FQRs may consider or apply POR to all types of determinations (i.e., fully favorable, less than fully favorable, or unfavorable).

For fully favorable determinations, the FQR may consider or apply POR at the initial and reconsideration level.

For less than fully favorable and unfavorable determinations, if the only issue is the need to complete the record, the FQR may consider or apply POR, but only at the initial filing level.

When the next level of appeal is a hearing, the FQR cannot apply POR because an administrative law judge is required to fully document the case record. If the only reason for returning a case to the adjudicating component is to complete the record in the event of a hearing, the case contains a TCA, not a group I or group II documentation deficiency, and the FQR must return the case to the adjudicating component for additional development.

FQRs may consider or apply POR for:

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  Group I medical documentation deficiencies

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  Group I vocational documentation deficiencies

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  Group I medical evaluation deficiencies involving vocational documentation

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  Group II onset date documentation deficiencies

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  Group II ending date documentation deficiencies

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  Group II cessation date documentation deficiencies

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  Group II work activity documentation deficiencies

For additional information regarding deficiency types, see the policy sections listed in DO 30005.110A.

The FQR must thoroughly review the sample case per normal procedures.

If the existing medical and vocational documentation is sufficient to support the adjudicating component’s determination and is policy compliant, the FQR must clear the case as clean and route it to the Field Office (FO).

If the federal quality review of the sample case reveals the existing medical and vocational documentation reasonably appears to support the adjudicating component’s determination, but the efforts made to obtain documentation are not fully policy compliant, the FQR may consider POR.

The FQR must specifically identify what medical or vocational documentation is missing and what policies the adjudicating component failed to follow when developing the documentation.

When a case does not contain complete medical documentation per SSA disability program policy, the FQR must send the case to the regional office MC and/or PC for review prior to making a POR determination.

The regional office MC or PC either indicates the evidence is insufficient to determine the severity of any alleged impairment(s) or prepares a conditional severity rating (CSR) (usually a residual functional capacity (RFC)) based on the existing evidence in file.

The regional office MC or PC may prepare a CSR when the medical evidence in file is insufficient to rate the overall severity of all of the claimant's allegations but is sufficient to prepare an assessment of the severity of one or more medically determinable impairments (MDI).

The regional office MCs or PCs may also offer opinions on the potential effect of missing documentation on impairment severity or RFC.

However, these opinions are not binding on the FQR. Moreover, FQRs should exercise caution when using a CSR to support a POR determination when the disability determination is unfavorable or less than fully favorable.

NOTE:In unfavorable or less than fully favorable determinations, there is a statutory requirement that adjudicators must "consider all evidence available in such individual's case record, and must develop a complete medical history of at least the preceding twelve months for any case in which a determination is made that the individual is not under a disability." See Section 223(d)(5)(B) of the Social Security Act. FQRs must return12-month medical evidence of record (MER) TCAs, which are limited to unfavorable or less than fully favorable determinations, to the adjudicating component for additional development and correction. For additional information, see Non-substantive Technical Corrective Action (TCA) DI 30005.232A.1. Adjudicators and FQRs are reminded that in some cases, such as those involving traumatic or acute illnesses or injuries, 12 months of evidence may not be available.

The FQR must determine what level of impairment severity, RFC, and vocational factors would reverse the disability determination or change the length of the period of disability.

EXAMPLE: If an unfavorable determination is not documented per policy, and the claimant is 25 years old with a high school education and has the capacity to perform a full range of sedentary work, the claimant's impairment(s) have to meet or medically equal the listings, or significantly reduce the RFC, for the missing documentation to reverse the disability determination. Thus, a TCA would more likely be supported in this case.

EXAMPLE: If an unfavorable determination is not documented per policy, and the claimant is 56 years old with a fifth grade education and does not retain the capacity for past relevant work (PRW), evidence of a severe impairment and certain functional limitations, potentially found in the missing documentation, are more likely to reverse the disability determination. Thus, citing a group I documentation deficiency would more likely be supported in this case.

If the FQR, based on disability policy knowledge and quality review case experience:

1. a. 

   surmises that the missing medical or vocational documentation is likely to reverse the determination or change the length of the period of disability, the FQR must:

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     cease consideration of POR,

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     cite the appropriate documentation deficiency on a Request for Corrective Action (SSA-1774-U5),

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     document consideration of POR on the Request for Corrective Action (SSA-1774-U5) per DI 30005.110E, and

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     return the case to the adjudicating component for additional development and correction.

2. b. 

   cannot reasonably ascertain whether the missing documentation is likely to reverse the determination or change the length of the period of disability, the FQR must:

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     cease consideration of POR,

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     cite the appropriate documentation deficiency on a Request for Corrective Action (SSA-1774-U5),

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     document consideration of POR on the Request for Corrective Action (SSA-1774-U5) per DI 30005.110E and

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     return the case to the adjudicating component for additional development and correction.

3. c. 

   surmises that the missing medical or vocational documentation is unlikely to reverse the determination or change the length of the period of disability, the FQR must:

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  apply POR,

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  cite a medical or vocational documentation TCA,

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  document application of POR using a case note per DI 30005.110E in this section , and

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  route the case back to the field office.

NOTE: The POR process is inherently subjective and difficult to define precisely. POR is most likely to be considered or applied with unfavorable determinations, but can also be used with favorable determinations.

When an adjudicating component does not fully document a case according to SSA disability program policy, and the FQR applies POR instead of returning the case to the adjudicating component for correction, the FQR must document the file with a rationale explaining the application of POR. The FQR's rationale must provide subsequent adjudicators and reviewers with an understanding of why the FQR did not return the case to the adjudicating component for additional development and correction.

When POR is applied, the FQR must document the file with a case note, stating, verbatim, the following:

The Office of Quality Review used probability of reversal, as explained in GN 04440.110 and DI 30005.110, to determine that obtaining additional evidence is unlikely to reverse the disability determination or change the length of the period of disability. This case contains a medical or vocational documentation technical corrective action. No adjudicating component action is required.

The FQR's POR rationale must also contain a brief summary of the case facts, what specific documentation is missing, and why obtaining the missing documentation is unlikely to reverse the disability determination or change the length of the period of disability. In addition to documenting the POR rationale on the required case note, FQRs must also cite a medical or vocational documentation TCA as outlined in DI 30005.232.B.2.

When the adjudicating component does not fully document a case according to SSA disability program policy, and the FQR determines the missing documentation has the potential to reverse the disability determination or change the length of the period of disability, or the likelihood of such cannot be determined, the FQR must document consideration of POR on the Request for Corrective Action (SSA-1774-U5), stating the following:

The Office of Quality Review considered probability of reversal for this case, as explained in GN 04440.110 and DI 30005.110. However, there is insufficient information to determine whether the missing evidence from (name missing evidence) is likely to reverse the disability determination or change the length of the period of disability because (Fill in particular case facts. Examples: the mental and physical demands of the missing job are unknown; the content of the missing records is unknown). Therefore, adjudicating component action is required. 

If a FQR considers POR, but ultimately decides to return the case to the adjudicating component for further development and correction, the paragraph above should appear on the Request for Corrective Action (SSA-1774-U5). There is no need for the FQR to provide further information regarding POR consideration, as the content of the Request for Corrective Action (SSA-1774-U5) must delineate the reason(s) the FQR cited a documentation deficiency.

If the medical evidence in the file is insufficient, FQRs should classify the missing documentation as a group I medical documentation deficiency, without making a POR determination, in the following situations:

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  The only medical evidence in the file consists of a diagnosis without any acceptable clinical or laboratory findings to establish a MDI. For additional information regarding MDIs, see DI 24501.020.

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  The only medical evidence in the file is unrelated to the alleged disabling impairment(s) (e.g., the medical evidence is about colds, flu, or other generally short-lived minor ailments when only a mental health impairment is alleged).

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  The only medical evidence in the file is irrelevant (e.g., evidence pertains to someone other than the claimant).

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  There is no medical evidence in the file.

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  The only medical evidence in the file is not from, or signed by, an acceptable medical source (AMS), as defined in DI 22505.003A.

NOTE: In rare situations, an adjudicator can make a disability determination, without evidence from an AMS, when the claimant has an obvious impairment (e.g., amputations as described in listing 1.20A. or 101.20A. or total blindness due to the loss of both eyes). FQRs should not cite a medical documentation deficiency, if the claimant has an obvious impairment, as defined in DI 22505.012B.2.

If a MDI was previously established, the adjudicating component needs medical evidence from a medical source (which need not be an AMS) to determine whether there is medical improvement (MI). For the definition of a "medical source", see DI 22505.001A.4.

For an exception to the medical source requirement in "medical improvement not expected" (MINE) CDR cases, see:

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  DI 28040.115 Verification of Continued Impairment Severity

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  DI 28040.125 (Determining the Need for a Medical Source or Third Party Contact in Medical Improvement Not Expected (MINE) or MINE-Equivalent Cases)

If it is necessary to establish a new MDI, SSA disability program policy requires medical evidence from an AMS. For examples, see Evidence from an Acceptable Medical Source (AMS) DI 22505.003A.

If the medical evidence in the file is insufficient, the FQR must classify the missing documentation as a group I medical documentation deficiency, without making a POR determination, when a CDR determination has been made in a "medical improvement expected" (MIE) or "medical improvement possible" (MIP) diary case, and one (or more) of the following is true:

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  The file does not contain sufficient evidence from a medical source to determine current severity or functioning.

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  The only evidence from a medical source is an opinion that is not supported by acceptable clinical or laboratory findings (e.g., the medical evidence contains only a statement regarding whether there has been any MI).

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  The evidence from a medical source is unrelated to the alleged disabling impairment (e.g., the medical evidence is about colds, flu, or other generally short-lived minor ailments when only a mental health impairment is alleged).

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  The evidence from the medical source is irrelevant (e.g., the evidence pertains to someone other than the claimant).

If the vocational evidence in the file is insufficient to rule out the performance of PRW, FQRs must not apply POR and must classify the missing documentation as a group I vocational documentation deficiency, regardless of how limited the proposed RFC or mental residual functional capacity (MRFC) may be.

Careful review of all vocational evidence in file is necessary as what constitutes "insufficient vocational evidence" depends on the specific facts of the case under review.

EXCEPTION: The FQR should not cite a group I vocational documentation deficiency if the vocational expedite described in Expedited Vocational Assessment at Steps 4 and 5 of Sequential Evaluation DI 25005.005.

EXAMPLE 1. Insufficient Vocational Evidence to Rule out PRW:

The claimant is 55 years old and has a light RFC with frequent handling and fingering. The claimant's PRW as described in the Work History Report (SSA-3369-BK) describes light exertion work with job duties and activities consistent with the Dictionary of Occupational Titles (DOT) occupation of Assembler, Small Products II 739.687-030, which is generally performed in the national economy at the light, unskilled level with constant handling and fingering. On the SSA-3369, the claimant checks boxes indicating use of his fingers and hands to manipulate objects without detailing the number of hours he performed these activities. DDS allows the claim indicating the claimant cannot return to PRW due to handling and fingering limitations. Although the RFC precludes PRW as generally performed in the national economy, the job description provided by the claimant is insufficient to rule out PRW as actually performed. In this situation, POR should not be considered and cannot be applied because the evidence is insufficient to determine whether the claimant retains the ability to perform PRW as actually performed.

EXAMPLE 2. Insufficient Vocational Evidence to Rule out PRW:

The claimant is 57 years old and has an RFC representing a significantly eroded range of sedentary work indicating a limitation on standing and/or walking to a few minutes a day. The claimant’s PRW as listed in the SSA-3369 is “Forklift Driver,” without any further details regarding, job duties, activities, exertional requirements, or non-exertional requirements. The only information regarding PRW is the job title. DDS allows the claim indicating the claimant cannot do PRW due to the RFC representing a significantly eroded range of sedentary work. However, even though it is not necessary to evaluate ability to do work as it is generally performed in the national economy with such a restrictive RFC, sufficient information about the claimant’s PRW is required to evaluate ability to do PRW as actually performed before a policy compliant determination can be made (DI 22515.010B.3). In this situation, POR should not be considered and cannot be applied because the vocational evidence is insufficient to determine whether the claimant can return to PRW as actually performed.

EXAMPLE 3. Sufficient Evidence to Rule out PRW:

The claimant is 57 years old and has a light RFC. DDS allows the claim indicating the claimant cannot do PRW. The claimant's PRW as described in the SSA-3369 is consistent with the job duties and activities of the DOT occupation of Laborer, Stores 922.687-058, which is generally performed in the national economy at the medium, unskilled level. Although the SSA-3369 includes a description of the job duties and activities of the claimant’s PRW, it does not contain the weight lifted frequently or the heaviest weight lifted. However, in describing job duties the claimant indicated she would lift and carry "heavy 5-gallon buckets of paint." Although the claimant did not report specific weights required in performance of her PRW, the FQR knows a 5-gallon bucket of liquid weighs around 40 pounds. In this situation, POR should be applied since there is sufficient evidence to rule out the performance of PRW based on the light RFC limiting the claimant to lifting no more than 20 pounds at a time. Additional documentation to determine the weights lifted in performance of the claimant’s PRW would be unlikely to reverse the determination given the typical weight of 5-gallon buckets of paint.