TN 2 (05-10)

DI 27025.020 Personalized Explanations in Reconsideration Denials

A. General

The Disability Determination Services (DDS) prepares a denial notice and personalized explanation for Title II and Title XVI reconsideration. The DDS must ensure that the information and dates are consistent with the basis code used to deny the claim. For notice instructions, see DI 27030.010 (Title II) and DI 27030.020 (Title XVI).

B. Concurrent Title II/Title XVI reconsideration denials

In reconsideration concurrent Title II/Title XVI denials, the DDS prepares a separate notice and personalized explanation for each claim. However, when the basis for the denial is the same for both claims (e.g., disability insurance benefit (DIB)/disability insurance (DI) denial based on past work ability) and the contents of the personalized explanation are the same, attach the personalized explanation to each denial notice. The correct SSN must be shown on each copy.

1. Insured status

When insured status or the prescribed period is last met prior to the date of the determination, the explanation should reflect the period of time considered and specify the date through which insured status or the prescribed period was met.

2. Medical and non-medical reports

Medical and non-medical reports listed on the initial personalized explanation are not repeated. It is also not necessary to repeat the personalized explanation paragraphs shown on the charts in DI 26530.025 through DI 26530.050.

3. Wording the personalized reconsideration explanation

The wording of a personalized reconsideration explanation is not the same as the initial notice even if the denial is affirmed on the same basis. The wording of the reconsideration explanation is rephrased to avoid the erroneous impression that the claim was not independently reviewed at the reconsideration level. If the basis for the denial changes at the reconsideration level, acknowledge the reason given at the initial level and then give the reason for the reconsideration denial.

C. Required elements of personalized explanation for reconsideration denials

The personalized explanation must contain the following elements:

1. Medical and non-medical reports

List the medical and if appropriate, non-medical reports (by name and date) evaluated (do not mention unresponsive medical sources) as shown in DI 26530.055 – Personalized Explanation Preparation Guide Form. Reports may be listed in paragraph form to save space or if more than three reports are used.

2. Unresponsive medical sources

When the medical sources were unresponsive, use the disclaimer statement in DI 26530.055 – Personalized Explanation Preparation Guide Form, which provides an optional fill-in stating that additional reports were not obtainable; however, we had enough information to evaluate the claimant's condition.

3. Impairments

Include a narrative list of the impairments evaluated. Do not use technical terms unless the claimant uses them and appears to understand them. When information in file suggests that the claimant has a mental impairment or is unaware of the exact nature of his or her condition, the examiner must exercise care not to offend or upset the claimant. If the claimant is unaware of the impairment, use general terms such as:

“The evidence does not show any other conditions which significantly limit your ability to work.”

4. Medical severity

Provide a brief narrative description of medical severity. When discussing medical evidence, ensure the personalized explanation meets the requirements in DI 26530.010.

5. Vocational factors

a. Past relevant work

When the basis for denial is the ability to perform past relevant work, include the job the claimant can perform. . Do not include a discussion of the residual functional capacity (RFC) as long as the job is consistent with the claimant’s description of his or her past work. If the claimant describes past work in terms of physical or mental requirements that are different than what is generally required for the job, advise him or her that he or she can do the job as it is generally performed in the national economy.

b. Other work

When the basis for denial is the ability to perform work other than past relevant work include a statement that while the person is unable to do any of the work he or she has done in the past, considering:

  • age,

  • education and;

  • past work experience

He or she still has the capacity to perform other work, which is less demanding (refers to exertion, mental capacities, skill level) or requires less physical effort (specify in general terms, e.g., degree of limitation). Do not cite other jobs.

6. Medical duration

When the reason for denial is that medical duration is not met, the medical and, if applicable, vocational information provided must cover this issue.

D. Examples of personalized explanations

1. Personalized explanation for reconsideration medical/vocational denial (ability to perform past relevant job), insured status currently met.

The following reports were used to decide your claim in addition to those listed in our previous notice.

Dr. Smith's report dated January 20, 2010 covering May-December 2009.

“You said that you are unable to work because of a back condition. The medical evidence shows that you were operated on for a slipped disc. The additional evidence also shows there are no signs of severe muscle weakness or nerve damage. While you cannot do past work you are now able to do work not requiring frequent bending. Based on your description of the job of rug inspector that you performed for the past 15 years, we have concluded that you can do this job.”

2. Personalized explanation for reconsideration of DIB medical/vocational denial (ability to perform other work) insured status currently met.

The following reports were used to decide your claim in addition to those listed in our previous notice.

Dr. John Howard's report dated October 20, 2009.

Dr. Albert Lane's report dated October 10, 2009.

“You said that you are unable to work because of pain and stiffness in your knees and lower back. The additional evidence also shows that you have arthritis in your knees and back which causes you discomfort. We realize that your condition prevents you from doing any of your past jobs, but it does not prevent you from doing other jobs which require less physical effort. Based on your age, education), and past work experience, you can do other work.”

E. Special situations

1. Insufficient evidence, failure or refusal to submit to a consultative examination, or does not wish to continue development of claim

The DDS prepares the personalized explanation based on the instructions in DI 27025.020B in this section. The explanation should also include:

  • a brief description of the evidence needed to adjudicate the claim; and

  • a brief description of the attempts to obtain evidence and the response received (if any).

2. Failure to follow prescribed treatment

The DDS prepares the personalized explanation based on the instructions in DI 27520.020B in this section. The explanation should also include:

  • a description of vocational limitations (e.g., age, education) if vocational factors are considered; and

  • a description of the prescribed treatment the claimant refuses to follow and what the treatment will allegedly accomplish.

3. Reference

For issues which also apply to reconsideration claims, see DI 26530.020D.3 – Personalized Explanation in Initial Denials, for issues which also apply to reconsideration claims.


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http://policy.ssa.gov/poms.nsf/lnx/0427025020
DI 27025.020 - Personalized Explanations in Reconsideration Denials - 07/26/2013
Batch run: 07/26/2013
Rev:07/26/2013