The disability determination process is inherently judgmental. Sometimes, adjudicating and reviewing components reach different disability conclusions, in a case that is fully documented per policy, after considering the same facts and evidence. In the absence of any of the three issues listed above, a differing opinion and/or disability conclusion from a quality reviewer, regional office medical contractor (ROMC), or medical advisor is SOJ and contrary to SSA policy.

EXAMPLE 1 of SOJ

An adjudicating component requested medical evidence, followed up with all of the claimant's treating sources per policy guidelines, obtained a complete vocational history, and obtained functional information from the claimant. The case is fully documented in accordance with SSA policy.

The adjudicating component medical consultant reviewed all of the evidence in the file and determined the claimant retained the physical capacity to lift and carry 20 pounds occasionally and 10 pounds frequently and stand, walk, and sit 6 hours in an 8-hour workday. The adjudicating component medical consultant found no additional limitations and explained all supporting evidence findings on the residual functional capacity (RFC) form. This proposed assessment would result in an allowance.

The ROMC reviewed all of the evidence in the file and determined the claimant retained the physical capacity to lift and carry 50 pounds occasionally and 25 pounds frequently. The ROMC affirmed the capacities to stand, walk, and sit for 6 hours in an 8-hour workday. This proposed assessment would result in a denial.

The ROMC explained the disagreement with the adjudicating component, but did not indicate that the adjudicating component medical consultant overlooked material findings or evidence or misapplied any SSA policy. In other words, the ROMC did not provide any evidence or policy-based reason not to accept the assessment proposed by the adjudicating component medical consultant.

The ROMC and the adjudicating component medical consultant used the same evidence to arrive at different RFC assessments and, ultimately, different disability determinations. This constitutes SOJ by the ROMC and is prohibited by SSA policy. In this example, the ROMC must accept the adjudicating component medical consultant assessment and affirm the proposed allowance.

EXAMPLE 2 of SOJ

The claimant is advanced age with an RFC for unskilled light work.

On the SSA-3369, the claimant reported one relevant job as a cashier at a retail store, listing the following duties: used a cash register to total purchases; issued receipts to customers; received cash/credit card payments; verified that cash provided by customers matches the items purchased; cashed checks; processed refunds; counted money in cash drawer and prepared reports of transactions; stocked shelves once a month.

The adjudicating component provided a rationale noting that Occubrowse shows several cashier related jobs, but the combination of cashier duties and occasional stocking duties in a retail setting resemble Dictionary of Occupational Titles (DOT) 211.462-014 (Cashier-Checker, SVP 3, Strength – Light). Therefore, the claimant does not meet the mental demands associated with the Cashier-Checker job, which results in an allowance.

The review component indicated the DOT counterpart proposed by the adjudicating component is not supported and DOT 211.462-010 (Cashier II, SVP 2, Strength – Light) is a more appropriate match. This DOT counterpart is within the confines of the claimant’s physical and mental RFC. While the proposed DOT alternative would lead to a step four denial, the review component did not identify any vocational assessment oversights or instances of policy noncompliance.

The adjudicating and review components arrived at conflicting determinations despite a shared evidentiary basis. This constitutes SOJ by the review component. Given the absence of a valid policy-related justification for challenging the step four conclusion, the review component must endorse the adjudicating component’s vocational analysis and affirm the proposed allowance.

When the adjudicating component's disability determination is compliant with SSA policy, federal quality reviewers, ROMCs, and medical advisors must avoid SOJ. Federal quality reviewers will not cite group I or group II decisional deficiencies when SOJ is at issue.

The intent of the SOJ provision is to ensure that federal quality reviewers do not cite decisional deficiencies unless the adjudicating component has not followed specific policy or procedure, or the evidence does not support the determination. Federal quality reviewers may only cite decisional deficiencies when the adjudicating component's proposed determination does not comply with disability program policy.

NOTE: The concept of SOJ applies only when determining whether a group I or group II decisional deficiency exists. SOJ does not apply when determining whether a documentation deficiency exists.

Federal quality reviewers should accept the adjudicating component's determination when all of the following are true:

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  The adjudicating component has documented the file according to current disability program policy (e.g., all impairments addressed, all evidence requested and followed up per policy).

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  The adjudicating component has provided a rationale of clear intent explaining the determination and free of any material inconsistencies that were not explained and/or resolved. For guidance on materially inconsistent evidence refer to DI 22515.003 and DI 24501.016 .

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  Both the adjudicating and review component determinations or assessments are supported by the evidence in file and are policy compliant.

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  The review component, after considering all the documented facts, believes the evidence directs a different assessment and/or determination than that of the adjudicating component.

If all of the above factors are present, a federal quality reviewer would be substituting judgment by citing a group I or group II decisional deficiency. Any material change to the assessment of severity or determination, or change that necessitates additional development by the adjudicating component, represents SOJ.

Before citing a group I or group II decisional deficiency, federal quality reviewers must be alert to the possibility of SOJ in a highly judgmental adjudicative issue, especially when disability program policy explicitly acknowledges that the issue is judgmental. For example, situations in which subtle differences in RFC (e.g., standing and walking reduced to four hours versus six hours) are material to the finding of disability or borderline age situations. (For additional information, see Borderline Age DI 25015.006.)

Federal quality reviewers should cite a group I or group II decisional deficiency when any of the following situations occur and the situation meets the criteria of one of the listed deficiencies in QR 04440.202 (Group I Decisional Deficiencies) or QR 04440.204 A.1. (Group II Decisional Deficiencies):

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  The adjudicating component's determination contradicts the evidence (e.g., the adjudicating component based their determination on an erroneous interpretation of a medical test or result, the determination is contrary to accepted medical knowledge, the evidence in file belongs to an individual other than the claimant).

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  The adjudicating component has misrepresented the evidence in the rationale for the determination.

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  The adjudicating component's determination does not comply with SSA policy, the adjudicator did not provide a rationale to explain the determination, and the review component reached a different conclusion that is supported by SSA policy.

CAUTION: Federal quality reviewers should not cite a deficiency and return a case to the adjudicating component merely because the rationale for the determination is inadequate or missing. If the adjudicating component's rationale is inadequate or missing, and the determination is correct, the quality reviewer prepares a policy-compliant rationale and does not return the case to the adjudicating component. If the adjudicating component's rationale is inadequate or missing, and the determination is not policy compliant, the quality reviewer will cite the appropriate deficiency and return the case to the adjudicating component for correction.

The federal quality reviewer's notification of deficiency to the adjudicating component must explain:

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  why the adjudicating component's determination does not comply with SSA policy and

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  why the reviewing component's deficiency citation complies with SSA policy.

For both items listed above, the quality reviewer must include specific POMS references and citations.

QR 04440.003K. Explanation of Quality Review Terms, for additional information regarding SOJ

QR 04440.130 Medical Review in the Quality Review (QR), for an explanation of SOJ and the ROMC review