BASIC (08-15)

A. Supplemental rationale documentation

Adjudicators must prepare a supplemental rationale to explain the decision-making process of various issues (1-9 below) if not documented elsewhere in the file. For a discussion of electronic rationale procedures, see DI 81020.230.

NOTE: A supplemental rationale is still required with issues 1 through 3 even if the required information is documented in the Personalized Disability Notice (PDN).

1. Discussion of medical improvement (MI)

We must explain whether MI has occurred in any determinations in which MI is considered. We must compare the severity of the impairment(s) considered at the comparison point decision (CPD) with the current severity of the same impairment(s), based on comparisons of symptoms, signs and laboratory findings, to determine if there has been any MI. When the findings demonstrate there has been MI, explain whether MI is related to the ability to work.

NOTE: If a listing is met or equaled, adjudicators should not discuss MI in Title II or Title XVI adult cases.

EXAMPLE:

Current medical evidence shows the disabled individual had full weight-bearing status at an examination in February 2014. X-rays interpreted at that time showed the fracture was well healed. A consultative orthopedic examination was secured to obtain needed range of motion data. The consulting orthopedic surgeon reported the individual had good range of motion of both lower extremities. He walked with a normal gait and had no difficulty in getting on and off the examining table. His impairment does not meet or equal listing severity.

At the CPD the individual was unable to walk without crutches and x-rays did not show the expected amount of healing. His impairment has decreased in severity since he is fully weight bearing and an x-ray shows solid union; therefore, MI has occurred. Since the individual’s condition met a listing at the CPD but no longer meets that listing, MI is related to the ability to work.

2. Basis for the most recent favorable medical decision (i.e., CPD)

In cessation determinations, explain the basis for the CPD only if the basis for the prior decision is undocumented.

EXAMPLE:

A continuance determination of 7/13/09 (the CPD) shows no basis for the determination. A medical-vocational decision was assumed based on vocational rule 201.10 in order to determine if MI is related to ability to work.

3. Exceptions to MI

In cessation determinations, explain the basis for determining that any exception(s) to MI applies.

4. Medical source opinion

For claims filed before March 27, 2017, when the total evidence does not support an opinion from the medical source stating the individual is “disabled,” “unable to work,” etc., cite the findings or evidence rebutting the medical source opinion.

5. Inconsistencies material to the determination

Explain any inconsistencies material to the determination; i.e., evidence that might indicate a different determination outcome.

6. Pain-related issues

Consider any allegation(s) or report(s) of pain:

1. in determining whether the individual has a severe impairment, and

2. at each step in the continuing disability review (CDR) evaluation process.

Adjudicators must resolve and explain inconsistencies in the evidence concerning pain (e.g., the individual alleges limitations or restrictions greater than that reasonably expected based on the objective medical findings, there are conflicts in the evidence). If these differences have not been addressed in the assessment forms (SSA-4734-BK Physical Residual Functional Capacity Assessment, SSA-2506-BK Psychiatric Review Technique, SSA-4734-F4-SUP Mental Residual Functional Capacity Assessment, or SSA-416 Medical Evaluation) prepare a supplemental rationale stating how the issue of pain was considered in the determination. For more information on pain-related issues, see DI 34001.010B.2.d.

7. Vocational rule

In assessing ability to engage in substantial gainful activity (SGA), if no vocational rule is met but the vocational rules are used as a framework for the determination, adjudicators must state which rules have been considered. For a listing of the vocational rules, see DI 25025.035.

8. Citation of jobs and incidence

In unfavorable determinations, cite jobs and incidence or a Social Security Ruling (SSR) when required. If an SSR or the absence of sufficient jobs is material to a favorable determination, address this in the supplemental rationale. For more information on the medical-vocational guidelines see DI 25025.001C.

9. Court cases

Address specific issues as required by court decisions. Adjudicators should follow the rationale requirements specified in DI 32500 for the specific court decision.

B. Preparation of the supplemental rationale

The adjudicative team (as appropriate) will prepare, sign, and date supplemental statements either:

• On a development worksheet if available, provided the worksheet remains in the file.

• On an SSA-4268 (Explanation of Determination).

• In the Electronic Claims Analysis Tool (eCAT) Disability Determination Explanation (DDE).

• On an SSA-5002 (Report of Contact).

• SSA-416 (Medical Evaluation).

NOTE: CDRs cannot be processed as Disability Redesign Prototype cases (e.g., Single Decisionmaker model (SDM)).

C. References

• DI 12015.100 Disability Redesign Prototype Model

• DI 25025.001 The Medical-Vocational Guidelines

• DI 28005.215 Evidence and Basis for Determination by a Disability Determination Services (DDS) Team

• DI 28090.000 Continuing Disability Review (CDR) Rationale Preparation

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