TN 16 (04-11)
GN 04440.118 Substitution of Judgment (SOJ) in the Quality Review (QR) Process
A. Introduction to SOJ
Federal quality reviewers assess the conformance of the adjudicating component's determinations to the regulations, rulings, and Program Operations Manual System (POMS), and to the documented facts in the case. Quality reviewers cite deficiencies when the adjudicating component's disability determination clearly contradicts the evidence, when the evidence is insufficient to support a determination, or when the determination does not meet a specific procedural or technical requirement. See Determining Whether SOJ is at Issue GN 04440.119D.
However, the disability determination process is inherently judgmental and situations occur in which the file is fully documented and the adjudicating component and the review component both considered all the facts, but arrived at different or opposite disability determinations. When this occurs, the quality reviewer must decide whether to cite a group I or group II decisional deficiency or whether the decision regarding the issue of disability constitutes SOJ on the part of the reviewer.
For a capsule explanation of SOJ, see GN 04440.003.
For an explanation of SOJ and the medical consultant’s and psychological consultant’s medical review, see GN 04440.130B.
B. Policy on SOJ
Federal quality reviewers must avoid substituting their judgment for the judgment of the adjudicating component's physicians and examiners, when the adjudicating component's disability determination is equally supportable, based on the evidence and documentation in file and the examiner has fully documented the file. In such instances, the review component will not cite a group I or group II decisional deficiency even though, after considering all the facts, they believe that the evidence directs a different or opposite determination than the adjudicating component's determination.
The intent of the SOJ policy is to ensure that review components do not cite decisional deficiencies unless the adjudicating component has clearly not followed specific policy or procedure or the evidence does not support the determination. If it is clear that the determination at issue is not within disability program policy guidelines, then the review component will cite a group I or group II decisional deficiency.
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.