Federal quality reviewers may consider or apply POR to all types of determinations (i.e., fully favorable, less than fully favorable, or unfavorable).

For fully favorable determinations, the federal quality reviewer may consider or apply POR at the initial and reconsideration level.

For less than fully favorable and unfavorable determinations, the federal quality reviewer may consider or apply POR, but only at the initial filing level.

When the next level of appeal is a hearing, the federal quality reviewer cannot apply POR because an administrative law judge is required to fully document the case record. If the only reason for returning a case to the adjudicating component is to complete the record in the event of a hearing, the case contains a TCA, not a group I or group II documentation deficiency, and the federal quality reviewer will return the case to the adjudicating component for additional development.

REMINDER: Federal quality reviewers cannot consider or apply POR to disability determinations originating from the remaining prototype states.

Federal quality reviewers may consider or apply POR for:

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  Group I medical documentation deficiencies

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  Group I vocational documentation deficiencies

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  Group I medical evaluation deficiencies involving vocational documentation

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  Group II onset date documentation deficiencies

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  Group II ending date documentation deficiencies

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  Group II cessation date documentation deficiencies

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  Group II work activity documentation deficiencies

For additional information regarding deficiency types, see the policy sections listed in subsection A.

The federal quality reviewer will thoroughly review the sample case per normal procedures.

If the existing medical and vocational documentation is sufficient to support the adjudicating component’s determination and is policy compliant, the federal quality reviewer will clear the case as clean and route it to the Field Office (FO).

If the federal quality review of the sample case reveals the existing medical and vocational documentation reasonably appears to support the adjudicating component’s determination, but the efforts made to obtain documentation are not fully policy compliant, the federal quality reviewer may consider POR.

The federal quality reviewer will specifically identify what medical or vocational documentation is missing and what policies the adjudicating component failed to follow when developing the documentation.

The federal quality reviewer will determine what level of impairment severity, RFC, and vocational factors would reverse the disability determination or change the length of the period of disability.

EXAMPLE: If an unfavorable determination is not documented per policy, and the claimant is 25 years old with a high school education and has the capacity to perform a full range of sedentary work, the claimant's impairment(s) will generally have to meet or medically equal the listings for the missing documentation to reverse the disability determination. Thus, a TCA would generally be prudent in this case.

EXAMPLE: If an unfavorable determination is not documented per policy, and the claimant is 56 years old with a fifth grade education and does not retain the capacity for past relevant work (PRW), a moderately severe impairment and certain functional limitations, potentially found in the missing documentation, are much more likely to reverse the disability determination. Thus, citing a group I documentation deficiency would generally be prudent in this case.

If the federal quality reviewer, based on disability policy knowledge and quality review case experience:

1. a. 

   surmises that the missing medical or vocational documentation is likely to reverse the determination or change the length of the period of disability, the federal quality reviewer must:

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     cease consideration of POR,

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     cite the appropriate documentation deficiency on a Request for Corrective Action (SSA-1774-U5),

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     document consideration of POR on the Request for Corrective Action (SSA-1774-U5) per subsection E, and

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     return the case to the adjudicating component for additional development and correction.

2. b. 

   cannot reasonably ascertain whether the missing documentation is likely to reverse the determination or change the length of the period of disability, the federal quality reviewer must:

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     cease consideration of POR,

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     cite the appropriate documentation deficiency on a Request for Corrective Action (SSA-1774-U5),

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     document consideration of POR on the Request for Corrective Action (SSA-1774-U5) per subsection E and

   • •

     return the case to the adjudicating component for additional development and correction.

3. c. 

   surmises that the missing medical or vocational documentation is unlikely to reverse the determination or change the length of the period of disability, the federal quality reviewer must document application of POR using a case note. For POR documentation requirements, see subsection E.

NOTE: The POR process is inherently subjective and difficult to define precisely. POR is most likely to be considered or applied with unfavorable determinations, but can also be used with favorable determinations.

When an adjudicating component does not fully document a case according to SSA disability program policy, and the federal quality reviewer applies POR instead of returning the case to the adjudicating component for correction, the federal quality reviewer must document the file with a rationale explaining the application of POR. The federal quality reviewer's rationale must provide subsequent adjudicators and reviewers with an understanding of why the federal quality reviewer did not return the case to the adjudicating component for additional development and correction.

When POR is applied, the federal quality reviewer must document the file with a case note, stating, verbatim, the following:

The Office of Quality Review used probability of reversal, as explained in GN 04440.110 and DI 30005.110, to determine that obtaining additional evidence is unlikely to reverse the disability determination or change the length of the period of disability. This case contains a medical or vocational documentation technical corrective action. No adjudicating component action is required.

The federal quality reviewer's POR rationale must also contain a brief summary of the case facts, what specific documentation is missing, and why obtaining the missing documentation is unlikely to reverse the disability determination or change the length of the period of disability.

When the adjudicating component does not fully document a case according to SSA disability program policy, and the federal quality reviewer determines the missing documentation has the potential to reverse the disability determination or change the length of the period of disability, or the likelihood of such cannot be determined, the federal quality reviewer will document consideration of POR on the Request for Corrective Action (SSA-1774-U5), stating the following:

The Office of Quality Review considered probability of reversal for this case, as explained in GN 04440.110 and DI 30005.110. However, there is insufficient information to determine whether the missing evidence from (name missing evidence) is likely to reverse the disability determination or change the length of the period of disability because (Fill in particular case facts. Examples: the mental and physical demands of the missing job are unknown; the content of the missing records is unknown). Therefore, adjudicating component action is required. 

If a federal quality reviewer considers POR, but ultimately decides to return the case to the adjudicating component for further development and correction, the paragraph above should appear on the Request for Corrective Action (SSA-1774-U5). There is no need for the federal quality reviewer to provide further information regarding POR consideration, as the content of the Request for Corrective Action (SSA-1774-U5) must delineate the reason(s) the federal quality reviewer cited a documentation deficiency.

If the medical evidence in the file is insufficient, federal quality reviewers should classify the missing documentation as a group I medical documentation deficiency, without making a POR determination, in the following situations:

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  The only medical evidence in the file consists of a diagnosis without any acceptable clinical or laboratory findings to establish a MDI. For additional information regarding MDIs, see DI 24501.020.

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  The only medical evidence in the file is unrelated to the alleged disabling impairment(s) (e.g., the medical evidence is about colds, flu, or other generally short-lived minor ailments when only a mental health impairment is alleged).

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  The only medical evidence in the file is irrelevant (e.g., evidence pertains to someone other than the claimant).

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  There is no medical evidence in the file.

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  The only medical evidence in the file is not from, or signed by, an acceptable medical source (AMS), as defined in DI 22505.003A.

NOTE: In rare situations, an adjudicator can make a disability determination, without evidence from an AMS, when the claimant has an obvious impairment (e.g., amputations as described in listing 1.20A. or 101.20A. or total blindness due to the loss of both eyes). Federal quality reviewers should not cite a medical documentation deficiency, if the claimant has an obvious impairment, as defined in DI 22505.012B.2.

If a MDI was previously established, the adjudicating component needs medical evidence from a medical source (which need not be an AMS) to determine whether there is medical improvement (MI). For the definition of a "medical source", see DI 22505.001A.4.

For an exception to the medical source requirement in "medical improvement not expected" (MINE) CDR cases, see:

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  DI 28040.115 Verification of Continued Impairment Severity

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  DI 28040.125 (Determining the Need for a Medical Source or Third Party Contact in Medical Improvement Not Expected (MINE) or MINE-Equivalent Cases)

If it is necessary to establish a new MDI, SSA disability program policy requires medical evidence from an AMS. For examples, see Evidence from an Acceptable Medical Source (AMS) DI 22505.003A.

If the medical evidence in the file is insufficient, the federal quality reviewer must classify the missing documentation as a group I medical documentation deficiency, without making a POR determination, when a CDR determination has been made in a "medical improvement expected" (MIE) or "medical improvement possible" (MIP) diary case, and one (or more) of the following is true:

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  The file does not contain sufficient evidence from a medical source to determine current severity or functioning.

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  The only evidence from a medical source is an opinion that is not supported by acceptable clinical or laboratory findings (e.g., the medical evidence contains only a statement regarding whether there has been any MI).

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  The evidence from a medical source is unrelated to the alleged disabling impairment (e.g., the medical evidence is about colds, flu, or other generally short-lived minor ailments when only a mental health impairment is alleged).

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  The evidence from the medical source is irrelevant (e.g., the evidence pertains to someone other than the claimant).

If the vocational evidence in the file is insufficient to rule out the performance of PRW, federal quality reviewers should not apply POR. Federal quality reviewers should classify the missing documentation as a group I vocational documentation deficiency, as the facts of each case warrant. What constitutes "insufficient vocational evidence" depends on the specific facts of the case under review.

If the vocational evidence in the file is insufficient to rule out the performance of PRW, federal quality reviewers should classify the missing documentation as a group I vocational documentation deficiency, without making a POR determination, regardless of how limited the proposed RFC or mental residual functional capacity (MRFC) may be.

EXCEPTION: The federal quality reviewer should not cite a group I vocational documentation deficiency if the vocational expedite described in Expedited Vocational Assessment at Steps 4 and 5 of Sequential Evaluation DI 25005.005.