DI 28501.015:
Reopening of Prior Favorable Initial Continuing Disability Review (CDR) Cases
Effective Dates: 09/24/2013 - Present- Effective Dates: 12/12/2017 - Present
BASIC (03-86)- TN 1 (12-17)
DI 28501.015 Reopening in Continuing Disability Cases- DI 28501.015 Reopening of Prior Favorable Initial Continuing Disability Review (CDR) Cases
Cases may be encountered in which the CDR reviewer finds that the prior favorable initial determination (SSA-831-U5) was in error. In this situation reopening is appropriate when there “good cause,” i.e., new and material evidence has been received or there is error on the face of evidence and such reopening is not precluded by the rules of administrative finality (see DI 27501.000 and DI 27505.000). Good cause, however, is not required where a reopening action is initiated within 1 year from the date of notice. When reopening is not permitted in accordance with the above criteria, a continuing disability review must be initiated and a determination of continuance or cessation prepared.- A. Prior favorable initial determination
Cases may also be encountered in which the prior favorable continuing determination (SSA-833-U5) was in error. In this situation, reopening is appropriate unless such action is precluded by the rules of administrative finality (see DI 27505.000). Such reopenings should be done but only when the previous favorable continuing disability determination is wholly unsupported by the evidence, not because of difference in judgment (see DI 27525.000 for due process in adverse reopening cases). When reopening is precluded, a continuing disability review must be initiated and a determination of continuance or cessation prepared. See DI 28501.030 for routing reopened cases.- When a prior favorable initial determination is incorrect, reopening is appropriate when there is “good cause” and the rules of administrative finality allow. For example, good cause for reopening exists when there is new and material evidence or there is an error on the face of evidence. For more information on errors on the face of evidence or new and material evidence, see DI 27505.010, DI 28020.355, and DI 28020.365.
- We do not require good cause when reopening of an incorrect determination occurs within one year from the date of the notice of the initial determination. However, certain adverse reopenings and revisions cannot occur unless the medical improvement (MI) regulations allow a finding that disability has ceased or does not exist. For more information about MI in CDR cases, see DI 28005.001.
- B. Prior favorable CDR determination
- The Disability Determination Services (DDS) may reopen a case if a prior favorable CDR determination is incorrect and such action is not precluded by the rules of administrative finality.
- Reopen the case only when the prior favorable CDR determination is wholly unsupported by the evidence, not because of a difference in judgment.
- C. Administrative finality does not allow reopening
- When the rules of administrative finality do not allow reopening, the disability examiner must initiate a CDR claim and prepare a determination of continuance or cessation using the usual CDR procedures.
- D. References
- DI 27501.001 Reopenings and Revisions: Pertinent Definitions and Related Policy
- DI 27501.005 Reopening and Revising a Determination or Decision
- DI 27505.015 Fraud of Similar Fault - Reopenings
- DI 81030.120 Reopenings – Certified Electronic Folders (CEF)
- GN 04020.010 Unrestricted Reopening for Determinations or Decisions Involving Fraud or Similar Fault
- GN 04440.250 Reviewing Cases That Have Been Inadvertently Effectuated
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