I-3-8-20.Writing an Appeals Council Decision
Last Update: 3/10/16 (Transmittal I-3-132)
The primary audience for a decision is the claimant. Therefore, the Appeals Council (AC) will use plain language that an individual unfamiliar with Social Security terminology can understand, regardless of whether the claimant is represented.
When preparing a decision, the AC will give special attention if a record includes evidence that is potentially detrimental to the claimant's health. If disclosure or discussion of a particular condition may be detrimental to a claimant's health, and the individual is represented, the AC may elect to send a copy of the decision only to the representative. When a decision is sent only to the representative, the AC must also:
inform the claimant that the decision has been sent only to the representative; and
advise the representative to exercise discretion in deciding whether to show the claimant the decision.
When the claimant is unrepresented, the AC must send a copy of the decision to the claimant.
An AC decision must be legally sufficient and defensible. The rationale must support and fully explain the conclusion. Decisional templates for AC decisions are available in the Document Generation System (DGS).
An AC decision generally has four basic sections: procedural history, rationale, findings, and decisional paragraph.
1. Procedural History
The procedural history sets forth how the case came before the AC, the AC's jurisdiction, the issue(s) to be resolved, and a short statement regarding the AC's ultimate conclusion. The AC will also address other procedural issues such as reopening in this section.
In the rationale, the AC:
Discusses and resolves the issue(s) in the case;
Incorporates pertinent findings and conclusions in mental impairment cases, based on the technique in 20 CFR 404.1520a and 416.920a. The decision must include a specific finding regarding the degree of limitation in each of the functional areas described in 20 CFR 404.1520a(c) and 416.920a(c);
Discusses the weight assigned to evidence in resolving conflicts in the record, stating which evidence is more persuasive and why;
States the consideration given to State agency medical consultant opinions, as required in 20 CFR 404.1527 and 416.927, and Social Security Ruling 96-6p: Policy Interpretation Ruling Titles II and XVI: Consideration of Administrative Findings of Fact by State Agency Medical and Psychological Consultants and Other Program Physicians and Psychologists at the Administrative Law Judge and Appeals Council Levels of Administrative Review; Medical Equivalence;
Addresses subjective complaints, pain, and other symptom evaluation when factors to the decision;
Cites the applicable sections of the Social Security Act, regulations, Social Security Rulings, and, when applicable, Acquiescence Rulings; and
Addresses drug addiction and/or alcoholism (DAA), when applicable. When a claimant is found disabled and DAA is involved, the AC must address whether DAA is a contributing factor material to the finding of disability, pursuant to 20 CFR 404.1535 and 416.935.
Findings usually appear as a list of numbered statements. The findings are a brief summary of the issues the AC resolved and explained in the rationale section.
When a claimant is found disabled and DAA is involved, the AC must make a specific finding regarding whether DAA is a contributing factor material to the finding of disability, pursuant to 20 CFR 404.1535 and 416.935. See question 14 in Social Security Ruling 13-2p: Titles II and XVI: Evaluating Cases Involving Drug Addiction and Alcoholism (DAA).
4. Decisional Paragraph
The decisional paragraph generally begins with a summary of the ultimate conclusion and a reference to the appropriate sections of the Social Security Act. The paragraph must provide sufficient information for other agency components to understand and effectuate the decision.
C. Spanish Translations
If the claimant has requested correspondence in Spanish or the file indicates there is a need to communicate with the claimant in Spanish, branch staff will prepare the appropriate Spanish language version of the cover notice concerning the claimant's appeal rights. Instructions are set forth in HALLEX I-3-1-60.
D. Claimant Resides in Foreign Country
If the claimant resides in a foreign country, staff must modify the cover letter to advise the claimant that a civil action may be filed in the U.S. District Court for the District of Columbia, or, if applicable, in the judicial district of the United States where the claimant has his or her principal place of business. For authority, see section 205(g) of the Social Security Act.
Residents of Puerto Rico, Guam, the Northern Mariana Islands and the Virgin Islands are considered United States residents.
At least two administrative appeals judges (AAJ) must sign an AC decision. The AAJs are also responsible for acting on any fee agreement issues associated with a favorable decision, when applicable.