Only federal quality reviewers can make POR determinations. An adjudicating component cannot use POR in deciding whether to request required medical or vocational documentation or as the basis for a rebuttal of a cited deficiency. (See DI 22505.001 for additional information regarding evidence requirements.)
The consideration or application of POR is solely at the discretion of the
federal quality reviewer.
Under the POR policy, if a disability determination is not documented per SSA disability program policy, but the evidence is sufficient for the federal quality reviewer to determine that the missing documentation is unlikely to reverse the disability determination or change the length of the period of disability, the federal quality reviewer may classify the missing documentation as a medical or vocational documentation TCA, as defined in GN 04440.232A.3., and not return the case to the adjudicating component for further development and correction.
When a case does not contain complete medical documentation per SSA disability program policy, the federal quality reviewer must send the case to the regional office medical contractor (MC) and/or psychological contractor (PC) for review prior to making a POR determination. The regional office MC or PC will generally either indicate the evidence is insufficient to determine the severity of any alleged impairment(s) or prepare a conditional severity rating (CSR) (usually a residual functional capacity (RFC)) based on the existing evidence in file. A regional office MC and/or PC may prepare a CSR when the medical evidence in file is insufficient to rate the overall severity of all of the claimant's allegations, but is sufficient to prepare an assessment of the severity of one or more medically determinable impairments (MDI). Regional office MCs or PCs may also offer opinions on the potential effect of missing documentation on impairment severity or RFC. However, these opinions are not binding on the federal quality reviewer. Federal quality reviewers should exercise caution when using a CSR to support a POR determination when the disability determination is unfavorable or less than fully favorable.
NOTE: In unfavorable or less than fully favorable determinations, there is a statutory requirement that adjudicators must "consider all evidence available in such individual's case record, and shall develop a complete medical history of at least the preceding twelve months for any case in which a determination is made that the individual is not under a disability." Federal quality reviewers must return
12-month medical evidence of record (MER) TCAs, which are limited to unfavorable or less than fully favorable determinations, to the adjudicating component for additional development and correction. See GN 04440.232A.1. (Non-substantive Technical Corrective Action (TCA)) for additional information. Adjudicators and federal quality reviewers are reminded that in some cases, such as those involving traumatic or acute illnesses or injuries, 12 months of evidence may not be available.
If the federal quality reviewer determines that the missing documentation is likely to reverse the disability determination or change the length of the period of disability, or if the federal quality reviewer is unable to determine whether the missing documentation may reverse the disability determination or change the length of the period of disability, the federal quality reviewer will cite a group I or group II documentation deficiency and return the case to the adjudicating component for further development and correction.