The disability determination process is inherently judgmental. Sometimes, adjudicating and reviewing components reach different disability conclusions,
in a case that is fully documented per policy, after considering the same facts and
evidence. In the absence of
any of the three issues listed above, a differing opinion and/or disability conclusion
from a
quality reviewer, regional office medical contractor (ROMC), or medical advisor is
SOJ and contrary
to SSA policy.
EXAMPLE 1 of SOJ
An adjudicating component requested medical evidence, followed up with all of the
claimant's treating sources per policy guidelines, obtained a complete vocational
history, and
obtained functional information from the claimant. The case is fully documented in
accordance with
SSA policy.
The adjudicating component medical consultant reviewed all of the evidence in the
file
and determined the claimant retained the physical capacity to lift and carry 20 pounds
occasionally
and 10 pounds frequently and stand, walk, and sit 6 hours in an 8-hour workday. The
adjudicating
component medical consultant found no additional limitations and explained all supporting
evidence
findings on the residual functional capacity (RFC) form. This proposed assessment
would result in an
allowance .
The ROMC reviewed all of the evidence in the file and determined the claimant retained
the physical capacity to lift and carry 50 pounds occasionally and 25 pounds frequently.
The ROMC
affirmed the capacities to stand, walk, and sit for 6 hours in an 8-hour workday.
This proposed
assessment would result in a denial .
The ROMC explained his or her findings, but did not indicate that the adjudicating
component medical consultant overlooked material findings or evidence or misapplied
any SSA policy.
In other words, the ROMC did not provide any evidence or policy based reason not to
accept the
assessment proposed by the adjudicating component medical consultant.
The ROMC and the adjudicating component medical consultant used the same evidence
to
arrive at different RFC assessments and, ultimately, different disability determinations.
This
constitutes SOJ by the ROMC and is prohibited by SSA policy. In this example, the
ROMC
must accept the adjudicating component medical consultant assessment and affirm the
proposed allowance.
EXAMPLE 2 of SOJ
The
claimant is advanced age with an RFC for unskilled light work.
On
the SSA-3369, the claimant reported one relevant job as a cashier at a retail store,
listing the
following duties: used a cash register to total purchases; issued receipts to customers;
received
cash/credit card payments; verified that cash provided by customers matches the items
purchased;
cashed checks; processed refunds; counted money in cash drawer and prepared reports
of transactions;
stocked shelves once a month.
The
adjudicating component provided a rationale noting that Occubrowse shows several cashier
related
jobs, but the combination of cashier duties and occasional stocking duties in a retail
setting
resemble Dictionary of Occupational Titles (DOT) 211.462-014 (Cashier-Checker, SVP
3, Strength –
Light). Therefore, the claimant does not meet the mental demands associated with the
Cashier-Checker
job, which results in an allowance.
The
review component indicated the DOT counterpart proposed by the adjudicating component
is not
supported and DOT 211.462-010 (Cashier II, SVP 2, Strength – Light) is a more appropriate
match.
This DOT counterpart is within the confines of the claimant’s physical and mental
RFC. While the
proposed DOT alternative would lead to a step four denial, the review component did
not identify any
vocational assessment oversights or instances of policy noncompliance.
The
adjudicating and review components arrived at conflicting determinations despite a
shared
evidentiary basis. This constitutes SOJ by the review component. Given the absence
of a valid
policy-related justification for challenging the step four conclusion, the review
component must
endorse the adjudicating component’s vocational analysis and affirm the proposed
allowance.