Last Update: 9/08/05 (Transmittal I-3-36)
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APPEALS COUNCIL DECISIONS CLAIM TYPE: _________ If concurrent, is the action the same for both? Yes No If no, complete the following information separately for both Titles. If yes, complete only the DIWC / DIWW / RSI portion. DIWC / DIWW / RSI Initial Claim Cessation DECISION: Fully Favorable Affirmation Part. Favorable Reversal Unfavorable If partially favorable: Closed POD Later Onset Other EOD: ________ If Reversal, enter position codes - see APPENDIX I 1st Position: _____ - 2nd Position: _____ ============================== SSID / SSIA / SSIB Initial Claim Cessation DECISION: Fully Favorable Affirmation Part. Favorable Reversal Unfavorable If partially favorable: Closed POD Later Onset Other EOD: ________ If Reversal, enter position codes - see APPENDIX I 1st Position: _____ - 2nd Position: _____ |
PFI / 2PF Codes F = Fully Favorable C = Closed POD / Later Cessation L = Later Onset O = Other APPENDIX I Reversal Reason Codes The following are permissible reversal reasons for use in blocks RRC and 2RC in the OHA CCS system. 1st Position: A= New Evidence B= Same Evidence 2nd Position: A= Age B= Consultative Examination C= Credibility D= Different Interpretation of Law/Statues E= Different Evaluation of Evidence F= Impairment — New G= Impairment — Same H= Impairment — Worsened I= Income J= Resources K= Insured Status L= Living Arrangements M= MA Testimony N= MA Answers to Interrogatories O= Other Medical Judgments/Reports P= Overpayment Q= Physical Observation R= Report from FO S= Relationship T= Technical Error U= Underpayment V= VE Testimony W= VE Evidence other than Testimony X= Vocational Factors |
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The DAA indicator below must be completed in all disability cases. Drug Addiction and/or Alcoholism Indicator: _________ |
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Regulation Basis Code(s) (Complete in fully favorable and partially favorable AC decisions) The following are permissible Regulation Basis Codes for use in blocks 1RG/3RG and 2RG/4RG in the OHA CCS system. A = Impairment Meets Listing B = Impairment Medically Equals Listing K = Severe Impairment and Vocational Factors L = Severe Impairment and Arduous Work History P = Engaging in SGA O = Impairment Not Severe M = Impairment Severe, But Does Not Preclude PRW U = Impairment Severe, Bu Does Not Preclude Other Work S = Failure to Follow Prescribed Treatment Q = Impairment Severe But, Not Expected to Last 12 Months First Regulation Basis Code: 1RG (Title II) ________ 3RG (Title XVI) ________ Second Regulation Basis Code (Partially Favorable): 2RG (Title II) ________ 4RG (Title XVI) ________ |
Impairment Code(s) (Complete in fully favorable and partially favorable AC decisions) The following POMS references contain codes for use in describing primary and secondary impairments. 1MP and 2MP are used for the Title II portion of cases. 5MP and 6MP are used for the Title XVI portion of cases. See POMS DI 26510.015G. for a complete list of these codes.
Primary Impairment Code: 1MP (Title II) ________ 5MP (Title XVI) ________ Secondary Impairment Code: 2MP (Title II) ________ 6MP (Title XVI) ________ |