United States Government Accountability Office

GAO Report to the Chairman, Committee on 

Finance, U.S. Senate 

SOCIAL SECURITY 

DISABILITY 

PROGRAMS 

Clearer Guidance 

Could Help SSA Apply 

the Medical 

Improvement 

Standard More 

Consistently 

October 2006 

 

GAO-07-8
What GAO Found

United States Government Accountability Office

Why GAO Did This Study

Highlights

Accountability Integrity Reliability

October 2006

SOCIAL SECURITY DISABILITY 

PROGRAMS 

Clearer Guidance Could Help SSA Apply 

the Medical Improvement Standard More 

Consistently 

Highlights of GAO-07-8, a report to the 

Chairman, Committee on Finance, U.S. 

Senate 

The Social Security Act requires 

that the Social Security

Administration (SSA) find an 

improvement in a beneficiary’s 

medical condition in order to 

remove him or her from either the

Disability Insurance (DI) or 

Supplemental Security Income 

(SSI) programs. GAO was asked to

(1) examine the proportion of 

beneficiaries who have improved

medically and (2) determine if 

factors associated with the

standard pose challenges for SSA 

when determining whether

beneficiaries continue to be eligible

for benefits. To answer these 

questions, GAO surveyed all 55

Disability Determination Services

(DDS) directors, interviewed SSA

officials, and reviewed pertinent 

SSA data. 

What GAO Recommends

GAO is making a recommendation

to SSA to clarify guidance

regarding the degree of medical 

improvement required to meet the

standard, the use of exceptions, 

and the presumption of disability 

for assessing medical improvement 

when conducting CDRs. 

While generally agreeing with the

value of additional guidance, SSA 

expressed reservations about the

need for further guidance on the 

exceptions. GAO continues to see 

such a need since 7 of the 11

disability examiners we spoke with 

were uncertain regarding when to 

apply the exceptions.

Each year, about 13,800 beneficiaries, or 1.4 percent of all the people who 

left the disability programs between fiscal years 1999 and 2005, did so 

because SSA found that they had improved medically. More beneficiaries 

leave because they convert to regular retirement benefits, die, or for other 

reasons—including having earnings above program limits. In addition, while 

continuing disability reviews (CDR) are SSA’s most comprehensive tool for 

determining whether a recipient continues to have a disability, on average, 

2.8 percent of beneficiaries were found to have improved medically and to 

be able to work following a CDR during this 7-year period. 

Several factors associated with the medical improvement standard (the 

standard) pose challenges for SSA when assessing whether beneficiaries 

continue to be eligible for benefits. First, limitations in SSA guidance may 

result in inconsistent application of the standard. For example, SSA does not 

clearly define the degree of improvement needed to meet the standard, and 

the DDS directors GAO surveyed reported that they use different thresholds 

to assess if medical improvement has occurred. Second, contrary to existing

policy, disability examiners in a majority of the DDSs are incorrectly 

conducting CDRs with the presumption that a beneficiary has a disability 

rather than with a “neutral” perspective. Other challenges associated with 

the standard include inadequate documentation of evidence as well as the

judgmental nature of medical improvement determinations. All these factors 

have implications for the consistency of CDR decisions. However, due to 

data limitations, GAO was unable to determine the extent to which these 

problems affect decisions to continue or discontinue benefits. 

Average Percentage of All Beneficiaries Who Were Removed from the DI and SSI Programs 

by Category (Fiscal Years 1999 to 2005) 

21%

32%

45%

Source: GAO analysis of SSA data.

1.1%

Failure to cooperate

Conversion to

retirement benefits

Death

Other

1.4%

Medical improvement

www.gao.gov/cgi-bin/getrpt?GAO-07-8. 

To view the full product, click on the link 

above. To view results of GAO’s survey of 

DDS directors, click: www.gao.gov/cgibin/getrpt?rptno=GAO-07-4sp. For more 

information, contact Robert E. Robertson 

(202) 512-7215 or robertsonr@gao.gov. 
Contents 

Letter 1

Results In Brief 3

Background 4

Few Beneficiaries Are Removed from the Disability Programs 

Because They Are Found to Have Improved Medically 12 

Several Factors Challenge SSA’s Ability to Assess Whether 

Beneficiaries Continue to Be Eligible for Benefits 15 

Conclusions 22

Recommendation 23

Agency Comments and Our Evaluation 23 

Appendix I Scope and Methodology 26 

Appendix II The Continuing Disability Review Evaluation Process 30 

Appendix III Comments from the Social Security Administration 33 

Appendix IV GAO Contact and Staff Acknowledgments 39 

Related GAO Products 40 

Figures 

Figure 1: Current Medical CDR Evaluation Process 10 

Figure 2: Average Percentage of All Beneficiaries Who Were 

Removed from the DI and SSI Programs by Category 

(Fiscal Years 1999 to 2005) 13 

Figure 3: Number of Full Medical CDRs Conducted and Resulting 

Benefit Discontinuations (Fiscal Years 1999 to 2005) 15 

Page i GAO-07-8 Social Security Disability Programs
Abbreviations 

ALJ administrative law judge

DDS Disability Determination Services 

DI Disability Insurance 

CDR Continuing Disability Review 

CPD comparison point decision 

POMS Program Operations Manual System 

RFC residual functional capacity 

SGA substantial gainful activity 

SSA Social Security Administration 

SSI Supplemental Security Income 

This is a work of the U.S. government and is not subject to copyright protection in the 

United States. It may be reproduced and distributed in its entirety without further 

permission from GAO. However, because this work may contain copyrighted images or 

other material, permission from the copyright holder may be necessary if you wish to 

reproduce this material separately. 

Page ii GAO-07-8 Social Security Disability Programs
United States Government Accountability Office

Washington, DC 20548 

October 3, 2006 

The Honorable Charles E. Grassley 

Chairman 

Committee on Finance 

United States Senate 

Dear Mr. Chairman: 

In fiscal year 2005, the Social Security Administration (SSA) paid about 

$126 billion to approximately 12.8 million beneficiaries under the 

Disability Insurance (DI) and Supplemental Security Income (SSI) 

programs. These disability programs provide income support and in most 

cases, access to medical care for people unable to work due to physical or

mental impairments, or both. In recent years, both programs have grown 

and are poised to grow even faster as the baby boom generation enters its 

disability-prone years. For example, SSA expects that by 2010 the number 

of DI beneficiaries and their eligible family members will increase by more 

than one-third over 2001 levels. 

SSA is required to conduct periodic continuing disability reviews (CDR) to 

ensure that only eligible people continue to receive benefits. These 

reviews assess whether individuals are still eligible for benefits based on 

their current medical condition and ability to work, among other criteria.1

When SSA was conducting these reviews in the early 1980s, there were 

concerns that some beneficiaries were being arbitrarily removed from the 

programs. In response, Congress passed the Social Security Disability 

Benefits Reform Act of 19842

 (the act), which among other things 

established a medical improvement standard (the standard). Under this 

standard, unless certain exceptions apply, SSA must find improvement in a 

beneficiary’s medical condition and that the individual is able to work in 

order to discontinue benefits.3

 If SSA determines that the standard has 

 1

 In addition to medical CDRs, SSA also conducts “work CDRs” where it assesses if an 

individual’s earnings exceeded program limits. Our analysis only looked at medical CDRs. 

It did not include work CDRs. 

2

 Pub. L. No. 98-460 (1984). 

3

 For this report, we refer to “medical improvement” and individuals who have “improved

medically” as a finding that meets the requirements of the medical improvement standard

(improvement in a beneficiary’s medical condition that is related to the ability to work). 

Page 1 GAO-07-8 Social Security Disability Programs
been met in the course of conducting a CDR, the beneficiary may continue

to receive benefits until the individual receives another CDR (which 

potentially could result in a discontinuation of benefits), dies, or 

transitions into Social Security retirement benefits. 

Since the standard has been implemented, some observers have suggested 

that certain factors associated with the standard may lead SSA to continue

benefits for some individuals who might otherwise be able to work. Given 

this observation and the continued growth in the DI and SSI programs, the 

Senate Committee on Finance asked us to (1) examine the proportion of 

beneficiaries who are removed from the disability programs because they 

have improved medically and (2) determine if factors associated with the 

standard pose challenges when determining whether beneficiaries 

continue to be eligible for benefits. 

To address these questions, we reviewed the act, regulations, and SSA 

guidance and processes for evaluating whether beneficiaries continue to 

be eligible for benefits. We examined SSA data on CDR outcomes for a 7-

year period (fiscal years 1999 to 2005). We looked only at DI and SSI adult 

beneficiaries.4

 We verified the statistical data on CDR outcomes, 

interviewed knowledgeable officials about the data, and determined that 

the data were sufficiently reliable for the purposes of our review. 

Furthermore, we conducted a national survey of all 55 Disability 

Determination Services (DDS) directors and received 54 completed 

responses to achieve a response rate of 98 percent. In addition, we 

interviewed various SSA officials, disability experts, and disability 

advocacy groups regarding the standard. We also conducted site visits in 

three states (Massachusetts, Texas, and California). We selected these 

states based on several criteria, including number of disability 

beneficiaries, proportion of CDRs that result in a discontinuation of 

benefits, and geographic dispersion, among other criteria. During these 

visits, we conducted in-depth interviews with 80 selected SSA officials, 

including DDS directors, CDR supervisors, disability examiners, 5 and 

 4

 For the purposes of our study, we only assessed DI and SSI adult beneficiaries who 

received a full medical CDR. We did not include children or the “age 18 re-determinations” 

in our analysis since there are differences between the medical CDR sequential evaluation 

processes for adults and children. Also, we only assessed the outcome of the full medical 

CDRs. 

5

 During our site visits, we met with 11 CDR supervisors and disability examiners who the

DDS directors selected as the most knowledgeable in their office about the CDR process 

and the medical improvement standard. 

Page 2 GAO-07-8 Social Security Disability Programs
medical specialists. We also interviewed regional office disability officials, 

regional Office of Disability Adjudication and Review officials, 

administrative law judges, and regional Office of Quality Performance 

officials and examiners. Moreover, we reviewed selected CDR cases to 

obtain examples of how the standard may impact decisions to continue or 

discontinue benefits. In addition, we consulted with outside groups 

including the Social Security Advisory Board and disability advocacy 

groups. We conducted our work from October 2005 through June 2006 in

accordance with generally accepted government auditing standards. 

Appendix I discusses our scope and methodology in more detail. The 

survey and a tabulation of the results can be viewed at 

http://www.gao.gov/cgi-bin/getrpt?rptno=GAO-07-4sp. 

On average, each year about 13,800 beneficiaries, or 1.4 percent of all the

people who left the disability programs between fiscal years 1999 and 

2005, were removed because SSA found that they had improved medically. 

More beneficiaries leave the programs because they die or convert to 

regular retirement benefits. Moreover, while CDRs are the agency’s most 

comprehensive tool for determining whether a recipient continues to have 

a disability, on average, about 2.8 percent of beneficiaries who undergo a 

CDR leave the DI and SSI programs due to medical improvement. For 

example, in fiscal year 2005, SSA conducted about 333,000 medical CDRs 

and discontinued disability benefits for about 10,300 recipients for medical 

improvement. 

Results In Brief 

Our review suggests that several factors associated with the standard pose

challenges for SSA’s ability to assess whether beneficiaries continue to be 

eligible for benefits. First, limitations in SSA guidance may result in 

inconsistent application of the standard. For example, we found that SSA 

does not clearly define the degree of improvement needed to meet the 

standard, and the directors we surveyed reported using different 

thresholds to show medical improvement. From our survey, 17 DDS 

directors reported that a large or very large increase in a recipient’s ability 

to perform basic work activities is required to show medical improvement, 

while 24 reported that a moderate increase is required. In addition, while 

the act does provide for certain exceptions to medical improvement that 

could result in additional individuals having their benefits discontinued 

following a CDR, most of the disability examiners whom we spoke with on 

our site visits (7 of the 11 examiners) told us that they were uncertain 

about when to apply the exceptions. Second, incorrect application of one 

element of the standard by a majority of DDSs—CDRs should be 

conducted on a neutral basis, without a presumption that an individual 

Page 3 GAO-07-8 Social Security Disability Programs
continues to have a disability—may make it difficult to determine if 

beneficiaries have improved medically. Finally, we found that other 

factors, such as inadequate documentation of evidence and the judgmental 

nature of the decision process concerning what constitutes medical 

improvement may make it difficult for SSA to determine whether a 

beneficiary remains eligible for benefits. These problems have

implications for the consistency and fairness of SSA’s medical 

improvement decision-making process. However, due to data limitations, 

we were unable to determine the extent to which these problems actually

affect decisions to continue or discontinue benefits. 

We are recommending that the Commissioner of Social Security clarify 

policies for assessing medical improvement. Areas that could benefit from 

improved clarity in guidance include what degree of improvement is 

needed to meet the standard, when the use of exceptions is appropriate, as 

well as clarification for DDSs about presumption of disability when 

conducting CDRs. 

SSA generally agreed with our recommendation but expressed 

reservations about the need for further guidance on the proper use of the 

exceptions to medical improvement. SSA believed that its implementation 

of the statutory exceptions is appropriate and that its instructions are 

consistent with the intent of the law. We revised the report to more clearly

highlight that the need for further guidance stems from our discussions 

with disability examiners, most of whom expressed uncertainty regarding

the application of the exceptions. 

The Social Security Administration (SSA) administers two programs under 

the Social Security Act that provide benefits to people with disabilities: (1) 

Disability Insurance (DI) and (2) Supplemental Security Income (SSI).6

Established in 1956, DI is an insurance program that provides benefits to 

workers who become unable to work because of a long-term disability. 

Workers who have paid into the Social Security Trust Fund are insured 

under this program. At the end of calendar year 2005, the DI program 

served about 8.3 million workers with disabilities, their spouses, and 

dependent children and paid out about $85 billion in cash benefits 

throughout the year. Once found entitled, individuals continue to receive 

Background 

 6

 Some disability recipients receive both DI and SSI benefits because of the low level of 

their income and resources. 

Page 4 GAO-07-8 Social Security Disability Programs
benefits until they either die, return to work and earn more than allowed 

by program rules, are found to have improved medically and are able to

work, or reach regular retirement age7

 (when disability benefits convert to 

retirement benefits). 

SSI serves people with disabilities on the basis of need, regardless of 

whether they have paid into the Social Security Trust Fund. Created in 

1972, SSI is an income assistance program that provides cash benefits for 

disabled, blind, or aged people who have low income and limited 

resources. At the end of calendar year 2005, the SSI program served about

6.8 million people and paid about $36 billion in federal cash benefits 

throughout the year.8

 These cash benefits are paid from general tax 

revenues. SSI benefits generally can be discontinued for the same reasons 

as DI benefits, although SSI benefits also may be discontinued if a person

no longer meets SSI income and resource requirements. Unlike the DI 

program, SSI benefits can continue even after the person reaches full 

retirement age. 

The Social Security Act’s definition of disability for adults is the same 

under both programs. A person’s physical or mental impairment must (1) 

have lasted or be expected to last at least 1 year or to result in death and 

(2) prevent or be expected to prevent him or her from being able to engage 

in substantial gainful activity (SGA) for that period of time. People are 

generally considered to be engaged in SGA if they earn above a certain

dollar level. For 2006, SSA considers countable earnings above $860 a 

month to be SGA for an individual who is not blind and $1,450 a month for 

an individual who is blind. 

History of the Medical 

Improvement Standard 

and the Current 

Continuing Disability 

Review Process 

Prior to 1980, some studies indicated that many beneficiaries of the 

disability programs no longer had a disability and could work. To ensure 

that only eligible beneficiaries remained in the programs, Congress passed 

a law requiring SSA to conduct continuing disability reviews (CDR) 

beginning in January 1982. State Disability Determination Services (DDS) 

examiners began conducting medical CDRs under the same criteria used 

 7

 Beginning at age 62, workers receiving DI benefits may elect to receive retirement 

benefits in lieu of disability benefits. 

8

 Of these beneficiaries, about 5.7 million were blind or had a disability and received about 

$31.8 billion in benefits. About 1.1 million beneficiaries did not have a disability, but were 

aged and received about $4.1 billion in benefits. 

Page 5 GAO-07-8 Social Security Disability Programs
to evaluate initial disability claims. In 1981 and 1982, about 45 percent of 

those individuals who received a CDR had their benefits discontinued.9

There was no statutory requirement for SSA to show that a beneficiary had 

improved medically in order to remove him or her from the programs. 

Disability advocacy groups and others became concerned that some 

beneficiaries were being inappropriately removed from the disability 

programs, and by 1984 SSA placed a moratorium on all CDRs. 

To address concerns that some beneficiaries were being inappropriately 

removed from the programs, Congress enacted the Social Security 

Disability Benefits Reform Act of 1984. The act included a provision 

requiring SSA to find substantial evidence demonstrating medical 

improvement before ceasing a recipient’s benefits (the medical 

improvement standard). SSA resumed CDRs in January 1986 using this 

standard, which is among the first steps of the CDR evaluation process.10

The standard has the following two elements that need to be met 

• Is there improvement in a beneficiary’s medical condition? The 

regulations implementing the act define improvement as any decrease 

in the medical severity of the beneficiary’s impairment(s) since the last 

time SSA reviewed his or her disability, based on changes in symptoms, 

signs, or laboratory findings. 

• Is this improvement related to the ability to work? Improvement 

related to the ability to work is evaluated two different ways, 

depending on whether the comparison point decision (CPD) was based 

 9

 SSA officials noted that the discontinuation rate in the early 1980s may not have been

representative of the results of the CDR process before the implementation of the medical 

improvement standard. SSA officials stated that in response to reports that suggested that

many individuals who did not have a disability were receiving benefits, an aggressive effort 

was initiated in 1981 to remove individuals from the DI program whose impairments were 

not severe enough to entitle them to benefits. The agency reported that this effort focused

on beneficiaries who were deemed at the time most likely to be determined not to have a 

disability and led to a large, temporary increase in the number of DI program 

discontinuances in the early to mid-1980s. 

10 Before disability examiners assess if a beneficiary has improved medically, they first 

assess if the beneficiary is working at the level of SGA. If beneficiaries are working at or 

above the SGA level, then benefits are discontinued. If not, then the CDR process proceeds 

to the second step. 

Page 6 GAO-07-8 Social Security Disability Programs
on: (1) meeting or equaling a prior disability listing11 or (2) a residual 

functional capacity (RFC) assessment.12

• Meeting or equaling the prior listing: In this case, a disability 

examiner will determine if the beneficiary’s same impairment(s) 

still meets or equals the prior listing. A disability examiner 

compares the beneficiary’s condition with the list of impairments in 

effect at the time he or she was first awarded disability benefits.13 If 

the impairment(s) meets or equals the prior listing, then benefits are 

continued. If not, then the examiner proceeds with the CDR 

evaluation. 

• Residual functional capacity assessment: In this case, a disability 

examiner compares the beneficiary’s previous functional capacity 

to the current functional capacity for the same impairment. If 

functional capacity for basic work activities has improved, then the 

examiner finds that the medical improvement is related to the 

ability to work and proceeds with the CDR evaluation. 

The act allows SSA to discontinue benefits even when the beneficiary has 

not improved medically if one of the specific “exceptions” to medical 

improvement applies14

• the person benefits from advances in medical or vocational therapy or 

technology,

• the person has undergone a vocational therapy program that could help 

him or her work, 

 11 SSA maintains a list of impairments that, by definition, are so severe that they are 

disabling. 

12 The assessment of a beneficiary’s actual ability to work comes later in the CDR process 

(steps 7 and 8). See appendix II for a more detailed description of the CDR process. 

13 At this step of the evaluation, a disability examiner considers only the listings that were 

met (or equaled) the last time the beneficiary was evaluated, not all of the listings that 

existed at the time of the last review. 

14 In addition to the Group I exceptions listed above, benefits may also be discontinued if a

DI beneficiary is engaging in substantial gainful activity. The act also provides for other 

situations (called Group II exceptions) where SSA can discontinue either DI or SSI

benefits. Group II exceptions are: (a) the prior determination or decision was fraudulently 

obtained, (b) the beneficiary does not cooperate with SSA, (c) SSA is unable to locate the

beneficiary, and (d) the beneficiary fails to follow prescribed treatment which would be

expected to restore his or her ability to do SGA. For Group II exceptions, SSA discontinues

benefits immediately without further development. 

Page 7 GAO-07-8 Social Security Disability Programs
• new or improved diagnostic techniques or evaluations reveal that the 

impairment is less disabling than originally thought, or 

• the prior decision was in error. 

In order to be removed from the disability programs for one of the 

exceptions, disability examiners must also show that the individual has the 

ability to engage in SGA. 

SSA does not conduct CDRs on all beneficiaries each year. At the time 

beneficiaries enter the DI or SSI programs, DDSs determine when they will 

be due for CDRs based on their likely potential for medical improvement. 

Based on SSA regulations, DDSs classify beneficiaries into one of three 

medical improvement categories 

• medical improvement expected—CDR generally once every 6 to 18 

months; 

• medical improvement possible—CDR once every 3 years; or 

• medical improvement not expected—CDR once every 5 to 7 years. 

SSA has also developed a method, called profiling, to determine the most 

cost-effective method of conducting a CDR. SSA applies statistical 

formulas that use data on beneficiary characteristics—such as age, 

impairment type, length of time on disability programs, previous CDR 

activity, and reported earnings—to predict the likelihood of medical 

improvement and, therefore, of benefit discontinuation. SSA assigns a 

“score” to beneficiaries indicating whether there is a high, medium, or low 

likelihood of medical improvement. In general, beneficiaries with a high 

score are referred for full medical CDRs. Beneficiaries with lower scores 

are, at least initially, sent a questionnaire, known as a “mailer.”15 Full 

medical CDRs involve an in-depth examination of a beneficiary’s medical 

and possibly his or her vocational status. This may include a review of the 

recipient’s case file, physical and psychological condition, and medical 

evidence by a disability examiner and physician. Unlike full medical CDRs, 

CDR mailers consist of a short list of questions asking beneficiaries to selfreport information on their medical condition, treatments, and work 

activities. Appendix II describes the medical CDR evaluation process in 

detail. 

 15 If beneficiaries’ responses to a mailer indicate possible improvement in medical 

condition or vocational status, SSA may refer these individuals for a full medical review. 

However, in most cases, SSA decides that a full medical review is not warranted and that 

benefits should be continued.

Page 8 GAO-07-8 Social Security Disability Programs
SSA will find that disability has ended and discontinue benefits16 if it 

determines that medical improvement related to the ability to work has 

occurred or that one of the exceptions applies, and the person’s 

impairments are not severe or the person can do past work or other work. 

If SSA determines that medical improvement has not occurred and that 

none of the exceptions apply, then benefits are continued17 (see fig. 1). 

 16 Beneficiaries may elect to have benefits continued while they appeal the decision that 

their disability has ended. 

17 SSA also conducts work CDRs where it may remove a beneficiary from the disability 

programs if their earnings exceed SGA. 

Page 9 GAO-07-8 Social Security Disability Programs
Figure 1: Current Medical CDR Evaluation Process 

Is the person currently doing SGA?

No 

No No 

No 

No 

No

Does the person’s current impairment(s) 

meet or equal a current listing? 

Is there improvement in the person’s medical condition?

(Compare findings for impairments at comparison 

point decision (CPD) to current findings for same impairments)

Yes 

Yes 

Yes 

Yes 

Yes 

Yes

 Is the improvement related to the ability to work? 

 (Consider only CPD impairments. Determine if either the 

 impairment(s) still meets/equals a CPD listing or if the 

beneficiary's RFC has improved.)

No 

No

 Does an exception 

apply?

No 

Are the current impairments severe?

Yes 

Does the person have the ability to do past work?

Does the person have the ability to do other work?

Step 1 

Step 2 

Step 3 

Step 4 Step 5 

Step 6 

Step 7 

Step 8 

Yes

Prepare current RFC for all impairments

 

Discontinue

benefits

Discontinue

benefits

Discontinue

benefits

Discontinue

benefits

Continue 

 benefits

Continue 

 benefits

Continue 

 benefits

Source: GAO and SSA.

a

b c

c

c

c

Page 10 GAO-07-8 Social Security Disability Programs
a

For SSI beneficiaries, SGA is not considered and the CDR evaluation process is started at Step 2.

Instructions for SGA considerations differ for beneficiaries covered by certain work incentive 

programs. 

b

If a group II exception applies, discontinue benefits immediately without a medical determination. 

c

Consider age and time on the disability programs.

If SSA finds that the individual no longer has a disability and discontinues 

benefits following a CDR, the individual has the right to appeal the CDR 

decision, first to another reviewer for a reconsideration, second to an 

administrative law judge, then to the Appeals Council, and finally to 

federal courts. At the hearing before the administrative law judge (ALJ), 

the ALJ reviews the file, including any additional evidence submitted after 

the DDS determination and may hear testimony from the individual as well

as medical and vocational experts. 

SSA’s Office of Quality Performance conducts quality reviews of disability 

determination outcomes. To conduct these quality reviews, SSA selects a 

random sample of cases each month from all final CDR decisions, 

stratifying the selection of cases by state and outcome (cases where 

benefits are continued and discontinued). Then, a quality examiner 

reviews the case to ensure it adheres to SSA guidance, including a review 

of the DDS decision, the documentation of that decision, and the evidence 

contained in the case. During these reviews, physicians18 evaluate the 

evidence to ensure that the decision adheres to the medical improvement 

standard. In fiscal year 2005, SSA’s Office of Quality Performance reported 

nationwide accuracy rates for cases where CDR benefits were continued 

and discontinued of 95 percent and 93 percent respectively. The combined

accuracy rate for all CDRs was about 95 percent.

 18 A psychologist may evaluate the evidence if the individual has a psychological 

impairment. 

Page 11 GAO-07-8 Social Security Disability Programs
We found that on average, about 1.4 percent of all individuals who left the 

programs between fiscal years 1999 and 2005 were removed for medical 

improvement. More beneficiaries leave the disability programs because 

they either die or convert to social security retirement benefits. In 

addition, while full medical CDRs are the agency’s most comprehensive 

tool for determining whether a beneficiary continues to have a disability, 

about 2.8 percent of those who receive these CDRs are found to no longer 

have a disability under the medical improvement standard. 

Between fiscal years 1999 and 2005, annually, an average of 13,80019

people—or about 1.4 percent of all individuals who left the disability 

programs—were removed because SSA found that they had improved 

medically.20 More people leave the programs when they die, convert to full 

retirement benefits,21 or leave for other reasons. For example, between 

fiscal years 1999 and 2005, each year an average of about 311,00022

recipients (about 32 percent of all recipients who were removed from the 

disability programs) died, and about 209,000 (about 21 percent) converted 

from DI benefits to retirement benefits. In addition, each year about 

444,000 beneficiaries (about 45 percent) were removed from the disability 

programs for other reasons. These include about 54,000 DI beneficiaries 

who SSA determined had earnings in excess of SGA, about 11,000 DI 

beneficiaries who either converted to old-age retirement benefits prior to 

reaching the full retirement age23 or were found to be erroneously eligible 

Few Beneficiaries Are 

Removed from the 

Disability Programs 

Because They Are 

Found to Have 

Improved Medically

Few Beneficiaries Are 

Removed from the 

Programs Due to Medical 

Improvement 

 19 For the purposes of our study, we only assessed DI and SSI adult beneficiaries who 

received full medical CDRs. We did not include children or the “age 18 re-determinations” 

in our analysis since there are differences between the medical CDR sequential evaluation 

processes for adults and children. Also, we only assessed the outcome of the full medical 

CDRs. We did not assess the outcome of the CDR mailers or CDRs of beneficiaries’

earnings and work activity—referred to as work CDRs. 

20 The 13,800 people who were removed from the disability programs for medical 

improvement as a result of receiving a CDR represent about 0.1 percent of all adult DI and 

SSI disability beneficiaries. Of these 13,800 recipients, about 9,260 were DI recipients and 

about 4,580 were SSI recipients. 

21 SSA converts DI beneficiaries to retirement benefits when they attain full retirement age. 

22 The 311,000 recipients who died consisted of about 180,000 DI recipients and about

131,000 SSI recipients. 

23 Beginning at age 62, workers receiving DI benefits may elect to receive retirement 

benefits in lieu of disability benefits. Although most beneficiaries receiving DI benefits

elect to receive their disability benefits until full retirement age—at which time disability 

benefits convert to benefits paid from the Old-Age and Survivors Insurance program—

some choose to switch earlier. 

Page 12 GAO-07-8 Social Security Disability Programs
for benefits, and about 379,000 SSI beneficiaries who were removed from 

the SSI program for all reasons other than death and medical improvement 

(including earnings and resources above the limit allowed by program 

guidelines) (see fig. 2). 

Figure 2: Average Percentage of All Beneficiaries Who Were Removed from the DI 

and SSI Programs by Category (Fiscal Years 1999 to 2005) 

21%

32%

45%

Source: GAO analysis of SSA data.

1.1%

Failure to cooperate

Conversion to

retirement benefits

Death

Other

1.4%

Medical improvement

Note: While the combined DI and SSI programs in figure 2 illustrate the reasons why beneficiaries are 

removed from the DI and SSI programs, there are some differences between these two programs. 

For the same time period, for the DI program, about 2 percent of all recipients who were removed 

from the DI program improved medically; about 45 percent converted from disability benefits to 

retirement benefits; about 39 percent died; about 12 percent had earnings in excess of SGA; and 

about 2 percent left for other reasons. For the SSI program, about 1 percent of all recipients who 

were removed from the SSI program improved medically; about 25 percent died; and about 74 

percent left for other reasons. 

During fiscal years 1999 to 2005, the proportion of all beneficiaries who 

were removed from the programs in each of the above categories 

remained fairly consistent. For example, during this period, the proportion 

of individuals removed from the disability programs in a fiscal year for 

medical improvement ranged from 1.0 percent to 1.7 percent; the 

proportion of individuals who died ranged from 31.1 percent to 33.0 

percent; and the proportion of individuals who converted from disability 

benefits to retirement benefits ranged from 19.7 percent to 22.7 percent.

Page 13 GAO-07-8 Social Security Disability Programs
SSA data show that few beneficiaries who receive medical CDRs are 

removed from the disability programs. Full medical CDRs are the agency’s 

primary tool to determine whether a beneficiary has improved medically. 

Between fiscal years 1999 and 2005, the number of full medical CDRs 

conducted ranged from a high of 608,000 in 2001 to a low of 333,000 in 

2005 (see fig. 3). 24 Between fiscal years 1999 and 2005, an average of about

26,000 individuals each year (about 5.3 percent) were removed from the 

disability programs as a result of receiving a medical CDR. Some of the 

officials we interviewed stated that the medical improvement standard 

may artificially limit the percentage of recipients who are found to have 

improved medically. However, we were unable to identify any empirical 

data regarding the impact of the standard on the percentage of recipients

who have their benefits discontinued, or what a “proper” discontinuation

rate should be. 

Few Beneficiaries Who 

Receive Full Medical 

Continuing Disability 

Reviews Are Removed 

from the Programs Each 

Year 

While the number of CDRs conducted between fiscal years 1999 and 2005 

fluctuated,25 the percentage of beneficiaries removed from the programs 

remained fairly constant.26 For example, in fiscal years 1999, 2002, and 

2004, the percentage of recipients who were removed from the disability 

programs as a result of receiving a CDR was 5.4 percent, 5.6 percent, and 5 

percent respectively. In addition to medical improvement, SSA also 

removes beneficiaries for failing to cooperate during a CDR. For example, 

a beneficiary may fail to appear for scheduled meetings with disability 

examiners or physicians and thus may have their benefits discontinued. Of

the individuals removed from the programs as a result of receiving a CDR 

between fiscal years 1999 and 2005, an average of about 13,800 individuals 

(or 2.8 percent of all CDRs conducted between fiscal years 1999 and 2005)

were removed annually because SSA determined that they had improved 

medically, while an average of about 10,300 individuals (or about 2.1 

percent) were removed each year for failure to cooperate. 

 24 For fiscal years 2000 to 2004, in addition to the full medical CDRs, SSA also conducted an 

average of about 834,000 CDR mailers annually, ranging from a high of 960,000 mailers in 

2000 to a low of 692,000 mailers in 2003. 

25 In the late 1990s Congress appropriated special funds for SSA to alleviate backlogs of

CDRs. These special funds began in fiscal year 1996 and expired at the end of fiscal year 

2002. Because of this special funding, the number of full medical CDRs conducted by SSA

increased. 

26 We did not determine why the discontinuation rate remained consistent considering the

change in the number of CDRs conducted. 

Page 14 GAO-07-8 Social Security Disability Programs
Figure 3: Number of Full Medical CDRs Conducted and Resulting Benefit 

Discontinuations (Fiscal Years 1999 to 2005) 

0

100,000

200,000

300,000

400,000

500,000

600,000

700,000

1999 2000 2001 2002 2003 2004 2005

0

10

20

30

40

50

60

70

80

90

100

Volume Discontinuations as a percent of total CDRs

Source: GAO analysis of SSA Data.

Year

Discontinuation rate

Number of full medical CDR’s conducted

Number of individuals removed from the disability programs as a result of receiving a CDR

Our review suggests that several factors associated with the standard pose

challenges for SSA’s ability to assess whether beneficiaries continue to be 

eligible for benefits. First, limitations in SSA guidance may result in 

inconsistent application of the standard. For example, we found that SSA 

does not clearly define the degree of improvement needed to meet the 

standard, and the DDS directors we surveyed reported using different 

thresholds to show medical improvement. As a result of this apparent 

limitation in SSA guidance, disability examiners may incorrectly decide to

continue or discontinue benefits. In addition, while the act provides for 

certain exceptions that could result in additional individuals having their 

benefits discontinued following a CDR, most of the disability examiners 

we spoke with told us that they were uncertain about when to apply the 

exceptions. Second, we found that most DDSs are incorrectly conducting 

CDRs with the presumption that a beneficiary has a disability. Finally, 

other factors, such as inadequate documentation of evidence and the 

Several Factors 

Challenge SSA’s

Ability to Assess 

Whether Beneficiaries 

Continue to Be

Eligible for Benefits 

Page 15 GAO-07-8 Social Security Disability Programs
judgmental nature of the decision process for assessing medical 

improvement may make it more difficult to determine whether a 

beneficiary remains eligible for benefits. However, due to data limitations, 

we were unable to determine the extent to which these challenges impact 

decisions to continue or discontinue benefits during a CDR. 

Limitations in SSA 

Guidance for Applying the 

Medical Improvement 

Standard May Result in 

Inconsistent Disability 

Decisions 

Our work shows that SSA does not clearly define the degree of 

improvement needed for examiners to determine if a beneficiary has 

improved medically. Many disability examiners and DDS officials told us 

that they were unsure about the degree of improvement required to meet 

the standard, and some said this confusion stems from unclear SSA 

guidance. In particular, SSA guidance instructs examiners to disregard 

“minor” changes in a beneficiary’s condition.27 However, this guidance 

does not adequately describe what constitutes a minor change. When we 

asked SSA officials to clarify their understanding of what constitutes a 

minor change, they told us that only changes that would not affect a 

beneficiary’s ability to work should be considered minor. However, this 

explanation of minor changes is not included in the agency’s guidance. As 

a result, some DDSs may be inconsistently defining what constitutes a 

minor change. For example, five DDS directors told us that they define

minor changes to include those that may actually improve functioning or 

allow the beneficiary to work. In doing so, our review suggests that some 

DDSs may be inconsistently applying the standard as to what constitutes 

medical improvement. However, DDS directors differed on the extent to

which the guidance to disregard minor changes impacts CDRs. Of the 52 

DDS directors who answered a question in our survey on “minor” changes,

21 reported that the practice of disregarding minor changes is not an 

impediment to making a disability determination, while 31 reported that it

is an impediment.28

Similarly, we found that SSA guidance may not provide DDS examiners 

with sufficient detail to determine whether improvements in beneficiaries’ 

medical conditions are related to their ability to work. At this step of the 

CDR process, examiners look for changes in a beneficiary’s ability to 

 27 See SSA Program Operations Manual System (POMS) section DI 28010.015. 

28 While we received 54 completed surveys, not every director responded to every question. 

In presenting our results, we only included the directors who answered a particular 

question with a value on our response scale. If a director answered “no basis to judge,” we

did not count that response. 

Page 16 GAO-07-8 Social Security Disability Programs
perform basic work activities since the last review, such as lifting heavy 

objects or standing or sitting for periods of time.29 The guidance instructs 

examiners to ensure a “reasonable relationship” between the amount of 

improvement and the increase in the ability to perform basic work 

activities.30 However, the guidance does not require a specific amount of 

increase in functioning. The DDS directors we surveyed reported that they

interpret this guidance differently. Specifically, 17 of 49 directors reported 

that a large or very large increase in a recipient’s ability to do basic work 

activities is required; 24 reported that a moderate increase is required; and

8 reported that a minor or any increase at all is required. Furthermore, two 

DDS directors in our survey inaccurately noted that the standard requires 

that a beneficiary’s improvement be great enough so that it actually 

enables the individual to work.31 One of these directors commented that 

because SSA guidance on this aspect of the standard is open to broad 

interpretation, it is difficult to document improvement to the extent the 

individual is able to work. As a result, some DDSs may be inconsistently 

applying this aspect of the standard that could potentially impact 

decisions to continue or discontinue benefits. However, we were unable to

determine how much of an impact clarification of this guidance would 

have on CDR outcomes. 

The disability advocates we spoke with differed in their views on the 

clarity of SSA guidance on medical improvement. While some stated that it 

is clear and adequate, others stated that the guidance on assessing medical 

improvement in psychological impairments and determining if 

improvement is related to the ability to work is confusing and unclear. One 

advocate stated that current SSA policies contribute to some recipients 

remaining in the disability programs despite their ability to work. 

We also found that while the act provides for exceptions to medical 

improvement that could result in additional individuals having their 

benefits discontinued as a result of receiving a CDR, most of the disability 

examiners whom we spoke with on our site visits told us that they were 

 29 At this step (step 4 of the CDR evaluation process), the assessment of working at the 

level of SGA is not considered. SGA is evaluated in the first step of the CDR evaluation 

process. See appendix II for a detailed description of the CDR process. 

30 See POMS section DI 28015.320. 

31 The assessment of a beneficiary’s actual ability to work comes later in the CDR process 

(steps 7 and 8). See appendix II for a more detailed description of the CDR process.

Page 17 GAO-07-8 Social Security Disability Programs
uncertain about when to apply the exceptions.32 SSA policies allow for 

various exceptions, including when the prior decision was in error or 

when persons benefit from education or training programs that could help

the individuals work. However, we found that while the examiners and 

ALJs routinely assess whether a beneficiary has improved medically, they 

do not routinely assess whether or not each of the exceptions applies to

the case. Moreover, many of the DDS officials and examiners we 

interviewed told us that the guidelines for using the error exception are 

written in a way that precludes its use, except in the most extreme 

situations.33 

SSA officials explained that the exceptions were written to intentionally 

limit their use in order to prevent examiners from circumventing the 

standard, and that their infrequent use is appropriate. In addition, SSA 

explained that when it issued the final rules governing the medical 

improvement standard, it intended the exceptions to be true 

“exceptions”—not to be routinely applied (including the error exception). 

The agency also noted that a broader application of the error exception 

could lead to a substitution of judgment by an adjudicator for the original 

finding of disability in instances where a person’s medical condition had 

not substantially improved. Some disability advocates we spoke with also 

noted that the narrow interpretation of the error exception is appropriate 

because it prevents substitution of judgment and arbitrary 

discontinuations. 

A Majority of DDSs 

Incorrectly Apply SSA 

Guidelines Stating That 

CDRs Should Be 

Conducted Neutrally,

without a Presumption of 

Disability 

According to our survey, a majority of DDSs incorrectly presume that a 

beneficiary continues to have a disability when conducting CDRs, which 

may make it more difficult for examiners to determine if a beneficiary has 

improved medically. This is contrary to the act as well as SSA regulations 

and policy, which require that CDR decisions be made on a “neutral basis.” 

SSA defines neutral basis as a review that neither presumes that a 

beneficiary (1) is still disabled because he or she was previously found 

disabled and (2) is no longer disabled because he or she was selected for a

CDR. Under a neutral review, it is assumed that beneficiaries had a 

 32 During our site visits, we met with 11 CDR supervisors and disability examiners who the

DDS directors selected as the most knowledgeable in their office about the CDR process 

and the medical improvement standard. Seven of these 11 individuals stated that they were

uncertain about when to apply the exceptions to medical improvement. 

33 The error exception applies when an error was evident in the prior decision. 

Page 18 GAO-07-8 Social Security Disability Programs
disability at the time of the prior decision, but it is not assumed they still 

have a disability at the time of a CDR. However, in survey responses, 31 

DDS directors responded that in practice, CDRs are conducted with the 

presumption that a beneficiary continues to have a disability.34 When asked 

to explain this response, directors cited various factors that likely 

contribute to the presumption of disability during a CDR. Thirteen 

directors commented that the individuals are already receiving disability 

benefits, and as a result, the directors assume that the beneficiary 

continues to have a disability. Some of these directors also noted that they 

make this presumption because the beneficiary was found disabled when 

initially awarded benefits, and examiners must show medical 

improvement to remove them from the programs. 

Since a majority of DDSs are conducting CDRs with a presumption that 

beneficiaries have a disability, those DDSs may be setting a higher bar 

than required by the standard for these reviews. Moreover, by requiring 

more evidence of medical improvement than is necessary under the 

standard, it may be harder to assess whether a recipient no longer has a 

disability and is able to work. Because 31 directors reported that 

examiners conduct CDRs with the presumption that beneficiaries continue 

to have a disability, a significant number of beneficiaries may be evaluated

under this higher standard, and some may have their benefits erroneously 

continued. While these problems raise concerns about the consistency of 

decisions when determining if medical improvement has occurred, the 

ultimate impact of presuming that an individual has a disability on CDR 

decisions is unknown because we were unable to empirically test how the 

presumption of a disability impacts CDR decisions to continue or 

discontinue benefits. 

Other Factors May Make 

Assessing Medical 

Improvement Difficult 

Inadequate documentation of evidence and the judgmental nature of the 

process for assessing medical improvement are two additional factors that 

make it challenging to assess medical improvement. The standard 

establishes the prior decision as the starting point for conducting a CDR 

and requires examiners to find evidence of medical improvement since 

this last decision. Some DDS directors reported that it may be difficult to 

assess medical improvement in cases where the prior disability decision 

was based on incomplete or poorly documented evidence. For example, in 

 34 Of the 48 DDS directors who responded to this question, 17 indicated that CDR decisions

are made on a neutral basis. 

Page 19 GAO-07-8 Social Security Disability Programs
one of the CDR cases we reviewed, a beneficiary had his benefits 

continued following the CDR because the rationale for the prior disability 

decision was vague, according to the examiner who reviewed the case 

with us. This beneficiary was originally awarded benefits on appeal based 

on recurrent stomach problems and depression. When the case was 

selected for a CDR, the case file included a general description of the 

beneficiary’s medical condition, but lacked sufficient evidence to 

determine if medical improvement had occurred since the initial decision, 

according to the examiner. As a result, medical improvement could not be

shown and benefits were continued. While many examiners and officials 

we interviewed agreed that it is difficult to show medical improvement in 

cases that lack adequate documentation, they differed in their opinions 

about how frequently this occurs. Of the directors who answered our 

survey question on insufficient documentation, 33 responded that they 

encounter cases with insufficient documentation infrequently or very 

infrequently, and 17 responded that such cases occurred more often.35

Survey respondents also differed in their opinions about the types of cases 

that more typically lack adequate documentation, but 15 directors 

commented that cases decided on appeal were the most likely to lack 

adequate documentation. One possible explanation for this may be 

streamlined processes at the appeals level. For example, one ALJ we 

interviewed noted that, in an effort to process cases in a timely manner, 

ALJs sometimes issue quick decisions in which most of the evidence is on 

tapes that are not transcribed or placed in the beneficiary’s case file. In 

such instances, it is unlikely that the DDS examiner would have complete 

information for conducting a CDR and determining if medical 

improvement had taken place. Furthermore, several officials told us that 

guidance instructs ALJs to include enough information in their decisions 

so that the decisions will be legally sufficient. However, the guidance does 

not specifically instruct ALJs to include all of the evidence that will be 

needed to assess medical improvement at a future CDR. However, in 

recent regulations to implement changes to its disability determination 

process, SSA is taking steps that may help to address the problem of 

incomplete documentation for future CDRs. Specifically, SSA is 

 35 We asked directors to exclude cases missing the entire case file (i.e. lost folders) in their 

responses to this survey question. We asked the directors a separate question regarding

how frequently or infrequently they encounter cases where the entire case file is missing.

Although SSA has established a new electronic system to process initial claims, it has yet to

expand this new process to CDRs. As a result, CDRs are still being conducted in a paper 

environment. 

Page 20 GAO-07-8 Social Security Disability Programs
developing requirements for training examiners to ensure they understand

the information needed to make accurate and adequately documented 

decisions, has adopted guides for decision writing at the appeals level, and 

is in the process of developing guides for use at the DDS level. 

In addition to the challenges associated with problems of inadequate

documentation, many examiners also told us that the judgmental nature of

the decision process concerning what constitutes an improvement can 

make it difficult to assess medical improvement. One examiner may 

determine that a beneficiary has improved medically and discontinue 

benefits, while another examiner may determine that medical

improvement has not been shown and will continue the individual’s 

benefits. For example, in one of the CDR cases that we reviewed, the 

examiner conducting the initial CDR determined that medical

improvement was shown and discontinued the individual’s benefits. The 

recipient was initially awarded disability benefits for a back injury with 

limited range of motion in the recipient’s back. When the CDR was 

conducted, the examiner evaluated all of the relevant evidence and 

concluded that the individual’s range of motion had improved. The 

examiner also noted that the individual’s allegations of pain did not 

correlate with the findings from both the physical exam and the laboratory 

findings. As a result, the examiner concluded that medical improvement 

had occurred. On appeal to reconsideration 6 months later, a different 

DDS examiner conducted a review using the same medical evidence as the 

original examiner, but determined that medical improvement had not 

occurred, and continued benefits. The examiner conducting the appeal 

concluded that the beneficiary continued to experience pain consistent 

with the back condition, and thus medical improvement was not shown. 

However, we had no basis for determining which decision was correct. 

The amount of judgment involved in the decision-making process 

increases when the process involves certain types of impairments that are 

difficult to assess. More specifically, assessing medical improvement may 

be more difficult in cases that involve certain types of psychological 

impairments, such as depression, than cases with physical impairments, 

such as amputations. In elaborating on their survey responses, 17 directors 

commented that assessing medical improvement is more difficult in cases 

with psychological impairments because evidence of these impairments is 

generally more subjective than evidence of many physical impairments. In 

addition, six directors commented that evaluations of psychological 

impairments tend to rely more heavily on assessment of functionality. 

According to some of these officials, an assessment of functionality is 

more subjective because it relies more on the beneficiaries’ account of 

Page 21 GAO-07-8 Social Security Disability Programs
their own conditions than on laboratory findings. Furthermore, some 

officials reported that the severity of psychological impairments can 

fluctuate over time, making it difficult to assess whether improvement has

taken place. Two directors commented that determining whether there is 

medical improvement for some types of psychological impairments can 

also be complicated because medical experts’ opinions can vary. One of 

these directors commented that the evidence to support psychological 

impairments, such as evaluations for depression, rely less on laboratory 

findings and more on clinical judgment. In contrast, certain tests for 

physical impairments tend to be less open to interpretation. For example, 

one director commented that X-rays of joint deterioration can generally be 

interpreted consistently among radiologists. The potential difficulty of 

assessing medical improvement in beneficiaries whose disability is based 

on certain types of psychological impairments is especially relevant, given

that the proportion of all individuals in the disability programs whose 

disability is based on a psychological impairment has grown in recent 

years. 

SSA is responsible for assuring that individuals who truly have a disability 

that prevents them from being able to work continue to receive benefits. 

At the same time, SSA has a stewardship responsibility to identify those 

beneficiaries who have improved medically and are no longer eligible for 

benefits. The medical improvement standard is intended to help SSA 

accomplish both of these responsibilities. However, several factors 

associated with the standard pose challenges for ensuring that the 

standard is implemented in a consistent and fair manner. Specifically, 

potential limitations in SSA guidance regarding the degree of improvement 

needed to meet the standard as well as a lack of clarity with respect to the 

appropriate use of the exceptions to medical improvement may make it 

difficult to assess if medical improvement has occurred. Clear guidance is 

especially important in view of the judgmental nature of the disability 

determination process. Additionally, while SSA guidelines regarding the

presumption of disability during CDRs tend to be generally clear, incorrect

application of these guidelines by several DDSs suggests that the 

outcomes of CDRs could be affected and may result in benefit

continuation for some individuals who might otherwise been found to 

have improved medically. Other factors, including inadequate 

documentation of evidence, are more difficult to address in the short term. 

However, SSA is taking actions intended to address some of these 

problems. 

Conclusions 

Page 22 GAO-07-8 Social Security Disability Programs
To ensure that SSA is able to consistently assess whether DI and SSI 

beneficiaries have improved medically, we recommend that the 

Commissioner of Social Security clarify guidance for assessing medical 

improvement when conducting CDRs. More specifically, SSA should 

clarify guidance concerning (1) what degree of improvement is required to

meet the standard and (2) when the use of exceptions to medical 

improvement is appropriate. SSA should also work with DDSs to ensure 

that CDRs are conducted on a neutral basis, without a presumption that 

beneficiaries continue to have a disability. 

We obtained written comments on a draft of this report from the 

Commissioner of the Social Security Administration (SSA). The agency 

generally agreed with our recommendation, but expressed reservations 

about the need for further guidance on the use of exceptions. More 

specifically, SSA believed that its implementation of the statutory 

exceptions to medical improvement is appropriate and that its instructions 

are consistent with the intent of the law. As such, SSA was concerned 

about language in the draft report that characterized SSA’s guidance as 

discouraging and limiting the use of the exceptions. After considering 

these comments, we revised the report to include additional information 

on (1) examiners’ confusion on the use of the exceptions when conducting

CDRs and (2) SSA’s rationale for its current exception guidance. Having

made these changes, we continue to believe that additional guidance in

this area is warranted if only, as the report notes, because most of the 

disability examiners whom we spoke with told us that they were uncertain

about when to apply the exceptions. Moreover, while answering a survey 

question on the exceptions to medical improvement, 4 DDS directors 

commented that more guidance regarding the use of the exceptions is 

needed. 

Recommendation 

Agency Comments 

and Our Evaluation 

SSA generally agreed with the need for clarifying guidance concerning the

degree of improvement required to meet the medical improvement 

standard. However, the agency believed that the report was unclear with 

regard to whether this part of the recommendation applied only to 

guidance for determining if there has been any medical improvement, or 

also to the guidance for determining if any medical improvement is related 

to the ability to work. As stated in the draft report, our discussion of 

medical improvement encompasses both elements (improvement in a 

beneficiary’s medical condition and its relation to the ability to work). 

However, we did further clarify this throughout the entire report to 

minimize any confusion on this matter. Additionally, SSA indicated that 

clarification of this guidance would probably have little noticeable impact 

Page 23 GAO-07-8 Social Security Disability Programs
on the number of cases in which SSA finds that a disability has ended. As 

our report notes, we cannot quantify the impact that clearer guidance 

would have on the discontinuation of benefits. Even so, we continue to 

believe that it is important for DDSs to consistently apply this aspect of 

the medical improvement standard and that, towards that end, additional

guidance would be useful. 

SSA agreed with the need for further training to ensure that CDRs be 

conducted on a neutral basis. However, it believed that more adjudicator 

training in this area would likely have little impact on discontinuing 

benefits. We cannot predict the impact additional guidance and training 

would have on continuing or discontinuing benefits. However, as the 

report points out, there are large numbers of DDS directors who are 

incorrectly applying the neutrality standard and, in our view, would 

benefit from additional guidance in this area. 

Beyond commenting on our recommendation, SSA suggested that we 

provide additional context for some of the statistical information 

presented in our discussion of the proportion of beneficiaries removed 

from the disability programs each year. For example, SSA commented that 

the disability discontinuation rates in the early 1980s may not have been 

representative of the discontinuation rates prior to the implementation of 

the medical improvement standard due to special targeted initiatives 

aimed at removing individuals from the DI program who no longer had a 

disability. We revised the report to take into account these suggestions. 

The Commissioner’s comments have been reproduced in appendix III. SSA 

also provided additional technical comments, which have been 

incorporated in the report as appropriate. 

Unless you publicly announce its contents earlier, we plan no further 

distribution until 30 days after the date of this report. At that time, we will 

make copies available to other parties upon request. In addition, the report 

will be available at no charge on GAO’s Web site at http//:www.gao.gov.

This report does not contain all the results from the survey. The survey 

and a more complete tabulation of the results can be viewed at 

http://www.gao.gov/cgi-bin/getrpt?rptno=GAO-07-4sp. 

Page 24 GAO-07-8 Social Security Disability Programs
If you or your staff have questions concerning this report, please contact 

me at (202) 512-7215. Contact points for our Offices of Congressional 

Relations and Public Affairs may be found on the last page of this report. 

See appendix IV for a listing of major contributors to this report. 

Robert E. Robertson, 

Director, Education, Workforce, 

 and Income Security Issues 

Page 25 GAO-07-8 Social Security Disability Programs
Appendix I: Scope and Methodology Appendix I: Scope and Methodology 

This appendix provides additional details about our analysis of the 

medical improvement standard (the standard), including challenges the 

standard poses for the Social Security Administration (SSA) when 

conducting medical continuing disability reviews (CDR). To meet the 

objectives of this review, we reviewed prior studies by GAO, SSA, SSA’s 

Inspector General, Congressional Research Service, and external 

organizations related to the disability determination process and CDRs. 

We also reviewed the Social Security Disability Benefits Reform Act of 

1984, regulations, and SSA policies and processes for assessing whether 

beneficiaries continue to be eligible for benefits. In addition, we analyzed

SSA data on CDR outcomes over a 7-year period for fiscal years 1999 to

2005 as well as reports identifying the number of beneficiaries who leave 

the disability programs and the reasons why they leave. For the purposes 

of our study, we only assessed DI and SSI adult beneficiaries who left the 

programs as a result of receiving a full medical CDR. We did not include 

children or “age 18 re-determinations” in our analysis since there are 

differences between the medical CDR sequential evaluation processes for 

adults and children. We also did not assess the outcome of CDR mailers or 

work CDRs. We verified the statistical data on CDR outcomes for internal 

logic, consistency, and reasonableness. We determined that the data were

sufficiently reliable for the purposes of our review. We also met with 

knowledgeable SSA officials to further document the reliability of these 

data. 

We interviewed 34 officials from SSA’s central offices (including officials 

from the Office of the Chief Actuary, the Office of Quality Performance, 

the Office of General Counsel, the Office of Research and Evaluation 

Statistics, the Office of Disability Programs, the Office of Disability 

Adjudication and Review, and the Office of Program Development and 

Research) to discuss the disability programs and the CDR process. 

We conducted a national Web-based survey of all 55 Disability 

Determination Services (DDS) directors in the 50 states, the District of 

Columbia, Puerto Rico, the Virgin Islands, the Western Pacific Islands, and 

the federal DDS. DDSs are the agencies responsible for conducting 

periodic CDRs to determine if beneficiaries’ medical conditions have 

improved and if they are able to work. We received 54 completed surveys 

for a response rate of 98 percent. The purpose of this survey was to assess 

the extent to which the standard impacts outcomes of CDRs and 

determine if the standard poses any special challenges for SSA when 

determining whether beneficiaries continue to be eligible for benefits. We 

asked the directors about particular elements of the standard and how 

these elements, alone or in combination with other factors, impact CDR 

Page 26 GAO-07-8 Social Security Disability Programs
Appendix I: Scope and Methodology 

outcomes. We also asked them how SSA guidance on implementing the 

standard affects CDR outcomes. We determined that the survey data are 

sufficiently reliable. Because this was not a sample survey, there are no 

sampling errors. However, the practical difficulties of conducting any 

survey may introduce errors, commonly referred to as nonsampling errors. 

For example, difficulties in how a particular question is interpreted, in the

sources of information that are available to respondents, or in how the 

data are entered into a database or were analyzed, can introduce 

unwanted variability into the survey results. We took steps in the 

development of the questionnaire, the data collection, and the data 

analysis to minimize these nonsampling errors. For example, social 

science survey specialists designed the questionnaire in collaboration with 

GAO staff with subject matter expertise. Then, the draft questionnaire was 

pretested with a number of state officials to ensure that the questions were 

relevant, clearly stated, and easy to comprehend. The questionnaire was 

also reviewed by an additional GAO survey specialist. When the data were 

analyzed, a second, independent analyst checked all computer programs. 

Since this was a Web-based survey, respondents entered their answers 

directly into the electronic questionnaire. This eliminated the need to have 

the data keyed into a database thus removing an additional source of 

error. We conducted three pretests of this survey with DDS directors in 

three different states. We modified the survey to take their comments into 

account. We also provided SSA with a copy of the survey and incorporated 

its technical comments into the final version. This report does not contain 

all the results from the survey. The survey and a more complete tabulation 

of the results can be viewed at http://www.gao.gov/cgibin/getrpt?rptno=GAO-07-4sp. 

To augment information from our state survey, we conducted independent 

audit work in three states (California, Massachusetts, and Texas) to 

examine how SSA policies and procedures are carried out in the field. We

selected locations for field visits based on the following criteria: (1) 

geographic dispersion; (2) states with large numbers of CDRs conducted;

(3) states with CDR discontinuation rates above, below, and at the 

national average; (4) states with varying DDS structures (i.e., centralized 

and decentralized); and (5) states with large numbers of Disability 

Insurance (DI) beneficiaries and large DI expenditures. In each state, we

visited a DDS office, the SSA regional office, the regional Office of Quality

Performance, and the regional Office of Disability Adjudication and 

Review (formerly known as the Office of Hearings and Appeals). In total,

we conducted in-depth interviews with 80 SSA and DDS managers and line 

staff responsible for conducting medical CDRs, including DDS directors, 

Page 27 GAO-07-8 Social Security Disability Programs
Appendix I: Scope and Methodology 

CDR supervisors and examiners, medical consultants, and administrative 

law judges. 36

During our meetings with SSA and DDS officials, we documented 

management and staff views on the challenges associated with applying

the medical improvement standard. In particular, we documented 

management and staff views on (1) the impact of the standard on CDR 

outcomes, (2) the effectiveness of SSA policies and procedures for 

applying the standard, and (3) the degree to which factors external to the 

standard create challenges when determining if a beneficiary has 

improved medically and is able to work. To further assess how the 

standard is applied in practice, we took a nonprobability sample of 12 CDR 

case files from the DDSs in California and Texas. We asked CDR 

supervisors to provide several cases that were (1) discontinued for 

medical improvement, (2) continued because the beneficiary was clearly 

disabled, and (3) ambiguous cases where it was difficult to apply the 

standard and determine if benefits should be continued or discontinued.

These case files serve to illustrate the difficulties examiners face when 

determining if a beneficiary has improved medically and is able to work. 

In addition, we interviewed seven disability policy experts from national 

disability research and advocacy organizations to obtain their input on the 

impact of the standard on the disability programs and any challenges it 

poses when assessing individuals’ continued eligibility for benefits. We 

spoke with individuals affiliated with the following organizations 

• American Association of People with Disabilities, 

• Center for Health Services Research and Policy at George Washington 

University, 

• Center for the Study and Advancement of Disability Policy, 

• Consortium for Citizens with Disabilities, 

• Disability Law Center, 

• Disability Policy Collaboration, 

• National Organization of Social Security Claimants’ Representatives, 

and 

• National Organization on Disability. 

 36 During our site visits, we met with 11 CDR supervisors and disability examiners who the

DDS directors selected as the most knowledgeable in their office about the CDR process 

and the medical improvement standard. 

Page 28 GAO-07-8 Social Security Disability Programs
Appendix I: Scope and Methodology 

Finally, we spoke with representatives from the National Association of 

Disability Examiners, the National Council of Disability Determination 

Directors, and the Social Security Advisory Board. We spoke with these 

disability experts about the effect of the standard on CDR outcomes and 

any challenges it presents when conducting CDRs. We conducted our 

work from October 2005 through June 2006 in accordance with generally 

accepted government auditing standards. 

Page 29 GAO-07-8 Social Security Disability Programs
Appendix II: The Continuing Disability Appendix II: The Continuing Disability Review Evaluation Process 

Review Evaluation Process 

In the first step of the CDR evaluation process for adult beneficiaries, an

SSA field office representative determines if the beneficiary is working at 

the level of substantial gainful activity (SGA). A beneficiary who is found 

to be not working or working but earning less than the SGA level (minus 

allowable exclusions) has his or her case forwarded to the state Disability 

Determination Services (DDS).37

The second step is to determine if the individual’s current impairment(s) is 

included on the current list of disabilities that SSA maintains. The list 

describes impairments that, by definition, are so severe that they are 

disabling. If the individual’s current impairment(s) does meet or equal a 

current listing, then the DDS continues the individual’s benefits and does 

not continue with the evaluation process. If the individual’s current 

impairment(s) does not meet or equal a current listing, then the DDS 

proceeds to step three in the evaluation process. 

The third step is to determine if improvement in the individual’s medical 

condition has occurred. This improvement is any decrease in the medical 

severity of the impairment(s) that was present at the time of the most 

recent favorable medical decision (i.e., the initial decision to award 

disability benefits or the most recent CDR continuance—usually referred

to as the comparison point decision, or CPD). At this step, the DDS 

examiner compares the current signs, symptoms, and laboratory findings 

associated with the beneficiary’s impairment(s) to those recorded from 

the last review. If improvement has not occurred, the disability examiner

skips to the fifth step in the evaluation. If improvement has occurred, the 

disability examiner proceeds to next step, the fourth step. 

The fourth step is to determine if the improvement found in step three is 

related to the ability to work. Improvement related to the ability to work is 

evaluated two different ways, depending on whether the CPD was based 

on: (1) meeting or equaling a prior listing or (2) a residual functional 

capacity (RFC) assessment: 

• Meeting or equaling the prior listing: In this case, the disability 

examiner will determine if the beneficiary’s same impairment(s) still 

meets or equals the prior listing. Unlike step two, the examiner 

compares the beneficiary’s condition with the list of impairments in 

 37 For SSI beneficiaries, do not consider SGA but skip to the second step in the CDR

evaluation. 

Page 30 GAO-07-8 Social Security Disability Programs
Appendix II: The Continuing Disability 

Review Evaluation Process 

effect at the time he or she was first awarded disability benefits. 38 If the 

impairment(s) no longer meets or equals the prior listing, then the 

examiner finds that the improvement is related to the ability to work 

and proceeds to step six of the evaluation process. If the impairment(s) 

meets or equals a prior listing, then benefits are continued. 

• Residual functional capacity assessment: In this case, the disability 

examiner compares the beneficiary’s previous functional capacity to 

the current functional capacity for the same impairment. If functional 

capacity for basic work activities has improved, then the examiner 

finds that the improvement is related to the ability to work and 

proceeds to step six of the evaluation process. If the current 

assessment does not show improvement, then the disability examiner 

proceeds to step five. 

The fifth step is to determine whether an exception to medical 

improvement applies. The law provides for certain limited situations when 

the DDS may discontinue a recipient’s benefits even though medical 

improvement has not occurred. The specific group I exceptions are (a) the 

individual is the beneficiary of advances in medical or vocational therapy

or technology (related to the ability to work), (b) evidence shows that the 

individual has undergone vocational therapy (related to the ability to 

work), (c) evidence shows that, based on new or improved diagnostic or

evaluative techniques, the individual’s impairment(s) is not as disabling as

it was considered at the time of the CPD, and (d) evidence shows that any 

prior determination or decision was in error. If an exception applies, the 

examiner continues through to step six of the evaluation process.39 If an 

exception does not apply, benefits are continued.

The sixth step is to determine if the current impairments are severe. At 

this step, the examiner considers all of the beneficiary’s impairments—

 38 At this step of the evaluation, a disability examiner considers only the listings that were 

met (or equaled) the last time the beneficiary was evaluated, not all of the listings that 

existed at the time of the last review. 

39 In addition to Group I exceptions, the law provides for additional situations (called 

Group II exceptions) to show that that disability discontinues. Group II exceptions are: (a)

the individual’s prior determination or decision was fraudulently obtained, (b) the 

individual does not cooperate with SSA, (c) SSA is unable to find the individual, and (d) the

individual fails to follow prescribed treatment that would be expected to restore his or her

ability to do SGA. In these situations, SSA discontinues benefits immediately without 

further development. SSA does not determine if medical improvement has occurred or if 

the individual is able to do SGA. 

Page 31 GAO-07-8 Social Security Disability Programs
Appendix II: The Continuing Disability 

Review Evaluation Process 

those present at the previous decision as well as any new impairments 

found in the current review. If the DDS determines that the beneficiary’s 

current impairment(s) is not severe, benefits are discontinued without 

further development. If it is determined that the impairment(s) is severe, 

then the examiner considers the impact of the beneficiary’s impairment(s) 

on his or her ability to function. This consideration will result in a current 

residual functional capacity (RFC) assessment that shows the 

beneficiary’s ability to do basic work activities and the evaluation 

continues to the seventh step. 

The seventh step is to determine whether the beneficiary has the capacity 

to do the work that he or she did before having a disability. If the 

beneficiary has the ability to do past work, then benefits are discontinued. 

If the beneficiary does not have the ability to do work he or she has done 

in the past, the evaluation continues to the eighth step. 

The eighth step is to determine if the beneficiary has the ability to do other 

work. At this step, the disability examiner considers the complete 

vocational profile (the beneficiary’s age, education, and past relevant work 

experience) together with the beneficiary’s RFC to determine if he or she 

has the ability to do other work. If the beneficiary has the ability to do 

other work, disability benefits are discontinued. If he or she does not have 

the ability to do other work, benefits are continued. 

Page 32 GAO-07-8 Social Security Disability Programs
Appendix III: Comments from the Social Appendix III: Comments from the Social Security Administration 

Security Administration 

Page 33 GAO-07-8 Social Security Disability Programs
Appendix III: Comments from the Social 

Security Administration 

Page 34 GAO-07-8 Social Security Disability Programs
Appendix III: Comments from the Social 

Security Administration 

Page 35 GAO-07-8 Social Security Disability Programs
Appendix III: Comments from the Social 

Security Administration 

Page 36 GAO-07-8 Social Security Disability Programs
Appendix III: Comments from the Social 

Security Administration 

Page 37 GAO-07-8 Social Security Disability Programs
Appendix III: Comments from the Social 

Security Administration 

Page 38 GAO-07-8 Social Security Disability Programs
Appendix IV: 

A

GAO Contact and Staff 

cknowledgments 

Page 39 GAO-07-8

Appendix IV: GAO Contact and Staff 

Acknowledgments 

Robert E. Robertson, Director, (202) 512-7215. 

The following team members made key contributions to this report: 

Kelly Agnese; Jeremy D. Cox; Susan E.M. Etzel; Stuart M. Kaufman; Luann

M. Moy; George H. Quinn, Jr.; Daniel A. Schwimer; Salvatore F. Sorbello; 

Wayne T. Turowski; Vanessa R. Taylor; and Rachael C. Valliere. 

GAO Contact 

Staff 

Acknowledgments 

Social Security Disability Programs
Related GAO Products Related GAO Products 

Social Security Administration: Agency Is Positioning Itself to 

Implement Its New Disability Determination Process, but Key Facets 

Are Still in Development. GAO-06-779T. Washington, D.C.: June 15, 2006.

Social Security Disability Insurance: SSA Actions Could Enhance 

Assistance to Claimants with Inflammatory Bowel Disease and Other 

Impairments. GAO-05-495. Washington, D.C.: May 31, 2005. 

High Risk Series: An Update. GAO-05-207. Washington, D.C.: January 

2005. 

SSA’s Disability Programs: Improvements Could Increase the Usefulness 

of Electronic Data for Program Oversight. GAO-05-100R. Washington, 

D.C.: December 10, 2004.

Disability Insurance: SSA Should Strengthen Its Efforts to Detect and 

Prevent Overpayments. GAO-04-929. Washington, D.C.: September 10, 

2004. 

Social Security Administration: More Effort Needed to Assess

Consistency of Disability Decisions. GAO-04-656. Washington, D.C.: July 

2, 2004. 

Social Security Disability: Commissioner Proposes Strategy to Improve 

the Claims Process, but Faces Implementation Challenges. GAO-04-552T. 

Washington, D.C.: March 29, 2004. 

SSA Disability Decision Making: Additional Steps Needed to Ensure 

Accuracy and Fairness of Decisions at the Hearings Level. GAO-04-14. 

Washington, D.C.: November 12, 2003. 

Social Security Disability: Reviews of Beneficiaries’ Disability Status 

Require Continued Attention to Achieve Timeliness and CostEffectiveness. GAO-03-662. Washington, D.C.: July 24, 2003. 

Social Security Disability: Reviews of Beneficiaries’ Disability Status 

Require Continued Attention to Improve Service Delivery. GAO-03-1027T. 

Washington, D.C.: July 24, 2003. 

High Risk Series: An Update. GAO-03-119. Washington, D.C.: January 

2003. 

Page 40 GAO-07-8 Social Security Disability Programs
Related GAO Products 

Major Management Challenges and Program Risks: Social Security 

Administration. GAO-03-117. Washington, D.C.: January 2003. 

SSA and VA Disability Programs: Re-Examination of Disability 

Criteria Needed to Help Ensure Program Integrity. GAO-02-597. 

Washington, D.C.: August 9, 2002. 

SSA Disability Programs: Fully Updating Disability Criteria Has 

Implications for Program Design. GAO-02-919T. Washington, D.C.: July 

11, 2002. 

Social Security Disability: SSA Making Progress in Conducting 

Continuing Disability Reviews. GAO/HEHS-98-198. Washington, D.C.: 

September 18, 1998. 

Supplemental Security Income: SSA Is Taking Steps to Review

Recipients’ Disability Status. GAO/HEHS-97-17. Washington, D.C.: 

October 30, 1996. 

Social Security Disability: SSA Quality Assurance Improvements Can 

Produce More Accurate Payments. GAO/HEHS-94-107. Washington, D.C.: 

June 3, 1994.

Social Security: Disability Rolls Keep Growing, While Explanations 

Remain Elusive. GAO/HEHS-94-34. Washington, D.C.: February 11, 1994.

Social Security Disability: Implementing the Medical Improvement 

Review Standard. GAO/HRD-88-108BR. Washington, D.C.: September 30, 

1988. 

Social Security Disability: Implementation of the Medical Improvement 

Review Standard. GAO/HRD-87-3BR. Washington, D.C.: December 16, 

1986. 

Review of the Eligibility of Persons Converted from State Disability 

Rolls to the Supplemental Security Income Program. HRD-78-97. 

Washington, D.C.: April 18, 1978. 

(130525) Page 41 GAO-07-8 Social Security Disability Programs
GAO’s Mission The Government Accountability Office, the audit, evaluation and 

investigative arm of Congress, exists to support Congress in meeting its 

constitutional responsibilities and to help improve the performance and 

accountability of the federal government for the American people. GAO 

examines the use of public funds; evaluates federal programs and policies; 

and provides analyses, recommendations, and other assistance to help

Congress make informed oversight, policy, and funding decisions. GAO’s 

commitment to good government is reflected in its core values of 

accountability, integrity, and reliability. 

The fastest and easiest way to obtain copies of GAO documents at no cost

is through GAO’s Web site (www.gao.gov). Each weekday, GAO posts 

newly released reports, testimony, and correspondence on its Web site. To

have GAO e-mail you a list of newly posted products every afternoon, go 

to www.gao.gov and select “Subscribe to Updates.” 

The first copy of each printed report is free. Additional copies are $2 each. 

A check or money order should be made out to the Superintendent of 

Documents. GAO also accepts VISA and Mastercard. Orders for 100 or 

more copies mailed to a single address are discounted 25 percent. Orders 

should be sent to: 

U.S. Government Accountability Office 

441 G Street NW, Room LM 

Washington, D.C. 20548 

To order by Phone: Voice: (202) 512-6000 

TDD: (202) 512-2537 

Fax: (202) 512-6061 

Contact: 

Web site: www.gao.gov/fraudnet/fraudnet.htm

E-mail: fraudnet@gao.gov

Automated answering system: (800) 424-5454 or (202) 512-7470 

Gloria Jarmon, Managing Director, JarmonG@gao.gov (202) 512-4400 

U.S. Government Accountability Office, 441 G Street NW, Room 7125 

Washington, D.C. 20548 

Paul Anderson, Managing Director, AndersonP1@gao.gov (202) 512-4800

U.S. Government Accountability Office, 441 G Street NW, Room 7149 

Washington, D.C. 20548 

Obtaining Copies of 

GAO Reports and 

Testimony

Order by Mail or Phone 

To Report Fraud,

Waste, and Abuse in 

Federal Programs 

Congressional 

Relations 

Public Affairs 

PRINTED ON RECYCLED PAPER