TN 2 (08-15)

DI 28090.200 Rationale Content - Special Situations

A. Discussion of special situations in the rationale

The following situations have specific issues that must be addressed using a modified rationale where specified.

NOTE: When a “one-time-only” category of cases requires special processing, the POMS will provide additional instructions. If necessary, the instructions will include a sample rationale to reflect the specific issues and any special modifications unique to the situation.

1. Clear-cut cessation rationales

Cite current sources in “clear-cut” medical cessations, but do not list the comparison point decision (CPD) sources.

Provide a concise statement of the pertinent evidence sufficient to make the conclusion clear. The rationale must include the following items:

  • the nature of the impairment;

  • the established onset date (EOD);

  • the fact that it was a medical improvement expected (MIE) case;

  • a statement that the individual has returned to full-time work with no significant restrictions;

  • a statement that the individual has acknowledged that medical improvement occurred in or before the month he or she returned to work, and that he or she expects to be able to continue working;

  • a statement that the individual does not want medical evidence for the previous l2 months to be obtained before a decision is made;

  • a statement that the individual’s medical source has released him or her to return to full-time unrestricted work; and

  • an explanation that disability ended in the past, in the first month the individual returned to full-time unrestricted work.

2. Lost folder case rationales

In continuing disability review (CDR) cases where the prior medical folder cannot be located, the rationale reflects the procedures described in DI 28035.001 regarding lost folder cases.

NOTE: If you reconstruct the prior folder, the case would no longer be considered as a lost folder case and we will follow the usual CDR evaluation process in the rationale.

We will modify rationales when the prior folder is not available as follows:

a. Meets or equals a listing

If current evidence indicates the individual meets or equals a listing, find disability continues without further development. Follow the procedures for rationales in DI 28090.040.

b. Unable to perform past or other work

If the individual is obviously unable to perform past or other work based on medical-vocational factors (a residual functional capacity (RFC) assessment was prepared) and none of the exceptions apply, and it is determined that disability continues, state in the rationale that “disability continues and medical improvement (MI) was not been formally considered”.

c. Cessation likely or the determination is not clear

If review of the current evidence indicates a determination is unclear or cessation would be likely, the rationale will contain a summary of:

  • attempts to identify the CPD; and

  • efforts to reconstruct the prior folder.

Ensure that current documentation is complete and continues disability in the absence of current substantial gainful activity or a group II exception. For a rationale example, see DI 28090.300L.

3. Non-rollback conversion case rationales

If an individual, who was originally found disabled under a State plan, continues to be disabled based on the current Federal CDR evaluation process, follow the usual rationale procedures. If the individual is found “not disabled” after the CDR evaluation process, the individual will be evaluated under the appropriate State plan, using the medical improvement review standard. Provide a summary discussion supporting this conclusion as part of the rationale.

NOTE: In concurrent Title II/Title XVI cases that need a decision under the State plan for the Title XVI case, prepare two Forms SSA-4268 (Explanation of Determination). The Title XVI rationale can incorporate the Title II rationale before including the evaluation of the case under the appropriate State plan. For more information on conversion cases, see DI 28075.010.

4. Medical improvement not expected (MINE) case rationales

Prepare an abbreviated rationale. Include the first four elements of the rationale, from DI 28090.015 through <