The following prescribed forms are appropriate for documenting the childhood disability case explanation:

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  SSA 538 - Childhood Disability Evaluation Form (CDEF)

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  Childhood Domain Evaluation (CDE) for cases processed in the Disability Case Processing Systems (DCPS) or other electronic systems such as the Electronic Claims Analysis Tool (eCAT)

The SSA-538 or CDE must be used in all assessment scenarios that require a domain evaluation due to a severe impairment(s) that does not meet or equal a listing, or functionally equal a listing by example, see DI 25225.060.

An SSA-416 may be used in lieu of the CDE in DC claims completed electronically, that do not require a domain evaluation and the findings of fact and supporting evidence results in the following scenario:

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  Meets or equals a listing

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  Functionally equals a listing based on example only, see DI 25225.060

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  Insufficient evidence

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  No severe impairment(s)

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  No medically determinable impairment(s)

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  No medical improvement (for Title XVI child continuing disability review (CDR) cases)

NOTE: For non-electronic claims, if the severe impairment(s) requires a domain evaluation, there must be one prescribed form in the case record that gives the disposition and clearly supports it.

For a detailed explanation of documenting the findings on DC prescribed forms refer to DI 25230.005.

The policies in this section apply to:

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  Initial (DC) determinations

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  Reconsideration DC determinations

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  Initial level DC determinations for CDRs

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  Reconsideration level DC determinations for CDRs unless a Disability Hearing officer (DHO) makes the determination

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  Reopening determinations, if the determination being reopened is covered by these policies

We require a second prescribed form for specific cases involving Drug Addiction or Alcoholism (DAA). In all DAA materiality determinations, apply the appropriate sequential evaluation process a second time considering whether the individual is disabled without DAA involvement.

A complete explanation includes the following elements:

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  Identifying information (name, SSN, date of birth), filing date, level of determination

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  Established and alleged impairments

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  Disposition

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  Explanation for all the dispositions, except “meets listing”

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  Consultant (MC/PC/non-physician) statement that all relevant factors and evidence have been considered

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  Signature of Consultant with overall responsibility for evaluating the case

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  Signatures of additional MC/PC/non-physician participating in the evaluation

The Consultant with overall responsibility for the findings in the determination, affirms on the SSA-538 or within the electronic Claims Analysis that they considered the following:

1. a. 

   All relevant factors

2. b. 

   All relevant evidence in deciding if:

   • •

     The child has a severe impairment(s)

   • •

     An impairment(s) meets or medically equals a listing, or

   • •

     An impairment(s) functionally equals the listings

The affirmation statement on the SSA-538 or within the electronic Claims Analysis does not mean that the consultant needs to explicitly address each of these factors in every case. It means, the consultant has considered whether the factors apply; and has properly considered those that are relevant. The factors and evidence serve as a reminder to the consultants.

The medical or psychological consultant(s) may affirm the initial prescribed form without fully completing a new prescribed form if the following conditions are satisfied:

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  There is no allegation of a worsening of any previously documented impairments;

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  There is no allegation of any new impairment(s);

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  There has been no treatment for any impairment(s) since the prior determination;

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  The prior determination was substantively and technically correct and the prior decision rationale correctly presented and resolved all pertinent issues to be adjudicated; and

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  There are no changes in the functional limitations

The reconsideration determination can reference the initial determination with a remark noting, “I have reviewed all the evidence in the file and the assessment of (date) is affirmed as written. The medical or psychological consultant(s) must sign and date this statement.