TN 4 (10-15)
DI 28040.225 Rationale Preparation of the Continuing Disability Review (CDR) Determination in Medical Improvement Not Expected (MINE) or MINE-Equivalent Cases
A. CDR rationale purposes
The purposes of a rationale are to:
Identify all the medical and nonmedical factors that have been considered (e.g., documentation requested and used).
Explain the thought process used to arrive at the determination.
Provide a permanent evidentiary record of the reasoning for the conclusion.
Inform subsequent reviewers, including quality assessment components, of the basis for the determination.
B. Preparing the summary CDR rationale
Adjudicators must prepare a rationale (using SSA-4268, claims communication, or other approved method) for continuances and cessations to reflect all applicable steps in the CDR evaluation process, present an explicit explanation of the determination including the documentation used to support the decision, and incorporate the medical improvement review standard (MIRS). The rationale should contain the following elements:
A listing of the sources on which the comparison point decision (CPD) was based.
A listing of all new sources of medical evidence when contact was made with a medical source.
A brief statement indicating the established onset date, the basis for the most recent prior favorable determination, and the reason the current medical review has been undertaken.
A brief statement outlining the reasons the individual gave for believing he or she is still disabled, as appropriate.
A statement of nonmedical issues (whether the individual is engaging in substantial gainful activity, work activity, vocational rehabilitation involvement (301 cases), etc.).
The findings of fact showing the existence of the MINE or MINE-equivalent impairment and showing how the current development verifies those findings. The findings of fact summarized in this determination along with the current verification will serve as the basis of comparison in any future CDR. Include a statement regarding medical improvement and a statement that a continuance is appropriate.
NOTE: Summary rationales largely contain information documented elsewhere in the file. If this is the situation, a simplified “supplemental” rationale may be used as described in DI 28091.000 instead of the summary rationale.
C. MINE rationale examples
1. Use of a summary rationale
The following example shows a summary rationale from DI 28090.300S
The following reports were used at the CPD:
John Smith, M.D., report of 2/25/07
General Hospital, inpatient treatment, 2/3/07 - 3/15/07
The following report was used to decide if disability continues:
The individual was found to be disabled beginning 2/3/07 due to Huntington's Chorea which met Listing 11.17. Medical improvement was not expected, but current review is required by law. The individual advises that he has not worked and there is no improvement in his impairment.
Contact with the current evidence source reveals that the individual is under the care of a physician. The treating physician confirmed the individual's statements and further stated that the individual's condition continues to deteriorate, there has been no treatment and none is planned.
The individual's impairment has shown no medical improvement and no exception applies; therefore, a continuance is appropriate.
2. Use of a supplemental rationale
The following example demonstrates a supplemental rationale, per DI 28091.005. A supplemental rationale may be used if information required on the summary rationale is available elsewhere in the case file. For example, the medical sources and statements do not need to be repeated as they are contained in the file; the reason for CDR is noted on the SSA-832; the CPD date is noted in the prior file, etc.
This case was processed using medical improvement not expected (MINE) criteria established in DI 28040.000.
The individual was found to be disabled due to Huntington's Chorea. The individual's impairment has shown no medical improvement and no exception applies; therefore, a continuance is appropriate.
DI 28090.000 CDR Rationale Preparation
DI 28091.000 CDR Simplified Rationale Procedures
DI 28091.005 Issues Requiring Rationalization or Documentation in the Disability Decision-making Process
DI 81020.230 Documenting Comparison Point Decision (CPD) Evidence and Preparing the Electronic Continuing Disability Review (eCDR) Rationale