TN 39 (07-21)

DI 28020.365 Group I Exception - Prior Error, New Evidence Related to the Prior Determination or Decision

A. When the new evidence related to the prior determination or decision error exception applies

This category of exception applies if:

  • new evidence that relates to the prior determination or decision refutes the conclusions that were based on the prior evidence; and

  • evidence shows the claim would not have been allowed or continued if the new evidence had been considered at the time of the prior decision.

In deciding whether this category of error applies, carefully consider whether any new evidence provides useful medical information about the status of the impairment(s) at the time of the prior decision.

B. Examples of the new evidence related to the prior determination or decision error exception

1. Tumor - Error Applies

Current evidence might show that a tumor thought to be malignant was actually benign.

2. Sickle cell disease - Error Applies

Comparison point decision (CPD): At the time of the CPD, the adjudicator found the individual disabled based on listing 7.05A for sickle cell anemia crises requiring parenteral narcotic medication. The individual's own medical source, Dr. J. Smith, documented the appropriate amount of crises with prescription and treatment with narcotic medication to meet the listing criteria.

Continuing disability review (CDR) decision: At the time of the CDR, Dr. J. Smith, the same doctor who submitted evidence at the CPD, submits records for the current CDR period and includes records from the CPD period as well.

  • The CPD period records from Dr. J. Smith were the same records used to support the allowance decision when the claimant originally met 7.05A.

  • The adjudicator notices that several pages of records from the CPD period included the beneficiary’s name and date of birth, but referred to a 56 year old female and the beneficiary was only 42 at that time of the CPD.

  • The adjudicator contacts Dr. Smith's office to clarify the discrepancy in the records. Dr. Smith reviewed the records and determined the error, that the beneficiary’s sister was a patient at the facility during that time and also was treated for sickle cell anemia.

  • Dr. Smith determined that the records were mistakenly entered under the beneficiary’s file for several visits due to a computer error. Dr. Smith's office corrected and re-sent the records, indicating that the beneficiary did not meet listing criteria at the CPD.

 

Explanation: Find the prior decision in error given the clarification received in the new evidence.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0428020365
DI 28020.365 - Group I Exception - Prior Error, New Evidence Related to the Prior Determination or Decision - 07/06/2021
Batch run: 07/06/2021
Rev:07/06/2021