Citations:

Childhood Disability Evaluation Form (SSA-538)

TN 2 (07-15)

DI 25230.001 Explaining Title XVI Childhood Disability Evaluation Determinations

Citations:

20 CFR 416.924(g)

A. Introduction to Disabled Child (DC) Claims

All Title XVI childhood disability determinations or decisions require an explanation of the findings, documented in writing, in a manner that we prescribe. For the requirement of how we will explain, our findings see DI 25201.015.

B. Policy for Prescribed Forms

1. Where to document findings

There are two prescribed forms for documenting the case explanation:

  • Childhood Disability Evaluation Form (CDEF), SSA-538

  • Childhood Disability Evaluation (CDE) for cases processed in the electronic Claims Analysis Tool (eCAT)

NOTE: For non eCAT claims there must be one “official” prescribed form in the case record that gives the disposition and clearly supports it.

For claims completed in eCAT, a CDE is optional for dispositions of Meets, Medically Equals, Functionally Equals listing based on example, and Other. A CDE is only required if the severe impairment(s) require a domain evaluation.

Refer to DI 25230.005 for a detailed explanation of documenting the findings.

2. When to complete the prescribed form

The policies in this section apply to:

  • Initial Disabled Child (DC) determinations

  • Reconsideration DC determinations

  • Initial level DC determinations for continuing disability reviews (CDRs)

  • Reconsideration level DC determinations for CDRs unless a Disability Hearing officer (DHO) makes the determination

  • Reopening determinations, if the determination being reopened is covered by these policies

3. When to complete more than one prescribed form

We require a second prescribed form for specific cases:

  • DA/A: In all DA/A materiality determinations, apply the appropriate sequential evaluation process a second time considering whether the individual is disabled without DA/A involvement.

  • DC CDRs: When medical improvement (MI) of the Comparison Point Decision (CPD) impairment(s) is established and there are new impairments to consider in the current assessment at Step 3 of sequential evaluation.

4. Required elements in the explanation

A complete explanation includes the following elements:

  • Identifying information (name, SSN, date of birth), filing date, level of determination

  • Established and alleged impairments

  • Disposition

  • Explanation for all the dispositions, except “meets listing”

  • Consultant (MC/PC/non-physician) statement that all relevant factors and evidence have been considered

  • Signature of Consultant with overall responsibility for evaluating the case

  • Signatures of additional MC/PC/non-physician participating in the evaluation

5. Factors and evidence

The Consultant with overall responsibility for the findings in the determination, affirms that he or she considered the following:

  1. All relevant factors

  2. All relevant evidence in deciding if:

    • The child has a severe impairment(s)

    • An impairment(s) meets or medically equals a listing, or

    • An impairment(s) functionally equals the listings

The affirmation statement does not mean that the consultant needs to explicitly address each of these factors in every case. It means, the consultant has considered whether the factors apply, and has properly considered those that are relevant. The factors and evidence serve as a reminder to the consultants.

6. Affirmation of the initial level findings at the reconsideration level

The medical or psychological consultant(s) may affirm the initial prescribed form without fully completing a new prescribed form if the following conditions are satisfied:

  • There is no allegation of a worsening of any previously documented impairments;

  • There is no allegation of any new impairment(s);

  • There has been no treatment for any impairment(s) since the prior determination;

  • The prior determination was substantively and technically correct and the prior decision rationale correctly presented and resolved all pertinent issues to be adjudicated; and