
      

  6. District Court Approval. This agreement is conditioned upon approval of this agreement by the district court. The parties will jointly submit this stipulation to the district court and move for entry of judgment dismissing the action in accordance with this agreement.

    
    

  7. Attorney's Fees. The parties reserve the question of attorney's fees. The dismissal of this action pursuant to this agreement does not waive any claims for attorney's fees by plaintiffs or any defenses against such claims by defendants, including the defense that plaintiffs are not entitled to fees under 42 U.S.C. 1988. Furthermore, it is the intention of the parties that dismissal of this action pursuant to this agreement will not deprive the district court or the court of appeals of jurisdiction to entertain an application for attorney's fees.

    
    

  8. Dispute Resolution and Modification of the Agreement. The parties will attempt to resolve any disputes arising under this agreement by negotiation between counsel or their designees. Counsel for the parties may agree to modify this agreement:

    
    

  9. Admissions. This agreement is not and shall not be construed as an admission by the defendants of the truth of any allegation or the validity of any claim asserted in this action or of the defendants' liability therein, nor is it a concession or an admission of any fault of omission in any act or failure to act, or in any statement, communication, report, instruction, rule, regulation or other document or computer data, record or program made or maintained by the defendants, nor shall this agreement nor any of the terms hereof be offered or received in evidence or in any way referred to in any civil, criminal, or administrative action or proceeding other than such proceedings that arise under or may be necessary to consummate or enforce this agreement, nor shall it be construed by anyone for any purpose whatsoever as an admission or presumption of any wrongdoing on the part of the defendants, nor an admission by any party that the consideration given hereunder represents the relief which could be recovered after trial or that the scope of the relief provided in this agreement could be ordered by the District Court without the consent of the defendants.

* * * * *

Three attachments follow and are part of this agreement.


Attachment 1.


Office of Disability
Division of Medical and Vocational Policy


__________________________________________________

REGIONAL SSA PROGRAM CIRCULAR -- Chicago Region

__________________________________________________

EVALUATION OF SUBSTANCE ADDICTION DISORDER CASES .

EXPLANATION OF CURRENT POLICY

In connection with the Schoolcraft court case, SSA has agreed to reexamine certain prior claims for benefits under title II or title XVI of the Social Security Act (disability benefits) based in whole or in part on allegations of substance addiction disorders. This program circular (PC) is being issued to all adjudicators, quality assurance personnel, and medical and psychological consultants in the Minnesota Disability Determination Services (DDS) to clarify how alcoholism and related drug addiction cases are to be evaluated in Minnesota in light of the settlement agreement in Schoolcraft and the definition of disability contained in the Social Security Act.


Under the law, disability is defined as the inability to do any substantial gainful activity (SGA) by reason of any medically determinable physical or mental impairment which has lasted or can be expected to last for a continuous period of not less than 12 months, or to result in death. As with any other medical condition, for a substance addiction disorder to be disabling under the law, it must be a medically determinable impairment that meets the duration requirement and produces significant functional limitations that preclude the performance of substantial gainful work, either alone or in combination with other impairments.

  ______________________________
  Destruction Date: To be announced in the Schoolcraft court case POMS instructions (future publication). Distribution: All adjudicators, quality assurance personnel, medical and psychological consultants in the Minnesota DDS; SSA personnel, overseeing/reviewing decisions made by the Minnesota DDS (DPB, OPIR, ODIO).

We are continuing to evaluate experience from ongoing quality review and operating experience to determine whether there is a need to change or refine our rules for adjudicating substance addiction disorder claims.


This PC discusses existing policy in terms of the statutory requirements and provides answers to some frequently asked questions. In this PC, the terms “substance addiction disorder” and “alcoholism or other drug addiction disorder” are used interchangeably.


  1. Can a substance addiction disorder be considered a medically determinable impairment that could satisfy the definition of disability?

    
    

    Yes. A substance addiction disorder, in and of itself, can be a disabling medically determinable impairment if it satisfies the requirements of the Social Security law. No additional physical or mental impairment (e.g., irreversible organ damage) is required for a finding of disability. As with any impairment, a diagnosis, alone, cannot be the sole basis for finding disability.

    
    

    A medically determinable substance addiction disorder is established when behavioral changes or physical changes associated with the regular use of substances that affect the central nervous system are documented. According to the “Diagnostic and Statistical Manual of Mental Disorders (Third Edition - Revised)” (DSM-III-R), some examples of these changes include:

    
    

    • using the substance in larger amounts or over a longer period of time than intended;

      
      

    • continued use of the substance despite the presence of a persistent or recurrent social, occupational, psychological, or physical problem that the person knows may be exacerbated by that use;

      
      

    • unsuccessful attempts to reduce or cease use of the substance (e.g., repeated detoxification treatments);

      
      

    • the development of severe withdrawal symptoms (e.g., agitation, hallucinations, and vomiting) following cessation or reduction in use of the substance.

      
      

    Once a medically determinable substance addiction impairment (which encompasses the inability or impaired ability to control the use of addictive substances) is established, a finding of disability will depend on the severity and duration of the impairment and, where appropriate, the individual's remaining functional capacity. In each case, all symptoms, signs, and findings of the substance addiction (and any other impairments, whether or not related to the substance addiction) must be considered to determine the complete picture of the individual's impairment severity and, where appropriate, remaining functional capacity.

    
    

    The claimant's ability to control his or her excessive drinking or other drug use must be evaluated 1) when establishing the presence of a medically determinable impairment, and 2) when determining the severity of the impairment to the extent that it is functionally limiting. A finding of “impaired ability to control” the use of addictive substances does not, in and of itself, establish any discrete level of impairment severity, e.g., meets or equals, or direct a finding of disabled. The “impaired ability to control” relates to the issue of impairment severity to the extent that it is functionally limiting. Therefore, the degree of functional limitations, if any, caused by an “impaired ability to control,” must be assessed to determine impairment severity. See Regulation No. 4, Subpart P, Section 404.1508, 404.1525 (e); Regulation No. 16, Subpart I, Section 416.908, 416.925(e); POMS DI 24515.045ff.

    
    

  2. What other significant signs, symptoms, and laboratory findings are typically associated with substance addiction disorders?

    
    

    In addition to the behavioral and physical changes needed to establish the existence of these disorders, individuals with substance addiction disorders may manifest a wide variety of mental, neurological, gastrointestinal, and other symptoms, signs and findings. In some cases, these symptoms, signs, and findings may actually represent co-existing physical and mental impairments. A co-existing impairment is not required, however, in order to find an individual with a substance addiction disorder disabled under the Social Security law.

    
    

    Individuals with substance addiction disorders may also have:

    
    

    • Neurological signs and symptoms such as seizures, blackouts, dizziness, lightheadedness, blurred vision, confusion, numbness, tingling, and muscle weakness.

      
      

    • Gastrointestinal manifestations such an liver dysfunction, pain, abdominal bleeding, tenderness, cramps, nausea, diarrhea and weight loss.

      
      

    • Psychiatric or psychological symptoms and signs such as anxiety, depression, disorientation, confusion, impulsivity, suicidal ideation, lability, compulsivity, seclusivity, memory loss, paranoid ideation, delusions or hallucinations. They may also show evidence of impaired judgment, fatigability, or decreased ability to concentrate, persist and maintain pace.

      
      

    • other symptoms and signs such as metabolic disturbances, hepatitis, and alcoholic myocarditis.

      
      

    Consideration must be given to the frequency, duration, effect on functioning and precipitating and exacerbating factors of these and other signs and symptoms of substance addiction disorders. The effects of the addiction disorder which may be transient or not persistent must be distinguished from those which are persistent or of long duration. Because the claimant's impairment severity may vary significantly in periods of remission and exacerbation, it is important to document carefully both phases. Thus, it is necessary to obtain all available evidence regarding the claimant's history of remissions and exacerbations in the context of their frequency, duration, effects on function, and precipitating and exacerbating factors. As always, the adverse effects of medication and the duration of such side effects must also be considered.

    
    

    If material to the determination, i.e., a favorable determination is not possible without their consideration, these signs, symptoms and findings must be developed for their frequency, duration and effect on ability to function. See POMS DI 22511.000ff, DI 24501.020 - .025, DI 32551.025D.

    
    

  3. How should substance addiction disorder cases be documented?

    
    

    As with any mental impairment case, efforts must be made to establish a longitudinal history for all substance addiction cases. As indicated in POMS DI 22505.005A.2., development outside a minimum 12-month period may be needed to document the history and progression of the disease.

    
    

    Medical evidence is needed from an acceptable medical source (see POMS DI 22505.003B.1.) to establish: 1) the existence of a medically determinable substance addiction impairment, and 2) the functional limitations attributable to the impairment. Efforts should be made to secure all existing relevant medical evidence from prior and current treating sources.

    
    

    When developing medical evidence, it is important to request the source 1) to identify all information used to substantiate the existence of the substance addiction impairment, and 2) to provide information on how the impairment affects the claimant's ability to function. (See POMS DI 22505.006B., DI 22511.007D.) Per the DSM-III-R, the existence of the impairment is substantiated when the evidence shows a cluster of diagnostic findings which indicate that the claimant has impaired control of drugs and/or alcohol and continues use of the substance despite adverse consequences. It is also important to request records of treatment for substance addiction, including detoxification attempts, remissions and exacerbations, unless those records are not needed to establish the existence of the substance addiction impairment (see DSM-III-R) and are not relevant to the claimant's ability to function during the period for which the claim is made.

    
    

    If the medical source does not initially provide sufficient evidence to document the existence of a substance addiction impairment (see DSM-III-R), or to determine the claimant's ability to function, a follow-up contact with the source is necessary to determine the availability of the additional information. (See POMS DI 22505.006B., DI 22505.00BC.1., DI 22511.007D.) When recontacting the medical source, the most appropriate format should be used (e.g., telephone, letter, informal report) and the following should be explained:

    
    

    • the nature of the missing evidence,

      
      

    • why clarifying information is needed,

      
      

    • the types of evidence needed.

      
      

    Information from other than acceptable medical sources (see POMS DI 2250.003B.2.) is also useful. These sources include other professional health care providers (see POMS DI 22511.007E.) as well as collateral sources (see POMS DI 22511.007F.) outside the health care field, e.g., spouse, other relatives, friends, neighbors. This information may aid an acceptable medical source, as well as our medical and psychological consultants, in determining whether a medically determinable impairment exists and in assessing the functional impact of the impairment. Therefore, all relevant evidence should be requested.

    
    

    Other professional health care providers which usually are valuable in providing information relative to the claimant's functioning could include: psychiatric nurses, social workers, administrators of substance addiction detoxification programs or other treatment centers, as well as shelters or other programs or facilities where the claimant has been observed over time (e.g., prisons or detention facilities). Evidence from these sources should always be requested. Obtain additional functional information, if necessary, from collateral sources such as family members, former employers, friends or other persons who: 1) live with or have close contact with the claimant, and 2) have knowledge of his functioning.

    
    

    If sufficient evidence is unavailable from all potential sources, it may be necessary to obtain a consultative examination (CE). Specific diagnostic findings (see DSM-III-R) and functional information, taking into account the effects of the claimant's substance addiction disorder, should be requested from the CE provider. See Regulation No. 4, Subpart P, Section 404.1513(e), Regulation No. 16, Subpart I, Section 416.913(e) POMS DI 22501.001ff, DI 22505.005ff, DI 22505.010ff, DI 22510.005ff, DI 22511.001ff, DI 22511.009, DI 24501.020, DI 24501.025, DI 24515.045F, DI 32551.025D.

    
    

  4. What if the claimant is intoxicated at the CE?

    
    

    CE's of intoxicated persons can contribute useful information. However, they may also be unreliable. Therefore, they must be reviewed for consistency with all the other evidence in file.

    
    

    If the claimant reports to the CE in an intoxicated state, rely on the CE provider's professional judgment to determine whether to continue the examination. He/she should consider postponing and rescheduling the CE if the claimant is acutely intoxicated and/or reliable or valid information cannot be obtained about the claimant's history, functional limitations, intellectual abilities or other relevant clinical findings.

    
    

    If the CE provider decides to continue the examination, ask the provider to include a statement of CE validity or reliability and to describe:

    
    

    • the degree of intoxication displayed by the claimant at the time of the examination;

      
      

    • recent substance use and its effect on the claimant's ability to function during the examination;

      
      

    • the claimant's overall physical and mental status;

      
      

    • details of the claimant's addiction history in terms of frequency, duration, exacerbating factors, and effect on functioning.

      
      

    If the examination cannot be performed due to the claimant's intoxicated state, reschedule the CE only if the claimant or a responsible individual indicates the claimant will attend in a sober state.

    
    

    The claimant's failure to attend the CE in a sober state is not automatic grounds for a denial or a cessation. Before making an adverse decision:

    
    

    • determine whether there is good cause for the claimant's failure to appear for the CE;

      
      

    • review the file, including the medical evidence of record (MER), and determine if any other potential sources of evidence could be contacted;

      
      

    • evaluate the case according to the available-MER.

      
      

    See POMS DI 22510.018, DI 22510.019, DI 32551.025D.7.

    
    

  5. What is the significance of “confinement” in assessing the severity of the substance addiction disorder?

    
    

    Confinement in an institution or other facility, whether for treatment or otherwise, does not provide a conclusive basis for determining impairment severity. Confinement may occur for reasons other than the severity of the impairment. Although the circumstances concerning the confinement must be determined and considered, confinement alone does not establish that the impairment is severe. Also, confinement prescribed as treatment by an appropriate treating source does not, in and of itself, establish the presence or severity of an impairment. The presence of an impairment and its severity are established on the basis of symptoms, signs, laboratory findings and functional limitations.

    
    

    Similarly, release from an institution or any other facility does not establish that an impairment has improved, or that an impairment is not severe. In assessing a claimant's functioning while in an institution, due consideration must be given to the support of the structured setting and the ability of the claimant to maintain the same level of functioning outside the structured setting. Such a setting might reduce or attenuate the claimant's symptoms and make functioning appear only minimally restricted. See Regulation No. 4, Subpart P, Appendix 1, Section 12.00F; POMS DI 24515.045C.

    
    

  6. How is Listing 12.09, Substance Addiction Disorder, used to evaluate alcoholism or other drug addiction disorders?

    
    

    Listing 12.09 has two components:

    
    

    • The capsule definition of a substance addiction disorder. This component is satisfied when the behavioral or physical changes associated with the regular use of substances that affect the central nervous system are documented. (See Question #1 of this PC).

      
      

    • The severity component contained is the appropriate cross-reference listing. The adjudicator/reviewer must examine the total constellation of symptoms, signs and laboratory findings and then select the most appropriate reference listing, or another listing in the Listing of Impairments, to evaluate the manifestations of the substance addiction and assess the impairment severity. The use of a cross-reference listing does not mean that a co-existing impairment is required before a substance addiction disorder can be found disabling, because the claimant is not required to demonstrate that he or she has the cross-referenced disorder. For example, a claimant whose substance addiction disorder is manifested by disorientation to time and place could be evaluated using Listing 12.02 as the cross-reference listing. The criterion is paragraph A.1. under Listing 12.02. should be identified on the PRTF; then, if the paragraph B. criteria under Listing 12.02 are satisfied, Listing 12.09A. is met. The claimant does not have to meet the capsule definition of Listing 12.02 for organic mental disorders.

      
      

    A physical or mental cross-reference listing not specified in Listing 12.09 may be used if it best reflects the manifestations of the substance addiction in a specific case. In such a case, the substance addiction disorder will be evaluated using that cross-reference listing's criteria. If those criteria are satisfied, the substance addiction disorder will be found to equal Listing 12.09. Use of a combination of reference listings (based on the claimant's signs, symptoms, and laboratory findings) may also equal Listing 12.09. See Regulation No. 4, Subpart P, Appendix I, Part A, Sections 12.00 and 12.09; POMS DI 34001.010 Section 12.00.

    
    

  7. How is Listing 112.09, Psychoactive Substance Dependence Disorders, used to evaluate substance addiction disorder cases?

    
    

    Listing 112.09 is found in the revised childhood mental disorders listings published and effective on December 12, 1990. Listing 112.09 employs updated terminology; however, “psychoactive substance dependence disorders” and “substance addiction disorders” refer to the same diagnostic classification.

    
    

    The listing's capsule definition requires “a cluster of cognitive, behavioral, and physiologic symptoms that indicate impaired control of psychoactive substance use with continued use of the substance despite adverse consequences.” If this definition, which encompasses impairment of the ability to control the use of the substance, is satisfied, a medically determinable psychoactive substance dependence (substance addiction) disorder is present.

    
    

    Unlike Listing 12.09, Listing 112.09 contains its own paragraph A and B criteria, rather than cross-references to other listings. It is applied the same as other mental disorders listings that have their own paragraph A and B criteria. If a child does not meet the listing because he or she does not satisfy the specific criteria, the child can still be evaluated under this listing to determine whether he or she has an impairment equivalent in severity and duration to this listing. See Regulation No. 4, Subpart P, Appendix 1, Part B, Sections 112.00 and 112.09.

    
    

  8. What is the role of the Psychiatric Review Technique Form (PRTF) in the evaluation of substance addiction disorders under Listing 12.09?

    
    

    The PRTF is required to evaluate cases involving substance addiction under Listing 12.09.

    
    

    • If the capsule definition of Listing 12.09 is satisfied, mark the “Present” block at the top of page 7 of the PRTF;

      
      

    • Identify which of the cross-referenced listings is being used to evaluate the disorder by checking one of the blocks numbered 1 through 10 on page 7 of the PRTF;

      
      

    • If a mental cross-reference listing is chosen:

      
      

    1. Go to the appropriate listing on the PRTF (e.g., Listing 12.02 is located on page 3 of the PRTF), and check the A criteria that are present in the specific case. Since the presence of another disorder is not required, the capsule definition of the cross-reference listing must not be marked 'Present' unless that separate mental impairment (e.g., organic mental disorder) is clinically documented as being present. We do not require the presence of a co-existing impairment, but we do recognize the possibility.

      
      

    2. The B criteria will then be assessed on page 8 of the PRTF. If appropriate, the C criteria will be assessed on page 9.

      
      

    3. If the requisite paragraph A and paragraph B criteria are satisfied for that particular cross-reference listing, then Listing 12.09 is met. For example, if the cross-reference listing being used is Listing 12.02, and at least one of the paragraph A criteria items on page 3 has been satisfied, and two of the criteria in paragraph B are assessed as marked, frequent, or repeated, then Listing 12.09A is met.

      
      

    • If a physical cross-reference listing is chosen, mark page 1 of the PRTF for referral to another medical specialty. If based on that referral, it is determined that the criteria of the physical cross-reference listing are satisfied, the file is returned to update page 1 of the PRTF to show which subsection of Listing 12.09 is met. For instance, if the medical consultant performing the referral evaluation determines that the criteria of Listing 5.05 are satisfied, the PRTF will be updated to show that Listing 12.09F is met.

      
      

    • If a cross-reference listing not specified under Listing 12.09 is used to evaluate the claim, that specific listing is entered in the “Other” block on page 7 of the PRTF, e.g., “Listing 12.03, Schizophrenia.” If the “Other” listing is a mental disorder listing, the appropriate listing in Section III is used to evaluate the claim and the PRTF is completed as explained above. If it is a physical listing, it will be referred to another specialty as explained above. In either case, if the cross-reference listing criteria are satisfied, the claimant will equal Listing 12.09. See Regulation No. 4, Subpart P, Section 404.1520(a), Regulation No. 16, Subpart I, Section 416-920(a); POMS DI 24505.025, DI 32551.025D.4.

      
      

  9. What if the substance addiction impairment is severe, but not of listing-level severity?

    
    

    For all substance addiction disorder cases, if the impairment is severe but does not meet or equal a listing, the adjudication must continue through the sequential evaluation process. Generally, the disability decision then will be based on the residual functional capacity (RFC) assessment and the impact of the substance addiction impairment and any other impairment(s) on the individual's ability to do past relevant work, or to perform any other work considering the vocational factors of age, education, and prior work experience.

    
    

    For children's SSI claims, it must be determined whether the impact of the impairment on the child's ability to function is comparable to that which would make an adult unable to engage in substantial gainful activity (SGA). This requires an individualized functional assessment (IFA) and consideration of the impact of the substance addiction impairment and any other impairment (s) on the child's ability to function in an age- appropriate manner.

    
    

    In assessing function (i.e., RFC or IFA), all mental and physical limitations must be considered. All symptoms, signs, and laboratory findings associated with the substance addiction, and the manifestations of any co-existing mental or physical impairment(s), must be carefully evaluated. As in all cases, descriptions and observations of the claimant's restrictions by both medical and non-medical sources, including the claimant's treating source opinion regarding the nature and severity of impairment, must be considered in determining RFC or IFA.

    
    

    The functional assessment must consider the claimant's ability to function over time, including both periods of intoxication and non-.intoxication. Periods of intoxication and withdrawal must be documented as fully as possible is terms of precipitating and exacerbating factors, frequency, duration, and effect on function. While the claimant's inability to control the use of addictive substances must be considered in assessing RFC, a finding of uncontrollable substance use, alone, does not establish a level of functional deficit that prevents the performance of SGA or age-appropriate functioning. When there is a medically determined substance addiction disorder that produces significant functional limitations which preclude the performance of SGA, a finding of disability must be made. See Regulation No. 4, Subpart P, Section 404.1545, Regulation No. 16, Subpart I, Sections 416.924a. and 416.945; POMS DI 22511.005, DI 24510.060ff.

    
    

Attachment 2.


NOTICE OF DECISION THAT PRIOR DENIAL OR
TERMINATION WILL BE REOPENED

 
NOTICE


Our records show that you are one of a group of people covered by a court case called Schoolcraft v. Shalala. The Schoolcraft court case involves disability due to drug addiction or alcoholism. Because of that court case, we have taken another look at our (mm/yy) decision(s) to deny or terminate your disability benefits. We have determined that our prior decision(s) may have been incorrect. Therefore, we are reopening our prior decision(s). You may be eligible to get more disability benefits as a result of this reopening process.


When we reopen a decision, that means we are reviewing your claim again and will make a new determination on whether or not you were disabled at the time of your claim. We may gather additional evidence that we do not have which will assist us is deciding whether or not you were disabled at the time of our past decision. The evidence we considered in making our past decision is listed in the copy of the “Disability Determination Rationale” that is attached as the next page. You may also submit evidence that we do not already have to help us in making our new decision. If you wish to submit additional evidence, you must do so within 45 days of this notice.


THIS REOPENING PROCESS NORMALLY SHOULD NOT AFFECT ANY DISABILITY BENEFITS YOU MAY NOW BE GETTING BASED ON A LATER APPLICATION. YOU WILL CONTINUE TO RECEIVE THOSE AS LONG AS YOU CONTINUE TO MEET ALL OF OUR ELIGIBILITY REQUIREMENTS.


Once we have gathered any additional evidence we need and have reviewed the prior claim (s) you made, we will issue a new initial decision on whether or not you were disabled at the time of that claim.


Attachment 3.


NOTICE OF DECISION UPHOLDING PRIOR DENIAL OR
TERMINATION OF DISABILITY BENEFITS
NOTICE

You are one of a group of people covered by a court case called Schoolcraft v. Shalala. Because of the court case, we have taken another look at our (mm/yy) decision(s) to deny or terminate your disability benefits. We have determined that our prior decision was correct, and therefore we will not reopen our earlier decision(s).


THIS REVIEW DOES NOT AFFECT ANY BENEFITS YOU MAY NOW BE GETTING BASED ON A LATER APPLICATION. IF YOU ARE GETTING BENEFITS, YOU WILL CONTINUE TO GET THEM AS LONG AS YOU CONTINUE TO MEET ALL OF OUR ELIGIBILITY REQUIREMENTS.


YOUR OPTION TO APPEAL


If you disagree with this decision, you can ask that the decision be looked at by a different person. This is called a reconsideration. Your request must be made is writing through any Social Security office. Be sure to tell us your name, Social Security number and why you disagree. If you cannot write to us, call a Social Security office or come in and someone will help you. IF YOU WANT A RECONSIDERATION, YOU MUST ASK FOR IT WITHIN 60 DAYS FROM THE DATE YOU RECEIVE THIS NOTICE. UNLESS YOU SHOW US OTHERWISE, WE WILL ASSUME THAT YOU RECEIVED THE NOTICE FIVE DAYS FROM THE DATE OF THE NOTICE. IF YOU WAIT MORE THAN 60 DAYS, YOU MUST GIVE US A GOOD REASON FOR THE DELAY.


If You Want Help With Your Reconsideration Request


You can have a friend, lawyer, or someone else help you. There are groups that can help you find a lawyer or give you free legal services if you qualify. There are also lawyers who do not charge unless you win your appeal. Your local Social Security office has a list of groups that can help you with your appeal. The attorneys who handled Schoolcraft are the Legal Aid Society of Minneapolis. They are a free legal service and if you have questions or want help you can also contact them. They can be reached at (phone #). They will either be able to help you with your case or refer you to a lawyer who can.


If you get someone to help you, you should let us know. If you hire someone, we must approve the fee before he or she can collect it. And if you hire a lawyer, we may withhold up to 25 percent of any past benefits due you to pay toward the fee.


Signature Page for Schoolcraft Settlement


The undersigned persons agree on behalf of the parties indicated to be bound by the terms of the forgoing agreement.

/s/

 

6/23/94

_________________________   _________________________
     
Mary E. Goetten  

Date

Director, Federal Programs Branch    
Civil Division; U.S. Department of Justice    
Counsel for the federal defendants    
     
     
     

/s/

 

6/27/94

_________________________   _________________________
     
Donald E. Notvik  

Date

Assistant Attorney General, State of
Minnesota
   
Counsel for the state defendants    
     
     
     

/s/

 

6/30/94

_________________________   _________________________
     
M. Francesca Chervenak  

Date

Legal Aid Society of Minneapolis    
Counsel for plaintiffs    
     
     
     

/s/

 

6/30/94

_________________________   _________________________
     
Laurie N. Davison  

Date

Legal Aid Society of Minneapolis    
Counsel for plaintiffs    

Attachment 2. Published version of the Regional Program Circular, dated August 5, 1994.


SSA Program Circular


Disability


U.S. Department of Health and Human Services/Social Security Administration/Office of Policy

01-94-OD August 5, 1994

Office of Disability

Division of Medical and Vocational Policy

_____________________________________________________________

REGIONAL SSA PROGRAM CIRCULAR -- Chicago Region

_____________________________________________________________

EVALUATION OF SUBSTANCE ADDICTION DISORDER CASES

EXPLANATION OF CURRENT POLICY

In connection with the Schoolcraft court case, SSA has agreed to reexamine certain prior claims for benefits under title II or title XVI of the Social Security Act (disability benefits) based in whole or in part on allegations of substance addiction disorders. This program circular (PC) is being issued to all adjudicators, quality assurance personnel, and medical and psychological consultants in the Minnesota Disability Determination Services (DDS) to clarify how alcoholism and related drug addiction cases are to be evaluated in Minnesota in light of the settlement agreement in Schoolcraft and the definition of disability contained in the Social Security Act.


Under the law, disability is defined as the inability to do any substantial gainful activity (SGA) by reason of any medically determinable physical or mental impairment which has lasted or can be expected to last for a continuous period of not less than 12 months, or to result in death. As with any other medical condition, for a substance addiction disorder to be disabling under the law, it must be a medically determinable impairment that meets the duration requirement and produces significant functional limitations that preclude the performance of substantial gainful work, either alone or in combination with other impairments.

  Destruction Date: To be announced in the Schoolcraft
  court case POMS instructions (future publication).
   
  Distribution: All adjudicators, quality assurance personnel,
  medical and psychological consultants in the Minnesota
SSA Pub. No. 64-044 DDS; SSA personnel overseeing/reviewing decisions
  made by the Minnesota DDS (DPB, OPIR, ODIO).

We are continuing to evaluate experience from ongoing quality review and operating experience to determine whether there is a need to change or refine our rules for adjudicating substance addiction disorder claims.


This PC discusses existing policy in terms of the statutory requirements and provides answers to some frequently asked questions. In this PC, the terms “substance addiction disorder” and “alcoholism or other drug addiction disorder” are used interchangeably.


  1. Can a substance addiction disorder be considered a medically determinable impairment that could satisfy the definition of disability?

    
    

    Yes. A substance addiction disorder, in and of itself, can be a disabling medically determinable impairment if it satisfies the requirements of the Social Security law. No additional physical or mental impairment (e.g., irreversible organ damage) is required for a finding of disability. As with any impairment, a diagnosis, alone, cannot be the sole basis for finding disability. A medically determinable substance addiction disorder is established when behavioral changes or physical changes associated with the regular use of substances that affect the central nervous system are documented. According to the “Diagnostic and Statistical Manual of Mental Disorders (Third Edition - Revised)” (DSM-III-R), some examples of these changes include:

    
    

    • using the substance in larger amounts or over a longer period of time than intended;

      
      

    • continued use of the substance despite the presence of a persistent or recurrent social, occupational, psychological, or physical problem that the person knows may be exacerbated by that use;

      
      

    • unsuccessful attempts to reduce or cease use of the substance (e.g., repeated detoxification treatments);

      
      

    • the development of severe withdrawal symptoms (e.g., agitation, hallucinations, and vomiting) following cessation or reduction in use of the substance.

      
      

    Once a medically determinable substance addiction impairment (which encompasses the inability or impaired ability to control the use of addictive substances) is established, a finding of disability will depend on the severity and duration of the impairment and, where appropriate, the individual's remaining functional capacity. In each case, all symptoms, signs, and findings of the substance addiction (and any other impairments, whether or not related to the substance addiction) must be considered to determine the complete picture of the individual's impairment severity and, where appropriate, remaining functional capacity.

    
    

    The claimant's ability to control his or her excessive drinking or other drug use must be evaluated: 1) when establishing the presence of a medically determinable impairment, and 2) when determining the severity of the impairment to the extent that it is functionally limiting. A finding of “impaired ability to control” the use of addictive substances does not, in and of itself, establish any discrete level of impairment severity, e.g., meets or equals, or direct a finding of disabled. The “impaired ability to control” relates to the issue of impairment severity to the extent that it is functionally limiting. Therefore, the degree of functional limitations, if any, caused by an “impaired ability to control,” must be assessed to determine impairment severity.See Regulation No. 4, Subpart P, Section 404.1508, 404.1525(e); Regulation No. 16, Subpart I, Section 416.908, 416.925(e); POMS DI 24515.045ff.

    
    

  2. What other significant signs, symptoms, and laboratory findings are typically associated with substance addiction disorders?

    
    

    In addition to the behavioral and physical changes needed to establish the existence of these disorders, individuals with substance addiction disorders may manifest a wide variety of mental, neurological, gastrointestinal, and other symptoms, signs and findings. In some cases, these symptoms, signs, and findings may actually represent co-existing physical and mental impairments. A co-existing impairment is not required, however, in order to find an individual with a substance addiction disorder disabled under the Social Security law. Individuals with substance addiction disorders may also have:

    
    

    • Neurological signs and symptoms such as seizures, blackouts, dizziness, lightheadedness, blurred vision, confusion, numbness, tingling, and muscle weakness.

      
      

    • Gastrointestinal manifestations such as liver dysfunction, pain, abdominal bleeding, tenderness, cramps, nausea, diarrhea and weight loss.

      
      

    • Psychiatric or psychological symptoms and signs such as anxiety, depression, disorientation, confusion, impulsivity, suicidal ideation, lability, compulsivity, seclusivity, memory loss, paranoid ideation, delusions or hallucinations. They may also show evidence of impaired judgment, fatigability, or decreased ability to concentrate, persist and maintain pace.

      
      

    • Other symptoms and signs such as metabolic disturbances, hepatitis, and alcoholic myocarditis.

      
      

    Consideration must be given to the frequency, duration, effect on functioning and precipitating and exacerbating factors of these and other signs and symptoms of substance addiction disorders. The effects of the addiction disorder which may be transient or not persistent must be distinguished from those which are persistent or of long duration. Because the claimant's impairment severity may vary significantly in periods of remission and exacerbation, it is important to document carefully both phases. Thus, it is necessary to obtain all available evidence regarding the claimant's history of remissions and exacerbations in the context of their frequency, duration, effects on function, and precipitating and exacerbating factors. As always, the adverse effects of medication and the duration of such side effects must also be considered.

    
    

    If material to the determination, i.e., a favorable determination is not possible without their consideration, these signs, symptoms and findings must be developed for their frequency, duration and effect on ability to function. See POMS DI 22511.000ff, DI 24501.020-.025, DI 32551.025D.

    
    

  3. How should substance addiction disorder cases be documented?

    
    

    As with any mental impairment case, efforts must be made to establish a longitudinal history for all substance addiction cases. As indicated in POMS DI 22505.005A.2., development outside a minimum 12-month period may be needed to document the history and progression of the disease. Medical evidence is needed from an acceptable medical source (see POMS DI 22505.003B.1.) to establish: 1) the existence of a medically determinable substance addiction impairment, and 2) the functional limitations attributable to the impairment. Efforts should be made to secure all existing relevant medical evidence from prior and current treating sources.

    
    

    When developing medical evidence, it is important to request the source: 1) to identify all information used to substantiate the existence of the substance addiction impairment, and 2) to provide information on how the impairment affects the claimant's ability to function. (See POMS DI 22505.006B., DI 22511.007D.). Per the DSM-III-R, the existence of the impairment is substantiated when the evidence shows a cluster of diagnostic findings which indicate that the claimant has impaired control of drugs and/or alcohol and continues use of the substance despite adverse consequences. It is also important to request records of treatment for substance addiction, including detoxification attempts, remissions and exacerbations, unless those records are not needed to establish the existence of the substance addiction impairment (see DSM-III-R) and are not relevant to the claimant's ability to function during the period for which the claim is made.

    
    

    If the medical source does not initially provide sufficient evidence to document the existence of a substance addiction impairment (see DSM-III-R), or to determine the claimant's ability to function, a follow-up contact with the source is necessary to determine the availability of the additional information. (See POMS DI 22505.006B., DI 22505.008C.1., DI 22511.007D.) When recontacting the medical source, the most appropriate format should be used (e.g., telephone, letter, informal report) and the following should be explained:

    
    

    • the nature of the missing evidence,

      
      

    • why clarifying information is needed,

      
      

    • the types of evidence needed.

      
      

    Information from other than acceptable medical sources (see POMS DI 22505.003B.2.) is also useful. These sources include other professional health care providers (see POMS DI 22511.007E.) as well as collateral sources (see POMS DI 22511.007F.) outside the health care field, e.g., spouse, other relatives, friends, neighbors. This information may aid an acceptable medical source, as well as our medical and psychological consultants, in determining whether a medically determinable impairment exists and in assessing the functional impact of the impairment. Therefore, all relevant evidence should be requested.

    
    

    Other professional health care providers which usually are valuable in providing information relative to the claimant's functioning would include: psychiatric nurses, social workers, administrators of substance addiction detoxification programs or other treatment centers, as well as shelters or other programs or facilities where the claimant has been observed over time (e.g., prisons or detention facilities). Evidence from these sources should always be requested. Obtain additional functional information, if necessary, from collateral sources such as family members, former employers, friends or other persons who: 1) live with or have close contact with the claimant, and 2) have knowledge of the claimant's functioning.

    
    

    If sufficient evidence is unavailable from all potential sources, it may be necessary to obtain a consultative examination (CE).

    
    

    Specific diagnostic findings (see DSM-III-R) and functional information, taking into account the effects of the claimant's substance addiction disorder, should be requested from the CE provider.

    
    

    See Regulation No. 4, Subpart P, Section 404.1513(e), Regulation No. 16, Subpart I, Section 416.913(e); POMS DI 22501.001ff, DI 22505.005ff, DI 22505.010ff, DI 22510.005ff, DI 22511.001ff, DI 22511.009, DI 24501.020 - DI 24501.025, DI 24515.045F, DI 32551.025D.

    
    

  4. What if the claimant is intoxicated at the CE?

    
    

    CE's of intoxicated persons can contribute useful information. However, they may also be unreliable. Therefore, they must be reviewed for consistency with all the other evidence in file. If the claimant reports to the CE in an intoxicated state, rely on the CE provider's professional judgment to determine whether to continue the examination. He/she should consider postponing and rescheduling the CE if the claimant is acutely intoxicated and/or reliable or valid information cannot be obtained about the claimant's history, functional limitations, intellectual abilities or other relevant clinical findings.

    
    

    If the CE provider decides to continue the examination, ask the provider to include a statement of CE validity or reliability and to describe:

    
    

    • the degree of intoxication displayed by the claimant at the time of the examination;

      
      

    • recent substance use and its effect on the claimant's ability to function during the examination;

      
      

    • the claimant's overall physical and mental status;

      
      

    • details of the claimant's addiction history in terms of frequency, duration, exacerbating factors, and effect on functioning.

      
      

    If the examination cannot be performed due to the claimant's intoxicated state, reschedule the CE only if the claimant or a responsible individual indicates the claimant will attend in a sober state.

    
    

    The claimant's failure to attend the CE in a sober state is not automatic grounds for a denial or a cessation. Before making an adverse decision:

    
    

    • determine whether there is good cause for the claimant's failure to appear for the CE;

      
      

    • review the file, including the medical evidence of record (MER), and determine if any other potential sources of evidence could be contacted;

      
      

    • evaluate the case according to the available MER.

      
      

    See POMS DI 22510.018, DI 22510.019, DI 32551.025D.7.

    
    

  5. What is the significance of “confinement” in assessing the severity of the substance addiction disorder?

    
    

    Confinement in an institution or other facility, whether for treatment or otherwise, does not provide a conclusive basis for determining impairment severity. Confinement may occur for reasons other than the severity of the impairment. Although the circumstances concerning the confinement must be determined and considered, confinement alone does not establish that the impairment is severe. Also, confinement prescribed as treatment by an appropriate treating source does not, in and of itself, establish the presence or severity of an impairment. The presence of an impairment and its severity are established on the basis of symptoms, signs, laboratory findings and functional limitations.

    
    

    Similarly, release from an institution or any other facility does not establish that an impairment has improved, or that an impairment is not severe. In assessing a claimant's functioning while in an institution, due consideration must be given to the support of the structured setting and the ability of the claimant to maintain the same level of functioning outside the structured setting. Such a setting might reduce or attenuate the claimant's symptoms and make functioning appear only minimally restricted. See Regulation No. 4, Subpart P, Appendix 1, Section 12.00F; POMS DI 24515.045C.

    
    

  6. How is Listing 12.09, Substance Addiction Disorders, used to evaluate alcoholism or other drug addiction disorders?

    
    

    Listing 12.09 has two components:

    
    

    • The capsule definition of a substance addiction disorder. This component is satisfied when the behavioral or physical changes associated with the regular use of substances that affect the central nervous system are documented. (See Question #1 of this PC).

      
      

    • The severity component contained in the appropriate cross-reference listing. The adjudicator/reviewer must examine the total constellation of symptoms, signs and laboratory findings and then select the most appropriate reference listing, or another listing in the Listing of Impairments, to evaluate the manifestations of the substance addiction and assess the impairment severity. The use of a cross-reference listing does not mean that a co-existing impairment is required before a substance addiction disorder can be found disabling, because the claimant is not required to demonstrate that he or she has the cross-referenced disorder. For example, a claimant whose substance addiction disorder is manifested by disorientation to time and place could be evaluated using Listing 12.02 as the cross-reference listing. The criterion in paragraph A.1. under Listing 12.02 should be identified on the Psychiatric Review Technique Form (PRTF); then, if the paragraph B. criteria under Listing 12.02 are satisfied, Listing 12.09A. is met. The claimant does not have to meet the capsule definition of Listing 12.02 for organic mental disorders.

      
      

    A physical or mental cross-reference listing not specified in Listing 12.09 may be used if it best reflects the manifestations of the substance addiction in a specific case. In such a case, the substance addiction disorder will be evaluated using that cross-reference listing's criteria. If those criteria are satisfied, the substance addiction disorder will be found to equal Listing 12.09. Use of a combination of reference listings (based on the claimant's signs, symptoms, and laboratory findings) may also equal Listing 12.09. See Regulation No. 4, Subpart P, Appendix 1, Part A, Sections 12.00 and 12.09; POMS DI 34001.010 Section 12.00.

    
    

  7. How is Listing 112.09, Psychoactive Substance Dependence Disorders, used to evaluate substance addiction disorder cases?

    
    

    Listing 112.09 is found in the revised childhood mental disorders listings published and effective on December 12, 1990. Listing 112.09 employs updated terminology; however, “psychoactive substance dependence disorders” and “substance addiction disorders” refer to the same diagnostic classification.

    
    

    The listing's capsule definition requires “a cluster of cognitive, behavioral, and physiologic symptoms that indicate impaired control of psychoactive substance use with continued use of the substance despite adverse consequences.” If this definition, which encompasses impairment of the ability to control the use of the substance, is satisfied, a medically determinable psychoactive substance dependence (substance addiction) disorder is present.

    
    

    Unlike Listing 12.09, Listing 112.09 contains its own paragraph A and B criteria, rather than cross-references to other listings. It is applied the same as other mental disorders listings that have their own paragraph A and B criteria. If a child does not meet the listing because he or she does not satisfy the specific criteria, the child can still be evaluated under this listing to determine whether he or she has an impairment equivalent in severity and duration to this listing. See Regulation No. 4, Subpart P, Appendix 1, Part B, Sections 112.00 and 112.09.

    
    

  8. What is the role of the Psychiatric Review Technique Form (PRTF) in the evaluation of substance addiction disorders under Listing 12.09?

    
    

    The PRTF is required to evaluate cases involving substance addiction under Listing 12.09.

    
    

    • If the capsule definition of Listing 12.09 is satisfied, mark the “Present” block at the top of page 7 of the PRTF;

      
      

    • Identify which of the cross-referenced listings is being used to evaluate the disorder by checking one of the blocks numbered 1 through 10 on page 7 of the PRTF;

      
      

    • If a mental cross-reference listing is chosen:

      
      

    1. Go to the appropriate listing on the PRTF (e.g., Listing 12.02 is located on page 3 of the PRTF), and check the A criteria that are present in the specific case. Since the presence of another disorder is not required, the capsule definition of the cross-reference listing must not be marked “Present” unless that separate mental impairment (e.g., organic mental disorder) is clinically documented as being present. We do not require the presence of a co-existing impairment, but we do recognize the possibility.

      
      

    2. The B criteria will then be assessed on page 8 of the PRTF. If appropriate, the C criteria will be assessed on page 9.

      
      

    3. If the requisite paragraph A and paragraph B criteria are satisfied for that particular cross-reference listing, then Listing 12.09 is met. For example, if the cross-reference listing being used is Listing 12.02, and at least one of the paragraph A criteria items on page 3 has been satisfied, and two of the criteria in paragraph B are assessed as marked, frequent, or repeated, then Listing 12.09A is met.

      
      

    • If a physical cross-reference listing is chosen, mark page 1 of the PRTF for referral to another medical specialty. If, based on that referral, it is determined that the criteria of the physical cross-reference listing are satisfied, the file is returned to update page 1 of the PRTF to show which subsection of Listing 12.09 is met. For instance, if the medical consultant performing the referral evaluation determines that the criteria of Listing 5.05 are satisfied, the PRTF will be updated to show that Listing 12.09E is met.

      
      

    • If a cross-reference listing not specified under Listing 12.09 is used to evaluate the claim, that specific listing is entered in the “Other” block on page 7 of the PRTF, e.g., “Listing 12.03, Schizophrenia.” If the “Other” listing is a mental disorder listing, the appropriate listing in Section III is used to evaluate the claim and the PRTF is completed as explained above. If it is a physical listing, it will be referred to another specialty as explained above. In either case, if the cross-reference listing criteria are satisfied, the claimant will equal Listing 12.09. See Regulation No. 4, Subpart P, Section 404.1520(a), Regulation No. 16, Subpart I, Section 416.920(a); POMS DI 24505.025, DI 32551.025D.4.

      
      

  9. What if the substance addiction impairment is severe, but not of listing-level severity?

    
    

    For all substance addiction disorder cases, if the impairment is severe but does not meet or equal a listing, the adjudication must continue through the sequential evaluation process. Generally, the disability decision then will be based on the residual functional capacity (RFC) assessment and the impact of the substance addiction impairment and any other impairment(s) on the individual's ability to do past relevant work, or to perform any other work considering the vocational factors of age, education, and prior work experience.

    
    

    For children's SSI claims, it must be determined whether the impact of the impairment on the child's ability to function is comparable to that which would make an adult unable to engage in SGA. This requires an individualized functional assessment (IFA) and consideration of the impact of the substance addiction impairment and any other impairment(s) on the child's ability to function in an age-appropriate manner.

    
    

    In assessing function (i.e., RFC or IFA), all mental and physical limitations must be considered. All symptoms, signs, and laboratory findings associated with the substance addiction, and the manifestations of any co-existing mental or physical impairment(s), must be carefully evaluated. As in all cases, descriptions and observations of the claimant's restrictions by both medical and non-medical sources, including the claimant's treating source opinion regarding the nature and severity of impairment, must be considered in determining RFC or IFA.

    
    

    The functional assessment must consider the claimant's ability to function over time, including both periods of intoxication and non-intoxication. Periods of intoxication and withdrawal must be documented as fully as possible in terms of precipitating and exacerbating factors, frequency, duration, and effect on function. While the claimant's inability to control the use of addictive substances must be considered in assessing RFC, a finding of uncontrollable substance use, alone, does not establish a level of functional deficit that prevents the performance of SGA or age-appropriate functioning. When there is a medically determined substance addiction disorder that produces significant functional limitations which preclude the performance of SGA, a finding of disability must be made. See Regulation No. 4, Subpart P, Section 404.1545, Regulation No. 16, Subpart I, Sections 416.924a and 416.945; POMS DI 22511.005, DI 24510.060ff.

    
    

Attachment 3. - Flag Attached to DDS-Identified SchoolcraftClaims to Be Coded Into the OHA Case Control System (OHA CCS).






SCHOOLCRAFT
RECONSIDERATION DENIAL


NOTE TO HEARING OFFICES:


Upon receipt of a request for hearing in this claim, please key an “A” to the SPC field of the OHAQ for future identification as SCHOOLCRAFT.


DO NOT REMOVE UNLESS APPEAL PERIOD HAS EXPIRED OR APPEALS COUNCIL HAS TAKEN FINAL ACTION.


Attachment 4. - Flag Attached to OHA-Associated Potential Schoolcraft Claims to be Forwarded to ODIO After Agency/Judicial Action is Completed.




SCHOOLCRAFT



This is a potential Schoolcraft case.


After adjudication of the current claim, effectuation, if applicable, and the expiration of any retention period, forward all files to ODIO for Schoolcraft processing.


The ODIO address is:

 

Social Security Administration
Office of Disability and International Operations
P.O. Box 17369
Baltimore, MD 21298-0050

Attention: Schoolcraft Coordinator

If OHA personnel have any questions about the Schoolcraft aspects of handling this case, they should contact the OAO Class Action Coordinator at (703) 305-0656.