Effective Dates: 08/01/2023 - Present Previous | Next

TN 11 (08-23)

DI 12026.001 Reconsideration of a Continuing Disability Review (CDR) Based on Medical Cessation or Adverse Medical Reopening

CITATIONS:

Social Security Act Section 205(b); 20 CFR 404.907 - 404.922, 404.993, 404.999a - 404.999b, 404.1546, 404.1597, 404.1597a, 416.946, 416.995, 416.996 , 416.1407 - 416.1422, 416.1492 - 416.1493, 416.1495 - 416.1499, and 422.140

A. Levels of the appeal process

Claimants have the right to appeal an unfavorable medical CDR determination. This subchapter focuses on the reconsideration level of appeal.

There are four levels of medical CDR appeals:

  1. 1. 

    Reconsideration, which includes:

    • •

      Pre-hearing review by an adjudicative team or designated person that was not involved in the initial unfavorable determination; and

    • •

      Disability Determination Services (DDS) Disability hearing review by a Disability Hearing Officer (DHO), in person, by video teleconferencing (VTC), or by way of telephone (in some circumstances) with the claimant, their appointed representative (if applicable), and any witnesses. A Disability Hearing Unit (DHU) handles all disability hearings within the DDS.

  2. 2. 

    Hearing by an administrative law judge (ALJ)

  3. 3. 

    Appeals Council (AC) review

  4. 4. 

    Federal Court review

B. The DDS disability hearing at the reconsideration level

A DDS disability hearing is an evidentiary meeting that provides the claimant an opportunity to review the evidence, introduce new evidence, and present their objections to an unfavorable medical determination before a DHO.

NOTE: The DDS disability hearing at the reconsideration level applies to CDR determinations and adverse medical reopenings, and does not apply to initial disability determinations claims unless the new application is forwarded for association with a pending case that is subject to the reconsideration CDR process.

For information on reconsiderations of initial disability claims, see DI 12005.001 Documenting a Request for Reconsideration of an Initial Disability Claim.

C. Basics of the DDS disability hearing at the reconsideration level

The Social Security Act affords the claimant the right to a disability hearing at the reconsideration level of appeal in certain Title II and Title XVI cases.

1. Types of DDS disability hearing cases with appeal rights

An individual has a right to a DDS disability hearing at the reconsideration level if the initial medical determinations resulted in a:

  • •

    Medical cessation,

  • •

    Adverse medical reopening, or

  • •

    Reopening that changes only the basis of the cessation.

2. Issues that may be involved in unfavorable medical determinations with appeal rights

The DDS disability hearing process applies to unfavorable medical determinations involving:

  • •

    Medicare for Qualified Government Employees (MQGE) cases,

  • •

    Extended Period of Eligibility (EPE) cases,

  • •

    Prisoner cases,

  • •

    Foreign cases,

  • •

    Railroad cases,

  • •

    Whereabouts Unknown (WU) cases; if the claimant files an appeal on an initial cessation determination DDS has already made and,

  • •

    Fraud and Similar Fault (FSF) cases.

3. When a DDS reconsideration disability hearing applies

A DDS reconsideration disability hearing of a medical CDR applies when:

  • •

    An initial CDR determination finds that a claimant's impairment ceased, did not exist or is no longer disabling, or

  • •

    The Social Security Administration (SSA) proposes to adversely reopen and revise a favorable determination based on medical or medical-vocational factors. For more information on reopenings, see DI 33020.025 Reopenings by the Disability Hearing Officer (DHO).

4. When a DDS reconsideration disability hearing of a medical CDR does not apply

A DDS reconsideration disability hearing of a medical CDR is NOT applicable for:

  • •

    Initial determinations made on a new application, (including closed period cases), unless the new application is forwarded for association with a pending case that is subject to the reconsideration CDR process.

  • •

    Reconsideration of initial determinations made on new applications, including partially favorable determinations (for example, closed periods and later onsets).

  • •

    Cases involving nonmedical issues, for example, substantial gainful activity (SGA), overpayment of benefits, amount of income and resources (Title XVI), or reconsideration of cessations based on, 'whereabouts unknown.'

D. References

  • •

    DI 12005.001 Documenting a Request for Reconsideration of an Initial Disability Claim

  • •

    DI 29001.001 The Right to a Disability Hearing at the Medical Continuing Disability Review (CDR) Reconsideration Level

  • •

    DI 29001.005 The Scope of the Disability Hearing

  • •

    DI 29001.010 Overview of Component Responsibilities Related to Medical Continuing Disability (CDR) Disability Hearings

  • •

    DI 29005.022 New Application and Request for Reconsideration

  • •

    DI 33020.025 Reopenings by the Disability Hearing Officer (DHO)

To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0412026001
DI 12026.001 - Reconsideration of a Continuing Disability Review (CDR) Based on Medical Cessation or Adverse Medical Reopening - 08/01/2023
Batch run: 08/01/2023
Rev:08/01/2023