PROGRAM OPERATIONS MANUAL SYSTEMPart DI – Disability InsuranceChapter 275 – Reopenings, Res Judicata, and Collateral EstoppelSubchapter 01 – GeneralTransmittal No. 4, 09/24/2026
Audience
Originating Component
DP
Effective Date
Upon Receipt
Background
Disability Policy is updating the Program Operation Manual System (POMS) to include information about appeals of adverse medical reopenings (AMR) of initial and reconsideration level claims that are eligible for a disabilityhearing at the Disability Hearing Unit (DHU). An individual has the right to request a disability hearing at DHU if they have been receiving disability benefits and we make an initial or revised determination based on medical factors that they are not disabled because the impairment(s) has ceased, did not exist, or is no longer disabling. 20 CFR § 404.914, 416.1414. The first level of appeal for an AMR is called a Reconsideration of an Adverse Medical Reopening (RAMR) and is handled by the Disability Hearings Unit (DHU) .A RAMR for a more adverse onset is handled through the standard disability appeals process. A RAMR at the Disability Hearings Unit (DHU) involves two steps: a pre-hearing (PH) review and a disability hearing review by a disability hearing officer (DHO).
Summary of Changes
DI 27501.001 Reopenings and Revisions: Pertinent Definitions and Related Policy
We updated subsection A to include 1a and 1b which explain when AMRs and RAMRs occur, and we updated the titles of related policy references in section B.
DI 27501.005 Reopening and Revising a Determination or Decision
We updated subsection B3a to include information about the requirement for a DHO hearing for RAMRs that are not based only on a more adverse onset.
CITATIONS:
A medical reopening is a formal review of an administratively final determination or decision to admit new and material medical evidence or to reevaluate the evidence used in the prior determination or decision. A reopening generally results in a more favorable determination or decision although an adverse medical reopening is occasionally appropriate.
For additional information on when reopening is appropriate see DI 27501.005.
NOTE: The term “determination” refers to adjudications at the initial and reconsideration levels, and “decision” refers to adjudications at the Administrative Law Judge (ALJ) and Appeals Council (AC) levels.
An AMR is reopening of an administratively final initial or reconsideration-level allowance determination or continuing disability review (CDR) continuance based on medical factors that revise the determination to a denial, cessation, later onset, or closed period determination.
An AMR does not includes (1) adverse reopenings based on non-medical factors, such as substantial gainful activity (SGA) or field office (FO) determinations, or (2) medical reopenings that are not adverse, such as a reopening of a denial resulting in an allowance or a more favorable outcome.
An AMR does include cases that are reopened due to fraud or similar fault that involve medical matters. This does not include non-medical issues outside of DDS jurisdiction such as SGA and unreported work activity.
A RAMR occurs when an individual requests a reconsideration of an AMR. An individual has the right to request a reconsideration and receive a disability hearing if they have been receiving disability benefits and we make an initial or revised determination based on medical factors that the individual is not disabled because the impairment ceased, did not exist, or is no longer disabling.
A Disability Hearing Officer (DHO) review is not afforded to an individual who requests a RAMR for a less favorable onset. If an individual requests a RAMR for a less favorable onset, we follow the regular reconsideration process covered in DI 12005.000 and DI 27001.000. An appeal of an unfavorable RAMR for onset may ultimately result in an Administrative Law Judge (ALJ) review.
Any change in the end result or basis of a final determination or decision.
A determination or decision (initial or revised) is final as of the date of the notice unless:
it is timely appealed (or a civil action is filed); or
it is appealed late but good cause for late filing of an appeal or civil action is found; or
the Appeals Council (AC) takes jurisdiction on its own motion within 60 days of the date of the Administrative Law Judge (ALJ) decision; or
the AC denies a request for review (does not issue a decision), in which case the ALJ decision is the final decision; or
it is reopened and revised.
NOTE: Form SSA-L1157 Social Security Notice and SSA-L1157-SI Supplement Security Notice - are interim notices and not final notices.
Appeal Filing Issues (DI 27010.001)
Conditions for Reopening a Final Determination or Decision (DI 27505.001)
Legal Standard for Determining if Disability Continues (DI 28005.001 .)
Applying Collateral Estoppel in Disability Claims (DI 11011.001 )
Field Office Res Judicata Development and Processing (DI 27516.001)
Period Covered by a Final Determination or Decision: “Period Adjudicated” (DI 27510.001)
Reopening of Prior Favorable Initial Continuing Disability Review (CDR) Cases (DI 28501.015)
Good Cause for Reopening (DI 27505.010)
Conditions for reopening and revising are determined by the rules of administrative finality. If an individual does not file an appeal of an administratively final determination or decision in a timely manner, they may lose their right to further review.
Reopening and revising is at the discretion of the Social Security Administration (SSA) or the Disability Determination Services (DDS). However, when an individual requests reopening, it is our policy to review the evidence in the case. (See GN 04001.001D.3.) If the requirements for reopening are met and the evidence shows that the prior determination or decision was incorrect, we will reopen and revise the determination or decision. (See GN 04001.001D.4.)
Consider reopening when:
A party to the determination or decision requests (or makes an implied request for) reopening by:
Writing to SSA or the DDS;
Writing to a third party (e.g., a congressperson); or
Filing a new claim (e.g., when a denied claimant files a subsequent claim and alleges an onset of disability in the period adjudicated in the prior denial determination or decision).
SSA or the DDS questions the correctness of a prior determination or decision as a result of:
New information or evidence; or
Quality or other review.
The following are generally required before a determination or decision may be reopened:
An administratively final determination or decision as defined in DI 27501.001A.3 (the determination or decision may adjudicate an initial claim or may be the result of a continuing disability review (CDR)), and
Reason to consider reopening (e.g., new and material evidence), and
A timely written statement by a party to the determination or decision indicating disagreement with the correctness of a final determination or decision, or
A timely written statement from an authorized component of SSA or the DDS, questioning the correctness of the prior determination or decision.
“Timely” means within the time frames described in DI 27505.001 Conditions for Reopening a Final Determination or Decision.
“Authorized” means the component has the authority to reopen the determination or decision in question. For information on who may reopen, see DI 27501.005B.3, in this section.
NOTE 1: Always request the prior folder(s) per DI 20505.010C before reopening. There are circumstances that permit reopening without the prior paper folder. For more information, see DI 27510.005H.
NOTE 2: For information on time limits for reopening, see DI 27505.001.
A DDS component at the same or higher adjudicative level may reopen an administratively final determination or decision when reopening is appropriate.
The DHU has jurisdiction to reopen and revise administratively final determinations based on medical and medical-vocational factors. This includes making the medical determination for adverse medical reopenings (AMR) of reconsiderations and reconsiderations of adverse medical reopenings (RAMR). For more information, see:
DI 29001.001 The Right to a Disability Hearing at the Medical Continuing Disability Review (CDR) Reconsideration Level.
Because a DDS AMR for a less favorable onset does not require consideration of the medical improvement review standard, DHU does not have jurisdiction to consider a RAMR for a less favorable onset. The appeals process for a DDS AMR for a less favorable onset reverts to the standard initial appeals process.
NOTE: The DHU may reopen a DDS determination. A DHU decision may only be reopened by a Disability Hearings Officer (DHO), ALJ, or AC.
An ALJ has juridiction to reopen an ALJ decision or a determination made by the DHU or DDS.
NOTE: An adjudicative level below the ALJ may not reopen a decision made at the ALJ, AC or Court level.
The AC has jurisdiction to reopen an AC or ALJ decision, or a determination made by the DHU or DDS.
NOTE: An adjudicative level below the AC may not reopen a decision made at the AC or ALJ level.
These adjudicative levels may reopen substantial gainful activity (SGA), income and resources, or other non-medical issues at the initial and reconsideration levels.
NOTE: The FO has the authority to reopen the DDS's disability determination and deny the claim when an SGA, income, resources, or other non-medical issue arises after the DDS has made a medical determination on a disability claim. The FO does not have the authority to change onset of disability based on work issues that arise after the DDS has made a favorable determination. See DI 13010.105 Beneficiary Returns to Substantial Gainful Activity (SGA) Within One Year of the Onset Date - Title II.
The MIRS applies when a favorable disability determination or decision is being medically reopened and revised to a determination or decision of denial, or cessation. The favorable disability determination or decision may be reopened and revised to a denial, cessation, or closed period determination or decision only when:
There is medical improvement related to the ability to work (or a Group I exception is met) and the beneficiary/recipient can currently adjust to other work; or
A Group II MIRS exception is met.
The MIRS does not apply to reopening and revision to a later onset or to revised determinations concerning insured status or other non-medical issues.
A revised determination or decision is required to:
Make a less favorable (adverse) revision.
Make a more favorable revision.
Change a basis code only--no change in the determination or decision to deny or allow, or change in onset or cessation date.
Revise to a statutorily blind diagnosis, or revise from a statutorily blind diagnosis and diagnosis code to non-blind diagnosis and diagnosis code. See DI 28005.090 Evaluating Continuing Disability Review (CDR) Cases involving Blindness.
Correct conflicting determinations or decisions in common issue claims when not policy compliant. See: DI 27520.030 Conflicting Determinations or Decisions in Disability/Blindness Common Issue Claims.
Reopen certain erroneous notice or payment cases. See DI 27520.025 Erroneous Notice/Payment Cases
Unless otherwise instructed:
Base consideration for reopening on the statute, regulations, and rulings, that were applicable at the time of the adjudication of the prior determination or decision being considered for reopening.
If the applicable statute, regulations and rules have not changed since the adjudication of the prior determination or decision being considered for reopening, base a revised determination or decision on the current statute, regulations, and rulings.
Extend a revised determination or decision through the current date (or through the date last insured, age 22, or prescribed period, if earlier) rather than through the date covered by the determination or decision being revised. See DI 27510.001.
AMRs other than those indicated in DI 27501.005B.4.b. must follow the MIRS.
Reopening of a final determination is warranted in title II claims when a claimant returns to work at the SGA level in the waiting period and the SGA work activity is continuing per DI 13010.105 Beneficiary Returns to Substantial Gainful Activity (SGA) Within One Year of Onset Date - Title II.
When evidence of improvement is received before the notice of the award is released, prepare a new determination if warranted. This action is not considered a reopening.
When new information or evidence is received indicating that improvement in the claimant's condition occurred before the end of the required 12 months duration of disability and return to work is after a notice of determination or decision has been released, the case is generally considered a continuing disability issue. See DI 25505.025 Duration Requirement for Disability.
Establish onset of disability in a prior adjudicated period in a subsequent title II claim when:
The disability criteria has changed and more than 12 months have elapsed since the date of the notice of the initial determination on the previous claim (thereby precluding reopening for any reason); or
New and material evidence establishes disability within the period adjudicated and more than 4 years have elapsed since the date of the notice of the initial determination on the previous claim (thereby precluding reopening for good cause); or
The prior determination was an FO denial for "insufficient evidence furnished" (M5/M6) when a claimant fails to submit essential evidence. See DI 11018.005 Field Office Responsibilities in a Failure to Cooperate-Insufficient Evidence Decision (FTC).
NOTE 1: Establishing an onset within the prior period adjudicated establishes the disability freeze, which preserves the insured status and may result in an increased monthly benefit amount. When the prior determination is not reopened, the retroactivity of benefits is based on the new application.
NOTE 2: Do not set an onset in a prior adjudicated period for a CDR cessation.
Provide the individual a due process notice in adverse actions. See DI 27525.001 Due Process Notification for Adverse Reopenings.
NOTE: Provide a due process decision notice when statutory benefit continuation (SBC) rights are applicable.
Afford the individual an opportunity to present any additional information or evidence they believe may have a bearing on the determination or decision in adverse actions. See DI 27525.000 Reopenings – Due Process.
Take the following steps when reopening or revising a determination:
Document the file to ensure all applicable opportunities and efforts to comply with due process requirements have been satisfied. . See DI 27525.000 Reopenings-Due Process
Prepare a revised determination. See DI 27530.001 Documenting Revised Determination and GN 04001.080 Documenting the Rationale for Reopening.
Prepare a rationale. See DI 27536.015 Optional Use of a Summary Decision Rationale for Reopening, DI 26515.001 and GN 04001.080 Documenting the Rationale for Reopening.
Prepare the proper notices and provide appeal rights. See DI 27540.001 Due Process Requirements and NL 00708.100 Numbered Paragraphs.
Route the claim appropriately. See DI 32005.095 Disability Determination Services Reopenings and Revisions Case Routing-Initial and Reconsideration-Paper Cases only.
Provide the appropriate appeal rights to the claimant.
Give reconsideration appeal rights following a title II revised AMR that concerns the issue of whether, based on medical factors, the individual is disabled. Reconsideration is also the next level of appeal following a title XVI AMR that involves a suspension, reduction, or termination of SSI benefits.
NOTE: Do not give disability hearing rights at the reconsideration level if a revised determination establishes a later onset.
DHU has jurisdiction for appeal rights for AMRs that concern the issue of whether, based on medical factors the individual is disabled. Give ALJ hearing rights when DHU did not favorably decide a RAMR.
The ALJ hearing level is the next level of appeal following an unfavorable RAMR for a less favorable onset. The ALJ hearing level is also the next level of appeal following a title XVI revised initial determination that does not involve a suspension, reduction, or termination of SSI benefits.
When denying a request for reopening:
Document the file with an SSA-553 (Special Determination), or other electronic writing (RPOC, DW01) or form, describing facts and consideration given to the reopening issue, and reason for not reopening (See GN 04001.080 Documenting the Rationale for Reopening); and
Provide notification to the individual of the disposition of any reopening issue they are aware of, but do not include a right to appeal.