DI 52755.020 DDS Adjudication
The prior file must be requested anytime that the Chavez AR applies in adjudicating a subsequent claim. If the prior file is not available, an attempt should be made to secure a copy of the ALJ or AC decision. Normal case development procedures apply.
1. Prior file activities
a. Regular procedures
See DI 20505.015 for guidance on obtaining prior files.
b. Special instructions for Chavez
Process the subsequent claim under regular procedures if any one of the requirements in DI 52755.005 is not met.
In situations where the requirements listed in DI 52755.005 are met and there is no information in the current file regarding the prior file, ask the field office (FO) to obtain a copy of the ALJ or AC decision from the claimant and to initiate actions described in DI 20505.015 for obtaining the prior file.
If only the prior ALJ or AC decision is available, apply the Chavez AR using the decision.
NOTE: If the AC takes an unfavorable action on a claimant's request for review, the claim file is retained in ODAR Headquarters for five months pending potential filing of a civil action. In such instances the FO will obtain a copy of the ALJ or AC decision. Apply the AR using a copy of the ALJ or AC decision. The ALJ or AC decision generally contains a detailed discussion of the evidence and the findings of fact.
If the prior folder is lost or has been destroyed and the prior decision cannot be obtained, document the file to show such and take no further action with regard to the AR (see DI 52755.010A.5).
2. Medical/Vocational development and evaluation for Chavez
Normal development of the current claim will be undertaken.
Apply a presumption that the claimant continues to be not disabled after the period adjudicated in the final ALJ or AC decision that found the claimant not disabled. Determine if the claimant has rebutted the presumption of continuing nondisability. A claimant may rebut the presumption by showing a “changed circumstance” affecting the issue of disability with respect to the unadjudicated period; e.g., a change in the claimant's age category (DI 25001.001B.1.), an increase in the severity of the claimant's impairment(s), the alleged existence of an impairment(s) not previously considered, a change in the criteria for determining disability, or other change in the circumstances on which the ALJ or AC decision was based. See DI 52755.010A.3 for an explanation of “changed circumstance.” If the presumption has not been rebutted, determine that the claimant is not disabled with respect to the unadjudicated period. If the presumption has been rebutted, proceed as below.
Adopt a finding of the claimant's RFC, education, or work experience, or other finding described in DI 52755.010B.1.a (Note), or DI 52755.010B.1.b, as appropriate, from the final ALJ or AC decision, unless there is new and material evidence to change the prior finding or there has been a change in the law, regulations or rulings affecting the finding or the method for arriving at the finding. See DI 52755.010B.1 for further information on when not to adopt certain findings and DI 52755.010B.2 for an explanation of what constitutes “new and material evidence” to change a prior finding.
NOTE: An adopted RFC assessment must be signed by a medical or psychological consultant. The DDS medical or psychological consultant should record any appropriate comments or explanation on the RFC or MRFC forms.
If there are two or more final ALJ or AC decisions that found the claimant not disabled with respect to successive disability claims under the same title of the Act, determine with respect to each successive disability claim to which the AR could apply, whether the presumption of continuing nondisability arising from the final ALJ or AC decision on the preceding disability claim was rebutted by a changed circumstance affecting the issue of disability with respect to the later period that was adjudicated in the decision on the succeeding disability claim. Continue with this process until the presumption of continuing nondisability arising from the ALJ or AC decision on the preceding claim is determined to have been rebutted in connection with the succeeding claim. If the presumption is not rebutted by a “changed circumstance” in connection with any such succeeding disability claim, determine whether the presumption of continuing nondisability arising from the most recent final ALJ or AC decision on a prior claim is rebutted in connection with the current claim, and then process the current claim following the instructions in DI 52755.020B.2.b above. Once it has been determined that the presumption of continuing nondisability arising from a final ALJ or AC decision on a preceding claim was rebutted in connection with a succeeding disability claim to which the AR could apply, consider the findings described in DI 52755.010 B.1.a, DI 52755.010B.1.a (Note), or DI 52755.010B.1.b, as appropriate, which are contained in the final ALJ or AC decision on such preceding disability claim, and adopt any such finding which is not superseded by new and material evidence in a later decision or in the current claim file, or by a change in the law, regulations or rulings affecting the finding or the method for arriving at the finding.
The readjudication of a claim under the Chavez AR in an interim period case is distinct from the rules for reopening and revising final determinations or decisions. A claim on which there was a final determination or decision in the interim period described in DI 52755.010B.5. may be readjudicated under the AR even though the 4-year rule (title II) or 2-year rule (title XVI) for reopening does not apply.
The claim in an interim period case will be readjudicated under the Chavez AR where:
The individual requests application of the AR and demonstrates that application of the Ruling could change the final determination or decision on the claim (see DI 52755.010C.1.a); or
The interim period case is discovered in the course of development/ adjudication of a current claim of the individual and it is concluded that application of the AR would change the final determination or decision on the prior claim (see DI 52755.010C.1.b).
If concurrent title II/title XVI claims are filed subsequent to a final decision that the claimant is not disabled which is made by an ALJ or the AC in connection with a single claim of the individual under one title, adjudicate the new claim that is under the same title of the Act as the claim decided in the ALJ or AC decision in conformity with the AR. If the AR applies, first apply the presumption of continuing nondisability and then determine whether the presumption is rebutted. If the presumption is rebutted, adopt any of the findings described in DI 52755.010B.1. from the ALJ or AC decision in determining disability on the new claim under the same title as the prior claim, unless there is new and material evidence to change such finding or there has been a change in the law, regulations or rulings affecting the finding or the method for arriving at the finding. The determination on the issue of disability on this new claim then may be adopted for the same period for the concurrent claim under the other title, provided that the same rules for determining disability apply (see DI 27515.001).
The AR permits use of a higher (more favorable to the claimant) age category in subsequent claims based solely on the passage of time. For example, if no new and material evidence exists to change a prior ALJ finding of an RFC for light work, in adjudicating the current claim the subsequent adjudicator is required to use the RFC for light work. However, when using the medical-vocational guidelines, the adjudicator will use the appropriate grid rule applicable to the claimant's current age.
Do not adopt prior findings that are now obsolete because of subsequent changes in the law, regulations or rulings, or where the method for arriving at the findings has been changed by law, regulations or rulings.
3. Preparing the determination
When the AR is applied, explain in the PDN or in the rationale whether the presumption of continuing nondisability has been rebutted and, if so, the basis for the findings on the current claim. For example, if the presumption of continuing nondisability has been rebutted and you are adopting an ALJ finding for a light RFC, the rationale should indicate that the RFC finding was adopted from the previous ALJ decision. If you are making a finding different than the previous ALJ finding, the rationale must indicate the circumstances which permit a different finding (e.g., new and material evidence received).