PROGRAM OPERATIONS MANUAL SYSTEMPart DI – Disability InsuranceChapter 265 – Initial Case ProcessingSubchapter 15 – Rationale Preparation (Initial Claims)Transmittal No. 3, 02/14/2020
This is a Quick Action Transmittal. These revisions do not change or introduce new policy or procedure.
Summary of Changes
DI 26515.001 Rationale Preparation
We updated the wording and references in DI 26515.001B.11 for consistency with the revised FTC policy.
Disability policy requires the Disability Determination Services (DDS) to provide complete documentation of the sequential evaluation process used in claims adjudication. The Disability Determination Explanation (DDE) can serve as the rationale; however the analysis in the DDE must include all of the required elements discussed in this section. The DDS has the option to follow the instructions in this section or the instructions for the Simplified Rationale Procedures in DI 26516.001 through DI 26516.015.
Include the following elements in all rationales, as applicable. Not every claim requires a discussion of all of the elements. For example, address Drug Addiction and Alcoholism (DAA) only if it is material to the allowance.
For individual medical evidence of record (MER) sources, cite the source’s name and date of receipt.
For consultative examination (CE) sources, cite the CE’s name and date of the examination.
Cite name(s) and date(s) of receipts for each source.
Cite nonmedical professional sources by name and date of receipt.
Cite other nonmedical source evidence generically, e.g., third party report received on MM/DD/YY.
State the claimant’s allegations (illnesses, injuries, and conditions), related limitations, and date of alleged onset.
Include allegations and limitations at time of filing and others identified or alleged during claim development.
State whether the claimant is working or not. If applicable, explain the field office’s (FO) resolution of the work issue(s), e.g., the work is SGA or is not.
Identify and discuss other technical issue(s), e.g., date last insured (DLI); unsuccessful work attempt (UWA); and, if applicable, explain the FO or DDS resolution.
Discuss your analysis of the medical and nonmedical evidence, including objective medical evidence (signs, laboratory findings, or both) and evaluation of symptoms used to make the determination.
Make findings of fact; do not merely summarize evidence.
If applicable, consider and discuss the duration requirement.
If applicable, consider and discuss vocational issues.
State the established onset date (EOD) based on the claimant’s potential onset date (POD) provided by the FO. If the EOD differs from the alleged onset date (AOD), explain the reason(s) for the change. For more detailed information on documenting the EOD, see DI 25501.200C.2.
Discuss the claimant’s statements about his or her symptoms and their functional effects.
Assess the claimant’s statements and explain the reasons for your assessment and conclusion.
For more information on symptom evaluation, see DI 24501.021.
Cite each medical opinion by the source name and date of receipt, and briefly describe the content of each medical opinion.
Assess and determine what weight to give the medical opinion(s). Discuss the reasons, including supporting evidence, for the weight given to each medical opinion.
Discuss whether any treating source(s)’ medical opinion(s) is entitled to controlling weight; explain why.
For information on weight of medical opinions, see DI 24503.035.
Cite each by source name and date, and briefly described the content of each.
For articulation requirements, see DI 24503.030.
For information on medical opinions, see DI 24503.025.
If you find the claimant to be disabled and there is evidence of DAA, determine and discuss whether DAA is material to the finding of disability.
For more information on DAA, see DI 90070.000.
If there is evidence that the claimant may not have followed prescribed treatment, discuss whether to preclude the claimant from benefits by making a failure to follow prescribed treatment determination.
For information on failure to follow prescribed treatment, see DI 23010.006 through DI 23010.045.
If a reasonable effort to ensure claimant cooperation with our requests for evidence or action are unsuccessful, discontinue development that requires claimant cooperation (e.g., consultative examinations and claimant forms completion).
For a discussion of what represents a “reasonable effort to ensure claimant cooperation,” see DI 23007.001 through DI
23007.010, DI 22510.016, DI 22510.019, and DI 22505.014.
After making every reasonable effort to obtain a complete medical history without the claimant’s cooperation, make a determination based on the evidence in the file. For the definition of "every reasonable effort" and a "complete medical history," see DI