I-4-3-83.Appeals Council Decisions — ODAR Headquarters Development

Last Update: 9/13/05 (Transmittal I-4-15)

A. General

Although most types of case development can be handled more efficiently in the field through AC remand to an ALJ, there will be some situations calling for limited development of the record and a subsequent decision by the AC.

B. Additional Existing Evidence

The most common situation in which the AC may prefer not to remand the case to an ALJ is one in which the record is complete and current, but the court remanded the case for the Commissioner to consider additional evidence which the claimant submitted to the court. In these cases, the claimant must show the court not only that the evidence is new and material, but also that there was a good reason why it was not submitted timely to the ALJ or the AC. However, if the evidence is not received with the court's remand order, the analyst must contact OGC to request copies of the missing evidence. If the evidence cannot be obtained by OGC, the analyst will prepare and forward a letter to the claimant's representative requesting that the evidence be sent directly to the AC within 45 days. In this and any other letter or telephone conversation with the claimant or representative, the analyst must not participate in any off-the-record communications on the merits of the case.

More specifically, the analyst must not discuss any of the following issues:

  • Sufficiency of the evidence.

  • Conflicts in the evidence.

  • Weight to be accorded to evidence.

  • Conclusions to be drawn from evidence.

  • Procedural defects.

  • Any other matter bearing on the merits of the case or on the hearing and appeals proceedings.

C. Medical Support Staff (MSS) Referrals

After receipt of additional evidence, it may be necessary to request expert advice or interpretation from MSS. In addition to the in-house medical staff, there are many specialists under contract with ODAR who are available on a consulting basis. The MSS supervisor, or designee, selects the appropriate specialist based on the information supplied by the OAO analyst on the referral form. (See section I-4-7-3 for further information on MSS referrals.) The physician selected must review the evidence and provide a narrative medical opinion.

  1. If the medical opinion is inconclusive or indicates the need for further medical development, the AC may decide to remand the case to an ALJ to obtain additional evidence from treating or consulting sources.

  2. If the medical opinion provides adequate information for the analyst to prepare a final decision, it may be possible to utilize the medical information supplied without formally admitting the medical opinion into the record as evidence.

  3. However, it will be necessary to make the medical opinion a part of the formal record when the AC is relying on the MSS opinion when reaching a decision, including, for example, those occasions when a statement of equivalency is necessary or in cases where the decision is less than fully favorable. In cases where a partially favorable decision is being issued the analyst must:

    • After review by the AC, return the case to MSS for the medical opinion to be prepared in final form and for a copy of the physician's professional qualifications (PQs).

    • Mark the medical opinion and PQs as AC exhibits.

    • Proffer the proposed exhibits to the claimant and counsel or other representative (see I-4-3-84).

In cases where a fully favorable decision is being issued, the MSS analysis may be added to the record without being typed in final form.

D. Obtaining an Earnings Record

The analyst must obtain updated earnings information before making a recommendation to the AC on any court-remanded case. Current earnings information is necessary for the analyst to:

  • Resolve any discrepancy between the dates the claimant alleges having worked and information posted on a current earnings record.

  • Verify the claimant's employment and earnings from individual employers.

  • Detect possible work activity after the alleged onset of disability.

  • Obtain the most current information on the claimant's insured status.