TN 3 (02-20)

DI 23007.015 Making a Determination Based on the Evidence in the File

A. When to make a determination based on the evidence in the file

When you have made a reasonable, but unsuccessful effort to obtain the claimant’s cooperation to comply with a request for evidence or action, or to confirm or attend a consultative examination (CE) appointment, make a determination based on the evidence in file using the sequential evaluation process.

B. Actions to take before making a determination using the sequential evaluation process based on the evidence in the file

Before making a determination based on the evidence in the file using the sequential evaluation process, take the following actions to the extent that they do not require claimant cooperation:

  • Follow up on overdue medical evidence, as explained in DI 22505.001A.

  • Develop a complete medical history including any potential medical sources identified in the file since the claimant’s application for disability benefits, as defined in DI 22505.001A., and

  • Develop supplemental evidence, as required by DI 22505.008.

For continuing disability reviews (CDR), see DI 28030.020.

IMPORTANT: Once you have made a reasonable, but unsuccessful effort to obtain the claimant’s cooperation, you do not have to contact the claimant to update potential sources of evidence. Instead, make a reasonable effort to obtain a complete medical history based on the sources of evidence already in the file.

C. Using the sequential evaluation process to make a determination based on the evidence in the file

Make a determination based on the evidence in the file using the sequential evaluation process, see DI 22001.001.

Consider each step in this process in numerical order except where policy specifically permits a deviation:

  • Step 2 – When there is insufficient evidence to establish a severe, medically determinable impairment (MDI), find the claimant not disabled due to insufficient evidence.

  • Step 3 – When there is insufficient evidence to establish that the claimant meets or equals a listed impairment, assess the claimant’s residual functional capacity (RFC).

  • RFC – Only impose limitations supported by the evidence in the file. When the evidence does not support any limitations, do not assess any. The consultant must indicate in the RFC that the evidence in the file is insufficient to rate limitations on a particular impairment, symptoms, or alleged limitations because the evidence necessary for a full medical evaluation is not available.

  • Step 4 – When there is insufficient evidence to determine whether the claimant can perform his or her past relevant work (PRW), adjudicate the claim in accordance with DI 25005.005C.

  • Step 5 – When there is insufficient evidence to make a step 5 determination, find the claimant not disabled due to insufficient evidence.

For evaluating title XVI child claims, see DI 25205.020.

For evaluating continuing disability reviews (CDR), see DI 28075.005.

IMPORTANT: You may make a fully favorable determination at any point during development, see DI 24505.030E. You can make a partially favorable determination only after you have made a reasonable effort to develop the claimant’s complete medical history without his or her cooperation.

D. Regulation basis code

Any time the claimant has not cooperated with providing evidence, taking an action, or attending a CE and that evidence has the potential to change the determination, use the “Insufficient Evidence Furnished” regulation basis code in accordance with DI 26510.045. Do not use the failure or refusal to attend a CE regulation basis code.

Use the “Insufficient Evidence Furnished” Personalized Disability Explanation (PDE) language, do not use the Failure or Refusal to Attend a Consultative Examination PDE. For instructions on the PDE, see DI 26530.020D.

E. Examples

Example one: Insufficient evidence to establish a severe, medically determinable impairment (MDI).

Claimant is 57 years old with a high school education (no issues with communicating in English) and past relevant work (PRW) as a cashier. He alleges disability due to carpal tunnel syndrome (CTS). Development of a complete medical history includes a diagnosis of CTS in the file, but no Tinel’s sign or Phelan’s test and no electromyography (EMG) or nerve conduction study. Additionally there is no description of the claimant’s ability to handle or finger objects, nor is there any evidence regarding treatment for CTS. In his activities of daily living (ADL), the claimant indicates that he has problems opening jars due to his CTS.

The DDS orders a consultative exam for a Tinel’s sign and Phelan’s test, graded grip strength, and a description of his fingering abilities. The claimant misses his scheduled exam despite calling the DDS to tell them he will attend. The DDS documents how they evaluated the evidence in file using the sequential evaluation process. The claimant is not performing SGA. There is no severe MDI established by the evidence.

The DDS writes the case as an insufficient evidence denial. The DDS will use an insufficient evidence regulation basis code (RBC) and PDE because the claimant did not cooperate with the development process and the evidence available without the claimant’s cooperation is consistent with a denial for no severe MDI. The insufficient evidence RBC and PDE are appropriate because had the claimant cooperated, the determination might have been different.

Example two: Insufficient evidence to evaluate one of the claimant’s alleged impairments

The case facts are the same as example one with the exception of an additional allegation of back problems. The claimant has back pain when flexing his spine beyond 70 degrees. On most visits, he has palpable muscle spasm in the low back. He has negative straight leg raise (SLR) test bilaterally. X-rays show severe narrowing at L5-S1 and mild degenerative changes throughout the lumbar spine.

The DDS orders a consultative examination for graded strength of lower extremities, a gait description, Tinel’s sign and Phelan’s test, graded grip strength, and a description of fine fingering abilities. The claimant misses his scheduled examination despite calling the DDS to tell them he will attend. The medical evidence in file establishes that the claimant’s back impairment is a severe MDI that does not meet or equal a listing, however the evidence is insufficient to assess whether CTS is an MDI.

Because the claimant has a severe MDI that does not meet or equal a listed impairment, the adjudicative team must assess an RFC using the evidence available without the claimant’s cooperation. The medical consultant must indicate in the RFC that the evidence in file is insufficient to rate limitations on a particular impairment, symptom(s), or alleged limitation(s), because the evidence necessary for a full medical evaluation is not available due to the claimant’s failure to cooperate. The medical consultant adds this statement regarding the claimant’s CTS and assesses an RFC for light work with occasional postural limitations.

The DDS documents how they processed the evidence available without the claimant’s cooperation through the sequential evaluation process. The claimant is not performing SGA. He has a severe MDI of degenerative changes in the lumbar spine. He has a diagnosis of CTS, but there is nothing in the record to support an MDI of CTS. His impairments do not meet or equal a listed impairment. An RFC for light work with occasional postural limitations is consistent with ability to perform his PRW as he described it. The insufficient evidence RBC and PDE are appropriate because had the claimant cooperated, the determination might have been different.

Example three: Insufficient evidence to evaluate whether the claimant can perform Past Relevant Work (PRW)—expedite applies

All case facts are the same as example two except that the claimant is 50 years old and did not return his SSA-3369, despite follow-ups.

The claimant lists his PRW as cashier on the SSA-3368, but did not provide any description of the requirements of his work, nor did he provide evidence we would need to determine if his work was relevant. In addition, the claimant missed his scheduled consultative examination.

The evidence establishes that the claimant’s back impairment is a severe MDI that does not meet or equal a Listing; however, the evidence is insufficient to assess whether CTS is an MDI. Because the claimant has a severe impairment that does not meet or equal a listed impairment, the adjudicative team must assess an RFC using the evidence available without the claimant’s cooperation. The medical consultant must indicate in the RFC that the evidence in file is insufficient to rate limitations on a particular impairment, symptom(s), or alleged limitation(s) because the evidence necessary for a full medical evaluation is not available due to the claimant’s failure to cooperate. The medical consultant indicates this in the RFC regarding the claimant’s CTS and assesses an RFC for light work with occasional postural limitations.

The DDS documents how they processed the evidence available without the claimant’s cooperation through the sequential evaluation process. The claimant is not performing SGA. He has a severe MDI of degenerative changes of the lumbar spine. He has a diagnosis of CTS, but there is nothing in the record to support an MDI of CTS. His impairments do not meet or equal a listed impairment. We cannot determine if he can do any past relevant work. At age 50, with a light RFC and a high school education (no issues with communicating in English) all potentially applicable light rules would result in a denial, therefore, the expedite process would apply.

The DDS writes the case as an insufficient evidence denial. The DDS will use an insufficient evidence RBC and PDE because the claimant did not cooperate with the development process. If the claimant had cooperated and additional evidence about the claimant’s CTS was available, the determination may have been different.


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DI 23007.015 - Making a Determination Based on the Evidence in the File - 02/20/2020
Batch run: 02/20/2020
Rev:02/20/2020