TN 14 (12-10)

GN 04440.945 Definitions of Group I Deficiencies

For a complete explanation of group I deficiencies and the corresponding policy, refer to DI 30005.121 - DI 30005.123. In addition, for the complete list of deficiency codes for group I and group II deficiencies, refer to GN 04440.950.

A. Policy for Group I decisional deficiencies (initial and reconsideration levels)

Cite a group I decisional deficiency when the incorrect disability determination results from an incorrect decision regarding one of the following:

  1. Substantial gainful activity (SGA), when the adjudicating component (AC) allowed disability despite clear evidence the claimant is engaging in SGA;

  2. Impairment severity, and the AC made the disability determination, or should have been made, on the basis of medical considerations alone; i.e., the impairment:

    • Is not severe, or

    • Meets, medically equals or functionally equals the listings;

  3. Duration;

  4. Residual Functional Capacity (RFC);

  5. Evaluation of vocational factors including:

    • Age;

    • Education, literacy, or the ability to communicate in English;

    • Transferable skills;

    • Ability to do past relevant work (PRW); or

    • Ability to do other work.

  6. Failure to follow prescribed treatment;

  7. Drug addiction and alcoholism (DAA) materiality when:

    • The AC allowed disability despite clear evidence that DAA is material to the determination, or

    • The AC denied disability on the basis that DAA is material, despite clear evidence that DAA is not material to the determination;

  8. Onset of disability when:

    • The correct onset date is clearly after the date last insured (DLI) for a Title II disabled worker, the prescribed period for a disabled widow(er), or the attainment of age 22 for a childhood disability claimant;

    • The field office clearly documented the disability file with the correct DLI, prescribed period, or childhood disability claimant's date of birth;

    • The evidence indicates that an earlier onset date is not possible; and

    • The case must be denied;
      NOTE: In allowance determination cases involving a Title II worker, cite this deficiency when the Title II worker has a disabling impairment at the time of adjudication, but the impairment did not exist, or was not disabling, at the date the worker last met the insured status requirement.

  9. Adopting a prior administrative law judge (ALJ) or Appeals Council (AC) finding when the claim is a subsequent disability claim being adjudicated under an acquiescence ruling (AR) and one of the following is true:

    • The adjudicating component adopted the prior ALJ or AC disability decision when it should not have been adopted;

    • The adjudicating component did not adopt the prior ALJ or AC disability decision when it should have been adopted;

    • The adjudicating component adopted a prior ALJ or AC specific finding under the sequential evaluation process (e.g., impairment severity, RFC) when it should not have been adopted; or

    • The adjudicating component did not adopt a prior ALJ or AC specific finding under the sequential evaluation process (e.g., demands of PRW) when it should have been adopted.
      NOTE: Some (but not necessarily all) examples of ARs that require adopting a prior ALJ or AC finding, when appropriate, are AR 97-4(9) (Chavez) and AR 00-1(4) (Albright).

  10. Collateral estoppel, when:

    • A prior final determination was adopted when it should not have been, and disability cannot be established on the basis of the current claim, or
      NOTE: If a prior final determination is adopted when it should not be adopted and disability can be established on the basis of the current claim, there is no Group I decisional deficiency. There may be a Group II onset date decisional deficiency if the evidence in file does not support the established onset date in the current claim.

    • A prior final determination was not adopted when it should be adopted, and disability was not established on the current claim.
      NOTE: If a prior final determination is not adopted when it should be adopted, and disability is established on the current claim, there is no Group I decisional deficiency. There may be a Group II onset date decisional deficiency if the established onset date is less favorable than the onset date established in the prior claim that should have been adopted.

B. Policy for group I decisional deficiencies (continuing disability review level)

Cite a group I decisional deficiency when the incorrect disability determination results from an incorrect decision regarding one of the following:

  1. Medical improvement (MI), including whether there has been MI or whether MI is related to the ability to work;

  2. Medical improvement exceptions including:

    • Whether new medical evidence and a new assessment of RFC show that an individual is a beneficiary of advances in medical or vocational therapy or technology;

    • Whether the individual has successfully undergone vocational therapy;

    • Whether new or improved diagnostic techniques demonstrate that an individual’s impairment is not as disabling as it was considered at the time of the last determination;

    • Whether a prior determination was made in error; or

    • Whether the prior determination was based upon fraudulent circumstances.

  3. DAA materiality when:

    • Disability is continued, despite clear evidence that DAA is material to the determination; or

    • Disability is ceased on the basis that DAA is material, despite clear evidence that DAA is not material to the determination.

C. Policy for group I documentation deficiencies (initial and reconsideration levels)

1. Group I medical documentation deficiency

Cite a group I medical documentation deficiency when the medical documentation in file is insufficient to support the disability determination. Specifically, the medical documentation is insufficient to determine one of the following:

  • Impairment severity; i.e., whether there is a medically determinable severe impairment, or the impairment meets or medically or functionally equals the listings, and a medical-vocational fully favorable allowance cannot be made based on the evidence in file per Evaluating the Evidence DI 24515.001;

  • Duration;

  • RFC, when the claimant has a severe impairment and a determination cannot be made on medical considerations alone;

  • Failure to follow prescribed treatment;

  • DAA materiality, including unresolved conflicting evidence on the issue of materiality or insufficient documentation of all other alleged or potential non-DAA impairments, when DAA is material; or

  • Onset of disability relative to DLI for Title II workers, the prescribed period for a disabled widow(er), or attainment of age 22 for a childhood disability claimant. For instance, the DLI, prescribed period, or age 22 is clearly documented, the medical evidence in file does not support the onset date, and the correct onset date could be after DLI, prescribed period, or age 22.

2. Group I vocational documentation deficiency

Cite a group I vocational documentation deficiency when the adjudicating component's impairment severity or RFC assessment is correct but the vocational documentation is insufficient to determine the effect of the following factors on an individual's ability to engage in SGA:

  • Age;

  • Education, literacy, or the ability to communicate in English;

  • Work history, including transferable skills, physical, mental, and environmental demands of past work, and the relevance of past work;

  • Advances in vocational therapy or technology when there is new medical evidence and a new RFC, but no MI; or

  • Vocational therapy.

3. Group I medical evaluation deficiency involving vocational documentation

Cite a group I medical evaluation deficiency involving vocational documentation when the file contains sufficient documentation to determine impairment severity or RFC, but an incorrect assessment of impairment severity or RFC makes additional vocational documentation necessary to determine disability.

4. Group I procedural documentation deficiency

Cite a group I procedural documentation deficiency when the documentation in the case is insufficient to show conformance to prescribed procedures for a determination based on one of the following:

  • The prior determination was in error (MI review standard);

  • Failure to follow prescribed treatment;

  • Whereabouts unknown;

  • Failure to cooperate;

  • Work activity; or

  • ARs (e.g., Chavez AR 97-(9) and Albright 00-1(4) ) when the claim is a subsequent disability claim to which an AR applies, and the file is not sufficiently documented to conform with the AR requirement to consider the prior ALJ or AC final disability decision or findings. For instance, the case does not contain either the prior folder, a copy of the ALJ or AC final decision, or an explanation of why obtaining the prior folder or copy of the ALJ or AC final decision is not possible.

5. Group I collateral estoppel documentation deficiency

A group I collateral estoppel documentation deficiency exists when:

  • The documentation in file is insufficient to determine whether you can adopt a prior final determination, or

  • The documentation in file is sufficient to determine that you cannot adopt a prior final determination, the prior final determination was incorrectly adopted, and there is insufficient documentation in file to determine disability on the current claim.

D. Policy for group I documentation deficiencies (continuing disability review level)

1. Group I medical documentation deficiency

Cite a group I medical documentation deficiency when the medical documentation in file is insufficient to support the disability determination. Specifically, the medical documentation is insufficient to determine MI, including whether there has been MI, or whether MI is related to the ability to work.

a. DAA materiality

This deficiency includes unresolved conflicting evidence on the issue of materiality or insufficient documentation of all other alleged or potential non-DAA impairments, when DAA is material.

b. MI exceptions

MI exceptions include:

  • Whether, in the absence of MI, new medical evidence and a new assessment of RFC show that an individual is a beneficiary of advances in medical or vocational therapy or technology; or

  • Whether new or improved diagnostic techniques demonstrate that an individual’s impairment is not as disabling as it was considered at the time of the last determination.

2. Group I vocational documentation deficiency

Cite a group I vocational documentation deficiency when the adjudicating component's impairment severity or RFC assessment is correct but the vocational documentation is insufficient to determine the effect of the following factors on an individual's ability to engage in SGA:

  • Age;

  • Work history, including transferable skills, physical, mental, and environmental demands of past work, and the relevance of past work;

  • Advances in vocational therapy or technology when there is new medical evidence and a new RFC, but no MI; or

  • Vocational therapy.

3. Group I medical evaluation deficiency involving vocational documentation

Cite a group I medical evaluation deficiency involving vocational documentation when the file contains sufficient documentation to determine impairment severity or RFC, but an incorrect assessment of impairment severity or RFC makes additional vocational documentation necessary to complete the medical improvement review standard.

4. Group I procedural documentation deficiency

Cite a group I procedural documentation deficiency when the documentation in the case is insufficient to show conformance to prescribed procedures for a determination based on one of the following:

  • Work activity;

  • Failure to cooperate;

  • Whe