TN 31 (09-23)

DI 81020.230 Documenting and Copying Comparison Point Decision (CPD) Relevant Evidence and Preparing the Electronic Continuing Disability Review (eCDR) Rationale

These procedures do not modify existing documentation policies and procedures for CDR rationales, see Continuing Disability Review (CDR) Rationale Content – General - DI 28090.010.

The field office (FO) will make every effort to send the Disability Determination Services (DDS) the electronic or paper CPD folder at the time of transfer per DI 81010.242.

If the FO is unable to locate the CPD folder at transfer, refer to procedures in DI 81010.242.

If the FO finds the CPD folder during DDS, Office of Hearings Operations (OHO), or Office of Appeals Council (OAO) review or after the DDS, OHO, or OAO has made a CDR determination or decision, the FO will still send the CPD folder to the appropriate location (DDS, OHO, or OAO), see procedures in DI 81010.242 sections E.2 and E.4.

The DDS should follow the procedures outlined in Original Folder Received in the Disability Determination Services (DDS) After the Review Process Begins DI 28035.030.

While it is not necessary to provide a detailed description of every sign, symptom and laboratory finding from the CPD, relevant evidence should be clearly documented. Relevant evidence includes evidence that documents the existence of a medically determinable impairment; a test score that will be needed in a future CDR; or a longitudinal history that is needed to document impairment severity. See CDR Rationale Content – General -DI 28090.010 for required rationale content. The DDS must scan relevant evidence as described above from the paper CPD folder or copy it from the electronic CPD folder to the eCDR, so it is available for subsequent reviewers. For example, intelligent quotient (IQ) test scores, x-ray results, pathology findings, cardiac tests, operative reports, may still be valid for future reviews.

1. 1. 

   If the CPD folder is paper and contains relevant evidence for a future CDR, the DDS will:

   • •

     provide a detailed description of the relevant evidence; and

   • •

     scan the relevant paper CPD evidence into the eCDR folder. The DDS should use either document: type 0305 – CPD Documents – Non Medical; 0304 – CPD Documents – Medical; 0306 - CPD Documents - Payments/Decisions; or 0307 - CPD Documents - Jurisdictional/Notices. Enter the name of the source in the “note” field in eView.

2. 2. 

   If the CPD folder is electronically linked to the eCDR and contains relevant evidence for a future CDR, the DDS will:

   • •

     provide a detailed description of the relevant evidence;

   • •

     load the created analysis or rationale; and

   • •

     copy the relevant CPD evidence into the eCDR folder per DI 81005.052 .

EXAMPLE: Rationale for CPD findings in a case involving intellectual disability.

Ronald Wood, Ph.D. performed a WAIS-IV examination on 10/28/2014. The claimant was 23 years old at the time of the IQ testing. Results showed a Verbal Comprehension score of 60, Working Memory score of 61 and a Full Scale IQ of 59. The results were considered valid. The claimant's function report showed extreme problems in being argumentative and emotional. The claimant lacked appropriate social cues when responding to corrections or criticism. They had no past relevant work. Their Activities of Daily Living (ADL) in file were consistent with diminished intellectual functioning. Therefore, the claimant's impairment met Listing 12.05B.1.a.2.b.3.

EXAMPLE: Rationale for CPD findings in a case involving digestive impairment.

The CPD is dated 9/30/2016. At CPD, the claimant had ongoing inflammatory bowel disease complications with poor control through medication and diet. On 10/15/2015, the claimant underwent intestinal resection. Surgical report shows only a small amount of small intestine remaining. Prior to discharge on 11/01/2015, a central venous catheter was placed for nutritional requirements. Progress notes from 12/2015 to 07/2016 show the claimant is able to feed orally, however, is dependent on daily parenteral nutrition to provide most of the nutritional requirements. The claimant met Listing 5.07.