DI 26515: Rationale Preparation (Initial Claims)
TN 2 (03-17)
Citations:
20 CFR 404.1529 and 416.929; Social Security Ruling (SSR) 16-3p 20 CFR 404.1527 and 416.927; 20 CFR 404.1520c and 416.920c; P.L. 104-121, Section 105; Section 105; SSR 82-59
A. Rationale Basics
Disability policy requires the disability determination services (DDS) to provide complete documentation of the sequential evaluation process used in claims adjudication. The disability determination explanation (DDE) can serve as the rationale; however, users need to ensure that the analysis in the DDE includes all of the required elements discussed in this section. The DDS has the option to follow the instructions in this section or the instructions for the Simplified Rationale Procedures in DI 26516.001 through DI 26516.015.
B. Required elements of the rationale
Include the following elements in all rationales, as applicable. Not every claim requires a discussion of all of the elements. For example, address Drug Addiction and Alcoholism (DAA) only if it is material to the allowance.
1. Citation of the sources of evidence
a. Individual medical source(s) reports
For individual medical evidence of record (MER) sources, cite the source’s name and date of receipt.
For consultative examination (CE) sources, cite the CE’s name and date of the examination.
b. Hospital(s), clinic(s), mental health center(s) reports
Cite name(s) and date(s) of receipts for each source.
c. Nonmedical source(s) reports
Cite nonmedical professional sources by name and date of receipt.
Cite other nonmedical source evidence generically, e.g., third party report received on MM/DD/YY.
2. Statement of allegations
State the claimant’s allegations (illnesses, injuries, and conditions), related limitations, and date of alleged onset.
Include allegations and limitations at time of filing and others identified or alleged during claim development.
3. Statement on substantial gainful activity (SGA)
State whether the claimant is working or not. If applicable, explain the field office’s (FO) resolution of the work issue(s), e.g., the work is SGA or is not.
4. Discuss other technical issues
Identify and discuss other technical issue(s), e.g., date last insured (DLI); unsuccessful work attempt (UWA); and, if applicable, explain the FO or DDS resolution.
5. Discuss findings of fact and analysis of the evidence
Discuss your analysis of the medical and non-medical evidence, including objective medical evidence (signs, laboratory findings, or both) and evaluation of symptoms used to make the determination.
Make findings of fact; do not merely summarize evidence.
If applicable, consider and discuss the duration requirement.
If applicable, consider and discuss vocational issues.
State the established onset date (EOD) based on the claimant’s potential onset date (POD) provided by the FO. If the EOD differs from the alleged onset date (AOD), explain the reason(s) for the change. For more detailed information on documenting the EOD, see DI 25501.200C.2.
6. Discuss symptom evaluation
Discuss the claimant’s statements about his or her symptoms and their functional effects.
Assess the claimant’s statements and explain the reasons for your assessment and conclusion.
For more information on symptom evaluation, see DI 24501.021 and DI 24515.065
7. Discuss weight to give to medical opinion(s) for claims filed before March 27, 2017
Cite each medical opinion by the source name and date of receipt, and briefly describe the content of each medical opinion.
Assess and determine what weight to give the medical opinion(s). Discuss the reasons, including supporting evidence, for the weight given to each medical opinion.
Discuss whether any treating source(s)’ medical opinion(s) is entitled to controlling weight; explain why.
For information on weight of medical opinions, see DI 24503.035.
8. Discuss medical opinion(s) and prior administrative medical findings for claims filed on or after March 27, 2017
Cite each by source name and date, and briefly described the content of each.
For articulation requirements, see DI 24503.030.
For information on medical opinions, see DI 24503.025.
9. Discuss DAA
If you find the claimant to be disabled and there is evidence of DAA, determine and discuss whether DAA is material to the finding of disability.
For more information on DAA, see DI 90070.000.
10. Discuss a failure to follow prescribed treatment determination
If there is evidence that the claimant may not have followed prescribed treatment, discuss whether to preclude the claimant from benefits by making a failure to follow prescribed treatment determination.
For information on failure to follow prescribed treatment, see DI 23010.005 through DI 23010.025.
11. Discuss unsuccessful requests to the claimant for evidence or action and resulting determination
If reasonable attempts to ensure claimant cooperation with our requests for evidence or action are unsuccessful, discontinue development that requires claimant action (e.g., consultative examinations and claimant forms completion).
For a discussion of what represents a “reasonable attempt to ensure claimant cooperation,” see DI 23007.001 through DI 23007.010.
After making every reasonable effort to obtain all complete medical history available without the claimant’s cooperation, make a determination based on all of the evidence in the file. For further information on what constitutes “every reasonable effort” and “complete medical history,” see DI 22505.001.