PROGRAM OPERATIONS MANUAL SYSTEMPart DI – Disability InsuranceChapter 300 – Quality AssuranceSubchapter 05 – Adjudicating Component Actions on Deficient CasesTransmittal No. 30, 12/19/2019
This is a Quick Action Transmittal. These revisions do not change or introduce new policy or procedure.
Summary of Changes
DI 30005.121 Group I Decisional Deficiencies
This updates involves a few minor changes to definitions of existing OQR legacy system codes/deficiency codes.
A group I decisional deficiency is a substantive deficiency that affects the basic decision to allow or deny, or to continue or cease, disability benefits. The defined group I decisional deficiencies are listed in DI 30005.121C.
A group I decisional deficiency exists when the case contains sufficient documentation to support an opposite determination, and the decision is clearly contradicted by the evidence; e.g., an allowance instead of a denial or a cessation instead of a continuance.
A group I decisional deficiency is cited when the incorrect disability determination results from an incorrect determination regarding:
Substantial gainful activity (SGA) when disability is allowed or continued despite clear evidence the claimant is engaging in SGA;
Impairment severity, and the disability determination was made, or should have been made, on the basis of medical considerations alone; i.e., the impairment:
is not severe, or
meets, medically equals or functionally equals the listings;
Medical improvement (MI) including whether there has been MI or whether MI is related to the ability to work;
MI exceptions including:
whether new medical evidence and a new assessment of RFC show that an individual is a beneficiary of advances in medical or vocational therapy or technology,
whether the individual has successfully undergone vocational therapy,
whether new or improved methods of diagnostic or evaluative techniques show that the individual’s impairment is not as severe as it was considered at the time of the last determination,
whether a prior determination was made in error, or
whether the prior determination was fraudulently obtained;
Evaluation of vocational factors including:
education, literacy or the ability to communicate in English,
ability to do past relevant work, or
ability to do other work;
Failure to follow prescribed treatment;
Drug addiction and alcoholism (DAA) materiality when:
disability is allowed or continued despite clear evidence that DAA is material to the determination, or
disability is denied or ceased on the basis that DAA is material despite clear evidence that DAA is not material to the determination;
Onset of disability and the correct onset date is clearly:
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 (FO) clearly documented the disability 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, and
the case must be denied;
NOTE: In cases involving a Title II worker, this deficiency is cited when the Title II worker has a severe 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. It is immaterial whether the adjudicating component established the onset date before DLI but the correct onset date was determined to be after DLI, or they established the onset date after DLI, despite the documentation in file.
Adopting a prior administrative law judge (ALJ)/Appeals Council (AC) finding when:
the claim is a subsequent disability claim being adjudicated under an acquiescence ruling (AR), and
the DDS adopted the prior ALJ or AC disability decision when it should not have been adopted, or
the DDS did not adopt the prior ALJ or AC disability decision when it should have been adopted, or
the DDS adopted a prior ALJ or AC specific finding under the sequential evaluation process (e.g., impairment severity, RFC, etc.) when it should not have been adopted, or
the DDS did not adopt a prior ALJ or AC specific finding under the sequential evaluation process (e.g., demands of past relevant work) when it should have been adopted.
NOTE: Some (but not necessarily all) examples of ARs that require consideration of a prior ALJ/AC final decision or findings are AR 97-4(9) (Chavez) and AR 00-1(4) (Albright).
Collateral estoppel, when:
a prior final determination was adopted when it should not have been, and disability cannot be established on the basis of the current claim,
NOTE: If a prior final determination is adopted when it should not be adopted, and disability can be established on the basis of the current claim, there is no group I decisional deficiency. There may be a group II onset date decisional deficiency if the evidence in file does not support the DDS EOD in the current claim.
a prior final determination was not adopted when it should be adopted, and disability was not established on the current claim.
NOTE: If a prior final determination is not adopted when it should be adopted, and disability is established on the current claim, there is no group I decisional deficiency. There may be a group II onset date decisional deficiency if the DDS EOD is less favorable than the onset date established in the prior claim that should have been adopted.