The DDS will prepare a personalized disability explanation with a denial notice for initial title II and title XVI medical and medical/vocational denials. The information and dates must be consistent with the basis code used to deny the claim.
In initial concurrent title II/title XVI and in DIB/DWB, DIB/CDB denials, the DDS will prepare a separate notice and personalized disability explanation for each claim. However, when the basis for the denial is the same for both claims (e.g., DIB/CDB denial based on not severe impairment) and the contents of the personalized disability explanation are the same (i.e., decision and concluding paragraphs), the personalized disability explanation may be photocopied and attached to each denial notice. The correct SSN must be shown on each copy.
When insured status or the prescribed period is last met prior to the date of the determination, the explanation should reflect the period of time considered and specify the date through which insured status or the prescribed period was met.
The personalized disability explanation must contain the following elements:
Identify medical sources by name and date of receipt.If claimants (or attorneys or third parties) submit medical evidence with the claim from multiple sources, or multiple reports from various sources can't clearly be identified, use the following statement: Medical evidence that was submitted with your claim.
Nonmedical sources (e.g., school guidance counselors, welfare departments, vocational rehabilitation agencies, day treatment facilities, sheltered workshops, social workers, and third party lay evidence) will be listed as evidence sources but will not be identified by name. Excluding third party lay evidence, nonmedical sources should be identified by position and organization (e.g., Vocational Rehabilitation Counselor, Department of Rehabilitation Services, report received XX/XX/XX).
Third party lay evidence (e.g., family members, neighbors, coworkers, etc.) will be identified under the list of reports using the following statement: “Information from other people who know about your health.” If the lay evidence is the only evidence, omit the word “other.”
Reports may be listed in paragraph form if saving space becomes a consideration or more than three reports are used;
NOTE: It is permissible to include unresponsive sources or sources who respond indicating there are no records or the claimant is not a patient in the personalized disability explanation.
When the medical sources were unresponsive, the disclaimer statement in DI 26530.055 provides an optional fill-in to say that additional reports were not obtainable; however, we had enough information to evaluate the claimant's condition;
A decision paragraph to explain the basis for the denial as indicated in the charts in DI 26530.025 through DI 26530.050;
A list of the impairments evaluated. Do not use technical terms unless the claimant uses them and appears to understand them. When information in file suggests that the claimant has a mental impairment or is unaware of the exact nature of his or her condition, the examiner must exercise care not to offend or upset the claimant. If the claimant is unaware of the impairment, use general terms such as “The evidence does not show any other conditions which significantly limit your ability to work;”
A brief description of medical severity. When discussing medical evidence, ensure the personalized explanation meets the requirements in DI 26530.010.
For claims filed before March 27, 2017, explain how you considered a treating source’s medical opinion(s) and any opinion(s) that you gave more weight than a treating source’s medical opinion. For additional information, see DI 24503.035. For claims filed on or after March 27, 2017 see DI 24503.030.
When the basis for denial is the ability to do past relevant work, include the job the claimant can do. A discussion of the RFC is not required as long as the job is consistent with the claimant's description of his/her past work. If the claimant describes past work in terms of physical or mental requirements that are different than is generally required for the job, advise him/her that he/she can do the job as it is generally performed. (For additional instructions, see DI 25005.005 – Expedited Vocational Assessment at Steps 4 and 5 of Sequential Evaluation);
When the basis for denial is the ability to do work other than what the claimant has done in the past, a statement that, although the person is unable to do any of the work he/she has done in the past, considering age, education and past work experience, he/she still has the capacity to do other work which is less demanding (refer to exertion, mental, skill level) or requires less physical effort (specify in general terms, e.g., lighter work). Do not cite other jobs. (For additional instructions, see DI 25005.005 – Expedited Vocational Assessment at Steps 4 and 5 of Sequential Evaluation);
When the reason for denial is that medical duration is not met, the medical and, if applicable, vocational information provided must cover this issue; and
Add a concluding statement, if applicable, for the specific denial as indicated in the charts in DI 26530.025 through DI 26530.050.