TN 16 (04-11)

GN 04440.116 Guidelines for Making Probability of Reversal (POR) Determinations

The following guidelines are designed to assist quality reviewers in making a POR determination in cases in which the medical or vocational documentation does not fully conform to SSA disability program policy. For an explanation of when not to use the POR rule, see GN 04440.112.

A. Policy on making POR determinations

For the SSA quality reviewer to make a POR determination, there must be sufficient medical and non-medical evidence in file (but not necessarily complete documentation under disability program policy) to judge what level of impairment severity and residual functional capacity (RFC) you can infer from such evidence.

B. Steps for making POR determinations

Use the following guidelines in the order shown below in making a POR determination. If only vocational documentation is deficient, skip to Step 2.

1. Step 1

What conditional level of impairment severity and RFC assessment can you reasonably infer from all the evidence in file?

  • Based on all medical and non-medical evidence in file, including opinions expressed by Federal review physicians, information on the application form, reports of contact, etc., infer a conditional level of impairment severity and an RFC (if an RFC determination is required).

  • If you cannot infer a conditional level of impairment severity or RFC (when an RFC assessment is required) from the evidence in file, classify the deficiency as a group I medical documentation deficiency or a group II documentation deficiency. (If you cannot infer the current level of impairment severity, the deficiency is a group I medical documentation deficiency. If the past level of impairment severity is the issue, and you cannot infer it, cite a group II documentation deficiency.)

  • If you can infer a conditional level of impairment severity or RFC (when an RFC assessment is required) from the evidence in file, proceed to Step 2.

2. Step 2

What level of impairment severity, RFC, or vocational finding would cause a reversal of the disability determination or a change in the period of disability, given your knowledge of the vocational factors and other facts in the case?

  • Based on all medical and non-medical evidence in file, determine what level of impairment severity, RFC (if RFC determination is required), or vocational finding would result in a reversal of the disability determination or in a change in the period of disability, given the vocational factors (age, education, and work experience) and all the other facts of the case.

  • If the medical and vocational documentation is insufficient, cite a group I or group II documentation deficiency, unless there are other compelling reasons that indicate the missing medical and vocational evidence is unlikely to reverse the disability determination or change the period of disability.

  • If you can make a determination concerning the level of impairment severity, RFC, or vocational finding that would cause a reversal of the disability determination or a change in the period of disability, proceed to Step 3.

3. Step 3

What evidence is missing or needed and what impact could it have on impairment severity, RFC, vocational factors, and period of disability?

  • Determine precisely, and in detail, what medical or vocational evidence is missing; e.g., pulmonary function studies (PFS), electrocardiogram tracings, X-ray findings of a specific joint, complete vocational history, or description of skills used on previous jobs.

  • Within the limits established in Steps 1 and 2, determine the extreme possible findings that might be in the missing evidence, if obtained. For example, an extreme possible finding might be that a PFS could show that the impairment meets the listings, or that a full description of past relevant work could show that the person performed only unskilled work, despite job titles that imply skilled work.

4. Step 4

What is the POR if you obtained the missing documentation ?

Consider all the information you have gathered in Steps 1-3, and answer the following two questions:

  • Would the disability determination or the period of disability change if the missing evidence is extremely positive within the limits established in Step 3?

  • Would the disability determination or the period of disability