TN 113 (07-20)

GN 04440.202 Group I Decisional Deficiencies

A. Definitions of group I decisional deficiencies

A group I decisional deficiency is a substantive deficiency that affects the determination to allow or deny, or to continue or cease, disability benefits. The review component will cite a group I decisional deficiency based on the following issues:

1. Substantial gainful activity (SGA) (category 10)

The adjudicating component allowed a disability claim despite clear evidence of ongoing SGA submitted prior to case clearance, or otherwise evident in the file, and there is no possibility of a closed period of disability. Evidence of SGA may be documented on the following:

  • SSA-820-F4-SP, Work Activity Report (Self-Employed Person)

  • SSA-821-BK, Work Activity Report (Employee)

  • SSA-823, Report of SGA Determination

2. Impairment severity (category 11)

The adjudicating component based the determination on medical considerations alone (i.e., the impairment is not severe, or the impairment meets, medically equals, or functionally equals the listings). However, the evidence does not support the adjudicating component’s determination and an opposite determination is appropriate.

NOTE: The review component should not use this code if the adjudicating component’s determination is based on a residual functional capacity (RFC) assessment.

3. Duration (category 12)

The adjudicating component based the determination on the severity of the disabling impairment that did not meet policy requirements for 12-month duration.

4. Medical improvement (MI) and whether MI affects the ability to work (category 13)

The adjudicating component incorrectly determined, or should have determined, MI related to the ability to work, in a Continuing Disability Review (CDR).

5. MI exception regarding whether the individual has benefited from advances in medical or vocational therapy or technology (category 14)

The adjudicating component applied, or should have applied, the MI exception in a CDR regarding significant MI due to medical or vocational therapy or technology.

6. MI exception regarding successful vocational therapy (category 15)

The adjudicating component applied, or should have applied, the MI exception in a CDR regarding the individual’s successful completion of vocational therapy.

7. MI exception regarding new or improved diagnostic techniques or evaluation shows the individual's impairment(s) is not as disabling as it was at the time of the most recent prior favorable medical determination (category 16)

The adjudicating component applied, or should have applied, the MI exception in a CDR regarding new or improved diagnostic techniques that demonstrate an individual’s impairment(s) is not as disabling, as it was at the time of the most recent prior favorable medical determination.

8. MI exception regarding a prior determination made in error (category 17)

The adjudicating component applied, or should have applied, the MI exception in a CDR regarding a prior determination made in error, due to:

  • error on the face of the record,

  • missing required and material evidence , or

  • new evidence related to the prior determination or decision.

9. MI exception regarding a prior determination based on fraudulent circumstances (category 18)

The adjudicating component applied, or should have applied, the MI exception in a CDR regarding a prior determination made in error based on documentation of fraud and similar fault.

10. Residual functional capacity (RFC) (category 19)

The adjudicating component based the determination on an RFC assessment. However, the evidence does not support the adjudicating component’s RFC and an opposite determination is appropriate.

NOTE: The review component should not use this code if the adjudicating component’s determination is based on medical considerations alone (i.e., the impairment is not severe or the impairment meets, medically equals, or functionally equals the listings).

11. Evaluation of vocational factors (category 20)

The adjudicating component determined, or should have determined, disability based on one or more of the following vocational factors:

  • Age

  • Education (including illiteracy)

  • Transferability of skills

  • Ability to perform past relevant work (PRW)

  • Ability to perform other work

NOTE: Use this code only when the RFC assessment is correct, but the vocational determination is incorrect.

12. Failure to follow prescribed treatment (category 21)

The adjudicating component:

  • allowed or continued disability for a claimant who should have been denied or ceased because the individual failed, without good cause, to follow prescribed treatment, or

  • denied or ceased disability for a claimant who should have been allowed or continued because the individual had good cause for FTFPT.

13. Drug addiction and alcoholism (DAA) materiality (category 22)

The adjudicating component:

  • allowed or continued disability despite evidence that DAA is material to the determination, or

  • denied or ceased disability on the basis that DAA is material, despite evidence that DAA is not material to the determination.

14. Onset of disability (category 23)

The adjudicating component allowed a title II disability claim despite:

  • an established onset date (EOD) after the date last insured (DLI) for a Title II disabled worker, after the end of the prescribed period for a disabled widow(er), or after the attainment of age 22 for a childhood disability claim,

  • the field office (FO) documenting the certified electronic folder (CEF) with the correct DLI, prescribed period, or childhood disability claimant's date of birth, and

  • evidence indicating an earlier onset date is not supported.

NOTE: The review component will only cite this deficiency when the Title II claimant had a disabling impairment at the time of adjudication, but the impairment did not exist, or was not disabling, on or before the date the claimant last met the insured status requirements.

15. Adoption of a prior administrative law judge (ALJ) or Appeals Council (AC) finding under an acquiescence ruling (AR) (category 25)

The adjudicating component erroneously adopted, or should have adopted, a prior ALJ or AC disability decision or specific finding (e.g., impairment severity, RFC, demands of PRW) based on an AR.

16. Collateral estoppel (category 26)

The adjudicating component:

  • incorrectly adopted a prior final determination and disability cannot be established based on the current evidence in file, or

  • incorrectly denied a claim when adoption of a prior favorable determination or decision was warranted.

NOTE: If disability can be established based on the current evidence in file, no group I decisional deficiency exists.

B. Correcting group I decisional deficiencies

The review component returns all cases with group I decisional deficiencies to the adjudicating component for correction, with the exception of SGA deficiencies, which are returned to the FO to process an SGA denial.

1. Case returned to the adjudicating component for corrective action

For group I decisional deficiencies returned to the adjudicating component for corrective action, the review component will:

a. annotate all of the adjudicating component’s original determination and medical assessment forms, as well as notices, in the CEF, as “Do Not Process” or “Do Not Release”, as applicable,

b. code the deficiency in the case processing system,

c. notify the adjudicating component, via an SSA-1774-U5, Request For Corrective Action, to explain why the determination is not policy compliant and request the adjudicating component to change the determination,

d. route the case to the adjudicating component for correction, as a controlled return, and

e. follow-up with the adjudicating component in 30 days if the corrected determination has not been returned to the review component.

NOTE: All of the adjudicating component’s original determination and medical assessment forms, as well as notices, must remain in the CEF as part of the audit trail.

2. Case returned to the FO for corrective action

For a group I decisional deficiency involving clear evidence the claimant is engaging in SGA, the review component will:

a. annotate all of the adjudicating component’s original determination and medical assessment forms, as well as notices, in the CEF, as “Do Not Process” or “Do Not Release”, as applicable,

b. code the deficiency in the case processing system,

c. notify the FO, via an SSA-5524-U3, Request for Assistance, to explain there is clear evidence of SGA and an SGA denial is appropriate,

d. notify the adjudicating component, via an SSA-1774-U5, Request For Corrective Action, to explain why the determination is not policy compliant and that the case will be routed to the FO for an SGA denial, and

e. route the case to the FO.

NOTE: All of the adjudicating component’s original determination and medical assessment forms, as well as notices, must remain in the CEF as part of the audit trail.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0204440202
GN 04440.202 - Group I Decisional Deficiencies - 07/21/2020
Batch run: 07/21/2020
Rev:07/21/2020