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DI 27536: Simplified Reopening Rationale Procedures

Effective Dates: 03/24/2017 - Present

BASIC (01-12)

There is no need to duplicate information documented elsewhere in the file. Use the tables below to locate the information required to reopen continuing disability review (CDR) determinations; and, what actions are necessary if the information is not already contained in the file.

Required information for reopening a CDR determination includes:

  • Assessment of functional abilities

  • Basis for determination

  • Basis for the most recent prior favorable medical determination, i.e., comparison point decision (CPD)

  • Beneficiary's reason for continued entitlement or cessation

  • Citation of jobs and incidence

  • Date of CPD

  • Discussion of comparison of medical findings under medical improvement review standards (MIRS)

  • Evidence sources

  • Medical facts

  • Pain-related issues

  • Reason for current review

  • Resolution of conflicting medical opinions

  • Resolution of inconsistencies material to the determination

  • Statement of nonmedical issues

  • Vocational rule used for medical-vocational determinations

See Also:

DI 27536.001 Reopening Rationale Preparation

A. Location of required information

Use the table below to locate required information.

 Information Determination Where Usually Documented In File

Assessment of functional abilities

Continuance

  • Medical evidence

  • SSA-4734-BK Physical Residual Functional Capacity Assessment (RFC)

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

Cessation

  • Medical evidence

  • MRFC

  • RFC

Assessment of functional abilities

Continuance

  • Medical evidence

  • MRFC

  • RFC
 

Cessation

  • Medical evidence

  • MRFC

  • RFC

Basis for determination

Continuance

Items 10 and 12 on the SSA-832/833
 

Cessation

  • Items 10 and 11 on the SSA-832/833

  • Personalized cessation notice (PCN)

Basis for the most recent prior favorable medical determination, i.e., CPD

Continuance

  • Administrative law judge (ALJ) decision

  • Appeals Council (AC) decision

  • Federal court decision

  • SSA-831 Item 22 (Regulation basis code)

  • SSA-832 or SSA-833 item 10

  • SSA-5002 Report of Contact
 

Cessation

  • ALJ, AC or court decision

  • PCN

  • Regulation basis code

  • SSA-832 or SSA-833 item 10

  • SSA-5002

Beneficiary's reason for continued entitlement or cessation

Continuance

  • SSA-454-BK Continuing Disability Review Report

  • SSA-820-F4 Work Activity Report (Self-Employed Person)

  • SSA-821-BK Work Activity Report

  • SSA-5002 or SSA-553 Special Determination
 

Cessation

  • PCN

  • SSA-454-BK

  • SSA-820-F4

  • SSA-821-BK

  • SSA-5002 or SSA-553

Citation of jobs and incidence

Continuance

Not applicable
 

Cessation

Report by a vocational specialist

Date of CPD

Continuance

  • Case summary, developmental worksheet, or disability determination evaluation

  • Prior determination or decision

  • SSA-5002
 

Cessation

  • Case summary, developmental worksheet, or disability determination evaluation

  • PCN

  • Prior determination or decision

  • SSA-5002

Discussion of comparison of medical findings under MIRS

Continuance

  • MRFC

  • RFC

  • SSA-832 or SSA-833 item 10

  • SSA- 2506-BK Psychiatric Review Technique (PRTF)
 

Cessation

  • MRFC

  • PCN

  • PRTF

  • RFC

  • SSA-832 or SSA-833 item 10

Evidence sources

Continuance

Medical evidence
 

Cessation

  • Medical evidence

  • Personalized cessation notice

Medical facts

Continuance

  • Medical evidence

  • SSA-5002
 

Cessation

  • Medical evidence

  • SSA-5002

Pain-related issues

Continuance

  • Any medical listing that specifically mentions pain

  • PRTF

  • RFC

  • MRFC
 

Cessation

  • MRFC

  • PRTF

  • RFC

Reason for current review

Continuance

  • Diary matured

  • SSA-831, SSA-832, or SSA-833 diary block

  • SSA-832 or SSA-833 item 20

  • SSA-847 Request for Case Action

  • SSA-5526 Request for Assistance-Disability
 

Cessation

  • Diary matured

  • Personal decision notice

  • SSA-831, SSA-832, or SSA-833 diary block

  • SSA-832 or SSA-833 item 20

  • SSA-847

  • SSA-5526

Resolution of conflicting medical opinions

Continuance

Resolved by the determination of a continuance (SSA-832 or SSA-833
 

Cessation

  • MRFC

  • PRTF

  • RFC

Resolution of inconsistencies material to the determination

Continuance

Resolved by the determination of a continuance (SSA-832 or SSA-833
 

Cessation

  • MRFC

  • PRTF

  • RFC

Statement of nonmedical issues

Continuance

  • SSA-820-F4

  • SSA-821-BK

  • SSA-454-BK

  • SSA-832/833

  • SSA-899 Continuing Disability Review (Completed by the PSC's)
 

Cessation

  • PCN

  • SSA-820-F4

  • SSA-821-BK

  • SSA-454-BK or SSA-832/833

  • SSA-899

Vocational rule used for medical-vocational determinations

Continuance

Item 14 on the SSA-832 or SSA-833
 

Cessation

Item 14 on the SSA-832 or SSA-833

B. Rationale documentation required

A rationale must address specific information not already documented in the case file.

Use the table below to determine how you need to document the missing information.

 Information

Where Usually Documented In File

Action Required If Not Already In File

Basis for the most recent prior favorable medical determination, i.e., comparison point decision (CPD)

(cessation determination)

Personalized cessation notice

See DI 27536.001C.3.

Discussion of comparison of medical findings under MIRS

(cessation determination)

Items 10 and 12 on the SSA-832 or SSA- 833

See DI 27536.001C.1.
 

Personalized cessation notice

See DI 27536.001C.2.
 

  • SSA- 2506-BK Psychiatric Review Technique

  • SSA-4734-BK Physical Residual Functional Capacity Assessment

  • SSA- 4734-F4- SUP Mental Residual Functional Capacity Assessment

See specific instructions for:

  • Pain-related issues

  • Resolution of conflicting medical opinions

  • Resolution of inconsistencies material to the decision

C. References

  • DI 28501.001 Question of Reopening Arises

  • DI 28501.005 Reopening of Prior Cessation Determination

  • DI 28501.010 Processing Charts: CDR Reopenings Under Administrative Finality (Revision of Prior Cessation)

  • DI 28501.015 Reopening in Continuing Disability Cases

  • DI 28501.020 Unfavorable Reopening of Prior Continuance Determination

  • DI 28501.025 Reopening and Revision of a Prior CDR Reconsideration Determination

  • DI 28501.030 Routing Reopened Cases

Previous:
DI 27530: Reopenings - Completion of Form SSA-831-U5
Up:
DI 275: Reopenings, Res Judicata, and Collateral Estoppel
Next:
DI 27540: Reopening Notice Instructions
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