Apply this exception when all of the following apply:

• •

  Evidence shows error in a prior decision or determination was made in error.

• •

  Available evidence does not show a reasonable alternate basis for the disability finding in the prior determination or decision.

• •

  One of the following three requirements exists:

  1. a. 

     error on the face of record;

  2. b. 

     required and material evidence was missing; or

  3. c. 

     new evidence related to the prior determination or decision.

NOTE: Error may be a basis for reopening, if the rules for reopening, including time limits, are met. See DI 27505.000, Rules for Reopening - Table of Contents; DI 27501.001, Reopenings and Revisions: Pertinent Definitions and Related Policy; and DI 27501.005, Reopening and Revising a Determination or Decision.

In deciding whether this exception applies, consider both:

• •

  evidence on the record at the time of the prior determination or decision; and

• •

  any new evidence related to the prior determination or decision.

 

Do not substitute current judgment for judgment involved in the prior determination or decision.

For an example of substitution of judgment, see DI 28020.350F in this section.

If the prior error exception applies, then:

• •

  continue with the sequential evaluation process, see DI 28005.015A for the Title II and Title XVI adult continuing disability review (CDR) sequential evaluation process and DI 28005.030C for the Title XVI child CDR sequential evaluation process.

• •

  determine if reopening of the prior determination or decision is necessary after evaluation through all appropriate steps in the sequential evaluation process.

NOTE: If the sequential evaluation process leads to an unfavorable determination, the result may be a current cessation or an adverse reopening.

The medical improvement review standard (MIRS) applies to adverse reopenings of prior determinations and decisions. The MIRS includes the exceptions to medical improvement (MI). When the MIRS applies and the determination in a particular case supports a Group I error exception, the MIRS review evaluation process requires a finding of current ability to engage in SGA, before making any unfavorable decision, including adverse reopening.

See DI 28005.001D for application of the MIRS.

If a Group I prior error exception applies, the adjudicator must consider whether reopening the prior determination is appropriate and is possible under the rules for reopening.

Reopening is only necessary if both criteria are met:

• •

  Evidence on the file establishes that the prior determination or decision was completed in error and the prior error exception applies.

• •

  Conditions for reopening meet the criteria as defined in DI 27505.001A.

Reopening is NOT necessary if the prior error exception applies but the conditions for reopening in DI 27505.001A. are NOT met. The CDR sequential evaluation process still applies despite the ability to reopen.

If a decision made at a higher appeals level (for example, by an administrative law judge) is found in error and the individual can engage in substantial gainful activity (SGA), process the cessation on the pending CDR case first. After processing the cessation, if the time limit for reopening has not expired, refer the case for possible reopening at the prior appeal level.

• For an overview of considerations for reopening and revision a decision or determination, see DI 27501.005B.2.c. and DI 27501.005B.2.d.

• For reopening time limits, see DI 27505.001.

• For instructions routing reopened CDR cases, see DI 28501.030.

Prepare a rationale in a SSA-5002 or the disability determination explanation (DDE), based on facts in the evidence, that specifically explains and documents why the prior decision or determination was in error. Explain why you are or are not reopening the prior determination.

The prior error exception can apply to any medical determination or decision on the issue of disability, not just the comparison point decision (CPD).

While the CPD and supporting evidence must be reviewed in some detail, only develop the prior error exception if there is substantial evidence that suggests a decisional error was made on a previous claim. Do not begin to review the CPD (or any other prior determination or decision) with the intent of finding an error.

Do not find error where the prior folder has been lost (or evidence used for the CPD is either uninterpretable or lost from the file) and cannot be adequately reconstructed. For additional information, see DI 28035.001, Disability Determination Services (DDS) Initial Receipt and Development of Lost Folders/Medical Evidence for Continuing Disability Review (CDR).

If there has been an erroneous activation of an allowance subject to a pre-effectuation or other pre-adjudicative review, do not find error. Follow instructions in DI 81020.127 for medically reactivated claims.