TN 2 (08-15)
DI 28090.015 Rationale Content - Evidence Sources
A. Documentation of evidence sources on the rationale
The rationale will list the evidence considered in making the comparison point decision (CPD) and the current evidence obtained for the continuing disability review (CDR).
However, if the CPD includes a list of the evidence considered then, incorporate that list by reference (e.g., “in making the determination on the issue of continuing disability, all of the evidence listed on the CPD dated (MM/DD/YY) has been considered, as well as the following additional evidence:”).
If disability continues without consideration of the medical improvement review standard (MIRS) (i.e., based on meeting or equaling a listing or consideration of medical-vocational factors without formal consideration of the MIRS), there is no need to list the evidence from the CPD. This is not to circumvent the MIRS but to expedite action when a continuance is obvious. Always list the evidence obtained during the CDR process.
If the error exception applies to a decision other than the CPD, cite all of the evidence considered in that decision.
Identify any medical and nonmedical sources of evidence considered:
Medical source reports - Cite the source's name, including specialty if known, and the date the source signed the report. If undated, cite the last date of treatment. If no other date is available, cite the date of receipt. When teledictation is used, cite the date of dictation.
Hospitals, clinics or mental health centers - Identify the hospital, clinic or mental health center, and for:
inpatient treatment, cite admission and discharge dates; and
outpatient treatment, give specific dates of treatment unless three or more treatments are listed. For three or more treatments, give the first through last date.
Consultative examination (CE) reports - Indicate “consultative examination” and then cite consultant's name, specialty, and the date of the CE. When DDS purchased a CE connection with the CDR, the discussion of medical evidence must contain a statement to explain why the available evidence was not sufficient and why a CE was necessary.
Nonmedical sources (school guidance counselors, welfare departments, vocational rehabilitation agencies, day treatment facilities, sheltered workshops, social workers, etc.) - list nonmedical sources as evidence sources but do not identify those sources by name. Identify nonmedical sources by position and organization (e.g., “Vocational Rehabilitation Counselor, Department of Rehabilitation Services, report received XX/XX/XX”). For a rationale example, see DI 28090.300J or DI 28090.300O.
Third-party lay evidence (family members, neighbors, coworkers, etc.) - Identify third-party evidence only by the generic category; i.e., “Third- party report received XX/XX/XX.”
NOTE: Generally, information from any nonmedical or third-party source will be signed and dated. If the report is undated, cite the date of receipt.