TN 2 (08-15)

A. Complete rationales

A rationale is required in most CDR determinations, but certain case situations may require a modified rationale. For more information on these special situations, see DI 28090.200.

NOTE: Sites using the electronic Claims Analysis Tool (eCAT) will refer to the eCAT User Guide for eCDR documentation guidance.

The summary rationale must contain six elements:

1. Citation of the evidence sources;

2. Basis for most recent favorable medical determination (the comparison point decision (CPD)) and the reason for current medical review;

3. Summary of individual's reasons that he or she is still disabled;

4. Statement of nonmedical issues (e.g., substantial gainful activity (SGA), work activity, vocational rehabilitation involvement (Section 301 cases), extended period of eligibility (EPE) cases);

5. Discussion of the findings produced by the CDR evaluation process; and

6. Basis for the disability decision (the reason the individual's disability continues (e.g., meets a listing), or has ceased (e.g., medical improvement related to the ability to work has occurred and the individual has the ability to perform substantial gainful activity (SGA)).

The rationale will include accurate discussion of the medical findings. To ensure clarity and conciseness, avoid using highly technical medical terminology unless rephrasing would be misleading or would result in an incorrect medical conclusion. It is appropriate to use accepted medical abbreviations such as FEVl for “forced expiratory volume in 1 second,” and ECG for “electrocardiogram” and terms common to the medical improvement review standard (MIRS) and the CDR process, e.g., MI (medical improvement), CPD and SGA (substantial gainful activity). However, avoid excessive use of acronyms and abbreviations.

B. Preparation of the summary rationale

Prepare the rationale on an SSA-4268 (Explanation of Determination). The State or Federal agency medical or psychological consultant (MC/PC) and adjudicator will sign and date the SSA-4268 in the appropriate blocks. The adjudicator can sign the rationale singly if the MC/PC has otherwise completed a separate medical assessment using these forms:

• SSA-416 (Medical Evaluation),

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

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

• SSA-4734-F4-SUP (Mental Residual Functional Capacity assessment).

C. References

• DI 12015.100 Disability Redesign Prototype Model

• DI 24501.001 The Disability Determination Services (DDS) Disability Examiner (DE), Medical Consultant (MC), and Psychological Consultant (PC) Team

• DI 81020.230 Documenting Comparison Point Decision (CPD) Evidence and Preparing the Electronic Continuing Disability Review (eCDR) Rationale