Category 30 applies when:

• •

  medical evidence supports an allowance at Step 3 or Step 5,

• •

  the file contains evidence of work activity,

• •

  the evidence is insufficient to establish whether the work activity is ongoing SGA or "clearly not SGA", and

• •

  a potential SGA denial applies at Step 1.

The adjudicating component made an incorrect assessment of impairment severity or residual functional capacity (RFC), which makes additional vocational documentation necessary to determine disability.

The adjudicating component had insufficient documentation to determine whether adoption applied, or incorrectly adopted a prior favorable disability determination, which makes additional medical or vocational documentation necessary to determine disability on the current claim.

The adjudicating component based the determination on medical considerations alone (i.e., the impairment is not severe or the impairment meets, medically equals, or functionally equals the listings) without sufficient evidence to support the determination.

The adjudicating component had insufficient medical evidence to document the severity of the disabling impairment to meet policy requirements for 12-month duration.

The adjudicating component had insufficient medical documentation to determine whether or not MI has occurred or, whether MI is related to the ability to work in a continuing disability review (CDR).

The adjudicating component based the determination on an RFC assessment without sufficient evidence to support the assessment.

The adjudicating component had insufficient evidence to determine whether consideration of FTFPT policy was necessary prior to assessing impairment severity.

The adjudicating component had insufficient evidence to:

• •

  determine whether DAA is material in the case, or

• •

  determine the severity of the non-DAA impairments when DAA is material.

The adjudicating component had insufficient evidence to determine whether onset can, or cannot, be correctly established, in a Title II disability claim, relative to the date first insured, date last insured, end of the prescribed period, or before the attainment of age 22.

The adjudicating component had insufficient evidence to determine whether new or improved diagnostic or evaluative techniques showed the individual’s impairment(s) is, or is not, as severe as previously determined in the most recent favorable medical determination, in a CDR.

The adjudicating component had insufficient evidence to determine whether the MI exception, regarding significant MI in a CDR due to medical or vocational therapy, or technology, applies.

The adjudicating component had insufficient evidence to determine the claimant’s age, when it is material to the determination.

The adjudicating component had insufficient evidence to determine the claimant’s education or illiteracy, when it is material to the determination.

The adjudicating component had insufficient work history evidence to determine:

• •

  relevance of past work,

• •

  the demands of past relevant work, including physical, mental, and environmental demands, or

• •

  transferable skills.

The adjudicating component obtains new medical evidence that results in a new RFC, but no MI. However, the vocational evidence is insufficient to determine whether the MI exception in a CDR regarding significant MI due to medical or vocational therapy, or technology applies.

The adjudicating component had insufficient evidence to determine whether vocational therapy (related to the individual’s ability to work) improved the individual’s ability to meet the vocational requirements of more occupations, since the time of the most recent prior favorable medical determination, in a CDR.

The adjudicating component did not obtain the prior folder or a copy of the ALJ or AC decision as required by the AR. Therefore, the evidence is insufficient to make a determination.

The prior determination was potentially incorrect, indicating a group I or II exception, but the adjudicating component did not follow policy regarding application of the exception, in a CDR.

The adjudicating component had insufficient documentation to allow or deny the claim, or continue or cease benefits, when evidence implied FTFPT was central to the assessment of impairment severity.

The adjudicating component had insufficient documentation to deny the claim or cease benefits based on WU.

The adjudicating component had insufficient documentation to deny the claim or cease benefits based on FTC.

For group I documentation deficiencies returned to the adjudicating component for correction, the review component will:

1. a. 

   annotate all of the adjudicating component’s original determination and medical assessment forms, as well as notices, in the CEF as “Do Not Process” or “Do Not Release”, as applicable,

2. b. 

   code the deficiency in the case processing system,

3. c. 

   notify the adjudicating component, via a Request for Corrective Action, to explain why the determination is not policy compliant and request the adjudicating component to obtain additional documentation,

4. d. 

   route the case to the adjudicating component for correction as a controlled return, and

5. e. 

   follow-up with the adjudicating component in 60 days if the case has not been returned to the review component.

For group I documentation deficiencies based on work activity, the review component will:

1. a. 

   annotate all of the adjudicating component’s original determination and medical assessment forms, as well as notices, in the CEF as “Do Not Process” or “Do Not Release”, as applicable,

2. b. 

   code the deficiency in the case processing system,

3. c. 

   notify the FO, via Request for FO assistance to explain that SGA development is needed,

4. d. 

   notify the adjudicating component, via a Request for Corrective Action, to explain why the determination is not policy compliant and that the case will be routed to the FO for SGA development, and

5. e. 

   route the case to the FO.

After the FO resolves the work activity issue and determines an SGA denial or cessation is appropriate:

• •

  do not effectuate the denial or cessation,

• •

  code the case processing system for clearance, and

• •

  route the case to the FO.

After the FO resolves the work activity issue and determines an SGA denial is not appropriate:

• •

  code the case processing system as appropriate for clearance,

• •

  remove or add "Do Not Process" and "Do Not Release" annotations, as applicable to the adjudicating component's original determination(s), medical assessment form(s), and notice(s),

• •

  when necessary, correct the onset or ending date on the SSA-831-C3/U3,

• •

  prepare and release required personalized notices, and

• •

  route the case to the FO for effectuation.

If the FO determines SGA denial is not applicable, but FO documentation raises additional issues that require adjudicating component action, initiate a subsequent return to the adjudicating component per GN 04440.205B.2.

If the FO documentation does not fully resolve SGA issues or other technical factors needed to adjudicate the claim:

• •

  prepare a subsequent Request for FO Assistance,

• •

  specify the issues that need resolution or clarification, and

• •

  control the return to the FO.