Incapacity Determination

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Incapacity Determination - PEP Step I

Revised November 14, 2011

Review of medical evidence

WAC 182-508-0040

PEP Step I --Review of medical evidence required for eligibility determination. (Emergency rule effective 11/1/11.)

WAC 182-508-0040

Effective October 14, 2012

WAC 182-508-0040 PEP Step I --Review of medical evidence required for eligibility determination.

When the agency or the agency's designee receives the individual's medical evidence, the agency or the agency's designee reviews it to see if it is sufficient to decide whether the individual's circumstances meet incapacity requirements.

(1) The agency or the agency's designee requires medical information to determine incapacity. The information must:

(a) Contain sufficient information as described under WAC 182-508-0030;

(b) Be written by an authorized medical professional described in WAC 182-508-0020;

(c) Document the existence of a potentially incapacitating condition; and

(d) Indicate an impairment is expected to last ninety days or more from the application date.

(2) If the information received isn't clear, the agency or the agency's designee may require more information before the agency or the agency's designee decides the individual's ability to be gainfully employed. As examples, the agency or the agency's designee may require the individual to get more medical tests or be examined by a medical specialist.

(3) The agency or the agency's designee denies incapacity if:

(a) There is only one impairment and the severity rating is less than three;

(b) A reported impairment isn't expected to last ninety days or more from the date of application;

(c) The only impairment supported by objective medical evidence is drug or alcohol addiction; or

(d) The agency or the agency's designee doesn't have clear and objective medical evidence to approve incapacity.

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.

WORKER RESPONSIBILITIES

1. When it is clear that the effects on work activities are solely the result of alcohol or drug abuse/addiction, deny incapacity. When the available information in unclear as to what degree a person would be impaired without the effects of substance abuse or addiction, take the following actions:

a. Contact the provider to clarify whether the person has functional limitations due to mental or physical impairments and to clarify to what degree substance abuse may exacerbate these conditions.

b. Continue with the PEP process when the person has a physical or mental health impairment that is not a diagnosis or symptomatic of substance abuse or addiction.

c. The effects of substance abuse and addiction can't be used when determining severity or duration. The severity and duration assigned should reflect how the condition would impair the person if chemical abuse or addiction were not present.

d. Deny incapacity when the provider cannot determine that a physical or mental impairment would persist without the effects of substance abuse or the medical evidence supports a finding that the person is primarily incapacitated due to chemical dependency or abuse.

EXAMPLE

Terry is diagnosed with hepatitis and is impaired by fatigue. The doctor's chart notes show that Terry was advised his fatigue would resolve in a few weeks if he stopped consuming alcohol. Terry's primary impairment is alcohol dependence. Deny incapacity and refer Terry for a chemical dependency assessment if he is willing to undergo treatment.

2. Diagnosis:

a. We may accept a diagnosis of impairment from a provider's report or chart notes that are based on examination within 12 months prior to application.

b. We must have current medical evidence of how the impairment affects the person's functioning.

EXAMPLE

Michelle states during her intake interview that she was seen by an orthopedist 10 months ago for the same knee problem that is keeping her from working now. Request chart notes from the orthopedist and send the chart notes to the evaluator who will be assessing Michelle's current functioning.

3. Duration:

a. If the provider's estimate of the duration of the impairment is consistent with the medical evidence provided, accept it.

b. If the provider is unable to estimate duration, use reference sources and your professional judgment to assign duration.

c. When the provider identifies a condition as chronic, you may consider the condition to meet the 90-day duration requirement even when qualified as episodic or in remission if this determination is consistent with the objective medical evidence.

EXAMPLE

Dale is diagnosed with chronic rapid-cycling bi-polar disorder. The most significant impairment on work activities is due to psychotic symptoms which, according to his psychiatrist, are episodic in nature. Although not currently psychotic, he has had 3 major psychotic episodes within the last 2 months. He has not yet been stabilized on medication. Accept this as meeting the 90-day duration requirement.

EXAMPLE

Kim is diagnosed with chronic Crohn's disease, which affects her digestive system. Currently, there is no inflammation or pain associated with this disorder. It is not clear when the disease will flare up again. Her last episode was 4 months ago. Do not accept this as meeting the 90-day duration requirement.

4. "By history" means that a condition is reported by the person and that medical records don't support the diagnosis and suggests that the diagnosis isn't currently active. Request more information from the provider to determine if the impairment currently has an effect on work activities before accepting it as objective medical evidence.

5. If it is clear the impairment will last less than 90 days, deny assistance for lack of duration.

6. Follow the medical evidence procedures in WAC 182-508-0020 and WAC 182-508-0030. Deny incapacity if you are unable to obtain clear, current, objective medical evidence.