BASIC (08-15)

DI 28091.005 Issues Requiring Rationalization or Documentation in the Disability Decision-making Process

The table below shows the issues in the current disability decision-making process that require rationalization, and where these issues are usually documented in the file.

NOTE: For claims documented in the Electronic Claims Analysis Tool (eCAT), this information is generally found in the Disability Determination Explanation (DDE) stored in the electronic folder case documents (A. Payment Documents/Decisions (Yellow Front)).

Issues Needing Rationalization

Usual Location of Documentation in File

Action Required if not Already in File

1.

Evidence Sources

 

a. Continuances

Medical evidence

 
 

b. Cessations

  • Medical evidence

  • Personalized Disability Notice (PDN)

 

2.

Basis for the Most Recent Prior Favorable Medical Decision; i.e., Comparison Point Decision (CPD)

 

a. Continuances

  • Prior SSA-831 item 22

  • Prior SSA-832/833 (6/85 edition or later) item 10 and 12

  • Prior determination; i.e. SSA-4268 (Explanation of Determination), eCAT DDE

  • Administrative Law Judge (ALJ), Appeals Council (AC), or court decision

  • SSA-5002 (Report of contact)

 
 

b. Cessations

  • PDN

  • Prior SSA-831 item 22

  • Prior SSA-832/833 (6/85 edition or later) item 10 and 11

  • Prior determination

  • ALJ, AC, or court decision

  • SSA-5002

Supplemental rationale -see DI 28091.010A.2.1

3.

Date of CPD

 

a. Continuances

  • Prior determination or decision; i.e. SSA-4268 (Explanation of Determination), ALJ Decision

  • Prior SSA-831 item 31 and 33

  • Prior SSA-832/833 item 26 and 28

  • Development worksheet or SSA-5002

 
 

b. Cessations

  • PDN

  • Prior determination or decision

  • Prior SSA-831 item 31 and 33

  • Prior SSA-832/833 item 26 and 28

  • Development worksheet or SSA-5002

 

4.

Reason for Current Review

 

a. Continuances

  • SSA-832/833 (6/85 edition or later) item 20

  • Prior SSA-831 item 17, or SSA-832/833 item 23

  • SSA-847-U3 (Request for Case Action)

  • SSA-5526 (Request for Assistance-Disability)

 
 

b. Cessations

  • PDN

  • SSA-832/833 (6/85 edition or later) item 20

  • Prior SSA-831 item 17, or SSA-832/833 item 23

  • SSA-847-U3

  • SSA-5526

 

5.

Individual's Condition(s) that Limit His or Her Ability to Work

 

a. Continuances

  • SSA-454-BK (Continuing Disability Review Report)

  • Report(s) of work activity, e.g.;

    • SSA-820-BK (Work Activity Report-Self Employment)

    • SSA-821-BK (Work Activity Report-Employee)

    • Report(s) of contact

 
 

b. Cessations

  • SSA-454-BK

  • PDN

  • Report(s) of work activity

  • Report(s) of contact

 

6.

Statement of Nonmedical Issues

 

a. Continuances

  • Report(s) of work activity

  • SSA-454-BK

  • SSA-832/833

  • SSA-899-U2 (Continuing Disability Review)

 
 

b. Cessations

  • PDN

  • Report(s) of work activity

  • SSA-454-BK

  • SSA-832/833

  • SSA-899-U2

 

7.

Medical Facts

 

a. Continuances

  • Medical evidence

  • SSA-5002

  • SSA-795 (Statement of Claimant or Other Person

 
 

b. Cessations

  • Medical Evidence

  • SSA-5002

  • SSA-795

 

8.

Discussion of Comparison of Medical Findings Under the Medical Improvement Review Standard

 

a. Continuances

  • SSA-832/833 (6/85 edition) 2 items 10 and 12

  • Medical assessment form(s):

  • SSA-416 (Medical Evaluation)

  • SSA-2506-BK (Psychiatric Review Technique (PRT))

  • SSA-4734-BK (Physical Residual Functional Capacity Assessment (RFC))

  • SSA-4734-F4-SUP (Mental Residual Functional Capacity assessment (MRFC))

Supplemental rationale - see DI 28091.010A.1.

 

b. Cessations

  • SSA-832/833 (6/85 edition)2 items 10 and 11

  • PDN

  • Medical assessment form(s)

9.

Pain-Related Issues

 

a. Continuances

  • Any medical listing which specifically mentions pain

  • Medical assessment form(s)

 
 

b. Cessations

Medical assessment form(s)

Supplemental rationale - see DI 28091.010A.6.

l0.

Resolution of Conflicting Treating Source Opinion(s)

 

a. Continuances

Resolved by the determination of a continuance (SSA-832/833)

 
 

b. Cessations

Medical assessment form(s)

Supplemental rationale - see DI 28091.010A.4.

ll.

Resolution of Inconsistencies Material to Determination

 

a. Continuances

Resolved by the determination of a continuance (SSA-832/833)

 
 

b. Cessations

Medical assessment form(s)

Supplemental rationale - see DI 28091.010A.5.

12.

Vocational Rule Used for Medical-Vocational Decision

 

a. Continuances

SSA-832/833 item 14

Supplemental rationale - see DI 28091.010A.7.

 

b. Cessations

SSA-832/833 item 14

Supplemental rationale - see DI 28091.010A.7.

13.

Citation of Jobs and Incidence

 

a. Continuances

Not applicable (unless the determination considers a social Security Ruling (SSR), or the absence of sufficient jobs.).

When relevant, supplemental rationale - see DI 28091.010A.8.

 

b. Cessations

Report by a vocational specialist

Supplemental rationale - see DI 28091.010A.8.

14.

Assessment of Functional Abilities

 

a. Continuances

  • RFC

  • MRFC

  • Medical evidence

 
 

b. Cessations

  • RFC

  • MRFC

  • Medical evidence

 

15.

Basis for Determination

 

a. Continuances

SSA-832/833 items 10 and 12

 
 

b. Cessations

  • SSA-832/833 items 10 and 11

  • PDN

 

1 A supplemental rationale is still required even if the required information is documented in the personalized disability notice.

2 The 06/85 editions of the SSA-832 and SSA-833 shows the basis code only - a supplemental rationale is required to explain w