The purpose of a rationale is to:

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  Identify all the medical and non-medical factors that are considered in the determination (for example, documentation requested and used).

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  Explain the thought process used to arrive at the determination.

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  Provide a permanent evidentiary record of the reasoning for the conclusion.

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  Use the rationale to inform subsequent reviewers, including quality assessment components, of the basis for the determination.

1. 1. 

   Electronic Cases:

   The disability determination explanation (DDE) is used to document the CDR rationale. A detailed explanation of the CDR rationale policy and DDE documentation requirements is found at DI 28090.001.

2. 2. 

   Paper Cases:

   Adjudicators must prepare a rationale using a SSA-4268 (Explanation of Determination) or other approved method for continuances and cessations, to reflect all applicable steps in the CDR evaluation process, present a detailed explanation of the determination including the documentation used to support the determination, and incorporate the medical improvement review standard (MIRS). The rationale should contain the following elements:

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     A listing of the sources on which the comparison point decision (CPD) was based.

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     A listing of all new sources of medical evidence when contact was made with a medical source.

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     A brief statement indicating the established onset date, the basis for the most recent prior favorable decision, and the reason the current medical review has been undertaken.

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     A brief statement outlining the reasons the individual gave for believing they are still disabled, as appropriate.

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     A statement of non-medical issues (whether the individual is engaging in substantial gainful activity, work activity, vocational rehabilitation (VR) involvement, Section 301 cases, etc.).

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     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.

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  DI 28090.001 Disability Determination Rationale for Title II and Title XVI Adult Continuing Disability Review (CDR) Cases

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  DI 81020.230 Documenting and Copying Comparison Point Decision (CPD) Relevant Evidence and Preparing the Electronic Continuing Disability Review (eCDR) Rationale