TN 1 (03-17)
DI 27536.001 Rationale for Reopening a Prior Determination or Decision
CITATIONS: 20 CFR §§ 404.987, 416.1487
A. Policy for reopening rationale
Under certain circumstances, a Social Security Administration (SSA) or Disability Determination Services (DDS) component at the same or higher adjudicative level may reopen an administratively final determination or decision. All reopenings must include a rationale to address the reopening issues.
For electronic cases, use electronic Claims Analysis Tool (eCAT) to document the reopening rationale, unless the case is an eCAT exclusion. If an eCAT exclusion or a paper modular folder case, complete a SSA-4268 (Explanation of Determination) to document the reopening rationale.
This section provides instructions for completing the “simplified” or “supplemental” reopening rationale.
DDS management has the option to require a more detailed summary decision rationale (for example, training purposes). Summary decision rationales largely contain information documented elsewhere in the file. For instructions on completing an optional summary decision rationale for reopening, see DI 27536.015.
DI 27500.000 Reopenings, Adoptions and Refilings – Table of Contents
DI 27536.005 Required Information for Reopening Initial Determinations
DI 27536.010 Required Information for Reopening Continuing Disability Review Determinations
B. Reopening rationale format
The reopening rationale must:
State the conditions for reopening the prior determination(s) (for example, new and material evidence or error on the face of the evidence).
Explain why the prior determination is incorrect.
Discuss the findings pertinent to the reopening determination (for example, medical, vocational).
If new and material evidence is the basis for reopening, discuss how the evidence is material to the prior period. Also, discuss how this evidence changes the findings covered by the prior determination.
C. Reopening rationale information
The reopening rationale must explain the following situations if not documented elsewhere in the file.
1. Medical source opinion
Resolve any conflicting medical source opinions and cite the relevant evidence.
DI 24503.005 Categories of Evidence
DI 24503.030 Articulation Requirements for Medical Opinions and Prior Administrative Medical Findings – Claims Filed on or after March 27, 2017
DI 24503.035 Evaluation and Articulation Requirements for Medical Opinions, Opinions, and Prior Administrative Medical Findings – Claims Filed before March 27, 2017
2. Symptom evaluation needed
If the claimant has pain or other symptoms that require an evaluation, see Titles II and XVI: Evaluation of Symptoms in Disability Claims in SSR 16-3p; and Evaluating Symptoms in DI 24501.021.
3. Inconsistencies material to the determination
Explain any inconsistencies material to the determination; i.e., evidence that might indicate a different determination outcome.
4. Vocational rules
Explain which rule was met, or used as a framework, for medical-vocational determinations.
DI 25025.000 Medical-Vocational Guidelines - Table of Contents
5. Closed period
Explain how the evidence demonstrates medical improvement (MI) for closed periods of disability.
DI 25510.000 Closed Period - Table of Contents
6. Jobs and incidence
Include a citation of jobs and incidence when required.
DI 25000.000 Medical-Vocational Evaluation - Table of Contents
7. Court cases
Follow the rationale requirements specified for the particular court decision.
DI 32500.000 Court Cases - Table of Contents
D. Additional information for continuing disability review (CDR) reopening rationales
In addition to the information described in DI 27536.001B in this section, all CDR reopening rationales must:
1. Impairment(s) meets or equals a listing in adult claims
State the findings that indicate listing-level impairment. When you find an impairment(s) meets or equals a listing in adult claims, do not consider MI.
2. Discussion of MI
For determinations that consider MI:
Explain whether MI has occurred.
Compare the severity of the impairment(s) at the comparison point decision (CPD) with the current severity of the same impairment(s), discussing changes in the relevant signs, symptoms, and laboratory findings.
Explain whether MI relates to the ability to work when the findings demonstrate MI.
DI 28005.000 The CDR Evaluation Process - Table of Contents
DI 28010.000 Medical Improvement and Related Medical Issues - Table of Contents
DI 28015.000 Relating Medical Improvement to the Ability to Work - Title II and Adult Title XVI Beneficiaries - Table of Contents
Example of CDR reopening rationale:
DDS reopened the 01/01/2017 CDR determination due to new and material evidence documenting the beneficiary’s condition at the time of the CDR.
At the CPD, the beneficiary suffered a leg fracture. He was unable to walk without crutches, and x-rays did not show the expected amount of healing. At that time, we determined that his impairment met or equaled a medical listing and found him disabled.
During the CDR, the evidence received showed that he continued to have difficulty walking. We determined MI relating to his ability to work had not occurred.
However, medical evidence received after the CDR determination revealed the beneficiary had full weight bearing, good range of motion of the lower extremities, and normal gait during the CDR period. X-rays also showed a well-healed fracture.
By comparing the signs, symptoms and laboratory findings of the beneficiary’s impairments, and observing the decrease in the severity of his condition since his CPD, we can conclude that MI has occurred. Since the beneficiary met a listing at the CPD but no longer meets that listing, the MI relates to the ability to work.
3. Discussion of CPD
In cessation determinations, explain the basis for the CPD only if the basis for the prior decision is undocumented.
Example of CPD discussion:
The last continuance determination does not describe the basis for continuance. You determined the CPD maximum residual functional capacity (RFC) was consistent with less than a full range of sedentary work. Assume a medical-vocational continuance using vocational rule 201.10 as a framework. Explain your assumption is the basis for the CPD.
DI 28015.005 Two Mechanisms to Relate Medical Improvement (MI) to the Ability to Work
DI 28015.050 Consideration of Prior Listing
DI 28015.315 Comparison Point Decision (CPD) Residual Functional Capacity (RFC)
4. Exceptions to MI
In cessation determinations, explain the basis for determining whether any exception(s) to MI applies.
DI 28020.000 Exceptions to Medical Improvement – Table of Contents