BASIC (01-08)

These procedures are not intended to modify existing documentation policies and procedures for CDR rationales (see CDR Rationale Content – General - DI 28090.010 or for simplified rationales CDR Simplified Rationale Procedures - DI 28091.000), with one exception.

Because the paper CPD folder used for this CDR will not routinely be pulled for future CDRs, it is important that the eCDR folder/rationale includes extra detail when paper evidence is the basis for the current continuance and that same evidence is likely to be the basis for continuance in future CDRs.

While it is not necessary to provide a detailed description of every sign, symptom or laboratory finding from the CPD, when the paper folder contains a critical finding that documents the existence of an impairment, or a test score will be needed in a future CDR, or a longitudinal history that is needed to document impairment severity, the Disability Determination Services (DDS) must document those findings in sufficient detail so that subsequent CDR reviewers will not need to retrieve the paper folder. For example, IQ test scores, x-ray results, pathology findings, cardiac tests, operative reports, may still be valid for future reviews.

If the CPD folder is paper and contains critical findings that are likely to be the basis for continuance in a future CDR, the DDS may do one of the following or a combination of both, as necessary, to document the case:

• Provide a detailed description of the paper evidence in the CDR rationale or side-by-side review; and/or

• Add the relevant paper CPD evidence into the eCDR folder. If this option is chosen, the DDS should use either document type 0305 – CPD Documents – Non Medical OR 0304 – CPD Documents – Medical. Enter the name of the source in the “note” field in eView.

NOTE: Exception noted for some Medical Improvement Not Expected (MINE) cases in which no new medical development is required. See DI 28040.125 for detailed information.

If the DDS opts to summarize the CPD evidence in the eCDR rationale, it must contain sufficient detail so the next eCDR examiner can readily determine the critical findings from the paper folder that were used in the decision without recalling the paper folder.. The rationale must explain CPD signs, symptoms, and laboratory findings that could be critical in future eCDRs. See CDR Rationale Content – General - DI 28090.010 and CDR Simplified Rationale Procedures - DI 28091.000 for required rationale content.

EXAMPLE: Rationale evaluating a case involving intellectual disability.

A WAIS-III examination was performed by Ronald Wood, Ph.D. on 10/28/04. The claimant was 23 years old at the time of the IQ testing. Results showed a Verbal IQ of 60, Performance IQ of 61 and Full Scale IQ of 59. The results were considered valid; therefore this impairment met Listing 12.05B. She had no past relevant work. Her Activities of Daily Living (ADLs) in file were consistent with her diminished intellectual functioning.

EXAMPLE: Rationale in a case involving a musculoskeletal impairment

At CPD, the claimant had a history of right knee pain for which she saw her treating physician, Tom Shade MD, on 4/25/2000. The physical exam showed her right knee was swollen and tender to touch. Flexion and extension was only 100 degrees. She was placed on anti-inflammatory medications. She returned to her physician complaining of worsening knee pain on 10/28/01. Her medications were adjusted at that time. On 12/7/01 she returned to her physician with complaints of continuing knee pain and continuing limitation of motion. X-rays noted degenerative changes with loss of joint space. An MRI dated 12/13/01 showed advanced degenerative joint disease and a meniscal tear. The claimant underwent arthroscopic surgery 1/4/02 for repair of the torn meniscus. An orthopedic consultative examination performed by Karen Bird, MD, on 11/11/02 revealed the claimant had pain, stiffness, and swelling of her right knee. The flexion/extension was 100 degrees. She had difficulty walking and used a cane for stability. The claimant met listing 1.02A.