I-5-4-58.Titus v. Chater

Attachment 1. Titus v. Chater Stipulation; Approved and Entered by the District Court on April 12, 1996.

The parties, by and through their respective counsel, agree and state as follows:

1. This Stipulation and Consent Order addresses the initial and reconsideration determinations made by the Iowa Disability Determination Services (DDS) on behalf of defendant, the Commissioner of Social Security, with respect to claims by adult claimants for disability insurance benefits (DIB) under Title II of the Social Security Act (the Act) and supplemental security income (SSI) benefits based upon disability under Title XVI of the Act. See 20 C.F.R. §§ 404.1503 (a), 404.1601 et seq., and 416.901 et seq. The definition and meaning of any term or word used herein is the same as is set out in federal statute, regulations and other written guidelines. "Other written guidelines" is defined at 20 C.F.R. § 404.1602 and § 416.1002.

2. As directed by regulations and other written guidelines, DDS will make "every reasonable effort" to secure a "complete medical history," as those terms are defined in 20 C.F.R. §§ 404.1512 (d) (1) & (2) and 416.912 (d) (1) & (2), from acceptable medical sources, including treating sources, prior to making disability determinations. Acceptable medical source is defined in 20 C.F.R. §§ 404.1513 (a) and 416.913 (a).

3. The parties agree that, under certain circumstances set out in regulations and other written guidelines, DDS will make a decision based upon the information available. 20 C.F.R. §§ 404.1512 (e) (2), 404.1516, 404.1520 (b) & (c), 404.1527 (e), 416.912 (e) (2), 416.916, 416.920 b) & (c), 416.927 (c), and Social Security Ruling (SSR) 86-8. For example, pursuant to 20 C.F.R. §§ 404.1512 (e) (2) and 416.912 (e) (2), DDS will not seek additional evidence or clarification from a medical source when past experience has shown that the source cannot or will not provide the necessary findings.

4. Regulations provide that the medical evidence, including clinical and laboratory findings, must be complete and detailed enough to allow a determination of disability factors, including the probable duration of an impairment. 20 C.F.R. §§ 404.1513 (d), 404.1527 (c), 416.913 (d), and 416.927 (c). DDS will make every reasonable effort, as defined in 20 C.F.R. §§ 404.1512 (d) (1) and 416.912 (d) (1), to obtain from acceptable medical sources, including treating sources, evidence concerning the treatment prescribed, response to treatment, and prognosis of impairments, prior to making disability determinations with respect to claims by adults under Titles II and XVI of the Act, as is set out in 20 C.F.R. §§ 404.1513 and 416.913. See ¶ 3 supra.

5. As regulations and other written guidelines direct, DDS will not deny claims on medical or medical-vocational grounds without attempting to obtain medical evidence, including clinical and laboratory findings, which is complete and detailed enough to allow DDS to make a determination as to whether an individual is disabled, as is set out in 20 C.F.R. §§ 404.1513 (d) and 416.913 (d), except as provided in other regulations and written guidelines. See ¶ 3 supra.

6. As regulations at 20 C.F.R. §§ 404.1512 (e) and 416.912 (e) direct, DDS will recontact acceptable medical sources, including treating sources, when it is necessary and appropriate, in order to obtain evidence adequate to determine disability issues including, but not limited to, the issue of the duration of an impairment. DDS will seek additional evidence or clarification from acceptable medical sources on disability issues, including but not limited to the duration of an impairment, when the medical source's report contains a conflict or ambiguity that must be resolved, when the report does not contain all the necessary information, or when the report does not appear to be based on medically acceptable clinical and laboratory diagnostic techniques, as provided in 20 C.F.R. §§ 404.1512 (e) (1), 404.1527 (c), 416.912 (e) (1), and 416.927 (c). If information needed to resolve disability issues, including but not limited to duration, is not readily available from the records of the claimant's acceptable medical treatment source, and DDS is unable to seek clarification from that medical source, DDS will ask the claimant to attend one or more consultative examinations, in accordance with 20 C.F.R. §§ 404.1512 (f), 404.1527 (c), 416.912 (f), and 416.927 (c). See ¶ 3 supra.

7. Regardless of the alleged duration of an individual's impairment (s), DDS may deny claims for DIB or SSI benefits on other bases including, but not limited to; the claimant does not have insured status in DIB cases, the impairment or combination of impairments is not severe, the claimant is performing substantial gainful activity (SGA), the claimant does not have a good reason for failing or refusing to take part in a consultative examination, the claimant fails to prosecute the claim, or the claimant's impairment is related to a felony. See, e.g., 20 C.F.R. §§ 404.130-404.133, 404.1506, 404.1516, 404.1518 (a), 404.1520 (a) - (c), 404.1571, 416.916, 416.918 (a), 416.920 (a) - (c), and 416.971. See ¶ 3, supra.

8. Defendant will issue a Program Circular to clarify the evaluation of claims for DIB and SSI benefits which are based in whole or in part on the issue of duration. The Program Circular will focus on the issue of duration of the impairment (s). The Program Circular is reproduced as Attachment 1 and is hereby incorporated in this Stipulation and Consent Order. The Program Circular shall not supersede current regulations, provisions of the Program Operations Manual System (POMS), or other written guidelines. Defendant will distribute the Program Circular to all DDS and Social Security Administration (SSA) personnel who have any responsibility for adjudicating, consulting on, overseeing, or reviewing disability determinations for cases in Iowa. Defendant will issue and distribute the Program Circular to said personnel no later than 60 days after the date on which the Court approves the Stipulation and Consent Order, providing all issues related to the above-captioned case are resolved by that time. Defendant will instruct all said personnel to apply the guidance in the Program Circular to all DIB and SSI claims pending at the Iowa DDS on the date the Circular is issued and in which duration is an issue.

9. Defendant represents that she has no present intention to revise the Program Circular, which is attached and marked Attachment 1. Defendant agrees that the Program Circular will remain in effect for a period of two years after the date it is issued, unless there is an intervening change in federal law, regulations, or rulings that requires a revision of the Program Circular. Defendant will be under no obligation to obtain from Plaintiffs any comments or approval relating to any such future intervening change (s), nor will Court approval for such change be required. The sole issue raised by Plaintiffs in this case involved the duration of impairment. The parties agree that any change deemed necessary by Defendant to regulations or other written instructions referenced in the Stipulation and Consent Order or in the Program Circular which relates to issues other than duration is not subject to the two-year time limit and may be made at any time by Defendant.

10. Defendant will "monitor," as that term is defined in 20 C.F.R. §§ 404.1603 and 416.1003, Iowa DDS disability determinations to evaluate compliance with regulations, POMS, or other written guidelines, including this Stipulation and Consent Order and Program Circular.

11. This Stipulation and Consent Order shall not in any way constitute an admission by either party with respect to any of the allegations made by Plaintiffs in this case, nor with respect to the merits of this case. This Stipulation and Consent Order shall not constitute an admission by Defendant of liability, injury, or bad faith.

12. This Stipulation and Consent Order is not intended by the parties to be construed, nor shall it be offered in any proceeding, as evidence of an admission by Defendant that the Iowa DDS has in the past violated or failed to comply with any federal law, rule, or regulation dealing with any matter within the scope of the allegations contained in the Complaint or Amended Complaint or otherwise raised by Plaintiffs in this action. The relief offered herein is agreed to by Defendant solely to settle this case and to avoid the cost of further litigation.

13. The parties agree that, upon the Court's approval of this Stipulation and Consent Order and Judgment, the Court will enter an order dismissing, with prejudice, Plaintiffs' class action Complaint, as amended, and Plaintiffs' Motion for Class Certification in the above-captioned case.

14. Defendant agrees to pay Plaintiffs' costs in the above-captioned case, not to exceed $120.00, and Plaintiffs' attorney fees in the amount of $3,000.00 under the Equal Access to Justice Act (EAJA). Said attorney fees of $3,000.00 shall constitute payment in full of Defendant's obligation in the above-captioned case, under all relevant statutes and from whatever source, for any and all attorney services rendered on behalf of Plaintiffs in this case, regardless of when or by whom those services were or will be rendered.

15. This Stipulation and Consent Order will become effective prospectively upon written approval by the Court. The parties agree that the Court should approve this Stipulation and Consent Order and Judgment, and dismiss Plaintiffs' amended class action Complaint and Motion for Class Certification without notice to the named Plaintiffs or the purported class. The parties agree that no (0) individual cases which have been decided will be reviewed or reopened by Defendant as a part of this settlement.

16. The terms of the numbered paragraphs of this Stipulation and Consent Order as well as any memoranda or other submissions filed with the Court for approval of this Stipulation and Consent Order, constitute the entire agreement of the parties, and no statement, representation, agreement, or understanding, oral or written, which is not contained therein, shall have force or effect, nor does the Stipulation and Consent Order reflect any agreed upon purpose other than the desire of the parties to reach full settlement.

17. The terms set forth in this Stipulation and Consent Order shall be in full settlement and satisfaction of any and all claims and demands, of whatever nature, that Plaintiffs have against the DDS, the Commissioner of Social Security, or any of her agents or employees, based upon and with respect to the incidents, claims or circumstances giving rise to and/or alleged in the pleadings filed herein. Accordingly, and in consideration for the implementation of the provisions of this Stipulation and Consent Order, the parties, on behalf of themselves and any entity or individual on whose behalf they act or have acted, agree to resolve this action and to fully, finally and forever release, discharge and waive any and all claims, demands, liabilities, actions, rights of action and causes of action of any kind or nature whatsoever based on the incidents, claims or circumstances giving rise to and/or alleged in the pleadings filed herein.

18. The Court will retain jurisdiction of this case solely for the purpose of enforcing this Stipulation and Consent Order.

Approved by the Court this 12 day of April 1996. LET THIS JUDGMENT BE ENTERED ACCORDINGLY.

 

 

 

 

___________________________________________________________________________________________

The questions and answers below are intended to clarify issues regarding the determination of the duration of an impairment or combination of impairments of adult claimants alleging disability under Title II and Title XVI of the Social Security Act, in accordance with the Stipulation and Consent Order in Titus, et al v. Chater, Civil No. 4-91-CV-70014 (S.D. Iowa). This Circular does not address claims that may be denied on grounds other than insufficient duration of disability.

Question 1: What is meant by the term "duration of impairment" in Title II and Title XVI cases?

Answer: "Duration of impairment" under Titles II and XVI of the Social Security Act (the Act) refers to that period of time during which an individual is continuously unable to engage in substantial gainful activity (SGA) because of a medically determinable physical or mental impairment or combination of impairments resulting from anatomical, physiological, or psychological abnormalities. The duration of an impairment extends from the date of onset of disability to the time the impairment (s) no longer prevents the individual from engaging in SGA as demonstrated by medical evidence or the actual performance of SGA. The disabling impairment or combination of impairments preventing an individual from engaging in any SGA must be expected to result in death, or must have lasted or be expected to last for at least 12 continuous months from the date of onset.

Sources: 42 U.S.C. §§ 416 (i), 423 (d), and 1382c (a); 20 C.F.R. §§ 404.1509 and 416.909; SSR 82-53; SSR 82-52; POMS DI §§ 25505.001 et seq.

Question 2: When does the issue of duration arise in the disability determination process?

Answer: The issue of duration must be considered in the context of the sequential evaluation process. The issue of duration does not arise until the adjudicator has determined that the individual has an impairment or combination of impairments that is disabling. Once the adjudicator has determined the date the individual became disabled, an "insufficient duration" denial is appropriate if the individual's impairment or combination of impairments is not expected to result in death, and if the individual has regained or is expected to regain the ability to engage in SGA within the 12 months after onset of disability. If the individual's impairment or combination of impairments is not severe and does not prevent SGA, duration will not be an issue.

Sources: 42 U.S.C. §§ 416 (i), 423 (d), and 1382c (a); 20 C.R.R. §§ 404.314, 404.1505, and 416.905; SSR 82-52; POMS DI §§ 25505.001 and 22505.010.

Question 3: How is duration determined if the claimant has more than one impairment?

Answer: If the claimant has two or more concurrent, not severe impairments which when considered in combination are found to be severe, it is necessary to determine whether the combined effect of those impairments can be expected to be severe for 12 months. If one or more of the impairments improves or is expected to improve within 12 months, so that the combined effect of the remaining impairment(s) is no longer severe, the impairments will not meet the 12-month duration test.

     Severe impairments lasting less than 12 months cannot be combined with successive, unrelated impairments to meet the duration requirement. However, successive related impairments can be combined to meet the duration requirement. Successive impairments are considered related if the first impairment plays a part in causing the second impairment. For example, post-therapeutic residuals and depression resulting from treatment for cancer may be considered the consequences of the underlying physical impairment, and the beginning of the 12-month duration period could begin with the earliest time that the underlying impairment precluded the ability to perform SGA.

Sources: 42 U.S.C. §§ 416 (i), 423 (d) (2), and 1382C (A); 20 C.F.R. §§ 404.1522, 404.1523, 416.922, and 416.923, SSR 82-52, POMS DI §§ 25505.001 et seq.

Question 4: What should be considered in determining the duration of an impairment?

Answer: Evaluation of a claimant's alleged disability is based upon all the evidence in that case and follows a sequential process. If the claimant is not performing SGA and has a severe impairment(s), that has lasted, or is expected to last, 12 continuous months or result in death, the next step is a determination of whether the claimant's impairment(s) meets or equals the criteria for an impairment listed in the Listing of Impairments, 20 C.F.R. Part 404, Subpart P, Appendix 1, based upon medical evidence only. Medical findings in the evidence must be supported by medically acceptable clinical and laboratory diagnostic techniques. Consideration will also be given to the medical opinion of one or more medical or psychological consultants designated by the Commissioner of Social Security in deciding medical equivalence.

     If a claimant's impairment(s) does not meet or equal a Listing, consideration is given to whether the claimant can perform past relevant work by reviewing the claimant's residual functional capacity and the physical and mental demands of work the claimant has done in the past. If the claimant cannot perform past relevant work, the claimant's residual functional capacity, age, education, and past work experience are considered to determine if the claimant can do other work.

Sources: 42 U.S.C. §§ 416 (i), 423 (d), and 1382c (a); 20 C.F.R. §§ 404.1520, 404.1325, 404.1526, 404.1545-1575; SSR 86-8; SSR 82-53; SSR 82-52; and POMS DI §§ 22001.001 et seq.

Question 5: How is duration addressed if the adjudication takes place within 12 months of the onset date of disability?

Answer: In most cases in which the evidence substantiates a finding of disability, it will be readily apparent from the same evidence whether or not the impairment is expected to result in death or is expected to last 12 months from the onset of disability. When adjudication takes place before the impairment or combination of impairments has lasted 12 months, the obtainable evidence from acceptable medical sources as to the nature of the impairment (s), the medical history, the prescribed treatment, and the prognosis will serve as a basis for determining whether the impairment is expected to result in death or will continue to prevent the individual from engaging in SGA for 12 continuous months from the date of onset.

Sources: 42 U.S.C. §§ 416 (i), 423 (d) (5), 1382c (a); 20 C.F.R. §§ 404.1509, 404.1512, 416.909, and 416.912.

Question 6: How are a claimant's prescribed treatment or rehabilitation to be considered in assessing the issue of duration?

Answer: The duration of many impairments subject to improvement is usually directly related to the therapeutic regimen administered by the treating physician. An individual with a severe impairment which is amenable to treatment that would be expected to restore the ability to work would meet the duration requirement if the claimant is undergoing therapy or other treatment prescribed by treatment sources, but the evidence shows that disability, nevertheless, has lasted or can be expected to last for at least 12 continuous months.

Sources: SSR 82-52.

Question 7: At the initial and reconsideration stages, who is responsible for adjudicating the question of duration?

Answer: The determination of disability is a decision requiring team participation by a DDS examiner and a medical or psychological consultant trained in the disability process. The consultant provides expertise in defining the impairment, evaluates medical evidence to determine its adequacy for making disability decisions, assesses the severity of impairments, and describes the functional capacities or limitations imposed by impairments. The examiner determines disability based on the impairment and other nonmedical and vocational factors.

     If the consultant's findings concerning the test results differ from that of the treating source, this should be resolved if possible, if it is material to the determination of disability. The treating source should be recontacted to discuss the variant interpretation and, if necessary, other evidence such as a consultative examination will be requested. Federal regulations provide guidelines for evaluating medical reports and opinions and for determining if recontact with medical sources is appropriate.

Sources: 42 U.S.C. §§ 423.and 1382c (a); 20 C.F.R. §§ 404.130-404.133, 404.1506, 404.1512, 404.1516, 404.1518, 404.1520, 404.1527, 404.1571, 416.916, 416.918, 416.920, 416.927, and 416.971; POMS DI § 24501.001 et seq.

Question 8: What steps need to be taken to develop a claimant's record with respect to duration?

Answer: The claimant is responsible for providing medical evidence showing that he/she has an impairment(s) and how severe the impairment(s) is during the time disability is alleged. The claimant may also have to provide evidence about his/her age, education, training, work experience, daily activities, efforts to work, and any other factor showing how the impairment(s) affects the claimant's ability to work.

     The Iowa DDS is responsible for making every reasonable effort to assist the claimant. Before initiating a development request, DDS examines the entire record to determine the specific development needed. Generally, DDS will develop the individual's complete medical history for at least the 12 months preceding the application unless the alleged onset of disability is alleged to be less than 12 months before the claimant's application. If the evidence is consistent and sufficient to determine disability, DDS will make a determination on that evidence.

     If the evidence is internally inconsistent or inconsistent with other evidence, DDS will weigh the evidence to determine if it is sufficient to make a disability determination. If the evidence is consistent but not sufficient to support a determination, DDS will attempt to obtain additional existing evidence by recontacting treating or examining sources or by scheduling one or more consultative examinations. If there are inconsistencies in the evidence that cannot be resolved or if the evidence is incomplete despite efforts to obtain additional evidence, DDS will make a determination based upon the evidence in the record. Treating and examining sources ordinarily will be recontated prior to requesting a consultative examination. A cover letter to acceptable medical sources requests diagnosis, clinical findings, lab results, history of the impairment (s), treatment, response to treatment, prognosis, and assessment of the claimant's remaining work-related capacities.

Sources: 42 U.S.C. §§ 423 (d) (5) and 1382c; 20 C.F.R. §§ 404.1512, 404.1513, 404.1527, 416.912, 416.913, and 416.927; POMS DI §§ 22505.001 et seq.

Question 9: What action should be taken if the treating source is not responsive or provides an incomplete medical report?

Answer: If a treating source provides an incomplete medical report, and if it is material to the determination of disability, additional information should be requested and the file documented accordingly. If any medical source fails to provide the requested additional evidence after a reasonable effort has been made to obtain it, the file should be documented accordingly. An attempt should be made to obtain the necessary information from other sources. The medical evidence in the case must be sufficiently complete to permit a determination as to the probable duration of the impairment and, if necessary, the claimant's residual functional capacity during the 12-month period from onset of disability

     Under certain circumstances, DDS will make a decision based upon the information available. Individual case files will be documented with technical denial rationales completed in accordance with the Act, regulations, and other written guidelines.

Sources: 42 U.S.C. §§ 423 (d) (5) and 1382c (a), 20 C.F.R. §§ 404.1512, 404.1513, 404.1516, 404.1520 (b) & (c), 404.1527, 404.1545, 404.1546, 416.912, 416.913, 416.916, 416.920 (b) & (c), 416.927 (c), 416.945, and 416.946; SSR 86-8; POMS DI §§ 22505.001 et seq., 224501.001 et seq., and 26515.001 et seq.

 

 

 

 

     The Joint Motion to dismiss and approve the Proposed Settlement of the parties is granted, and the parties' Stipulation and Consent Order is approved. The Court will retain jurisdiction of this case solely for the purpose of enforcing the Stipulation and Consent Order. In all other respects the case is dismissed.

     IT IS ORDERED that plaintiffs' complaint, as amended, and plaintiffs' motion for class certification be DISMISSED with prejudice.

     Dated this _12_ day of _April_, 1996.

 

 

 

 

     In accordance with the Order of Settlement and Dismissal entered on this 12th day of April, 1996, by the Honorable Harold D. Vietor, United States District Judge, and Rules 23 (e). 54, 58, and 79 of the Federal Rules of Civil Procedure, it is now

     ORDERED that final judgment is entered as to all named plaintiffs and to the defendant, in accordance with the terms and conditions of the Stipulation and Consent Order approved by the Court and the Court's Order of Settlement and Dismissal.

     DATED this _15th_ day of _April_, 1996.

Attachment 2. Published version of the Regional Program Circular, dated June 7, 1996.

 

 

 

 

The questions and answers below are intended to clarify issues regarding the determination of the duration of an impairment or combination of impairments of adult claimants alleging disability under Title II and Title XVI of the Social Security Act, in accordance with the Stipulation and Consent Order in Titus, et al. v. Chater, Civil No. 4-91-CV-70014 (S.D. Iowa). This Circular does not address claims that may be denied on grounds other than insufficient duration of disability.

Question 1: What is meant by the term "duration of impairment" in Title II and Title XVI cases?

Answer: "Duration of impairment" under Titles II and XVI of the Social Security Act (the Act) refers to that period of time during which an individual is continuously unable to engage in substantial gainful activity (SGA) because of a medically determinable physical or mental impairment or combination of impairments resulting from anatomical, physiological, or psychological abnormalities. The duration of an impairment extends from the date of onset of disability to the time the impairment(s) no longer prevents the individual from engaging in SGA as demonstrated by medical evidence or the actual performance of SGA. The disabling impairment or combination of impairments preventing an individual from engaging in any SGA must be expected to result in death, or must have lasted or be expected to last for at least 12 continuous months from the date of onset.

Sources: 42 U.S.C. §§ 416 (i), 423 (d), and 1382c (a); 20 C.F.R. §§ 404.1509 and 416.909; SSR 82-53; SSR 82-52; POMS DI §§ 25505.001 et seq.

Distribution: Iowa DDS: ADJ, DHU

DQB

MAMPSC, DRS

Retention Date: June 30, 1998

 

Question 2: When does the issue of duration arise in the disability determination process?

Answer: The issue of duration must be considered in the context of the sequential evaluation process. The issue of duration does not arise until the adjudicator has determined that the individual has an impairment or combination of impairments that is disabling. Once the adjudicator has determined the date the individual became disabled, an "insufficient duration" denial is appropriate if the individual's impairment or combination of impairments is not expected to result in death, and if the individual has regained or is expected to regain the ability to engage in SGA within the 12 months after onset of disability. If the individual's impairment or combination of impairments is not severe and does not prevent SGA, duration will not be an issue.

Sources: 42 U.S.C. §§ 416 (i), 423 (d), and 1382c (a); 20 C.F.R. §§ 404.315, 404.1505, and 416.905; SSR 82-52; POMS DI §§ 25505.001 and 22505.010.

 

Question 3: How is duration determined if the claimant has more than one impairment?

Answer: If the claimant has two or more concurrent, not severe impairments which when considered in combination are found to be severe, it is necessary to determine whether the combined effect of those impairments can be expected to be severe for 12 months. If one or more of the impairments improves or is expected to improve within 12 months, so that the combined effect of the remaining impairment(s) is no longer severe, the impairments will not meet the 12-month duration test.

     Severe impairments lasting less than 12 months cannot be combined with successive, unrelated impairments to meet the duration requirement. However, successive related impairments can be combined to meet the duration requirement. Successive impairments are considered related if the first impairment plays a part in causing the second impairment. For example, post-therapeutic residuals and depression resulting from treatment for cancer may be considered the consequences of the underlying physical impairment, and the beginning of the 12-month duration period could begin with the earliest time that the underlying impairment precluded the ability to perform SGA.

Sources: 42 U.S.C. §§ 416 (i), 423 (d) (2), and 1382C (A); 20 C.F.R. §§ 404.1522, 404.1523, 416.922, and 416.923, SSR 82-52, POMS DI §§ 25505.001 et seq.

 

Question 4: What should be considered in determining the duration of an impairment?

Answer: Evaluation of a claimant's alleged disability is based upon all the evidence in that case and follows a sequential process. If the claimant is not performing SGA and has a severe impairment(s), that has lasted, or is expected to last, 12 continuous months or result in death, the next step is a determination of whether the claimant's impairment(s) meets or equals the criteria for an impairment listed in the Listing of Impairments, 20 C.F.R. Part 404, Subpart P, Appendix 1, based upon medical evidence only. Medical findings in the evidence must be supported by medically acceptable clinical and laboratory diagnostic techniques. Consideration will also be given to the medical opinion of one or more medical or psychological consultants designated by the Commissioner of Social Security in deciding medical equivalence.

     If a claimant's impairment(s) does not meet or equal a Listing, consideration is given to whether the claimant can perform past relevant work by reviewing the claimant's residual functional capacity and the physical and mental demands of work the claimant has done in the past. If the claimant cannot perform past relevant work, the claimant's residual functional capacity, age, education, and past work experience are considered to determine if the claimant can do other work.

Sources: 42. U.S.C. §§ 416 (i), 423 (d), and 1382c (a); 20 C.F.R. §§ 404.1520, 404.1525, 404.1526, 404.1545-1575; SSR 86-8; SSR 82-53; SSR 82-52; and POMS DI §§ 22001.001 et seq.

 

Question 5: How is duration addressed if the adjudication takes place within 12 months of the onset date of disability?

Answer: In most cases in which the evidence substantiates a finding of disability, it will be readily apparent from the same evidence whether or not the impairment is expected to result in death or is expected to last 12 months from the onset of disability. When adjudication takes place before the impairment or combination of impairments has lasted 12 months, the obtainable evidence from acceptable medical sources as to the nature of the impairment(s), the medical history, the prescribed treatment, and the prognosis will serve as a basis for determining whether the impairment is expected to result in death or will continue to prevent the individual from engaging in SGA for 12 continuous months from the date of onset.

Sources: 42 U.S.C. §§ 416 (i), 423 (d) (5), 1382c (a); 20 C.F.R. §§ 404.1509, 404.1512, 416.909, and 416.912.

 

Question 6: How are a claimant's prescribed treatment or rehabilitation to be considered in assessing the issue of duration?

Answer: The duration of many impairments subject to improvement is usually directly related to the therapeutic regimen administered by the treating physician. An individual with a severe impairment which is amenable to treatment that would be expected to restore the ability to work would meet the duration requirement if the claimant is undergoing therapy or other treatment prescribed by treatment sources, but the evidence shows that disability, nevertheless, has lasted or can be expected to last for at least 12 continuous months.

Sources: SSR 82-52.

 

Question 7: At the initial and reconsideration stages, who is responsible for adjudicating the question of duration?

Answer: The determination of disability is a decision requiring team participation by a DDS examiner and a medical or psychological consultant trained in the disability process. The consultant provides expertise in defining the impairment, evaluates medical evidence to determine its adequacy for making disability decisions, assesses the severity of impairments, and describes the functional capacities or limitations imposed by impairments. The examiner determines disability based on the impairment and other nonmedical and vocational factors.

     If the consultant's findings concerning the test results differ from that of the treating source, this should be resolved if possible, if it is material to the determination of disability. The treating source should be recontacted to discuss the variant interpretation and, if necessary, other evidence such as a consultative examination will be requested. Federal regulations provide guidelines for evaluating medical reports and opinions and for determining if recontact with medical sources is appropriate.

Sources: 42 U.S.C. §§ 423 and 1382c (a); 20 C.F.R. §§ 404.130-404.133, 404.1506, 404.1512, 404.1516, 404.1518, 404.1520, 404.1527, 404.1571, 416.916, 416.918, 416.920, 416.927, and 416.971; POMS DI § 24501.001 et seq.

 

Question 8: What steps need to be taken to develop a claimant's record with respect to duration?

Answer: The claimant is responsible for providing medical evidence showing that he/she has an impairment(s) and how severe the impairment(s) is during the time disability is alleged. The claimant may also have to provide evidence about his/her age, education, training, work experience, daily activities, efforts to work, and any other factor showing how the impairment(s) affects the claimant's ability to work.

     The Iowa DDS is responsible for making every reasonable effort to assist the claimant. Before initiating a development request, DDS examines the entire record to determine the specific development needed. Generally, DDS will develop the individual's complete medical history for at least the 12 months preceding the application unless the alleged onset of disability is alleged to be less than 12 months before the claimant's application. If the evidence is consistent and sufficient to determine disability, DDS will make a determination on that evidence.

     If the evidence is internally inconsistent or inconsistent with other evidence, DDS will weigh the evidence to determine if it is sufficient to make a disability determination. If the evidence is consistent but not sufficient to support a determination, DDS will attempt to obtain additional existing evidence by recontacting treating or examining sources or by scheduling one or more consultative examinations. If there are inconsistencies in the evidence that cannot be resolved or if the evidence is incomplete despite efforts to obtain additional evidence, DDS will make a determination based upon the evidence in the record. Treating and examining sources ordinarily will be recontacted prior to requesting a consultative examination. A cover letter to acceptable medical sources requests diagnosis, clinical findings, lab results, history of the impairment(s), treatment, response to treatment, prognosis, and assessment of the claimant's remaining work-related capacities.

Sources: 42 U.S.C. §§ 423 (d) (5) and 1382c; 20 C.F.R. §§ 404.1512, 404.1513, 404.1527, 416.912, 416.913, and 416.927; POMS DI §§ 22505.001 et seq.

 

Question 9: What action should be taken if the treating source is not responsive or provides an incomplete medical report?

Answer: If a treating source provides an incomplete medical report, and if it is material to the determination of disability, additional information should be requested and the file documented accordingly. If any medical source fails to provide the requested additional evidence after a reasonable effort has been made to obtain it, the file should be documented accordingly. An attempt should be made to obtain the necessary information from other sources. The medical evidence in the case must be sufficiently complete to permit a determination as to the probable duration of the impairment and, if necessary, the claimant's residual functional capacity during the 12 month period from onset of disability.

     Under certain circumstances, DDS will make a decision based upon the information available. Individual case files will be documented with technical denial rationales completed in accordance with the Act, regulations, and other written guidelines.

Sources: 42 U.S.C. §§ 423 (d) (5) and 1382c (a), 20 C.F.R. §§ 404.1512, 404.1513, 404.1516, 404.1520 (b) & (c), 404.1527, 404.1545, 404.1546, 416.912, 416.913, 416.916, 416.920 (b) & (c), 416.927 (c), 416.945, and 416.946; SSR 86-8; POMS DI §§ 22505.001 et seq., 24501.001 et seq., and 26515.001 et seq.