I-3-8-1.General

Last Update: 12/1/14 (Transmittal I-3-87)

A. Authority

Under 20 CFR 404.979 and 416.1479, the Appeals Council (AC) may affirm, modify, or reverse an administrative law judge's (ALJ) decision. Additionally, the AC may adopt, modify, or reject an ALJ's recommended decision. For additional information on recommended decisions, see Hearings, Appeals and Litigation Law (HALLEX) manual I-2-8-15 and I-3-1-6.

B. Purpose

The primary purpose of an AC decision is to dispose of all issues in a case. If the ALJ did not consider all elements of eligibility or entitlement or if new and material evidence (HALLEX I-3-3-6) is submitted to the AC, the AC's decision may extend beyond the scope of the ALJ's decision. However, when issuing a favorable decision, the AC will generally only exercise its authority to issue a decision when the AC determines that onset occurred on or before the date of the ALJ's decision.

C. Evidence Considered by AC

When the AC issues a decision, the AC will consider all the evidence of record and any additional evidence it received, subject to the regulatory limitations in 20 CFR 404.970(b), 404.976(b), 416.1470(b), and 416.1476(b).

NOTE 1:

If the ALJ issued the decision under Part 405, the AC will consider additional evidence subject to the regulatory limitations in 20 CFR 405.401.

NOTE 2:

If the AC is issuing a decision in a continuing disability review case, see subsection E below.

If the claimant submitted additional evidence that is new or material, and relates to the date on or before the ALJ decision and the AC issues a decision (see HALLEX I-3-3-6), the AC will exhibit the additional evidence and address it in the decision.

If the claimant submitted additional evidence that is not new, the AC will identify the evidence as duplicate in the notice of decision (but not in the decision itself) and will not exhibit the evidence.

If the claimant submitted additional evidence that is new and material but not related to the period at issue (see HALLEX I-3-3-6), and the AC issues an unfavorable decision or a closed period decision, the AC will:

  • Use the date of the request for review as a protective filing date;

  • Manually include modified protective filing date language in the notice of decision citing the additional evidence by source, date range, and number of pages (see Document Generation System denial 10 stored paragraph 4 for protective filing language); and

  • Not address the additional evidence in the decision.

NOTE:

When the claim is for title II benefits only and the claimant's insured status has expired, the AC will provide protective filing for a new title II claim if the date last insured was within two years of the AC decision. This is necessary to account for any lag earnings. See Program Operations Manual System RS 01404.005.

D. Effect of AC Decision

An AC decision is binding on all parties unless it is reversed or modified as the result of a civil action, or unless it is reopened and revised. See 20 CFR 404.981 and 416.1481.

E. Continuing Disability Reviews and Social Security Ruling 13-3p

On February 21, 2013, the Social Security Administration issued Social Security Ruling (SSR) 13-3p: Title II: Appeal of an Initial Medical Disability Cessation Determination or Decision. In the SSR, the agency adopted the holding in Difford v. Secretary of Health and Human Services, 910 F.2d 1316 (6th Cir. 1990) and extended the policy previously applied only in title XVI medical cessation claims to title II medical cessation claims. In sum, SSR 13-3p requires that, when issuing a determination or decision, an adjudicator evaluating a medical cessation claim must decide whether the beneficiary is under a disability at any time through the date of the adjudicator's determination or decision.

For more information and instruction regarding SSR 13-3p, see HALLEX I-3-1-75.