Essential material is necessary to make the disability determination and applies to certified electronic folders (CEFs), Modular Disability Folders (MDFs), and brown, non-MDF folders used prior to the inception of the MDF. Essential material includes:

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  The Case Development Summary worksheet (or any other documentation describing the development steps completed);

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  All unproductive requests (discard consultative examination (CE) notices to the medical source, regardless of whether the claimant kept the appointment).

See also:

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  DI 20503.001E – What is the Case Development Summary Worksheet;

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  DI 81020.065 – Electronic Case Documentation;

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  DI 81020.230 – Documenting Comparison Point Decision (CPD) Evidence and Preparing the Electronic Continuing Disability Review (eCDR) Rationale.

Relevant evidence is a type of essential material that is relevant to the issues in the case, including, but not limited to:

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  Establishing a medically determinable impairment (s);

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  Assessing severity;

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  Determining duration;

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  Establishing the onset date of disability;

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  Documenting fraud or similar fault (FSF) (See DI 23025.000 for documentation instructions for claims involving FSF).

Nonessential material does not serve to document the disability determination, is of no value for future reviews, and should be discarded. This definition applies to material in:

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  CEFs;

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  MDF; and

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  Brown non-MDF folders (used prior to the inception of the MDF).

NOTE: If in doubt as to whether evidence is essential or nonessential, the disability adjudicator must keep the evidence in file.

Nonessential material includes:

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  Duplicate medical evidence;

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  Internal DDS routing and case management slips;

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  Blank form(s) included with letters to claimants, medical sources, third parties, etc. if identified in the list of notice enclosures (e.g., “Enclosure: SSA-3369BK (Work History Report), SSA-3380BK (Function Report Adult Third Party”); and

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  Irrelevant evidence (see DI 20503.001D.3. for definition)

See also:

DI 70005.005 – General Overview of the MDF

Irrelevant evidence is material that does not meet the definition of “relevant evidence” as described in DI 20503.001B.2.

Only the DE making the determination on a case may decide which evidence is relevant or irrelevant. The DE cannot delegate this decision to anyone who is not making a determination on the case. Once the DE decides what evidence is irrelevant, any staff may carry out the handling and retention procedures.

NOTE: When the hearing office initiates an assistance request to the DDS, the DDS DE does not determine the relevancy of the evidence.

When an electronic document contains both relevant and irrelevant evidence, adjudicators must:

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  Create a new document for the relevant evidence by following the instructions in DI 81020.065E.3. – Electronic Case Documentation; and

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  Annotate on the Worksheet the new document containing only relevant evidence; annotate the original document from which the relevant evidence was extracted and describe briefly the materials not retained in file, including the type of material and the reason for discarding it.

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  Move the original document containing both relevant and irrelevant evidence into the green section (Current Development/Temporary) of the CEF. All material in the green section of the CEF will automatically be discarded after all quality reviews applicable to the current level of adjudication are completed.

NOTE: Page-level manipulation is dependent on the DDS’s jurisdictional control of the document.

After all quality reviews related to the current level of adjudication are complete, DE’s must:

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  Discard nonessential material in a manner that prevents unauthorized disclosure according to the instructions in DI 81020.055 – Document Retention and Destruction. (For MDFs see, DI 39567.220C – Disposal of Paper Records);

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  Include a brief description of material not retained in file, including the type of material and the reason for discarding, e.g., duplicate medical evidence received from the same source;

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  Retain any irrelevant evidence received as part of an informal remand unless a wholly favorable determination is effectuated.

Move the material to the green (Current Development/Temporary) section of the CEF. All material in the green section of the folder is automatically discarded after all quality reviews are complete.

NOTE: Do not delete nonessential material from a CEF (e.g. using the computer’s delete button) at any time.

When discarding nonessential material from the MDF:

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  Label material “Nonessential Material - Destroy After All Reviews Have Been Completed” (see exhibit of sample Nonessential Material flag in DI 20503.010); and

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  Place in the green section (Current Development/Temporary) of the MDF; or

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  Attach to the file if there is not enough room in the green section.

When all actions at the current level of adjudication are complete, including the component review, the office taking the last action will discard the material marked with the Nonessential Material flag.

The Case Development Summary is a worksheet the DE prepares to:

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  Document all disability development undertaken;

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  Record the receipt or non-receipt of requested evidence;

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  Describe any material not kept.

Permanently retain the worksheet as the top document in the Medical Records (Yellow/Back) section of the MDF or the CEF. Fully document all development pertaining to the current decision on the worksheet if development requests are not in file.

See also:

DI 20503.005 for an exhibit of a Model Case Development Summary worksheet.

When preparing the Case Development Summary worksheets ensure that:

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  All entries are precise and easily understood by subsequent reviewers and adjudicators, including quality reviewers, administrative law judges and the Federal courts.

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  The entries stand alone and do not require a coding key or interpretive guide to decipher (i.e., no encrypted entries).

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  DE’s complete a new worksheet form at each level of adjudication through the disability hearing officer level.

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  Locally created DDS development forms must contain the required claimant and development information described in DI 20503.001E.3. - DI 20503.001E.6.

The following claimant information is required and must be entered on the Case Development Summary worksheet:

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  Name and Social Security Number (SSN);

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  Date of Birth (DOB);

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  Representative information - i.e., attorney or other appointed representative;

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  Level of Claim – e.g., initial, reconsideration, CDR, etc;

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  Type of Claim – e.g., Disability Insurance Benefits (DIB), Childhood Disability Benefits (CDB), Disabled Window(er) Benefits (DWB), Disabled Individual (DI), Medicare for Qualified Government Employment.

NOTE: For DWB and CDB claims also enter the wage earner’s name and SSN.

Document on the Case Development Summary worksheet initial and follow-up requests for MER and non-MER made by:

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  Mail;

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  Telephone;

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  Fax;

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  Electronic Records Express (ERE); or

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  Other means.

See also:

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  DI 20503.001F – Guidelines for retaining or discarding MER requests, CE notices, claimant requests, or third party requests;

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  DI 22505.006 – Requesting Evidence – General; and

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  DI 22505.035 – Follow-up on Requests for Medical Evidence of Record (MER).

Enter the following information to document the development steps.

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  For unproductive requests, retain the request letter.

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  For productive requests, discard the request letter (e.g., requests for completion of an SSA-3373-BK - Function Report - Adult or SSA-3369BK-Work History Report, call-in letters, etc.)

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  For unproductive requests, retain the request letter.

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  For productive requests, discard the request letter (e.g., requests for completion of an SSA-3380BK-Function Report-Adult-Third Party Booklet, call-in letters, etc.)