For the first CDR involving a scenario where:
• The last favorable medical decision (i.e., the comparison point decision (CPD))
is a lost folder case, and
• A subsequent claim was filed after the CPD and the FO processed a collateral estoppel
adoption determination (i.e., the decision involving the lost folder was adopted by
the FO):
At CDR, the adjudicator must follow the instructions in DI 28035.000. This includes attempting to reconstruct the lost folder for the CPD, if appropriate,
per the policy guidance in DI 28035.020.
NOTE: A decision adopted through collateral estoppel with no medical evidence or development
is not the CPD.
If reconstruction is not possible (see DI 28035.025), medical improvement cannot be found. The adjudicator will assess and document the
severity of the current impairment(s). In the absence of a Group II exception, benefits
will continue.
Example: A Title XVI recipient was allowed at the initial level due to the severity
of their medical impairments. After the initial-level Title XVI allowance, the Title
XVI folder was lost. The FO processed a collateral estoppel determination on a subsequent
Title II claim, establishing that the individual was entitled to Title II benefits
based on the Title XVI disability determination, and the rules for collateral estoppel
were met as outlined in DI 11011.001A.
A CDR was initiated when the diary matured. At CDR, the adjudicator followed the instructions
in DI 28035.001. The adjudicator was unable to reconstruct the lost folder and determined that a
Group II exception did not apply. The adjudicator assessed the severity of the current
impairments and, following the guidance in DI 28035.010 and DI 28035.025, processed a continuance for both Title II and Title XVI claims. The adjudicator
processed a continuance because the evidence from the most recent medical determination
was insufficient to determine medical improvement. The ratings and evaluation of the
current impairments will serve as the CPD basis for future reviews.
For any subsequent CDRs, the normal CDR sequential evaluation process will apply,
as the CPD (being a continuance in the absence of a Group II exception) contains evaluation
of impairment severity. The adjudicator will then follow the MIRS process for subsequent
CDRs in DI 28005.015 and DI 28005.030.
E. References
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•
DI 22001.001 Sequential Evaluation of Title II and Title XVI Adult Disability Claims
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•
DI 25220.005 Determining if a Child Has a Severe Impairment(s)
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•
DI 25225.001 Functional Equivalence – Policy (Section 416.926a(a))
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•
DI 28020.001 General - Groups I and II of Exceptions to Medical Improvement (MI)
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•
DI 28035.015 Disability Determination Services (DDS) Identification of the Comparison Point Decision
Date
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•
DI 28035.020 Disability Determination Services (DDS) Reconstruction of Prior Folder
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•
DI 28035.025 Disability Determination Services Reconstruction of Prior Folder Not Possible