Identification Number:
GN 04440 TN 128
Intended Audience:See Transmittal Sheet
Originating Office:OARO Office of Quality Review
Title:Federal Quality Review of Disability Determinations
Type:POMS Transmittals
Program:All Programs
Link To Reference:
 

PROGRAM OPERATIONS MANUAL SYSTEM
Part GN – General
Chapter 044 – Quality Appraisal
Subchapter 40 – Federal Quality Review of Disability Determinations
Transmittal No. 128, 11/05/2020

Audience

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

Originating Component

OQR

Effective Date

Upon Receipt

Background

This is a Quick Action Transmittal. These revisions do not change or introduce new policy or procedure. To promote the ease of readability, reference identification, and usability for any related scenario, we are clarifying the group I documentation deficiency for category 30 and reorganizing instructions to new subsection C.

Summary of Changes

GN 04440.203 Group I Documentation Deficiencies

A1: replacing ‘SGA’ with ‘work activity’ and clarified application in bulleted form.

B and B2: replacing ‘SGA’ with ‘work activity’.

B2: added ‘to the FO’ and replaced ‘SGA’ with ‘work activity’.

Added new subsection C, “Review component action after the FO documents the CEF with completed development”.

B2e 1st bold-faced instructions: clarified review component instructions and moved to subsection C1 “FO determines SGA denial is applicable”.

B2e 2nd and 3rd bold-faced instructions: combined and clarified for broad usability in any scenario and moved to subsection C2 “FO determines SGA denial is not applicable”.

B2e 4th bold-faced instructions: clarified for broad usability in subsequent returns, with cross-reference, and moved to subsection C3 “FO documentation raises additional issues-adjudicating component or FO action required”.

 

GN 04440.203 Group I Documentation Deficiencies

A. Definitions of group I documentation deficiencies

A group I documentation deficiency is a substantive deficiency in which the medical, vocational, functional, or other relevant evidence, is insufficient to make a determination about the claimant’s disability, such that there is potential for reversing the determination to allow or deny, or to continue or cease, disability benefits. The review component will cite a group I documentation deficiency based on the following issues:

1. Work Activity (category 30)

Category 30 applies when:

  • medical evidence supports an allowance at Step 3 or Step 5,

  • the file contains evidence of work activity,

  • the evidence is insufficient to establish whether the work activity is ongoing SGA or "clearly not SGA", and

  • a potential SGA denial applies at Step 1.

2. Medical evaluation involving vocational documentation (category 31)

The adjudicating component made an incorrect assessment of impairment severity or residual functional capacity (RFC), which makes additional vocational documentation necessary to determine disability.

3. Collateral estoppel (CE) (category 36)

The adjudicating component had insufficient documentation to determine whether adoption applied, or incorrectly adopted a prior favorable disability determination, which makes additional medical or vocational documentation necessary to determine disability on the current claim.

4. Insufficient medical documentation to determine impairment severity (category 41)

The adjudicating component based the determination on medical considerations alone (i.e., the impairment is not severe or the impairment meets, medically equals, or functionally equals the listings) without sufficient evidence to support the determination.

NOTE: The review component should not use this code if the adjudicating component’s determination is based on an RFC assessment.

5. Insufficient medical documentation to determine duration (category 42)

The adjudicating component had insufficient medical evidence to document the severity of the disabling impairment to meet policy requirements for 12-month duration.

6. Medical improvement (MI) and whether MI affects the ability to work (category 43)

The adjudicating component had insufficient medical documentation to determine whether there is MI, or whether MI is related to the ability to work, in a continuing disability review (CDR).

7. RFC (category 44)

The adjudicating component based the determination on an RFC assessment without sufficient evidence to support the assessment.

NOTE: The review component should not use this code if the adjudicating component’s determination is based on medical considerations alone (i.e., the impairment is not severe, or the impairment meets, medically equals, or functionally equals the listings).

8. Failure to follow prescribed treatment (FTFPT) (category 45)

The adjudicating component had insufficient evidence to determine whether consideration of FTFPT policy was necessary prior to assessing impairment severity.

9. Drug addiction and alcoholism (DAA) materiality (category 46)

The adjudicating component had insufficient evidence to:

  • determine whether DAA is material in the case, or

  • determine the severity of the non-DAA impairments when DAA is material.

10. Onset of disability relative to a title II eligibility period (category 47)

The adjudicating component had insufficient evidence to determine whether onset can, or cannot, be correctly established, in a Title II disability claim, relative to the date first insured, date last insured, end of the prescribed period, or before the attainment of age 22.

11. MI exception regarding new or improved diagnostic or evaluative techniques (category 48)

The adjudicating component had insufficient evidence to determine whether new or improved diagnostic or evaluative techniques showed the individual’s impairment(s) is, or is not, as severe as previously determined in the most recent favorable medical determination, in a CDR.

12. MI exception regarding whether the individual has benefited from advances in medical or vocational therapy or technology (category 49)

The adjudicating component had insufficient evidence to determine whether the MI exception, regarding significant MI in a CDR due to medical or vocational therapy, or technology, applies.

13. Age (category 51)

The adjudicating component had insufficient evidence to determine the claimant’s age, when it is material to the determination.

14. Education or illiteracy (category 52)

The adjudicating component had insufficient evidence to determine the claimant’s education or illiteracy, when it is material to the determination.

15. Work history (category 53)

The adjudicating component had insufficient work history evidence to determine:

  • relevance of past work,

  • the demands of past relevant work, including physical, mental, and environmental demands, or

  • transferable skills.

16. MI exception regarding advances in medical or vocational therapy or technology (category 54)

The adjudicating component obtains new medical evidence that results in a new RFC, but no MI. However, the vocational evidence is insufficient to determine whether the MI exception in a CDR regarding significant MI due to medical or vocational therapy, or technology applies.

17. MI exception regarding successful vocational therapy (category 55)

The adjudicating component had insufficient evidence to determine whether vocational therapy (related to the individual’s ability to work) improved the individual’s ability to meet the vocational requirements of more occupations, since the time of the most recent prior favorable medical determination, in a CDR.

18. Failure to obtain a prior folder or copy of the ALJ/AC ruling under an acquiescence ruling (category 60)

The adjudicating component did not obtain the prior folder or a copy of the ALJ or AC decision as required by the AR. Therefore, the evidence is insufficient to make a determination.

19. The prior determination was in error (category 61)

The prior determination was potentially incorrect, indicating a group I or II exception, but the adjudicating component did not follow policy regarding application of the exception, in a CDR.

20. Failure to follow prescribed treatment (FTFPT) (category 62)

The adjudicating component had insufficient documentation to allow or deny the claim, or continue or cease benefits, when evidence implied FTFPT was central to the assessment of impairment severity.

21. Whereabouts unknown (WU) (category 65)

The adjudicating component had insufficient documentation to deny the claim or cease benefits based on WU.

22. Failure to cooperate (FTC) (category 66)

The adjudicating component had insufficient documentation to deny the claim or cease benefits based on FTC.

B. Correcting group I documentation deficiencies

The review component returns all cases with group I documentation deficiencies to the adjudicating component for correction except for work activity category 30 deficiencies, which may require return to the field office (FO) or the adjudicating component.

1. Case returned to the adjudicating component for corrective action

For group I documentation deficiencies returned to the adjudicating component for correction, the review component will:

a. annotate all of the adjudicating component’s original determination and medical assessment forms, as well as notices, in the CEF as “Do Not Process” or “Do Not Release”, as applicable,

b. code the deficiency in the case processing system,

c. notify the adjudicating component, via an SSA-1774-U5, Request For Corrective Action, to explain why the determination is not policy compliant and request the adjudicating component to obtain additional documentation,

d. route the case to the adjudicating component for correction as a controlled return, and

e. follow-up with the adjudicating component in 60 days if the case has not been returned to the review component.

NOTE: All of the adjudicating component’s original determination and medical assessment forms, as well as notices, must remain in the CEF as part of the audit trail.

2. Case returned to the FO for a group I work activity documentation deficiency (category 30)

For group I documentation deficiencies based on work activity, the review component will:

a. annotate all of the adjudicating component’s original determination and medical assessment forms, as well as notices, in the CEF as “Do Not Process” or “Do Not Release”, as applicable,

b. code the deficiency in the case processing system,

c. notify the FO, via an SSA-5524-U3, Request for Assistance, to explain that SGA development is needed,

d. notify the adjudicating component, via an SSA-1774-U5, Request For Corrective Action, to explain why the determination is not policy compliant and that the case will be routed to the FO for SGA development, and

e. route the case to the FO.

NOTE: All of the adjudicating component’s original determination and medical assessment forms, as well as notices, must remain in the case record as part of the audit trail.

C. Review component action after the FO documents the CEF with completed development

The review component will take action based on the results of FO work activity development and SGA determination.

1. FO determines SGA denial is applicable

After the FO resolves the work activity issue and determines an SGA denial or cessation is appropriate:

  • do not effectuate the denial or cessation,

  • code the case processing system for clearance, and

  • route the case to the FO.

2. FO determines SGA denial is not applicable

After the FO resolves the work activity issue and determines an SGA denial is not appropriate:

  • code the case processing system as appropriate for clearance,

  • remove or add "Do Not Process" and "Do Not Release" annotations, as applicable to the adjudicating component's original determination(s), medical assessment form(s), and notice(s),

  • when necessary, correct the onset or ending date on the SSA-831-C3/U3,

  • prepare and release required personalized notices, and

  • route the case to the FO for effectuation.

NOTE: All of the adjudicating component’s original determination and medical assessment forms, as well as notices, must remain in the CEF as part of the audit trail.

3. FO documentation raises additional Issues- adjudicating component or FO action required

If the FO determines SGA denial is not applicable, but FO documentation raises additional issues that require adjudicating component action, initiate a subsequent return to the adjudicating component per GN 04440.205B.2.

If the FO documentation does not fully resolve SGA issues or other technical factors needed to adjudicate the claim:

  • prepare a subsequent request for FO assistance via SSA-5524,

  • specify the issues that need resolution or clarification, and

  • control the return to the FO.


GN 04440 TN 128 - Federal Quality Review of Disability Determinations - 11/05/2020