Aspects of Disability Decision Making: Data and Materials

claimants or their appointed representative mustfile the appeal request in writing within 60 daysfrom the date the notice of unfavorable decisionis received. If the claimant does not take the nextstep within the stated time period, he or she losesthe right to further administrative review and theright to judicial review of this particular claim,unless good cause can be shown for failure to makea timely request.ReconsiderationGenerally, the reconsideration is the first levelof appeal and consists of a DDS case review. It issimilar to the initial determination process exceptthat it is assigned to a different disability examinerand physician/psychologist team. Claimantsare given the opportunity to present additionalevidence to supplement the information that wassubmitted when the original decision was made.If the reconsideration team concurs with theinitial denial of benefits, the individual may thenrequest a hearing before an ALJ in the OfficeDisability Adjudication and Review.Administrative Law Judge HearingAdministrative law judges (ALJs) are based inthe 169 hearing offices (including seven satelliteoffices) located throughout the nation. At the hearing,claimants and their representatives may appearin person (or by videoconference), submit new evidence,examine the evidence used in making thedetermination under appeal, and present and questionwitnesses. The ALJ may request medical andvocational experts to testify at the hearing and mayrequire the claimant to undergo a consultative medicalexamination. The ALJ issues a decision based onthe hearing record and, in cases where the claimantwaives the right to appear at the hearing, the ALJmakes a decision based on the evidence that is in thefile and any new evidence that has been submittedfor consideration.DDSs and ALJs approach the decision makingprocess differently. DDSs conduct a paper review ofa claimant’s medical and vocational evidence, whileALJs hold face-to-face hearings and have the opportunityto observe the claimants firsthand. Due tothe passage of time between the two decisions, ALJsoften receive information that was not available tothe DDS and was not considered in that determination.In addition, hearings are more likely to involveprofessional representation. Another difference isthe instructional basis for the decision; DDS adjudicatorsuse instructions found in SSA’s ProgramOperations Manual System (POMS) while ALJs relydirectly on the law and regulations. SSA is currentlyworking on an electronic case analysis tool thatwill bridge the two determination standards andimprove both the quality and consistency of decisionsat all levels. Many experts contend that theseare some of the differences in the decision makingprocess that contribute to the high number of DDSdecisions that are reversed at the hearing level.Appeals Council ReviewSSA’s final administrative appeals step is tothe Appeals Council. If the claimant is dissatisfiedwith the hearing decision, he or she may requestthat the Appeals Council review the case. TheCouncil, made up of administrative appeals judges,may also, on its own motion, review a decisionwithin 60 days of the ALJ’s decision.The Appeals Council considers the evidence ofrecord, any allowable additional evidence submittedby the claimant, and the ALJ’s findings andconclusions. The Council may grant, deny, or dismissa request for review. If it agrees to review thecase, the Council may uphold, modify, or reversethe ALJ’s action, or it may remand it to the ALJso that he or she may hold another hearing andissue a new decision. The Appeals Council mayalso remand a case in which additional evidence isneeded or additional action by the ALJ is required.The Appeals Council’s decision, or the decisionof the ALJ if the request for Appeals Councilreview is denied, is binding unless the claimantfiles an action in a Federal District Court.Judicial AppealsFederal District CourtClaimants may file an action in a Federal DistrictCourt within 60 days after the date they receivenotice of the Appeals Council’s action. In fiscalyear 2010, 13,229 new Social Security cases wereappealed to the district courts, representing lessthan 5 percent of the district court civil caseload.Circuit Court of Appeals and Supreme CourtIf the U.S. District Court reviews the caserecord and does not find in favor of the claimant,the claimant can continue with the legal appealsprocess to the U.S. Circuit Court of Appeals andultimately to the Supreme Court of the UnitedStates. The Social Security Administration may,similarly, appeal district or circuit court decisionsthat are favorable to the claimant.88 Aspects of Disability Decision Making: Data and Materials