TN 29 (01-17)

GN 04440.130 Medical Review Policy

 

A. Policy on Medical Review

1. Review sequence

The regional Medical Consultant (MC) or Psychological Consultant (PC) staff may review disability determinations at any time the quality reviewer deems necessary during the entire quality review process.

2. Cases requiring medical review

The following cases require medical review:

  • any case with a medical deficiency requiring a Group I return (GN 04440.945) to the adjudicating component for correction.

    EXCEPTION: Cases that contain NO medical evidence in the file DO NOT require medical review.

  • any case with a medical issue that the Associate Commissioner of the Office of Quality Review (OQR), or designee, determines requires medical review; and

  • any case where OQR assumes jurisdiction (see GN 04440.244, GN 04440.245, and GN 04440.135B.4).

3. Discretionary MC or PC Consultation

Quality reviewers will use their judgment in the decision of whether to seek MC or PC consultation, except cases requiring medical review as noted in GN 04440.130A.2.

a. Examples of situations that may require MC or PC review

Situations that may require MC or PC review include cases with questions or issues regarding:

  • impairment severity,

  • inconsistencies in the evidence,

  • the claimant’s ability to sustain a normal work day or workweek,

  • medical improvement,

  • duration, onset, end or cessation dates, or closed periods,

  • sufficiency of the medical evidence in file,

  • symptom evaluation and functional limitations (e.g. allegations related to pain, fatigue, depression, etc.),

  • incomplete residual functional capacity (RFC) assessments, such as clarification of exertional and non-exertional limitations, and

  • RFC or mental RFC (MRFC) assessments.

b. Examples of Group I non-medical deficiency situations that may not require MC or PC review

Situations that may not require MC or PC review include cases with Group I non-medical deficiencies (GN 04440.945) and related OQR legacy system codes (GN 04440.950) such as:

  • clear evidence that the individual is engaging in Substantial Gainful Activity (SGA) ( DI 10500.000) code 10,

  • incorrect determination regarding vocational factors (DI 25000.000) code 20,

  • incorrect determination regarding onset relative to Title II eligibility period (DI 25501.300-350) code 23,

  • incorrect determination regarding collateral estoppel (DI 27515.000) code 26,

  • unresolved work activity that could affect the determination (DI 24000.000) code 30,

  • insufficient vocational documentation to determine the claimant’s age (DI 25015.005) code 51,

  • insufficient vocational documentation to determine the claimant’s education (DI 25015.010) code 52,

  • insufficient vocational documentation to determine the claimant’s work history (DI 25000.000) code 53,

  • failure to obtain a prior folder or copy of an administrative law judge (ALJ) or appeals council (AC) ruling when required by an acquiescence ruling (AR) (DI 52700.000) code 60,

  • whereabouts unknown procedures not followed by adjudicating component (DI 23005.001 and DI 13015.001) code 65, or

  • failure or refusal to cooperate procedures not followed by adjudicating component (DI 23007.000) code 66.

c. Examples of Group II onset deficiency situations that may not require MC or PC review

Situations that may not require MC or PC review include cases with Group II onset deficiencies (GN 04440.946) and related OQR legacy system codes (GN 04440.950) such as:

  • documented period of SGA after proposed onset (DI 25501.390) code 71,

  • failure to reopen a prior determination when onset falls within a previously adjudicated period and there is no medical issue to address (DI 25501.250) code 71,

  • clear-cut onset date errors involving traumatic onset (DI 25501.440) code 71,

  • incorrect onset decision based on vocational factors where the medical assessment is correct (i.e. borderline age, DI 25501.410) code 71,

  • incorrect cessation date (CDR involving failure to cooperate or whereabouts unknown) (DI 28075.005) code 73, and

  • unresolved work activity that could affect onset (with no unresolved medical issue) (DI 24000.000) code 85.

For specific instructions on processing Group II Onset Date Decisional Deficiencies, see GN 04440.220.

d. Examples of Technical Corrective Action (TCA) situations that do not routinely require MC or PC review

Situations that do not routinely require MC or PC review include cases with other issues such as Technical Corrective Actions (TCAs) that involve:

  • changes to the diary or

  • medical improvement not expected continuances without current medical evidence.

For specific instruction on processing TCAs, see GN 04440.230-GN 04440.243.

B. Description of the MC and PC reviews

The scope of the MC or PC review includes assessing impairment severity, the RFC, and related medical issues listed in GN 04440.130A.3a. The MC or PC review does not include assessing the accuracy of the disability determination.

The MC or PC reviews the adjudicating component's medical assessment of the facts of the case, using the quality review standard in “Quality Review (QR) Standard”, GN 04440.007A. The MC or PC review is not a de novo review. See the definition of a “de novo review” in GN 04440.003D.

During the case review, OQR’s MC or PC may independently arrive at a different assessment of impairment severity or RFC than that of the adjudicating component as long as the adjudicating component’s assessment complies with SSA disability program policy and the evidence in file fully supports and documents the assessment. When preparing an independent assessment of impairment severity or RFC, OQR’s MC or PC must not substitute judgment.

For a discussion of substitution of judgment, see “Substitution of Judgment (SOJ) in the Quality Review (QR) Process” at GN 04440.118.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0204440130
GN 04440.130 - Medical Review Policy - 01/06/2017
Batch run: 08/28/2017
Rev:01/06/2017