SOCIAL SECURITY 

DISABILITY PROGRAMS

SSA Could Take Steps to

Improve Its Assessment of

Continued Eligibility

Statement of Daniel Bertoni, Director 

Education, Workforce, and Income Security Issues

Testimony Before the Subcommittee on Energy 

Policy, Health Care, and Entitlements, 

Committee on Oversight and Government 

Reform, House of Representatives

For Release on Delivery 

1:30 p.m. EDT

Wednesday, April 9, 2014

GAO-14-492T

United States Government Accountability Office
United States Government Accountability Office

Highlights of GAO-14-492T, testimony before

the Subcommittee on Energy Policy, Health 

Care and Entitlements, Committee on 

Oversight and Government Reform, House of 

Representatives

April 2014

SOCIAL SECURITY DISABILITY PROGRAMS

SSA Could Take Steps to Improve Its Assessment of

Continued Eligibility 

Why GAO Did This Study

SSA administers DI and SSI, two 

disability programs that provided $189 

billion in cash benefits to eligible adults 

and children in 2012. Both the 

numbers of DI and SSI recipients, as 

well as program costs, have grown in 

recent years and are poised to grow 

further in the future. Both the initial 

determination of an individual’s 

medical eligibility at the time of 

application and CDRs after benefits 

have been granted are key to ensuring 

the integrity of these programs. CDRs 

also provide a check on program 

growth in a time of constrained federal 

resources. Since 1984, federal law has 

generally required SSA to find 

substantial evidence demonstrating 

medical improvement during a CDR 

before ceasing a recipient’s benefits—

known as the medical improvement 

standard. 

In this statement, GAO describes (1) 

SSA’s efforts to monitor DI and SSI 

beneficiaries’ continued eligibility, and 

(2) factors associated with the medical 

improvement standard that affect these 

efforts. This testimony is primarily 

based on GAO products related to 

these issues from 2006 and 2012.

GAO also updated selected

information related to SSA’s CDR 

backlog, budget requests, and 

guidance for assessing medical 

improvement as of 2014. 

What GAO Recommends

GAO is not making any new 

recommendations at this time.

What GAO Found

The Social Security Administration (SSA) reported in January 2014 that it 

is behind schedule in assessing the continued eligibility of recipients in its 

two disability programs, Disability Insurance (DI) and Supplemental 

Security Income (SSI),and has accumulated a backlog of 1.3 million 

continuing disability reviews (CDRs). From fiscal years 2000 to 2011, the 

numbers of adult and child CDRs conducted fell about 70 percent. 

Children make up about one fifth of all SSI recipients, and GAO reported 

in 2012 that many of their CDRs were overdue. For example, more than 

24,000 CDRs for children with mental impairments were overdue by 6 or 

more years, including over 6,000 CDRs for children who were expected to 

medically improve within 6 to 18 months of their initial determination. 

GAO also identified several cases which exceeded their scheduled review 

date by 13 years or more. When CDRs are not conducted as scheduled, 

the potential for improper payments increases as some recipients receive 

benefits for which they are no longer eligible. In September 2011, SSA’s 

Office of the Inspector General estimated that SSA had paid about $1.4 

billion in SSI benefits to children who should have not received them. 

SSA attributes delays in performing CDRs to resource limitations and 

other factors; SSA also generally gives lower priority to conducting CDRs 

for children receiving SSI. In 2012, GAO recommended that SSA 

eliminate the existing CDR backlog for children with impairments who are 

likely to improve, and regularly conduct reviews for this group. While SSA 

generally agreed with GAO’s recommendation, the CDR backlog remains. 

During CDRs, disability recipients that SSA determines to have improved 

medically may be removed from the program; however, several factors 

may hinder SSA’s ability to make this determination. In 2006, GAO

reported that 1.4 percent of people who left the disability programs did so 

because SSA found that they had improved medically. At that time, GAO 

identified several factors that hindered SSA’s ability to assess whether DI 

and SSI recipients met the medical improvement standard. These 

included: (1) limitations in SSA guidance for applying the standard; (2) 

inadequate documentation of prior disability determinations; (3) failure to 

abide with the requirement that CDR decisions be made on a neutral 

basis—without a presumption that the recipient remained disabled; and 

(4) the judgmental nature of the process for assessing medical 

improvement. Since 2006, SSA has taken some steps to address these 

issues; however, the agency has not fully clarified policies for assessing 

medical improvement, as GAO recommended.

View GAO-14-492T. For more information, 

contact Daniel Bertoni at (202) 512-7215 or 

bertonid@gao.gov. 
 

Page 1 GAO-14-492T 

Chairman Lankford, Ranking Member Speier, and Members of the 

Subcommittee:

I am pleased to discuss our prior work on the Social Security 

Administration’s (SSA) efforts to assess Disability Insurance (DI) and 

Supplemental Security Income (SSI) recipients’ continued medical 

eligibility for benefits. In 2012, these disability programs provided $189 

billion in cash benefits to 10.9 million DI recipients and 8 million SSI 

recipients, including adults and children. Both the numbers of DI and SSI 

recipients, as well as program costs, have grown in recent years, and 

both are poised to grow further in the future because of economic and 

population changes. Federal law, as well as SSA’s regulations and 

guidance, prescribe policies and procedures intended to ensure that only 

those eligible to receive benefits do so. Both the initial determination of an 

individual’s medical eligibility at the time of application and assessments 

conducted after benefits have been granted are key to ensuring the 

integrity of these programs. Assessments of continued eligibility provide 

an important check on program growth by removing ineligible recipients 

from the rolls, even while new applicants are added. If these reviews are 

not conducted in sufficient numbers, the agency will continue to struggle 

to contain growth in benefit payments, placing added burden on already 

strained federal resources. Over the years, the Congress has taken 

actions to add requirements related to SSA’s review of recipients’ 

continued medical eligibility for benefits. For example, beginning in 1982, 

federal law required SSA to conduct certain continuing disability reviews 

(CDRs) for this purpose, and since 1984, federal law has generally 

required SSA to find substantial evidence demonstrating medical 

improvement before ceasing a recipient’s benefits—known as the medical 

improvement standard.

My remarks today are based on our prior work that found several factors 

hindered SSA’s efforts to assess disability program recipients’ continued 

medical eligibility for benefits. I will discuss (1) SSA’s efforts to monitor DI 

and SSI recipients’ continued eligibility, and (2) factors associated with 

the medical improvement standard that affect these efforts. This 

information was drawn primarily from two reports we issued in 2006 and 

2012, as well as a review of SSA’s current related data we performed in 

March and April 2014. Specifically, we updated selected information 

related to SSA’s CDR backlog, budget requests, and guidance for 
 

Page 2 GAO-14-492T 

assessing medical improvement as of 2014.

1 For our prior reports, we 

reviewed relevant federal law, regulations, and guidance; interviewed 

SSA officials; and also relied on a variety of additional methodologies. For 

example, for our 2006 report on the medical improvement standard,2 we 

surveyed all 55 state directors responsible for disability determination 

services (DDS), and for our 2012 report on children receiving SSI 

benefits,3 we conducted site visits to 9 SSA field offices and 11 state DDS 

offices and reviewed SSA’s data on CDRs conducted from fiscal years 

2000 to 2011. We conducted our work in accordance with generally 

accepted government auditing standards. Those standards require that 

we plan and perform the audit to obtain sufficient, appropriate evidence to 

provide a reasonable basis for our findings and conclusions based on our 

audit objectives. We believe that the evidence obtained provides a 

reasonable basis for our findings and conclusions based on our audit 

objectives.

SSA administers two disability programs that provide monthly cash 

benefits to eligible individuals: DI, enacted in 1956, and SSI, enacted in 

1972. DI provides monthly cash benefits to eligible workers unable to 

work because of a long-term disability and who have paid into the Social 

Security Trust Fund, whereas SSI provides monthly cash benefits to 

people with disabilities on the basis of need, regardless of whether they 

have paid into the Social Security Trust Fund. In order to be eligible for DI 

or SSI benefits based on a disability, an individual must meet the 

definition of disability for these programs—that is, they must have a 

medically determinable physical or mental impairment that (1) prevents 

 

1

Beyond this review, we did not update our analyses from our prior reports. 

2

GAO, Social Security Disability Programs: Clearer Guidance Could Help SSA Apply the 

Medical Improvement Standard More Consistently, GAO-07-8 (Washington, D.C.: October 

3, 2006).

3

GAO, Supplemental Security Income: Better Management Oversight Needed for 

Children’s Benefits, GAO-12-497 (Washington, D.C.: June 26, 2012). 

Background
 

Page 3 GAO-14-492T 

the individual from engaging in any substantial gainful activity and (2) has 

lasted or is expected to last at least 1 year or result in death.4

The disability determination process is the same for DI and SSI 

applicants. An SSA field office determines that an applicant has met 

SSA’s nonmedical eligibility requirements for disability benefits,5 and then 

the applicant’s claim is sent to the state DDS for an initial review of the 

claimant’s medical eligibility.6 After assembling all medical and vocational 

information for the claim, a DDS examiner, in consultation with 

appropriate medical staff, determines whether the claimant meets the 

requirements of the law for having a disability. Claimants who are 

dissatisfied with the initial DDS determination may choose to pursue 

several levels of appeal, including: a “reconsideration” of the claim, 

conducted by DDS personnel who were not involved in the original 

decision; a hearing before an administrative law judge (ALJ); and a 

review of the claim by the Appeals Council, which is comprised of 

administrative appeals judges and appeals officers. Final SSA decisions 

are also subject to review in federal district court.

If SSA determines that an individual is disabled, the agency is required to 

conduct periodic CDRs to ensure that only recipients who remain 

disabled continue to receive benefits.7 These reviews assess whether 

individuals are still eligible for benefits based on several criteria, including 

their current medical condition and ability to work.8 DDS staff generally 

 

4

42 U.S.C. §§ 423(d)(1)(A) and 1382c(a)(3)(A). Substantial gainful activity is generally 

work activity involving significant physical or mental activities that is done for pay or profit, 

whether or not a profit is realized. 20 C.F.R. §§ 404.1572 and 416.972. In 2012, the 

substantial gainful activity threshold was $1,690 per month for blind recipients and $1,010 

per month for individuals with other disabilities. 

5

For example, field office staff are to ensure that an SSI applicant meets income and 

resource requirements and determine if a DI applicant has a sufficient work history. 

6

Although SSA is responsible for administering these programs, the law allows for initial 

determinations of disability to be made by state agencies, known as DDS offices. See 42 

U.S.C. § 421(a)(1).The work performed at DDS offices is federally funded and is carried 

out in accordance with applicable federal laws, as well as SSA regulations, policies, and

guidelines. 

7

SSA’s regulations pertaining to CDRs for DI and SSI can be found at 20 C.F.R. §§ 

404.1589 and 416.989, respectively.

8

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

individual’s earnings exceeded program limits. This testimony focuses on medical CDRs. 
 

Page 4 GAO-14-492T 

establish the timeframe for when SSA should conduct a CDR on the basis 

of the expected likelihood of a recipient’s medical improvement. However, 

SSA also uses a profiling model to score and prioritize CDRs if funding is 

not available to conduct all scheduled CDRs.

In response to prior concerns that some recipients were being arbitrarily 

removed from the disability programs via the CDR process, Congress 

passed the Social Security Disability Benefits Reform Act of 1984,9 which, 

among other things, established a medical improvement standard. Under 

this standard, SSA may only discontinue benefits for an individual if it 

finds substantial evidence demonstrating both that a beneficiary’s medical 

condition has improved10 and that the individual is able to engage in 

substantial gainful activity.11 If SSA determines that these conditions have 

not been met in the course of conducting a CDR, the recipient may 

continue to receive benefits until the individual receives a subsequent 

CDR (which potentially could result in a discontinuation of benefits), dies, 

or transitions to Social Security retirement benefits.

 

9

Pub. L. No. 98-460 § 2, 98 Stat. 1794. 

10The regulations implementing the act define improvement as any decrease in the 

medical severity of the recipient’s impairment(s) since the last time SSA reviewed his or 

her disability, based on improvements in symptoms, signs, or laboratory findings.

1142 U.S.C. §§ 423(f)(1) and 1382c(a)(4)(A)(i). The medical improvement standard for 

individuals under the age of 18 who receive SSI benefits is different. See 42 U.S.C. § 

1382c(a)(4)(B). The law also identifies certain other limited circumstances under which 

benefits may be discontinued, besides the medical improvement standard. See 42 U.S.C. 

§ 423(f) and § 1382c(a)(4)(A) and (C). 
 

Page 5 GAO-14-492T 

SSA reported in January 2014 that it is behind schedule in assessing the 

continued eligibility of DI and SSI recipients and has accumulated a 

backlog of 1.3 million CDRs. In recent years, SSA has cited resource 

limitations and a greater emphasis on processing initial claims and 

requests for hearings appeals as reasons for the decrease in the number 

of CDRs conducted. From fiscal years 2000 to 2011, the number of adult 

CDRs fell from more than 580,000 to about 180,000 (69 percent)12 and 

the number of childhood CDRs fell from more than 150,000 to about 

45,000 (70 percent), according to our analysis of SSA data (see fig. 1).13

More specifically, CDRs for children under age 18 with mental 

impairments—a group that comprises a growing majority of all child SSI 

recipients—declined from more than 84,000 to about 16,000 (an 80 

percent decrease). 

 

12In general, DDS staff consider the likelihood of a recipient’s medical improvement when 

establishing the timeframe for when SSA should conduct a CDR. Improvement categories 

and general time frames used are (1) “medical improvement expected,” 6 to 18 months; 

(2) “medical improvement possible,” 3 years; and (3) “medical improvement not expected,” 

5 to 7 years. For adults receiving SSI, SSA conducts CDRs using two methods: (1) SSA 

headquarters sends some cases to the DDS for a full medical review, and (2) SSA mails a 

questionnaire to other recipients and reviews their responses to determine continued 

eligibility. At this time, SSA does not use the mailer process for SSI child recipients. For 

comparability in the number of CDRs for adults and children, the CDR data in this section 

apply to full medical reviews only.

13With respect to children receiving SSI benefits, under Title XVI of the Social Security 

Act, SSA is generally required to (1) conduct a CDR at least every 3 years on all child 

recipients under age 18 whose impairments are likely to improve (or, at the 

Commissioner’s option, recipients whose impairments are unlikely to improve) (42 U.S.C. 

§ 1382c(a)(3)(H)(ii)(I)); (2) conduct a CDR within 12 months after the birth of a child who 

was granted benefits in part because of low birth weight (42 U.S.C. § 1382c(a)(3)(H)(iv)); 

and (3) redetermine, within 1 year of the individual’s 18th birthday (or whenever the 

Commissioner determines the individual is subject to a redetermination), the eligibility of 

any individual who was eligible for SSI childhood payments in the month before attaining 

age 18, by applying the criteria used in determining initial eligibility for adults (42 U.S.C. § 

1382c(a)(3)(H)(iii)). For children under the age of 18—except for the initial CDR for low 

birth weight babies—DDS offices are directed by SSA policy to determine when recipients 

will be due for CDRs on the basis of their potential for medical improvement, and select 

and schedule a review date—otherwise known as a “diary date”—for each recipient’s 

CDR.

SSA Has a Backlog of 

More Than 1 Million 

DI and SSI Benefit 

Eligibility Reviews
 

Page 6 GAO-14-492T 

Figure 1: Number of Childhood CDRs Conducted for SSI Recipients under Age 18, 

by Primary Impairment, Fiscal Years 2000 through 2011

Children make up about one fifth of all SSI recipients, and we reported in 

2012 that a large proportion of their CDRs were overdue. For example, 

CDRs for about one half of all child recipients with mental impairments 

(435,000) were overdue, according to our analysis of SSA data in 2012.

14

Of these recipients, about 344,000 (79 percent) had exceeded the 

scheduled date by at least a year, with about 205,000 (47 percent) 

exceeding their date by 3 years, and about 24,000 (6 percent) exceeding 

the scheduled date by 6 years. We also identified several cases which 

 

14A total of about 861,000 child recipients with mental impairments were receiving SSI 

benefits as of December 2011. 
 

Page 7 GAO-14-492T 

exceeded their scheduled date by 13 years or more. Of the 24,000 

childhood CDRs pending 6 years or more, we found that about 70 percent 

(over 17,000) were for children who had been categorized as “medical 

improvement possible” at initial determination, while 25 percent (over 

6,000) of these pending CDRs were for those children deemed medically 

expected to improve within 6 to 18 months of their initial determination 

(see fig. 2). Of these cases, we identified nine recipients who were 

expected to medically improve, but whose CDR had been pending for 13 

years or more. Reviews of children who are expected to medically 

improve are more productive than reviews of children who are not 

expected to medically improve because they have a greater likelihood of 

benefit cessation and thus yield higher cost savings over time.

Figure 2: Childhood CDRs Pending for at Least 6 Years, by Anticipated Medical 

Improvement Category, for Children with Mental Impairments

Note: Percentages do not equal 100 percent due to rounding.

When CDRs are not conducted as scheduled, the potential for improper 

payments may increase as some recipients can receive benefits for which 

they are no longer eligible. In September 2011, SSA’s Office of the 

Inspector General estimated that SSA had paid about $1.4 billion in SSI 

benefits to approximately 513,000 recipients under age 18 who should 
 

Page 8 GAO-14-492T 

have not received them—some of whom were pending reviews for 5 or 

more years.15 The Inspector General estimated that SSA will continue to 

make improper payments of approximately $461.6 million annually until 

these reviews are completed. Furthermore, in its May 2012 CDR report, 

SSA estimated a program savings of $9.30 for every $1 invested in 

conducting CDRs and projected that those CDRs conducted for adult DI 

and SSI recipients and for child SSI recipients combined in fiscal year 

2010 would have saved federal programs the present value of estimated 

lifetime benefits of $3.5 billion.16

For several reasons, SSA has placed a higher priority on conducting 

CDRs for DI recipients, although children’s SSI benefits are more likely to 

be ceased after review. According to SSA officials, when CDR funding is 

less than what is needed to conduct all CDRs at the scheduled intervals, 

the agency has historically given priority to performing reviews considered 

to be the most cost-effective, as well as staying current with DI CDRs and 

performing two specific statutorily required SSI reviews.17 SSA officials 

told us that it is more cost effective to conduct adult DI CDRs than 

childhood SSI CDRs, because ceasing benefits for a young adult DI 

recipient may potentially represent decades of saved benefits. For SSI, 

statutorily required age 18 redeterminations are cost effective for the 

 

15The SSA Inspector General estimated that SSA did not complete 79 percent of 

childhood CDRs and 10 percent of age 18 redeterminations on the basis of the results of 

275 cases of physical and mental impairments they reviewed. To estimate the amount of 

SSI payments made because SSA had not completed a timely childhood CDR, the 

Inspector General calculated the amount of SSI payments made between the 1-year 

anniversary of the scheduled CDR date and the earlier of the month of cessation or April 

2011 (the date the Inspector General reviewed the cases). 

16This represents the combined savings to the SSI, DI, Medicare, and Medicaid programs 

from CDRs conducted for the SSI and DI programs, from cessations and terminations due 

to failure to cooperate with a CDR in fiscal year 2010. The estimate includes savings to 

Medicare and Medicaid, as in some cases eligibility for SSI and SSDI confers eligibility for 

certain Medicare or Medicaid benefits, as well. SSA noted that the savings-to-cost ratio for 

fiscal year 2010 represents a significant drop from the average ratio for fiscal years 1996 

through 2009 of $10.60 to $1, attributing the drop largely to the Medicaid estimates, which 

now reflect the effects of a Patient Protection and Affordable Care Act provision that 

allows most disabled SSI recipients terminated due to a CDR to retain their Medicaid 

coverage beginning January 1, 2014. Annual Report of Continuing Disability Reviews, 

Fiscal Year 2010. 

17In particular, SSA officials identified the following two reviews: age 18 redeterminations, 

which are required within 1 year after a child turns age 18, and reviews required within 12 

months after birth for recipients whose low birth weight was a contributing factor material 

to the determination of their disability. 42 U.S.C. § 1382c(a)(3)(H)(iii) and (iv), respectively. 
 

Page 9 GAO-14-492T 

same reason. Additionally, because DI benefit payments are, on average, 

almost twice as much as SSI childhood payments, CDRs of adult DI 

cases generally produce greater lifetime savings, according to SSA 

officials. However, SSA reported that it ceased about 12 percent of all 

adult DI claims that received a CDR. In comparison, our analysis of SSA’s 

data showed that 32 percent of child SSI claims that received a CDR 

were ceased in fiscal year 2011. For example, of those childhood CDRs 

conducted for children under age 18 with mental impairments, SSA 

ceased benefits for about 28 percent on average in fiscal year 2011, with 

personality disorders and speech and language delay having the highest 

cessation rates, 39 and 38 percent, respectively.18 Despite these high 

cessation rates, SSA and state DDS officials have acknowledged that the 

agency has not conducted reviews for child recipients in a timely manner, 

and in some cases, they have not conducted childhood CDRs prior to a 

child’s age 18 redetermination.

In our 2012 report, we recommended that SSA eliminate the existing 

CDR backlog of cases for children with impairments who are likely to 

improve and, on an ongoing basis, conduct CDRs at least every 3 years 

for all children with impairments who are likely to improve, as resources 

are made available for these purposes. SSA generally agreed that it 

should complete more CDRs for SSI children but emphasized that it is 

constrained by limited funding and competing DI and SSI workloads. 

Moving forward, one of the major objectives in SSA’s Fiscal Year 2013-

2016 Strategic Plan19 is to “increase efforts to accurately pay benefits,” 

and the Plan indicates that SSA intends to conduct more CDRs, as 

funding is available. In addition, as part of the President’s fiscal year 2014

budget request, SSA asked for $1.227 billion to create a new Program 

Integrity Administrative Expenses account that the agency says would 

 

18The cessation rates cited in this paragraph reflect “initial cessations,” meaning that the 

agency concluded at the end of the CDR that the claimant involved no longer met the 

eligibility standards to continue receiving benefits, and therefore started the process to 

cease benefits. Claimants may subsequently avail themselves of an appeals process, 

which can result in a reversal of the initial cessation. 

19SSA, Strategic Plan: Security Value for America, Fiscal Years 2013-2016 (Feb. 2012). 
 

Page 10 GAO-14-492T 

establish a more reliable stream of mandatory program integrity funding.20

While additional funding may help address the CDR backlog, we continue 

to have concerns about the agency’s ability to manage limited funds in a 

manner that adequately balances its public service priorities with its 

stewardship responsibility. Because SSA has noted that it considers SSI 

childhood CDRs to be a lower priority than other CDRs, it is unclear 

whether the agency will use new increases in funding to review children 

most likely to medically improve—reviews that could yield a high return on 

investment.

During CDRs, disability recipients that SSA determines have improved 

medically may cease receiving benefits; however, several factors may 

hinder SSA’s ability to make this determination. In 2006,21 our analysis of 

SSA data showed that 1.4 percent of all the people who left DI and SSI 

between fiscal years 1999 and 2005 did so because SSA found that they 

had improved medically; however, more recipients left for other reasons, 

including conversion to regular Social Security retirement benefits or 

death. At that time, we identified a number of factors that challenged 

SSA’s ability to assess DI and SSI recipients using the medical 

improvement standard.22

• Guidance limitations—Limitations in the SSA guidance then in effect 

for applying the medical improvement standard may have resulted in 

inconsistent disability decisions. Specifically, in 2006, SSA guidance 

on CDRs instructed examiners to disregard “minor” changes in a 

recipient’s condition without defining what constituted a minor change. 

 

20This proposal was also included in the President’s fiscal year 2015 budget request. 

According to a statement by Acting Commissioner Carolyn Colvin, the Program Integrity 

Administrative Expenses account, as proposed, would be separate, and in addition to, 

SSA’s Limitation on Administrative Expenses account. Under the proposal, the funds 

would be available for 2 years, providing SSA with the flexibility to hire and train staff to 

support the processing of more program integrity work. See Carolyn W. Colvin, Acting 

Commissioner, SSA, Statement for the Record, testimony before Subcommittee on Social 

Security, Committee on Ways and Means, United States House of Representatives, 

January 16, 2014.

21See GAO, Social Security Disability Programs: Clearer Guidance Could Help SSA Apply 

the Medical Improvement Standard More Consistently, GAO-07-8 (Washington, D.C.: 

October 3, 2006).

22As previously noted, beyond our review of currently available data, we did not update 

our 2006 analyses.

Several Factors 

Associated with the 

Medical Improvement 

Standard Have 

Challenged the 

Assessment of 

Recipients’ Continued 

Eligibility
 

Page 11 GAO-14-492T 

In addition, when assessing whether improvements in recipients’ 

medical conditions were related to their ability to work, the SSA 

guidance instructed examiners to ensure a “reasonable relationship” 

between the amount of improvement and the increase in the ability to 

perform basic work activities. However, at that time, the guidance did 

not require a specific amount of increase in functioning to better guide 

examiners in their decision making.

• Inadequate documentation—If a prior disability determination was 

inadequately documented, it can be challenging for the disability 

examiner to demonstrate medical improvement in a CDR. Because 

the prior decision is the starting point for conducting a CDR and 

examiners are required to find evidence of medical improvement since 

that last decision in order to cease benefits, inadequate 

documentation of evidence in prior decisions may make it difficult to 

assess medical improvement. In our 2006 survey, some DDS 

directors commented that cases decided on appeal were the most 

likely to lack adequate documentation. Several officials reported that 

guidance in effect at that time instructed ALJs to include enough 

information to make their decisions legally sufficient, but there was no 

specific instruction to include all of the evidence that would be needed 

to assess medical improvement as part of a future CDR.

• Presumed disability—According to our 2006 survey,23 a majority of 

DDSs incorrectly presumed that a recipient had a disability when the 

CDR was being conducted, which may have made it more difficult for 

examiners to determine if a recipient had improved medically. We 

reported that this practice is contrary to the law as well as SSA 

 

23We 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. 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 medical improvement standard impacts outcomes of CDRs and determine if the 

standard poses any special challenges for SSA when determining whether recipients 

continue to be eligible for benefits. The results of this survey are available in GAO-07-

4SP, Social Security Disability Programs: Survey of Disability Determination Services 

Directors, an E-supplement to GAO-07-8. 
 

Page 12 GAO-14-492T 

regulations and policy, which require that CDR decisions be made on 

a “neutral basis.”

24

• Reliance on judgment—The judgmental nature of the process for 

assessing medical improvement likely hinders its reliability. For 

example, one examiner may determine that a recipient 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.25 Furthermore, we previously found 

that the amount of judgment involved in the decision-making process 

increases when the process involves certain types of impairments, 

such as psychological impairments, which are more difficult to assess 

than other impairments, such as physical impairments.

These issues have implications for the consistency and fairness of SSA’s 

medical improvement decision-making process, and in 2006, we 

recommended that SSA clarify policies for assessing medical 

improvement. Since then, SSA has taken some steps that may help 

address the issues we raised but has not fully implemented the actions 

we recommended. In 2009, SSA began implementing an electronic 

claims analysis tool for use during initial disability determinations to (a) 

document a disability adjudicator’s detailed analysis and rationale for 

either allowing or denying a claim, and (b) ensure that all relevant SSA 

policies are considered during the disability adjudication process. In 

 

24At the time our 2006 report was issued, SSA defined neutral basis as a review that 

neither presumes that a recipient (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. 

See also 42 U.S.C. § 423(f), 42 U.S.C. § 1382c(a)(4), 20 C.F.R. § 404.1594(b)(6), and 20 

C.F.R. §§ 416.994(b)(1)(vi) and 416.994a(a)(2).

25In one of the CDR cases that we reviewed for our 2006 report, 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 recipient 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.
 

Page 13 GAO-14-492T 

addition, SSA reported in February 2013 that it was developing a tool to 

help hearing offices standardize and document the hearing decision 

process and outcome. However, SSA’s guidance for assessing medical 

improvement may continue to present challenges when applying the 

standard. As of April 2014, the guidance does not provide any specific 

measures for what constitutes a “minor” change in medical 

improvement,26 and it instructs examiners to exercise judgment in 

deciding how much of a change justifies an increase in the ability to 

work.27

Chairman Lankford, Ranking Member Speier, and Members of the 

Subcommittee, this completes my prepared statement. I would be 

pleased to respond to any questions that you may have at this time.

If you or your staff have any questions about this testimony, 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 statement. GAO staff who made key contributions to this testimony 

include James Bennett, Holly Dye, Rachel Frisk, Isabella Johnson, 

Kristen Jones, Sheila McCoy, and Walter Vance.

 

26See SSA Program Operations Manual System (POMS) section DI 28010.015. The 

standards state that “although the decrease in severity may be of any quantity or degree, 

we will disregard minor changes in your signs, symptoms, and laboratory findings that 

obviously do not represent medical improvement and could not result in a finding that your 

disability has ended.” 

27See POMS section DI 28015.320. 

Contacts and 

Acknowledgments

(131307)
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