DI 30005.123: Group I Documentation Deficiencies

changes
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Effective Dates: 01/17/2017 - Present
TN 8 (04-04)
DI 30005.123 Group I Documentation Deficiencies
A. Definition - group I documentation deficiency
A group I documentation deficiency is a substantive deficiency that has the potential for reversing the disability determination from unfavorable to favorable or from favorable to unfavorable. The defined group I documentation deficiencies are listed in DI 30005.123C.
B. Policy
A group I documentation deficiency exists when the documentation in file is insufficient to support the disability determination. There are five types of group I documentation deficiencies:
* medical documentation deficiency
* vocational documentation deficiency
* medical evaluation deficiency involving vocational documentation
* procedural documentation deficiency
* collateral estoppel documentation deficiency
C. Procedure - defined group I documentation deficiencies
1. Group I medical documentation deficiency
A group I medical documentation deficiency is cited when the medical documentation in file is insufficient to support the disability determination. Specifically, the medical documentation is insufficient to determine one of the following:
* Impairment severity; i.e., whether:
* there is a medically determinable severe impairment that has lasted, or is expected to last,
* 12 continuous months or result in death, or
* the impairment meets or medically or functionally equals the listings, and a medical-vocational fully favorable allowance cannot be made based on the evidence in file per DI 24515.001 — DI 24515.001
* the impairment meets or medically or functionally equals the listings, and a medical-vocational fully favorable allowance cannot be made based on the evidence in file per DI 24515.001 — DI 24515.001
* Duration;
* MI including whether there has been MI or whether MI is related to the ability to work;
* MI exceptions including:
* whether new medical evidence and a new assessment of RFC show that an individual is a beneficiary of advances in medical or vocational therapy or technology, or
* whether new or improved diagnostic techniques demonstrate that an individual’s impairment is not as disabling as it was considered at the time of the last determination;
* RFC when the claimant has a severe impairment, and a determination cannot be made on medical considerations alone;
* Failure to follow prescribed treatment;
* DAA materiality including:
* Unresolved conflicting evidence on the issue of materiality, or
* Insufficient documentation of all other alleged or potential non-DAA impairments when DAA is material;
* Onset of disability relative to:
* DLI for Title II workers,
* the prescribed period for a disabled widow(er), or
* attainment of age 22 for a childhood disability claimant; i.e., the DLI, prescribed period or age 22 is clearly documented, the medical evidence in file does not support the onset date and the correct onset date could be after DLI, prescribed period or age 22.
2. Group I vocational documentation deficiency
A group I vocational documentation deficiency is cited when the adjudicating component's impairment severity or RFC assessment is correct but the vocational documentation is insufficient to determine the effect of the following factors on an individual's ability to engage in SGA:
* age,
* education, literacy, or the ability to communicate in English,
* work history including transferable skills, physical, mental and environmental demands of past work and the relevance of past work,
* advances in vocational therapy or technology when there is new medical evidence and a new RFC but no MI, or
* vocational therapy.
3. Group I medical evaluation deficiency involving vocational documentation
A group I medical evaluation deficiency involving vocational documentation is cited when the file contains sufficient documentation to determine impairment severity or RFC, but an incorrect assessment of impairment severity or RFC makes additional vocational documentation necessary to determine disability.
4. Group I procedural documentation deficiency
A group I procedural documentation deficiency is cited when the documentation in the case is insufficient to show conformance to prescribed procedures for a determination based on one of the following:
* Prior determination in error (MI review standard);
* Failure to follow prescribed treatment;
* Whereabouts unknown;
* Failure to cooperate;
* Work activity;
* AR (e.g. Chavez AR 97-4(9) and Albright 00-1(4)) when:
* the claim is a subsequent disability claim to which an AR applies, and
* the file is not sufficiently documented to conform with the AR requirement to consider the prior ALJ/AC final disability decision or findings; i.e., the case does not contain either the prior folder or a copy of the ALJ/AC final decision or an explanation of why the prior folder or copy of the ALJ/AC final decision cannot be obtained.
NOTE: Refer to DI 52715.000 for specific instructions for obtaining the prior file or prior ALJ/AC final decision.
5. Group I collateral estoppel documentation deficiency
A group I collateral estoppel documentation deficiency exists when:
* the documentation in file is insufficient to determine whether a prior final determination can be adopted,
or
* The documentation in file is sufficient to determine that a prior final determination cannot be adopted, and
* The prior final determination was incorrectly adopted, and
* There is insufficient documentation in file to determine disability on the current claim.

POMS Reference

DI 30005.123: Group I Documentation Deficiencies