Identification Number:
GN 04440 TN 90
Intended Audience:See Transmittal Sheet
Originating Office:OARO Office of Quality Review
Title:Federal Quality Review of Disability Determinations
Type:POMS Transmittals
Program:Disability
Link To Reference:
 

PROGRAM OPERATIONS MANUAL SYSTEM
Part GN – General
Chapter 044 – Quality Appraisal
Subchapter 40 – Federal Quality Review of Disability Determinations
Transmittal No. 90, 01/23/2020

Audience

PSC: DE, DEC;
OCO-OEIO: FDE;
DQB: DE, PL;
OCO-ODO: DE, DEC, DS, RECONE;

Originating Component

OQR

Effective Date

Upon Receipt

Background

The Office of Quality Review (OQR) reviewed and revised definitions for group I deficiencies. This transmittal presents updated definitions, formatting, and a few new examples for some of the deficiencies.

Summary of Changes

GN 04440.945 Definitions of Group I Deficiencies

This section has updated definitions, instructions, and formatting for group I deficiencies. They are the following:

  • A chart has been inserted for organization, clarity, and readability.

  • Corresponding deficiency codes were added for clarity.

  • Wording changes were added for clarity.

  • Added brief instructions to some of the coding sections for clarity

  • Added instructions explaining that the DQB should base the deficiency code on the adjudicating component’s basis for the determination.

  • Provided some examples to help differentiate between coding an 11 or 19, and a 41 or 44.

GN 04440.945 Definitions of Group I Deficiencies

For a complete explanation of group I deficiencies and the corresponding policy, refer to DI 30005.121 - DI 30005.123. In addition, for the complete list of deficiency codes for group I and group II deficiencies, refer to GN 04440.950.

A. Policy for Group I Decisional Deficiencies at Initial and Reconsideration Levels

Cite a group I decisional deficiency when the case contains sufficient documentation to support an opposite determination than found by the adjudicating component (i.e., disabled or not disabled; continuance or cessation), and the adjudicating component's determination is clearly contradicted by evidence.

Incorrect Determination

OQR Legacy System Code

Substantial gainful activity (SGA) - The adjudicating component allowed a claim despite clear evidence the claimant is engaging in SGA.

10

Impairment severity - The adjudicating component made, or should have made, the disability determination on the basis of medical considerations alone; i.e., the impairment:

  • Is not severe, or

  • Meets, medically equals, or functionally equals the Listings of Impairments (listings);

    NOTE: If the adjudicating component’s determination is based on meets, equals, or not severe, and the review component finds that the determination is incorrect, use deficiency code 11. Base the deficiency code on the adjudicating component’s basis for the determination.

    EXAMPLE: The adjudicating component incorrectly allows the case, determining that the severity of the claimant’s impairment(s) meet the requirements of Listing 1.04A. However, the review component finds the evidence does not support a Step 3 allowance: The requirements of Listing 1.04A (or any listing) are not met or equaled. The review component explains that the evidence supports a light residual functional capacity (RFC), and the claimant is not disabled at Step 4, as the claimant can perform past relevant work (PRW), as actually performed. Because the adjudicating component incorrectly allowed the case at Step 3, this deficiency involves impairment severity. Accordingly, code the case in the OQR legacy system as a Group I, deficiency code 11 rather than a Group I, deficiency code 19.

11

Duration - The adjudicating component incorrectly determined that the claimant’s impairment(s) has met, or did not meet, or will not meet duration, resulting in an incorrect allowance or denial.

12

RFC - The adjudicating component’s physical or mental RFC is not supported, resulting in an incorrect allowance or denial.

NOTE: If the adjudicating component’s determination is based on a physical or mental RFC, and the review component finds that the determination is incorrect, use deficiency code 19. Base the deficiency code on the adjudicating component’s basis for the determination.

EXAMPLE: The adjudicating component determines the claimant is limited to medium work and denies the case at Step 4. The review component explains that the evidence supports a Step 3 allowance: The claimant is disabled, as the severity of the claimant’s impairments meets the requirements of Listing 5.06A. Because the adjudicating component incorrectly denied the case at Step 4, this error involves the RFC. Accordingly, code the case in the OQR legacy system as a Group I, deficiency code 19 rather than a Group I, deficiency code 11.

19

Evaluation of vocational factors including - The adjudicating component incorrectly allowed or denied a claim at Steps 4 and/or 5, based on the following:

  • Age,

  • Education,

  • Transferable skills,

  • Ability to do PRW; or

  • Ability to do other work.

20

Failure to follow prescribed treatment The adjudicating component incorrectly determined whether the claimant failed to follow prescribed treatment.

21

Drug addiction and alcoholism (DAA) materiality - When the adjudicating component:

  • Allowed the claim despite clear evidence that DAA is material to the allowance determination, or

  • Denied the claim, concluding DAA is material to the allowance determination, despite clear evidence that DAA is not material.

22

Incorrect Onset (Title II) - When a claim must be denied for the following reasons:

  • The correct onset date is after

    • the date last insured (DLI) for a Title II disabled worker,

    • the prescribed period for a disabled widow(er), or

    • the attainment of age 22 for a childhood disability claimant; AND

  • The field office clearly documented the claim file with the correct DLI, prescribed period, or childhood disability claimant's date of birth; AND

  • The evidence indicates that an earlier onset date is not possible;

NOTE: In allowance determination cases involving a Title II worker, cite this deficiency when the Title II worker has a disabling impairment at the time of adjudication, but the impairment did not exist, or was not disabling, at the date the worker last met the insured status requirement.

23

Adopting a prior administrative law judge (ALJ) or Appeals Council (AC) finding when the claim is a subsequent disability claim being adjudicated under an acquiescence ruling (AR) and one of the following is true:

  • The adjudicating component adopted the prior ALJ or AC disability decision when it should not have been adopted;

  • The adjudicating component did not adopt the prior ALJ or AC disability decision when it should have been adopted;

  • The adjudicating component adopted a prior ALJ or AC specific finding under the sequential evaluation process (e.g., impairment severity, RFC) when it should not have been adopted; or

  • The adjudicating component did not adopt a prior ALJ or AC specific finding under the sequential evaluation process (e.g., demands of PRW) when it should have been adopted.

    NOTE: Common ARs that require adopting a prior ALJ or AC finding are AR 97-4(9) (Chavez), AR 98-3(6) (Dennard), and AR 98-4(6) (Drummond).

25

Collateral Estoppel - Erroneous application of collateral estoppel occurs when:

  • The adjudicating component erroneously allowed the claim, applying collateral estoppel, and an allowance cannot be established based on the current claim, or

  • The adjudicating component erroneously denied a claim when a collateral estoppel allowance was applicable.

  • NOTE: If the adjudicating component applies collateral estoppel erroneously (i.e., allows the claim), but an allowance is still supported based on the available evidence in the current claim, there is no Group I decisional deficiency. However, if the available evidence does not support the established onset date, there may be a Group II onset date decisional deficiency.

26

B. Group I decisional deficiencies (continuing disability review (CDR) level)

Cite a group I decisional deficiency when the incorrect disability determination results from an incorrect decision regarding one of the following:

Incorrect Determination

OQR Legacy System Code

SGA - The adjudicating component continues disability despite clear evidence the claimant is engaging in SGA.

10

Medical Improvement (MI) and whether MI affects the ability to work

13

MI Exception:

Whether new medical evidence and a new RFC assessment show that an individual has benefited from advances in:

  • Medical therapy, or

  • Vocational therapy, or

  • Technology.

14

MI Exception:

Whether the individual has successfully undergone vocational therapy

15

MI Exception

Whether new or improved methods of diagnostics or evaluative techniques show that the individual’s impairment(s) is not as severe as it was previously determined in the most recent favorable determination

16

MI Exception:

Whether a prior determination was made in error

17

MI Exception:

Whether a prior determination was based on fraudulent circumstances

18

DAA Materiality

  • The adjudicating component continues disability, despite clear evidence that DAA is material to the determination.

  • The adjudicating component ceases disability on the basis that DAA is material, despite clear evidence that DAA is not material.

22

C. Group I documentation deficiencies at the initial and reconsideration levels

1. Group I medical documentation deficiency

Cite a group I medical documentation deficiency when the medical documentation in file is insufficient to support the disability determination.

Insufficient Documentation to Determine:

OQR Legacy System Code

Impairment Severity - The evidence is insufficient to support:

  • Whether there is a medically determinable severe impairment, or

  • Whether the severity of the claimant's impairment(s) meet or medically equal the requirements of the listing(s), AND

  • A fully favorable medical-vocational allowance cannot be made based on the evidence.

NOTE: If the adjudicating component’s determination is based on meets, equals, or not severe, and the review component finds that there is insufficient evidence to support the determination, use deficiency code 41. Base the deficiency code on the adjudicating component’s basis for the determination.

EXAMPLE: If there is insufficient evidence to support the adjudicating component’s Step 3 allowance, and there is insufficient evidence to determine a physical or mental RFC, code as a Group I, deficiency code 41, not as Group I, deficiency code 44.

41

Duration - The evidence is insufficient to determine duration

42

 

RFC – While the evidence supports that the claimant has a severe impairment(s),

  • The evidence is insufficient to support the adjudicating component’s RFC assessment, AND

  • A fully favorable determination cannot be made on medical considerations alone.

Note : If the adjudicating component’s determination is based on a physical or mental RFC, and the review component finds that there is insufficient evidence to support the determination, use deficiency code 44. Base the deficiency code on the adjudicating component’s basis for the determination.

Example : If there is insufficient evidence to support the adjudicating component’s Step 5 allowance because development is needed to resolve material conflicts regarding how long the claimant can stand and walk in an 8-hour day, code as a Group I, deficiency code 44, not as a Group I, deficiency code 41.

44

Failure to Follow Prescribed Treatment – The evidence is insufficient to determine whether the claimant failed to follow prescribed treatment.

45

DAA materiality - the evidence is insufficient to:

  • Resolve conflicting information regarding whether DAA is material, or

  • Determine the severity of all other non-DAA impairments (i.e., alleged or potential) when DAA is material.

46

Onset (Title II) – The evidence is insufficient to determine whether the claimant is disabled relative to the:

  • DLI, or

  • Prescribed period for a disabled widow(er), or

  • Attainment of age 22 for a childhood disability benefits claim.

Example: The DLI, prescribed period, or age 22 date is clearly documented, but the medical evidence does not support the onset date, and the correct onset date could be after the DLI, prescribed period, or age 22.

47

2. Group I vocational documentation deficiency

Cite a group I vocational documentation deficiency when the adjudicating component's impairment severity or RFC assessment is correct, but there is insufficient evidence to document the vocational factors material to determining whether the claimant is disabled.

Insufficient Documentation to Determine:

OQR Legacy System Code

Age

51

Education, Level, including:

  • Illiteracy - The evidence is insufficient to determine whether the claimant is illiterate, which is material to the disability determination.

  • Inability to Communicate in English - The evidence is insufficient to determine whether the claimant has the ability to communicate in English, which is material to the disability determination.

52

Work history, including:

  • Transferable skills,

  • Demands of PRW:

    • Physical,

    • Mental, and

    • Environmental.

  • Relevance of PRW

53

3. Group I medical evaluation deficiency involving vocational documentation

Insufficient Documentation to Determine:

OQR Legacy System Code

Cite a group I medical evaluation deficiency involving vocational documentation when the file contains sufficient documentation to determine impairment severity or RFC, but an incorrect assessment of impairment severity or RFC makes additional vocational documentation necessary to determine disability.

31

4. Group I procedural documentation deficiency

Cite a group I procedural documentation deficiency when the adjudicating component did not sufficiently document the following:

Insufficient Documentation to Determine:

OQR Legacy System Code

Work Activity - The adjudicating component did not sufficiently document whether the claimant’s current work activity is ongoing SGA.

NOTE: In Title II cases with a DLI in the past, unresolved work activity may be material, even if the work was not ongoing (e.g., work in the waiting period or prior to the DLI).

30

ARs - The adjudicating component did not sufficiently document application of the appropriate AR, and without the documentation, it is not clear if the disability determination is supported.

EXAMPLE:: The Chavez AR 97-(9) applies to a subsequent claim, which the adjudicating component allowed. However, the adjudicating component did not document the file with either the prior file, a copy of the prior final ALJ decision, or an explanation of why obtaining the prior file or copy of the prior final ALJ decision was not possible.

60

Failure to Follow Prescribed Treatment - The issue of failure to follow prescribed treatment is material to the claim, but the adjudicating component’s determination is not sufficiently documented.

62

Whereabouts Unknown – The adjudicating component has not sufficiently documented or did not follow the required procedures prior to denying the claim.

65

Failure to Cooperate - The adjudicating component has not sufficiently documented or did not follow the required procedures prior to denying the claim.

66

5. Group I collateral estoppel documentation deficiency

A group I collateral estoppel documentation deficiency exists when:

 

Insufficient Documentation to Determine:

OQR Legacy System Code

Adoption – The evidence is insufficient to determine whether the prior final allowance can be adopted.

If there is sufficient evidence to show that the adjudicating component should not have adopted the prior final allowance determination, but there is insufficient documentation to make a substantive determination regarding whether the claimant is disabled, the deficiency category 36 applies.

 

36

D. Policy for group I documentation deficiencies (CDR level)

1. Group I medical documentation deficiency

Cite a group I medical documentation deficiency when the medical documentation is insufficient to support the disability determination.

Insufficient Documentation to Determine:

OQR Legacy System Code

MI – The evidence is insufficient to determine whether the claimant has had MI or if MI is related to the ability to work.

43

DAA - The evidence is insufficient to support the adjudicating component’s assessment of whether DAA is material.

46

MI Exception:

Whether new or improved methods of diagnostics or evaluative techniques show that the individual’s impairment(s) is not as severe as it was previously determined in the most recent favorable determination

48

MI Exception:

Whether new medical evidence and a new RFC assessment show that an individual has benefited from advances in:

  • Medical therapy, or

  • Vocational therapy, or

  • Technology.

49

2. Group I vocational documentation deficiency

Cite a group I vocational documentation deficiency if the adjudicating component's impairment severity or RFC assessment is correct but the vocational documentation is insufficient to determine the effect of the following factors on an individual's ability to engage in SGA:

Insufficient Documentation to Determine:

OQR Legacy System Code

Age

51

Work History, including:

  • Transferable skills,

  • Relevance of PRW;

  • Demands of PRW:

    • Physical

    • Mental

    • Environmental

53

Effects of advances in vocational therapy or technology when there is new medical evidence and a new RFC, but no MI

54

Effects of any Vocational Therapy

55

3. Group I medical evaluation deficiency involving vocational documentation

Insufficient Documentation to Determine:

OQR Legacy System Code

Cite a group I medical evaluation deficiency involving vocational documentation when the file contains sufficient documentation to determine impairment severity or RFC, but an incorrect assessment of impairment severity or RFC makes additional vocational documentation necessary to complete the MI review standard.

31

4. Group I procedural documentation deficiency

Cite a group I procedural documentation deficiency when the adjudicating component did not sufficiently document the following.

Insufficient Documentation to Determine:

OQR Legacy System Code

Work Activity – The adjudicating office did not sufficiently document whether the claimant’s current work activity is ongoing SGA.

30

Whether the Prior Determination was in Error (MI Review Standard)

61

Failure to Follow Prescribed Treatment – The issue of failure to follow prescribed treatment is material to the claim, but the adjudicating component’s determination is not sufficiently documented

62

Whereabouts Unknown – The adjudicating component has not sufficiently followed, or did not sufficiently document, the required procedures prior to ceasing benefits.

65

Failure to Cooperate - The adjudicating component has not sufficiently followed, or did not sufficiently document, the required procedures prior to ceasing benefits.

66


GN 04440 TN 90 - Federal Quality Review of Disability Determinations - 1/23/2020