Disability Determination - Step 2
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Disability Determination - Step 2


Revised December 30, 2013



WAC 388-449-0035How does the department assign severity ratings to my impairment?
WAC 388-449-0040How does the department determine the severity of mental impairments?
WAC 388-449-0045How does the department determine the severity of physical impairments?
WAC 388-449-0050How does the department determine the severity of multiple impairments?
WAC 388-449-0060Sequential Evaluation Process step II - How does the department review medical evidence to determine if I am eligible for benefits?

WAC 388-449-0035
WAC 388-449-0035

Effective June 1, 2012

WAC 388-449-0035 How does the department assign severity ratings to my impairment?

1.    "Severity rating"  is a rating of the extent of your impairment and how it impacts your ability to perform the basic work activities. The following chart provides a description of limitations on work activities and the severity ratings assigned to each.

Effect on Work Activities 

Degree of Impairment

Numerical Value 

(a) There is no effect on your performance of one or more basic work-related activities. 

None

1

(b) There is no significant limit on your performance of one or more basic work-related activities. 

Mild

2

(c) There are significant limits on your performance of  one or more basic work-related activities. 

Moderate

3

(d) There are very significant limits on your performance of  one or more basic work-related activities. 

Marked

4

(e) You are unable to perform basic work-related activities. 

Severe

5

 

2.    We use  the description of how your condition impairs your ability to perform work activities given by the acceptable medical source or treating provider, and review other evidence you provide, to establish severity ratings when the impairments are supported by, and consistent with, objective medical evidence.

3.    A contracted doctor reviews your medical evidence and the ratings assigned to your impairment when:

a.    The medical evidence indicates functional limitations consistent with at least a moderate physical or mental health impairment;

b.    Your impairment has lasted, or is expected to last, nine months or more with available medical treatment; and

c.    You were not an active ABD recipient previously determined likely to be disabled as defined in WAC 388-449-0010  through 388-449-0100.

4.    The contracted doctor reviews your medical evidence, severity rating, and functional assessment to determine whether:

a.    The Medical evidence is objective and sufficient to support the findings of the provider;

b.    The description of impairment(s) is supported by the medical evidence; and

c.    The severity rating, duration, and assessment of functional limitations assigned by DSHS are consistent with the medical evidence.

5.    If the medical evidence provider’s description of your impairment(s) is not consistent with the objective medical evidence, we will: 

a.    Assign a severity rating, duration, and functional limitations consistent with the objective medical evidence; and

b.    Clearly describe why we rejected the medical evidence provider's opinion; and

c.    Identify the medical evidence used to make the determination.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

WAC 388-449-0040
WAC 388-449-0040

Effective June 1, 2012

WAC 388-449-0040 How does the department determine the severity of mental impairments?

If you are diagnosed with a mental impairment by an acceptable medical source described in WAC 388-449-0010, we use information from medical sources described in  WAC 388-449-0010  to determine how the impairment limits work-related activities.

1.    We review the following psychological evidence to determine the severity of your mental impairment:

a.    Psychosocial and treatment history records;

b.    Clinical findings of specific abnormalities of behavior, mood, thought, orientation, or perception;

c.    Results of psychological tests; and

d.    Symptoms observed by the examining practitioner, and other evidence, that show how your impairment affects your ability to perform basic work-related activities.

2.    We exclude diagnosis and related symptoms of alcohol or substance abuse or addiction, if we have evidence substance use is material to your impairment.

3.    If you are diagnosed with mental retardation, the diagnosis must be based on the Wechsler Adult Intelligence Scale (WAIS). The following test results determine the severity rating:

Intelligence Quotient (IQ) Score 

Severity Rating 

 85 or above 

None (1)

 71 to 84 

 Moderate (3)

60 to 70

 Marked (4)

59 or lower 

 Severe (5)

 

4.    If you are diagnosed with a mental impairment with physical causes, we assign a severity rating based on the most severe of the following four areas of impairment:

a.    Short term memory impairment;

b.    Perceptual or thinking disturbances;

c.    Disorientation to time and place; or

d.    Labile, shallow, or coarse affect.

5.    We base the severity of an impairment diagnosed as a mood, thought, memory, or cognitive disorder on a clinical assessment of the intensity and frequency of symptoms that:

a.    Affect your ability to perform basic work related activities; and

b.    Are consistent with a diagnosis of a mental impairment as listed in the most recent published edition of the Diagnostic and Statistical Manual of Mental Disorders.

6.     We consider the combined effect of your symptoms on your ability to perform basic work activities. We determine the severity rating for a functional mental impairment as follows:

Symptom Ratings or Condition

Severity Rating 

a.    The clinical findings and objective evidence are consistent with significant limitation on performing one or more basic work activities.

Moderate (3)

b.    You  are diagnosed with a functional disorder with psychotic features.

c.    You have had two or more hospitalizations for psychiatric reasons in the past two years.

d.    You have had more than six months of continuous psychiatric inpatient or residential treatment in the past two years.

e.    The clinical findings and objective evidence are consistent with a very significant limitations on ability to one or more basic work activities.

Marked (4)

f.     The clinical findings and objective evidence are consistent with the inability to perform work activities.

 Severe (5)

 

 

7.    If you are diagnosed with any combination of mental retardation, mental impairment with physical causes, or functional mental impairment, we assign a severity rating as follows:


Condition

Severity Rating

a.    Two or more disorders with moderate severity (3) ratings; or

b.    One or more disorders rated moderate severity (3), and one rated marked severity (4).

 

Marked (4)

c.    Two or more disorders rated marked severity (4).

Severe (5)

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

WAC 388-449-0045
WAC 388-449-0045

Effective November 1, 2011

WAC 388-449-0045 How does the department determine the severity of physical impairments?

We must decide if your physical impairment is serious enough to significantly limit your ability to perform substantial gainful activity. "Severity of a physical impairment" means the degree that an impairment restricts you from performing basic work-related activities (see WAC 388-449-0005). Severity ratings range from none to severe. We will assign severity ratings according to the table in WAC 388-449-0035.

We assign to each physical impairment a severity rating that is supported by medical evidence.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

  1. The severity of an impairment is the extent to which it affects the individual's ability to perform basic work activities. 
  2. The Disability Specialist determines severity based on medical and other evidence received by the Department. When the individual needs help obtaining necessary evidence (e.g. meets Equal Access criteria or requests assistance), the Disability Specialist assists the individual in obtaining necessary evidence.  
  3. Severity ratings are assigned to all medically determinable impairments, meaning all impairments that could reasonably result from a condition diagnosed by an acceptable medical source identified in WAC 388-449-0010. 
  4. Severity ratings are assigned by the Disability Specialist based on the overall medical evidence and input received from the contracted Review of Medical Evidence (RME).

EXAMPLE

Betty provides a physical evaluation that indicates she has severe hyperlipidemia. Betty has no symptoms that currently impair her ability to perform basic work activities resulting from the condition. The Disability Specialist assigns a severity of "none" to Betty's hyperlipidemia.


EXAMPLE

Tim has been diagnosised with multi-level degenerative disc disease involving his lumbar spine. An L-spine MRI indicates a broad based disc protrusion mildly indents the thecal sac at the L4-5 level. Available medical evidence indicates Tim experiences intermittent numbness and weakness in his left leg and has significantly limited range of motion in his back secondary to pain. The Disability Specialist assigns a "marked" severity to Tim’s degenerative disc disease.


EXAMPLE

Phil has been diagnosed with Generalized Anxiety Disorder by a contracted psychologist. The Psychological Evaluation indicates Phil has suffered from frequent anxiety and excessive worry, which he is unable to control, for at least the past 12 months. The psychologist notes Phil has difficulty concentrating, becomes irritable, and has difficulty sleeping. The BAI completed as part of the Psychological Evaluation is consistent with marked-to-severe anxiety. The contracted psychologist notes significant limits on Phil's ADLs and assigned a GAF of 45. Based on the overall clinical findings and objective evidence, the Disability Specialist assigns a "marked" severity.  


WAC 388-449-0050
WAC 388-449-0050

Effective June 1, 2012

WAC 388-449-0050 How does the department determine the severity of multiple impairments?

1.    If you have more than one impairment, we decide the overall severity rating by determining if your impairments have a combined effect on your ability to be gainfully employed.

2.    When you have two or more diagnosed impairments that limit work activities, we assign an overall severity rating as follows:

Your Condition

Severity Rating

(i) All impairments are mild and there is no cumulative effect on basic work activities. 

Mild

(ii) All impairments are mild  and there is a significant cumulative effect on one or more basic work activities.

Moderate

(iii) Two or more impairments are of moderate severity and there is a very significant cumulative effect on basic work activities.

Marked

(iv) Two or more impairments are of marked severity. 

Severe

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

  1. When an individual has multiple impairments, we consider whether the impairments have a cumulative effect on their ability to perform basic work activities.
  2. The Disability Specialist assigns a higher overall severity if the cumulative effect of multiple impairments results in a greater impact on the individual's ability to perform one or more basic work activity. 

EXAMPLE

Jerry has been diagnosed with moderate C-spine degenerative disc disease. He also has moderate arthritis involving his dominant hand. Based on medical and other evidence received, the two conditions result in a very significant limitation in Jerry's ability to handle and manipulate objects. Based on the cumulative effect on Jerry's ability to perform a basic work activity, the Disability Specialist assigns a "marked" overall severity.


WAC 388-449-0060
WAC 388-449-0060

Effective June 1, 2012

WAC 388-449-0060 Sequential Evaluation Process step II - How does the department review medical evidence to determine if I am eligible for benefits?

When we receive your medical evidence, we review it to see if it is sufficient to decide whether your circumstances meet disability requirements.

1.    We require written medical evidence to determine disability. The medical evidence must:

a.    Contain sufficient information as described under WAC 388-449-0015;

b.    Be written by an acceptable medical source or treating provider described in WAC 388-449-0010;

c.    Document the existence of a potentially disabling condition by an acceptable medical source described in WAC 388-449-0010; and

d.    Document an impairment has lasted or is expected to last nine continuous months or more with available treatment, or result in death.

2.    If the information received isn't clear, we may require more information before we determine whether you meet ABD disability requirements. As examples, we may require you to get more medical tests or be examined by a medical specialist.

3.    We deny disability if:

a.    We don't have evidence that your impairment is of at least moderate severity as defined in WAC 388-449-0035388-449-0040388-449-0045, or 388-449-0050;

b.    Your impairment hasn't lasted or isn't expected to last nine or more months with available treatment or result in death; or

c.    We have evidence drug or alcohol abuse or addiction is material to your impairment(s) .

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

Clarifying Information

  1. ABD Disability Determinations are made by a team consisting of a Disability Specialist and a contracted doctor.
  2. The contracted doctor reviews the diagnosis, severity, functional limitations, duration and onset date recorded by the Disability Specialist if the individual has at least a moderate overall severity that has lasted or is expected to last 9 months or more or result in death. 
  3. The Disability Specialist makes necessary adjustments to the diagnosis, severity, functional impairments, and onset date based on the contracted doctor's professional medical opinion when supported by objective medical evidence. All adjustments are made prior to determining whether the individual meets the disability criteria in Step 2 of the ABD Sequential Evaluation Process (SEP).
  4. If the severity ratings or functional limitations provided by the evaluating medical provider are adjusted, the Disability Specialist must clearly describe the reason why we rejected the medical evidence provider's opinion and identify the medical evidence used to make the determination.  
  5. If the overall impairment is of at least a moderate severity and the impairment has lasted or is expected to last 9 months or more or result in death, the Disability Specialist proceeds with the ABD Sequential Evaluation process.
  6. The Disability Specialist denies ABD at Step II if: 

a)   The overall impairment is mild, meaning there is not a significant impact on the ability to perform at least one basic work activity.   

b)   The impairment has not lasted or is not expected to last 9 months or more or result in death; or

c)   Medical evidence indicates substance use is material to the impairment as defined in WAC 388-449-0015.


NOTE:

In general, the opinion of a treating provider is given more weight than that of the contracted RME doctor who has not examined or treated the individual. In addition, the opinion of a specialist involving an area of his or her expertise is given more weight than that of a non-specialist.

Modification Date: December 30, 2013