Identification Number:
DI 28035 TN 3
Intended Audience:See Transmittal Sheet
Originating Office:ORDP ODP
Title:Processing of Lost Folders/Medical Evidence
Type:POMS Transmittals
Program:Disability
Link To Reference:
 

PROGRAM OPERATIONS MANUAL SYSTEM
Part DI – Disability Insurance
Chapter 280 – Continuing Disability Review Cases
Subchapter 35 – Processing of Lost Folders/Medical Evidence
Transmittal No. 3, 11/15/2021

Audience

PSC: CS, DE, DEC, DTE, IES, RECONR, SCPS, TSA, TST;
OCO-OEIO: CR, ERE, FDE, RECONE;
OCO-ODO: BET, CR, CTE, CTE TE, DE, DEC, DS, PETE, PETL, RECONE;
ODD-DDS: ADJ, DHU;

Originating Component

ODP

Effective Date

Upon Receipt

Background

We are updating this Program Operations Manual System (POMS) chapter so it will comply with the plain language standards. We did not change any policy.

Summary of Changes

DI 28035.001 Disability Determination Services (DDS) Initial Receipt and Development of Lost or Destroyed Folders/Medical Evidence for Continuing Disability Review (CDR) Cases

We added "or Destroyed" to the title.

We added "Cases" to the title.

We added Subsection B back into the POMS.

We changed "beneficiary(ies)" and "recipient(s)" to "individuals" throughout the POMS.

 

DI 28035.010 Disability Determination Services (DDS) Review of Current Evidence to Determine Continuing Disability

In DI 28035.010C.3., we added "F6" to SSA-538.

 

DI 28035.015 Disability Determination Services (DDS) Identification of the Comparison Point Decision (CPD) Date

We added (CPD) to the title.

In DI 28035.015A, second bullet, we corrected "Office of Disability Adjudication and Review" to "Office of Hearings Operations."

In DI 28035.015B.1., we corrected the name of the DCF query to "MS 00501.018" ; we added "Query Medical Information Data Screen (QMID)

In DI 28035.015G, we deleted the last sentence "See DI 28091.010, Supplemental Rationale Procedures."

In DI 28035.015G, we corrected the name of DI 81001.005 to "Electronic Disability (eDib) and the Electronic Folder (EF)."

In DI 28035.015G, we corrected the query name to MS 00501.018, as titled above.

 

DI 28035.020 Disability Determination Services (DDS) Reconstruction of Prior Folder

In DI 28035.020B. NOTE:, we changed text to clarify the meaning of Age-18 cases.

 

DI 28035.025 Disability Determination Services (DDS) Reconstruction of Prior Folder Not Possible

In DI 28035.025A., we changed the text from second person to third person.

In DI 280035.025A.1st bullet, we changed the initial phrase to read "Disability is not continued …"

In DI 28035.025F., second paragraph, we corrected the POMS citation to "DI 28010.105B.4."

In DI 28035.025G, we added "DI 28005.020 The CDR Evaluation Process - Title XVI Child - General"

In DI 28035.025G., we added "DI 28020.001 General - Groups I and II Exceptions to Medical Improvement (MI)"

 

DI 28035.030 Comparison Point Decision (CPD) Folder Received in the Disability Determination Services (DDS) After the Review Process Begins

In DI 28035.030, we changed "Original " in the title to "Comparison Point Decision (CPD)"

In DI 28035.030, we changed the text from second person to third person.

In DI 28035.030A, we added information to clarify subsection A.

 

DI 28035.001 Disability Determination Services (DDS) Initial Receipt and Development of Lost or Destroyed Folders/Medical Evidence for Continuing Disability Review (CDR) Cases

IMPORTANT: These instructions incorporate policy and procedure for both electronic continuing disability review (eCDR) and eCDR exclusion (paper) cases when there is a lost or destroyed folder involved.

A. Background on CDR Cases

The law requires that SSA periodically reviews the continuing entitlement and eligibility of all Title II and Title XVI individuals. In performing this review, we compare the severity of the individuals' current medical condition(s) to the severity of the most recent favorable medical decision (i.e., comparison point decision (CPD)).

There may be situations when SSA is unable to locate a folder or, a folder has been destroyed. In either of these situations, the field office (FO) follows specific procedures for attempting to find the folder. See DI 13015.070 and DI 13015.080 for FO procedures to locate a folder.

B. Field Office (FO) requirements for lost or destroyed cases prior to transfer

Before transferring a CDR case to the DDS, the FO must make every effort to locate the CPD folder(s). The CPD folder could be a certified electronic folder (CEF) or a paper folder. A CEF cannot be a lost or destroyed folder because it is stored electronically. For further instructions regarding FO search and detective work that may be necessary to locate a medical folder see DI 13015.080.

NOTE: If the CDR is an Age-18 Redetermination, the CPD folder is not required. Age-18 Redeterminations are evaluated under adult listings and are considered a "new initial claim." However, if it is readily available, the FO will obtain it and forward it to the DDS.

For information on associating the CEF CPD folder with an electronic continuing disability review (eCDR), see DI 81010.235.

1. Paper CPD

If the CPD is a paper folder, the FO mails the CPD folder to the DDS when it transfers the case to the electronic disability collect system (EDCS). If the FO cannot locate the paper CPD folder, the FO must document all attempts to find the folder, including follow-up requests, on Form SSA-5002 (Report of Contact) or similar document.

The Form SSA-5002 or similar document must:

  • Identify the type(s) of file the FO attempted to locate (Title II Disability Insurance Benefits (DIB), Childhood Disability Benefits (CDB), Disabled Widow(er) Benefits (DWB), Supplemental Security Income (SSI), etc. and list the locations searched or eliminated based on queries;

  • Document a follow-up to the original search request(s) was completed;

  • Address the issue of cross-referenced social security numbers (SSN), or document there are no cross-referenced SSNs;

  • Address pertinent name changes by the individual and that the office searching for the folder was aware of and searched under all names involved.

 

2. Developmental evidence

The FO obtains the following developmental evidence:

  • Form SSA-454 (Report of Continuing Disability Interview) - the FO must key the Form SSA-454 into EDCS;

  • Form SSA-3368 (Disability Report - Adult) for Age-18 Redeterminations - the FO must key the SSA-3368 into EDCS, unless there is an eCDR exclusion. See (DI 81010.210 for eCDR exclusion cases;

  • Form SSA-3881 (Questionnaire for Children Claiming SSI Benefits) and the age-appropriate Function Forms (Forms SSA- 3375 through SSA-3379 for child CDRs;

  • Form SSA-827 (Authorization to Disclose Information to the Social Security Administration), see DI 11005.056 for signature requirements; and

  • Supporting documentation (e.g., queries, beneficiary-supplied documents) including Form SSA-5002 or similar document documenting the attempts to locate a missing CPD if necessary.

After the FO completes development, it transfers the case to the DDS.

NOTE: FOs should accurately complete the paper folder indicators prior to EDCS transfer per DI 81010.235.

C. DDS procedures for receipting CDR cases

DDS must review CDR cases for CPD folder documentation, which can be any of the following:

  • A linked CEF CPD (which indicates that the folder is electronic);

  • A paper CPD folder;

  • Form SSA-5002 or similar document which documents all FO search activity for a lost or destroyed folder;

  • Supporting documentation (e.g., queries); or

  • CPD date established by the FO (which should be the date 12 months prior to the CDR interview).

    NOTE: The FO keys a CPD date into EDCS that is 12 months prior to the interview for lost or destroyed folder cases. However, it is the DDS's responsibility to establish the actual CPD date.

If the FO forwards a CDR folder that does not contain documentation of efforts to locate the CPD folder, the DDS transfers the case back to the FO. The adjudicator includes this reason "Attempts to locate the CPD folder are not documented."

If the DDS receipts the case before discovering the missing CPD development, the adjudicator transfers the case back to the FO.

The FO should key the SSA-454-BK into EDCS; however, if it does not, the DDS can scan it into the CEF (per DI 81020.210).

NOTE: To ensure proper credit in workload assistance cases, when requesting assistance from another disability-processing component, DDS must use the Transfer (TR) decision code rather than the No Determination (ND) decision code. The DDS must route the claim using TR regardless of whether the DDS has already performed substantive work on the case. See SM 06001.355 and DI 81020.127.

 

D. DDS procedures for developing prior medical evidence

The DDS no longer creates or maintains paper residuals. All prior medical evidence should be available electronically.

Title XVI conversion:

Attempt to locate the prior State records because two CPDs may apply. The actions taken vary on a State-by-State and case-by-case basis. For additional information, see DI 28010.105.

E. DDS procedures for developing current evidence

When developing current evidence, the adjudicator will:

  • Review Form SSA-454;

  • Develop all current medical evidence and any necessary non-medical evidence (12 months before the date when the SSA-454 is signed to the present date); and

  • Order a consultative examination, if necessary.

For additional case development procedures, see DI 28030.020,

F. References

  • DI 28010.105 Comparison Point Decision (CPD)

  • DI 28030.020 Development of Medical Evidence

  • DI 81020.127 Processing "No Determination" (NC) Cases

  • DI 81020.205 Receipting an Electronic Continuing Disability Review (eCDR)

  • DI 81020.210 Scanning the SSA-454-BK (Continuing Disability Review Report) into the CEF

  • DI 81020.225 Linking and Unlinking the Comparison Point Decision (CPD) Folder

  • SM 06001.355 Transfer Cases

 

DI 28035.010 Disability Determination Services (DDS) Review of Current Evidence to Determine Continuing Disability

IMPORTANT: These instructions incorporate policy and procedure for both electronic continuing disability review (eCDR) and eCDR exclusion (paper) cases when there is a lost or destroyed folder involved.

A. Medical improvement review standard (MIRS)

The DDS cannot determine medical improvement without the comparison point decision(CPD) folder or medical evidence. If DDS is unable to locate the appropriate CPD folder or medical evidence, the adjudicator will bypass MIRS temporarily.

When the adjudicator receives current medical evidence covering at least the last 12 months, he or she will evaluate the evidence using the initial sequential evaluation process (subject to the trial work period (TWP), extended period of eligibility (EPE), and 1619 provisions, if the individual is working).

B. DDS procedures for adult CDRs

1. Individual does not have a severe impairment(s)

If the individual does not have a severe impairment(s), the adjudicator will follow the instructions on DDS prior folder reconstruction in DI 28035.020.

2. Individual has a severe impairment(s)

The adjudicator will determine if the impairment(s) meets or medically equals the severity of a listed impairment, according to the instructions in DI 22001.001D.3

3. Impairment(s) meets or medically equals a listing

If the current impairment(s) meets or medically equals the severity of an impairment in the current Listing of Impairments, disability continues. The adjudicator will:

  • Prepare a determination with the appropriate reexamination diary;

  • Use appropriate meets or equals continuance code; and

  • Show listing code 256 (Lost Folder Case) in item 34 of the SSA-832/833-U5 (Cessation or Continuance of Disability or Blindness Determination and Transmittal – Title XVI/Cessation or Continuance of Disability or Blindness Determination and Transmittal - Title II).

NOTE: The adjudicator should not use "Disability Continues – Date From Most Recent Prior Favorable Medical Determination Insufficient to Assess Medical Improvement."

4. Impairment(s) does not meet or medically equal a listing

If the current impairment(s) does not meet or medically equal the severity of an impairment in the current Listing of Impairments, the adjudicator will determine if the individual can perform past relevant work or other work.

5. Individual cannot perform past relevant work or other work

The adjudicator will prepare a determination to continue disability by following these instructions:

  • Use appropriate impairment plus vocational factors continuance code;

  • Enter list code 256 (Lost Folder Case) in item 34 of the SSA-832/833-U5 (Cessation of Continuance of Disability or Blindness Determination and Transmittal – Title XVI/Cessation or Continuance of Disability or Blindness Determination and Transmittal - Title II); and

  • Document the file on Form SSA-5002 or similar document that the adjudicator did not formally consider MIRS.

NOTE: The adjudicator should not use "Disability Continues – Data From Most Recent Prior Favorable Medical Determination Insufficient to Assess Medical Improvement."

6. Individual can perform past relevant work or other work

If the individual can perform either past relevant work or other work, the adjudicator will not cease disability on this finding alone. The adjudicator will:

  • Continue the sequential evaluation process to include consideration of the MIRS; and

  • Attempt to reconstruct the prior medical evidence, provided he or she can determine the date of the CPD.

For information on reconstructing prior medical evidence, see:

  • DI 28035.015 – Disability Determination Services (DDS) Identification of the Comparison Point Decision (CPD)Date;

  • DI 28035.020 – Disability Determination Services (DDS) Reconstruction of Prior Folder.

7. Medical or medical-vocational allowances

If, based on current medical or medical-vocational evidence, disability continues, this determination becomes the CPD for the next CDR.

NOTE: Group II Exceptions to Medical Improvement may result in a cessation at any point during the evaluation process. They are not controlled by sequence.

For information on exceptions to medical improvement, see:

  • DI 28020.001 – General - Groups I and II of Exceptions to Medical Improvement (MI);

  • DI 28020.900 – Group II Exceptions.

C. DDS procedures for child CDR determinations

1. Child does not have a severe impairment(s)

If the child does not have a severe impairment(s), the adjudicator will determine if he or she can reconstruct the prior folder according to the procedures in DI 28035.020.

2. Child does have a severe impairment(s)

If the child has a severe impairment(s), the adjudicator will determine if the impairment(s) medically meets or functionally equals the listings for Title XVI child cases according to the instructions in DI 25201.005 How We Determine Disability for Children and DI 25225.001 Functional Equivalence – Policy (Section 416.926a(a)).

3. Child’s impairment(s) medically meets or functionally equals the listing(s)

The adjudicator will prepare a determination to continue disability and follow these instructions.

  • Prepare a determination with the appropriate reexamination diary;

  • Use appropriate meets or equals continuance code for disabled child (DC) or blind child (BC).

  • Show listing code 256 (Lost Folder Case) in item 34 of the SSA-832/833-U5 (Cessation or Continuance of Disability or Blindness Determination and Transmittal – Title XVI/Cessation or Continuance of Disability or Blindness Determination and Transmittal - Title II).

NOTE: The adjudicator will not use "Disability Continues - Data from Most Recent Prior Favorable Medical Determination Insufficient to Assess Medical Improvement."

REMINDER: The adjudicator must complete an SSA-538-F6 (Childhood Disability Evaluation Form) for all Title XVI child CDRs.

4. Child’s impairment(s) does not medically meet or functionally equal the listing(s)

If the child’s current impairment(s) does not medically meet or functionally equal the severity of the listings, the adjudicator will determine whether to reconstruct the prior folder according to the instructions in DI 28035.020.

D. References

  • DI 22001.001 Sequential Evaluation of Title II and Title XVI Adult Disability Claims

  • DI 25201.005 How We Determine Disability for Children

  • DI 25220.005 Determining if a Child Has a Severe Impairment(s)

  • DI 25220.010 Meets or Medical Equals

  • DI 25225.001 Functional Equivalence – Policy (Section 416.926a(a))

  • DI 28020.001 General - Groups I and II of Exceptions to Medical Improvement (MI)

  • DI 28020.900 Group II Exceptions

  • DI 28035.015 Disability Determination Services (DDS) Identification of the Comparison Point Decision Date

  • DI 28035.020 Disability Determination Services (DDS) Reconstruction of Prior Folder

  • DI 28035.025 Disability Determination Services Reconstruction of Prior Folder Not Possible

 

DI 28035.015 Disability Determination Services (DDS) Identification of the Comparison Point Decision (CPD) Date

IMPORTANT: These instructions incorporate policy and procedure for both electronic continuing disability review (eCDR) and eCDR exclusion (paper) cases when there is a lost or destroyed folder involved.

A. Background on CPD date

The DDS attempts to determine the CPD date before reconstructing the prior medical evidence in a continuing disability review (CDR) case by:

  • Evaluating each case based on the facts and evidence available for that particular case;

  • Reviewing all evidence and documents in the current folder (either in eView or paper) to obtain the filing date, month of entitlement, Office of Hearings Operations decisions, etc.;

  • Reviewing all queries in file to document the date of the most recent favorable medical determination; and

  • Reviewing any evidence that may be available in a prior non-certified electronic folder.

NOTE: A non-certified electronic folder (CEF) may be available with prior documentation. While documents in a prior folder may be considered during a review, if the prior folder is not a CEF, DDS cannot rely on the completeness of the file. To determine if a case is a CEF, see DI 81001.005.

B. Review queries to locate the CPD date

The adjudicator will review the following processing systems and queries to locate and document the CPD date of the most recent favorable medical determination.

1. Disability Control File (DCF) MS 00501.018 Query Medical Information Data Screen (QMID)

The adjudicator will review the DCF Query Medical Information Data screen to determine the:

  • Date of the last medical review;

  • Diagnosis codes;

  • Next medical diary date; and

  • Basis for the diary date.

2. Queries

The following queries may have necessary information to determine the proper CPD.

a. Master beneficiary record (MBR) SM 00510.000

The adjudicator will review the following fields:

  • INSURED – Displays type of claim and date of filing

  • BENEFIT – Displays DOEI – date of entitlement initial

  • BENE ENT – CUR ENT CODE - Displays type of currently entitled benefit

  • DIB - Disability Insurance Benefits

  • DDO - Date of Disability Onset

  • DIG - Diagnosis Code - Mental or physical impairment that resulted in a disability

  • DOED - Date of entitlement to disability

b. Supplemental Security Record (SSR) SM 01601.000

The adjudicator will review the following fields:

  • CCTL – TMR – Master Record Type (DI, DS, DC, etc.)

  • DIAR – MR – Medical Review Diary

  • DISB – DSA - Date to State Agency

  • DDO - Date of Disability Onset

  • DIG - Diagnosis Code

  • DPM - Permanent Disability Indicator

  • CDR - CDR Event and Code

c. DDS Query (DDSQ) SM 06002.200

The adjudicator will review the following fields:

  • DEC – Decision

  • BAS – Basis

  • OND – Onset Date

  • DSI – Primary Diagnosis

  • DIA – Medical Diary Date

  • ESD – Examiner Signature Date

  • MSD – Medical Signature Date

  • SDI – Secondary Diagnosis

  • MLN – Medical Listing Number

  • SCD – State Cleared Date

C. Establish the CPD date

To establish the CPD date, the adjudicator will determine if the DDS:

  • Made the initial determination within the last 3 years. If there is no continuing disability review (CDR) date on the MBR, the allowance determination date is likely the CPD date.

  • Made the initial determination more than 3 years ago, or 7 years in medical improvement not expected (MINE) cases. The later decision should be the CPD date. However, due to delays in CDR processing, the absence of CDR data on the MBR may indicate that the initial decision is the CPD date.

D. Review other sources to identify the CPD date

If the DCF, MBR, SSR, and DDSQ do not provide all the information needed to determine the CPD date, the adjudicator will review the following information if available:

  • Consultative examination scheduling documents;

  • DDS residual files (e.g., records of determinations or decisions, consultative exams);

  • DIB line CDR code of “M” on the MBR; and

  • Trial work period (TWP) or extended period of eligibility (EPE) data on the DCF that may establish that a prior review was a work CDR.

NOTE: If a case pre-dates the DCF, the adjudicator will review the MBR to obtain the TWP/EPE data.

E. Explanation of a CPD determination

The DDS will explain how it determined the CPD date or why it was unable to determine the CPD date. The explanation will provide the determined CPD date and discuss the evidence considered to support the conclusion.

F. Example of determining CPD date

A CDR alert was generated 10/2018. The FO and the DDS were unable to locate the prior paper folder. The DDSQ shows 02/13/15 as the Title XVI onset date, with a 3-year medical re-exam diary. The case was closed (SCD) 06/07/15. The SSR shows current folder location L47 (Folder destroyed). There is no indication that SSA conducted a CDR between onset date and current CDR alert date. The established CPD is 06/07/15 – the date DDS made the last favorable determination.

G. References

 

DI 28035.020 Disability Determination Services (DDS) Reconstruction of Prior Folder

CITATIONS:

IMPORTANT: These instructions incorporate policy and procedure for both electronic continuing disability review (eCDR) and eCDR exclusion (paper) cases when there is a lost or destroyed folder involved. If the comparison point decision (CPD) folder is a certified electronic folder (CEF), these instructions do not apply.

A. Background for reconstruction of folders

When a Comparison Point Decision (CPD) folder is lost or destroyed, the DDS must determine if CPD folder reconstruction is necessary. Although reconstructing lost or destroyed CPD folder cases is costly, the erroneous continuation of medical disability benefits to an individual who is no longer disabled but continues in pay because the CPD medical folder cannot be found is more costly. It is imperative that the DDS makes an appropriate determination to reconstruct a folder.

B. When not to reconstruct a prior folder

The DDS will not pursue folder reconstruction when a continuance determination can be made based on current evidence (i.e., individual currently meets or medically equals a listing or can be a current medical-vocational continuance case).

NOTE: If the CDR is an Age-18 Redetermination, it is evaluated under the adult rules as a "new initial claim." Therefore, the DDS does not need to reconstruct the CPD folder. However, if the CPD folder is readily available, the field office (FO) will send it to the DDS.

C. Policy for determining when to reconstruct a prior folder

Reconstruction of the prior evidence may be appropriate when the DDS discovers that some or all of the evidence used in making the CPD is unreadable, unintelligible, or missing (e.g., a piece of evidence referred to in the rationale is no longer in file).

To determine if it is appropriate to reconstruct a folder, the DDS will:

  • Consider the potential availability of old records in light of their age,

  • Whether the source of the evidence is still in operation, and

  • Whether reconstruction efforts will yield substantial evidence of the basis for the most recent favorable medical decision.

The DDS must document a reason for not reconstructing a prior folder. The documentation can be on Form SSA-5002, or similar document. For more information, see DI 28035.025B.

D. Procedures for reconstructing a prior folder

When the DDS cannot make a continuance determination based on current medical evidence, the adjudicator must attempt to reconstruct the prior folder by following these instructions.

1. CPD date is known

Reconstruct portions of the missing file used in the CPD and relevant to the most recent favorable determination (e.g., work history, medical records from treating sources, school records, consultative examinations, and vocational evidence).

a. Form SSA-3368-BK, Form SSA-3820-BK, or eView equivalent is in the folder

  • Contact all medical and other relevant sources prior to the established CPD ; and

  • Determine if the reconstructed records adequately allow for consideration of the medical improvement review standard (MIRS). See DI 28005.001.

If the reconstructed records adequately allow for consideration of the MIRS:

  • Prepare a determination; and

  • Enter list code 256 (Lost Folder Case) in item 34 of Forms SSA-832/833 (Cessation or Continuance of Disability or Blindness Determination and Transmittal – Title XVI/Cessation or Continuance of Disability or Blindness Determination and Transmittal - Title II).

If a continuance is appropriate, this favorable determination becomes the CPD for the next CDR.

To reconstruct medical records adequately, the adjudicator will follow the documentation procedures in the following POMS sections:

NOTE: In some cases, particularly in mental impairment cases where a longitudinal history could be helpful, the adjudicator may secure additional medical evidence from before or after the CPD date.

b. Form SSA-3368-BK, Form SSA-3820-BK, or eView equivalent is not in folder

If Form SSA-3368-BK or Form SSA-3820-BK is not in the folder, prepare an assistance request (AR) to the FO asking them to obtain a Form SSA-3368-BK or Form SSA-3820-BK. The AR must contain:

  • The CPD date;

  • Instructions on the development needed;

  • Instructions on the forms needed; and

  • The applicable time period(s).

The adjudicator should allow the FO 30 days to obtain the information requested. After 30 days the adjudicator should proceed to the determination even if the FO did not obtain the information.

NOTE: For instructions on preparing an AR in an eCDR case, see DI 81020.100.

2. CPD date is unknown

If the individual is not currently disabled and the CPD date is not established:

  • Document the file on an SSA-5002 or similar document explaining why the CPD date is not established; and

  • Prepare a continuance according to the instructions in DI 28035.025.

E. Medical Improvement Review Standard (MIRS) and reconstructed evidence

In order to apply the MIRS to reconstructed evidence, there should be adequate evidence from the time of the CPD so that the basis for the CPD is clear.

1. Medical records can be adequately reconstructed

If DDS receives adequate evidence to reconstruct the medical records, the adjudicator will:

  • Prepare a determination under the MIRS (for adult cases, see DI 28005.005 and for -Title XVI child cases, see DI 28005.025);

  • Enter list code 256 (Lost Folder Case) in item 34 of the SSA-832/833 (Cessation or Continuance of Disability or Blindness Determination and Transmittal – Title XVI/Cessation or Continuance of Disability or Blindness Determination and Transmittal – Title II).

If a continuance is appropriate, this favorable determination becomes the CPD for the next CDR.

2. Medical evidence cannot be adequately reconstructed

If DDS does not receive adequate evidence to reconstruct the folder and apply the MIRS, the adjudicator should follow the instructions in DI 28035.025.

F. References

  • DI 22501.001 Disability Case Development for Evidence

  • DI 28005.001 Legal Standard for Determining if Disability Continues

  • DI 28005.005 The Continuing Disability Review (CDR) Evaluation Process for Title II and Adult Title XVI Individuals

  • DI 28005.025 The CDR Evaluation Process – Title XVI Child - Summary Chart

  • DI 28030.020 Development of Medical Evidence

  • DI 28035.025 Disability Determination Services (DDS) Reconstruction of Prior Folder Not Possible

  • DI 81020.100 Electronic Assistance Requests (AR)

 

DI 28035.025 Disability Determination Services (DDS) Reconstruction of Prior Folder Not Possible

A. Background

The DDS ensures that current documentation is complete and, in the absence of current substantial gainful activity (SGA) or Group II medical improvement exceptions, prepares a determination to continue disability if:

  • Disability is not continued based on current medical or medical-vocational evidence; and

  • Reconstruction of the prior medical records as described in DI 28035.020 is not possible.

REMINDER: The adjudicator will ensure a completed SSA-538-F6 (Childhood Disability Evaluation Form) is in file in all Title XVI child cases.

B. Documentation for not reconstructing prior folder

When the DDS determines not to reconstruct a prior lost or destroyed paper comparison point decision (CPD) folder, the DDS must document the reason on Form SSA-5002 or similar document. See Report of Contact Form SSA-5002 below.

Lost Folder Reconstruction Documentation

C. Title XVI and extended period of eligibility (EPE)

In Title XVI and EPE impairment severity determinations, the adjudicator will prepare a continuance of disability determination if there are no Group II medical improvement exceptions. The performance of SGA is not a basis for an unfavorable Title XVI continuing disability review (CDR) determination. For additional information on medical improvement exceptions, see DI 28005.015, DI 28005.020, and DI 28020.900.

D. Complete the SSA-832/833 ( Cessation or Continuance of Disability or Blindness Determination and Transmittal – Title XVI/Cessation or Continuance of Disability or Blindness Determination and Transmittal – Title II)

The adjudicator completes Forms SSA-832/833 according to instructions in DI 28084 including:

  • In item 12, enter reason for continuance code 37 (Disability Continues - Data From Most Recent Prior Favorable Determination Insufficient to Determine Medical Improvement) for Title II (DI 28084.020); and for Title XVI enter reason for continuance code 77 (Disability Continues - Data From Most Recent Prior Favorable Determination Insufficient to Determine Medical Improvement); and

  • In item 34, enter list code 256 (Lost Folder Case) for the SSA-832/833 for both cessations and continuances.

E. Schedule a medical reexamination diary

The adjudicator schedules the medical reexamination diary based on the type of impairment(s) involved and whether changes in the impairment could result in a cessation when the MIRS is applied in future CDRs.

F. Title XVI conversion cases

The adjudicator must carefully evaluate Title XVI conversion cases, as there may be two CPD folders. If evidence from one CPD (e.g., the State CPD) is not available and a continuance is processed under other rules, (e.g., under the Federal criteria), include a determination of continuance under these provisions (e.g., insufficient evidence to assess medical improvement under the State criteria).

The adjudicator will process the current continuance under both Federal and State criteria, and use the current CDR as the CPD for both Federal and State parts in future reviews. Medical improvement regulations provide that current documentation must provide the basis for any future reviews. For additional information on conversion cases, see DI 28010.105B.4.

G. References

  • DI 28005.015 Step-by-Step Discussion of the Adult Continuing Disability Review (CDR) Evaluation Process

  • DI 28005.020 The CDR Evaluation Process --Title XVI Child - General

  • DI 28020.001 General - Groups I and II of Exceptions to Medical Improvement (MI)

  • DI 28035.020 Disability Determination Services (DDS) Reconstruction of Prior Folder

  • DI 28084.020 Reason for Continuance Codes (Item 12)

 

DI 28035.030 Comparison Point Decision (CPD) Folder Received in the Disability Determination Services (DDS) After the Review Process Begins

If the field office (FO) finds a lost folder, the FO sends it to the DDS. The DDS associates it with the reconstructed folder based on the following criteria:

A. Determination not completed

If the DDS has not completed a determination, the adjudicator will verify the CPD is in the folder, and consider the material in the CPD folder before making the determination. The adjudicator will associate the found CPD folder with the current CDR and forward it as appropriate after making the determination.

B. Determination completed

If the DDS has completed a determination and the notice has been mailed to the individual, the adjudicator will verify the CPD is in file, and review the CPD folder material. The adjudicator will consider whether to reopen the determination under the rules for reopening in DI 27505.001 Conditions for Reopening a Final Determination or Decision. After the DDS completes all actions, the adjudicator will forward the current folder (which contains the found CPD folder) to the agency component that has jurisdiction of the case.


DI 28035 TN 3 - Processing of Lost Folders/Medical Evidence - 11/15/2021