I-3-2-22.Evaluating Whether Reviewing a Prior Claim(s) File Is Necessary

Last Update: 8/18/15 (Transmittal I-3-126)

Generally, if an administrative law judge (ALJ) was required to review a prior claim(s) file when adjudicating a claim (see Hearings, Appeals and Litigation Law (HALLEX) manual I-2-1-13), the Appeals Council (AC) will need the prior claim(s) file when adjudicating the claim. For instructions on how Office of Appellate Operations (OAO) staff requests a paper claim(s) file, see HALLEX I-3-1-23.

This means the AC will usually need a copy of the prior claim(s) file when the claim before the ALJ involved:

  • A continuing disability review (CDR);

  • A collateral estoppel issue;

  • A reopening issue when the ALJ did not make a finding;

  • A res judicata issue;

  • Findings of an ALJ or the AC on a prior claim(s) to comply with an Acquiescence Ruling (AR); or

  • Fraud or similar fault.

NOTE 1:

If the AC exercises its authority to issue a decision, it will use the same criteria in HALLEX I-2-1-13 to determine whether it needs a prior claim(s) file. If the AC finds it necessary to reference documents from the prior claim(s) file, it will use the same general principles in HALLEX I-2-1-13 in regard to exhibiting any evidence from a prior claim(s) file.

NOTE 2:

If an ALJ was required to obtain a prior claim(s) file but the file is missing, the AC will determine the appropriate action on a case-by-case basis. For example, if the record clearly shows the ALJ made all reasonable attempts to obtain and reconstruct a prior claim(s) file in a CDR case, there may be circumstances where the AC determines the facts of the case do not present a basis for granting review. In other circumstances, the AC may determine a finding that there has been no medical improvement is more appropriate, and the newly developed claim(s) file (see HALLEX I-2-1-12) may become the comparison point decision for a later CDR. See 20 CFR 404.1579(c)(3) and 416.994(b)(2)(iv)(E).

If an ALJ makes specific references to evidence in the prior claim(s) file in his or her decision, but does not associate the referenced documents with the current claim(s) file, the analyst will need to review the prior claim(s) file. In evaluating the issue, the analyst will determine whether the ALJ appropriately applied HALLEX I-2-1-13 in regard to exhibiting evidence (or citing exhibited evidence) and will recommend appropriate corrective action, if necessary.

NOTE 3:

It is important that the analyst ensures that the ALJ followed the appropriate procedures and that evidence is properly associated with the record. If the case proceeds to Federal court, the AC must ensure the certified administrative record is a full and accurate record of the proceedings. As explained in HALLEX I-4-2-30 B.4., missing exhibits that pertain to the current claim can compromise certification of the record.

Further, if the issue of reopening is before the AC, the analyst will make all reasonable attempts to obtain a prior claim(s) file. See HALLEX I-3-9-80.

When an analyst reviews a prior claim(s) file, the analyst will include in his or her analysis and recommendation to the AC appropriate references to the prior claim(s) file, and will ensure the prior claim(s) file is available for the AC when it reviews the analyst's recommendation.

NOTE 4:

For information about how the AC handles evidence in a subsequent claim(s) file, see HALLEX I-1-10-20.