A group I documentation deficiency is a substantive deficiency in which the medical,
vocational, functional, or other relevant evidence, is insufficient to make a determination
about the claimant’s disability, such that there is potential for reversing the determination
to allow or deny, or to continue or cease, disability benefits. The review component
will cite a group I documentation deficiency based on the following issues:
1. Work Activity (category 30)
Category 30 applies when:
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medical evidence supports an allowance at Step 3 or Step 5,
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the file contains evidence of work activity,
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the evidence is insufficient to establish whether the work activity is ongoing SGA
or "clearly not SGA", and
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a potential SGA denial applies at Step 1.
2. Medical evaluation involving vocational documentation (category 31)
The adjudicating component made an incorrect assessment of impairment severity or
residual functional capacity (RFC), which makes additional vocational documentation
necessary to determine disability.
3. Collateral estoppel (CE) (category 36)
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.
4. Insufficient medical documentation to determine impairment severity (category 41)
The adjudicating component based the determination on medical considerations alone
(i.e., the impairment is not severe or the impairment meets, medically equals, or
does/does not functionally equal the listings) without sufficient evidence to support
the determination.
NOTE: The review component should not use this code if the adjudicating component’s
determination is based on an RFC assessment.
5. Insufficient medical documentation to determine duration (category 42)
The adjudicating component had insufficient medical evidence to document the severity
of the disabling impairment to meet policy requirements for 12-month duration.
6. Medical improvement (MI), including whether MI affects the ability to work (category
43)
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.
NOTE: The review component should not use this code if the adjudicating component’s
determination is based on medical considerations alone (i.e., the impairment is not
severe, or the impairment meets, medically equals, or functionally equals the listings).
8. Failure to follow prescribed treatment (FTFPT) (category 45)
The adjudicating component had insufficient evidence to determine whether consideration
of FTFPT policy was necessary prior to assessing impairment severity.
9. Drug addiction and alcoholism (DAA) materiality (category 46)
The adjudicating component had insufficient evidence to:
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determine whether DAA is material in the case, or
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determine the severity of the non-DAA impairments when DAA is material.
10. Onset of disability relative to a title II eligibility period (category 47)
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.
11. MI exception regarding new or improved diagnostic or evaluative techniques (category
48)
The adjudicating component had insufficient evidence in a CDR 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.
12. MI exception regarding whether the individual has benefited from advances in medical
or vocational therapy or technology (category 49)
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.
14. Education or illiteracy (category 52)
The adjudicating component had insufficient evidence to determine the claimant’s education
or illiteracy, when it is material to the determination.
15. Work history (category 53)
The adjudicating component had insufficient work history evidence to determine:
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the demands of past relevant work, including physical, mental, and environmental demands,
or
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16. MI exception regarding advances in medical or vocational therapy or technology (category
54)
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.
17. MI exception regarding successful vocational therapy (category 55)
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.
18. Failure to obtain a prior folder or copy of the ALJ/AC ruling under an acquiescence
ruling (category 60)
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.
19. The prior determination was in error (category 61)
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.
20. Failure to follow prescribed treatment (FTFPT) (category 62)
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.
21. Whereabouts unknown (WU) (category 65)
The adjudicating component had insufficient documentation to deny the claim or cease
benefits based on WU.
22. Failure to cooperate (FTC) (category 66)
The adjudicating component had insufficient documentation to deny the claim or cease
benefits based on FTC.