DI 26516.010 Implementation of Simplified Decision Rationale Procedures
The summary decision rationale, as outlined in DI 26515.000, is not required. However, a supplemental rationale is still required to explain the rationalization of the following situations if not documented elsewhere in the file :
A. Medical opinion
When the evidence does not support a medical opinion, cite the findings or evidence which rebut(s) the medical opinion.
B. Inconsistencies material to the decision
Explain any inconsistencies material to the decision, i.e., evidence which might indicate a different decision outcome.
C. Pain-related issues
Any allegation(s) or report(s) of pain must be considered in (1) determining whether the claimant has a severe impairment, and (2) at each step in the sequential evaluation process. If there are inconsistencies in the evidence concerning pain, i.e., the claimant alleges limitations or restrictions greater than that reasonably expected based on the objective medical findings, there are conflicts in the evidence, etc., these differences must be reconciled and explained in the file. If these differences have not been dealt with in the RFC or PRTF, then a supplemental rationale stating how the issue of pain was considered in the decision must be prepared.
D. Closed period cases
In closed periods of disability, explain how medical improvement is demonstrated.
E. Vocational rule
In a medical/vocational decision, if no vocational rule is met, but the vocational rules are used as a framework for the decision, explain what rules have been considered.
F. Citation of jobs and incidence
In unfavorable decisions, a citation of jobs and incidence, when required.
G. Court cases
Specific issues as required by court decisions. The DDS should follow the rationale requirements specified in DI 32500.000ff. for the particular court decision.
The DDS will handwrite or type any of these supplemental statements on a DDS developmental worksheet if available, provided the worksheet is left in file, on an SSA-4268-U4/C4, or on a Report of Contact (SSA-5002). The DDS examiner will sign and date any of the forms used for this purpose.