The following prescribed forms are appropriate for documenting the childhood disability case explanation:

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  SSA 538 - Childhood Disability Evaluation Form (CDEF)

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  Childhood Domain Evaluation (CDE) for cases processed in the Disability Case Processing Systems (DCPS)

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  Childhood Disability Evaluation (CDE) for claims that were previously processed in the Electronic Claims Analysis Tool (eCAT)

The SSA-538 or CDE must be used in all assessment scenarios that require a domain evaluation due to a severe impairment(s) that does not meet or equal a listing, or functionally equal the listings by example, see DI 25225.060.

An SSA-416 may be used in lieu of the CDE in DC claims completed electronically, that do not require a domain evaluation and the findings of fact and supporting evidence results in one of the following scenarios:

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  Meets or equals a listing

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  Functionally equals the listings based on example only, see DI 25225.060

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  Insufficient evidence

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  No severe impairment(s)

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  No medically determinable impairment(s)

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  No medical improvement (for Title XVI child continuing disability review (CDR) cases)

NOTE: For non-electronic claims, if the severe impairment(s) requires a domain evaluation, there must be one prescribed form in the case record that gives the disposition and clearly supports it.

For a detailed explanation of documenting the findings on DC prescribed forms refer to DI 25230.005.

The policies in this section apply to:

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  Initial (DC) determinations

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  Reconsideration DC determinations

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  Initial level DC determinations for CDRs

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  Reconsideration level DC determinations for CDRs unless a Disability Hearing officer (DHO) makes the determination

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  Reopening determinations, if the determination being reopened is covered by these policies

We require a second prescribed form for specific cases involving Drug Addiction or Alcoholism (DAA). In all DAA materiality determinations, apply the appropriate sequential evaluation process a second time considering whether the individual is disabled without DAA involvement.

A complete explanation includes the following elements:

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  Identifying information (name, SSN, date of birth), filing date, level of determination

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  Established and alleged impairments

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  Disposition

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  Explanation for all the dispositions, except meets listing

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  Consultant (Medical Consultant (MC)/Psychological Consultant (PC)/non-physician) statement that all relevant factors and evidence have been considered

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  Signature of Consultant with overall responsibility for evaluating the case

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  Signatures of additional MC/PC/non-physician participating in the evaluation

The Consultant with overall responsibility for the findings in the determination, affirms on the SSA-538 or within the electronic case processing system that they considered the following:

1. a. 

   All relevant factors

2. b. 

   All relevant evidence in deciding if:

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     The child has a severe impairment(s)

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     An impairment(s) meets or medically equals a listing, or

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     An impairment(s) functionally equals the listings

The affirmation statement on the SSA-538 or within the electronic case processing system does not mean that the consultant needs to explicitly address each of these factors in every case. It means, the consultant has considered whether the factors apply; and has properly considered those that are relevant. The factors and evidence serve as a reminder to the consultants.

The MC, PC, and the disability examiner (DE) who makes the reconsideration determination, must be different from the adjudicative team members who made the initial determination. Upon receiving a reconsideration claim, the DE should follow the appropriate case development as outlined in DI 27001.010A.

After a complete, independent, and thorough review of all the evidence in the file at the reconsideration level, including any evidence received before or after the initial determination or any available evidence from prior folders, the MC and/or PC will:

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  Evaluate and document their findings on the appropriate prescribed form (e.g. CDE, SSA-416, or SSA-538), as described above in DI 25230.001B.1; and

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  Complete the medical disposition.

The reconsideration assessment can reference the initial determination's assessment to support the reconsideration determination. For reconsideration claims completed in DCPS, the MC and/or PC will need to complete, sign, and apply the appropriate prescribed form at the reconsideration level in order to make the reconsideration determination.

The consultant with the overall responsibility for evaluating the reconsideration claim will affirm the overall medical case review (see DI 25230.001B.5) and sign and date the medical disposition.