A rationale is required in all CDR determinations, whether the determination is a continuance or cessation.

The technical rationale must contain six elements:

1. 1. 

   Citation of the evidence sources;

2. 2. 

   Basis for most recent favorable medical determination (comparison point decision (CPD)) and the reason for current medical review;

3. 3. 

   Summary of individual's reason(s) that they are still disabled;

4. 4. 

   Statement regarding nonmedical issues (e.g., substantial gainful activity (SGA), work activity, vocational rehabilitation involvement (Section 301 cases), extended period of eligibility (EPE) cases);

5. 5. 

   Discussion of the findings produced by the CDR evaluation process; and

6. 6. 

   Basis for the disability decision, the reason the individual's disability continues (e.g., meets a listing)), or has ceased (e.g., medical improvement related to the ability to work has occurred and the individual has the ability to perform SGA).

The rationale will include an accurate discussion of the medical findings. To ensure clarity and conciseness, avoid using highly technical medical terminology unless rephrasing would be misleading or would result in an incorrect medical conclusion.

It is appropriate to use accepted medical abbreviations such as FEV1 for "forced expiratory volume in 1 second," ECG for "electrocardiogram," and terms common to the medical improvement review standard (MIRS) and the CDR process, e.g., MI (medical improvement), comparison point decision (CPD), and SGA (substantial gainful activity). However, avoid excessive use of acronyms and abbreviations.

In Disability Determination Services (DDSs) where the Disability Case Processing System (DCPS) is used, the adjudicator will follow instructions per their legacy systems.

In DDSs where the Electronic Claims Analysis Tool (eCAT) is still used, the adjudicator may prepare the rationale in the location of the Disability Determination Explanation (DDE) or on an SSA-4268 (Explanation of Determination). The State or Federal agency medical or psychological consultant (MC/PC) and adjudicator will sign and date the SSA-4268 in the appropriate blocks. The adjudicator can sign the rationale singly if the MC/PC has otherwise completed a separate medical assessment using any of these forms:

• •

  SSA-416 (Medical Evaluation),

• •

  SSA-5002 (Report of Contact),

• •

  SSA-2506-BK (Psychiatric Review Technique),

• •

  SSA-4734-BK (Physical Residual Functional Capacity Assessment), or

• •

  SSA-4734-F4-SUP (Mental Residual Functional Capacity Assessment).

• •

  DI 24501.001 The Disability Determination Services (DDS) Disability Examiner (DE), Medical Consultant (MC), and Psychological Consultant (PC) Team and the Role of the Medical Advisor

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