Effective Dates: 06/30/2023 - Present Previous | Next

TN 6 (06-23)

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 where specified.

NOTE: 

When a “one-time-only” (e.g., an audit or study) category of cases requires special processing, the Program Operations Manual System (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:

  • •

    Nature of the impairment;

  • •

    Established onset date (EOD);

  • •

    Fact that it was a medical improvement expected (MIE) case;

  • •

    Statement that the individual has returned to full-time work with no significant restrictions;

  • •

    Statement that the individual has acknowledged that medical improvement occurred in or before the month they returned to work, and that they expect to be able to continue working;

  • •

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

  • •

    Statement that the individual’s medical source has released them to return to full-time unrestricted work; and

  • •

    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 the Disability Determination Services (DDS) reconstructs the prior folder, the case would no longer be considered a lost folder case and the DDS will follow the usual CDR evaluation process in the rationale.

Modify rationales as follows when the prior folder is not available:

a. Meets or equals a listing

If current evidence indicates the individual meets or equals a listing, 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), none of the exceptions apply, and it is determined that disability continues, the rationale will state that “disability continues and medical improvement (MI) was not 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 must contain a summary of:

  • •

    Attempts to identify the CPD; and

  • •

    Efforts to reconstruct the prior folder.

The adjudicator must 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, the adjudicator will follow the usual rationale procedures. If the individual is found “not disabled” after the CDR evaluation process, the adjudicator will evaluate the individual under the appropriate State plan, using the medical improvement review standard. The adjudicator must provide a 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, in eCAT 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 cases in DCPS, follow current instructions. For more information on conversion cases, see DI 28075.010.

4. Medical improvement not expected (MINE) case rationales

The adjudicator must prepare an abbreviated rationale. The adjudicator will include the first four elements of the rationale, from DI 28090.015 through DI 28090.030:

  1. a. 

    Evidence sources;

  2. b. 

    Basis for CPD and reason for review;

  3. c. 

    Individual’s reason(s) for continued entitlement and eligibility; and

  4. d. 

    Statement of nonmedical issues.

MINE cases do not need an extensive discussion of medical findings. The adjudicator must provide findings of fact showing the existence of the MINE impairment, and how current development verifies those findings. For a rationale example, see DI 28090.300S.

B. References

  • •

    DI 28001.045 Rollback and Non-rollback Conversion Cases

  • •

    DI 28010.020 Comparison Point Decision (CPD)

  • •

    DI 28015.315 Comparison Point Decision (CPD) Residual Functional Capacity (RFC)

  • •

    DI 28020.001 General - Groups I and II of Exceptions to Medical Improvement (MI)

  • •

    DI 28030.035 Cessation Without Full Medical Development (Clear-Cut Cessations)

  • •

    DI 28035.000 Processing of Lost or Destroyed Folders/Medical Evidence

  • •

    DI 28035.015 Disability Determination Services (DDS) Identification of the Comparison Point Decision Date

  • •

    DI 28040.001 Background of Medical Improvement Not Expected (MINE) or MINE-Equivalent Cases

To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0428090200
DI 28090.200 - Rationale Content - Special Situations - 06/30/2023
Batch run: 06/30/2023
Rev:06/30/2023