3.1 Levels of Appeal

Question 1

“What are the four levels of appeal in the SSA disability process?”

Answer 1

Answer:
Reconsideration.
Hearing by an Administrative Law Judge (ALJ).
Appeals Council Review.
Federal Court Review.
Explanation: “Each level provides claimants with an opportunity to challenge unfavorable decisions and present additional evidence.”
Source: CFR §404.900.

Question 2

“What happens at the reconsideration level?”

Answer 2

Answer: “The SSA re-evaluates the claim with a fresh reviewer who was not involved in the initial decision.”
Explanation: “Reconsideration is a second review of the evidence provided in the initial application, with the opportunity to submit new evidence.”
Source: CFR §404.907.

Question 3

“What is the role of an Administrative Law Judge (ALJ) in disability hearings?”

Answer 3

Answer: “The ALJ conducts a hearing to review the claim and issues a decision based on the evidence and testimony presented.”
Explanation: “This is the first opportunity for claimants to present their case in person or via video/telephone.”
Source: CFR §404.929.

Question 4

“What is the Appeals Council’s function?”

Answer 4

“To review ALJ decisions for errors of law, abuse of discretion, or new and material evidence.”
Explanation: “The Appeals Council can grant, deny, or remand the case for further review.”
Source: CFR §404.967.

Question 5

“What happens in Federal Court Review?”

Answer 5

Answer: “Claimants file a lawsuit in federal district court to challenge the SSA’s final decision.”
Explanation: “Federal courts review the administrative record to determine whether the SSA’s decision was supported by substantial evidence or was legally erroneous.”
Source: CFR §404.981.

Question 7

Case Scenario: Sarah applies for SSDI benefits, but her claim is denied at the initial determination stage. She believes the SSA made an error in evaluating her medical evidence.

Question: What is Sarah’s next step in the appeals process?

Answer 7

Answer: Sarah should file a request for reconsideration, the first level of appeal.

Legal Explanation: The SSA appeals process has four levels:

Reconsideration.
Hearing before an Administrative Law Judge (ALJ).
Appeals Council review.
Federal Court review.
Reconsideration allows a fresh review of the claim by someone who was not involved in the initial decision.

Question 8

Case Scenario: Mike, whose SSDI claim was denied at reconsideration, requests a hearing before an ALJ. He submits additional evidence two days before the hearing.

Question: Can the ALJ consider the new evidence?

Answer 8

Answer: Yes, the ALJ can consider the evidence if there is good cause for its late submission.

Legal Explanation: Under the SSA’s Five-Day Rule, evidence must generally be submitted or identified at least five business days before the hearing. Exceptions are allowed for good cause, such as delayed receipt or discovery of new evidence.

Question 9

Levels of Appeal:

Answer 9

Reconsideration.
ALJ hearing.
Appeals Council review.
Federal court review.

Question 10

Scenario:
Michael’s SSDI application is denied. He files a reconsideration request but fails to include updated medical evidence. SSA denies his reconsideration, and Michael argues the ALJ should still consider the evidence at his hearing.

Question:
Can evidence submitted after the reconsideration denial be considered at the ALJ hearing?

Answer 10

Answer:
Yes, the ALJ can consider new evidence if it is submitted in compliance with the Five-Day Rule or if good cause for late submission is established.

Explanation:
SSA’s Five-Day Rule requires evidence to be submitted at least five business days before the hearing. Late submissions are allowed only if the claimant demonstrates good cause.
Key Resource: CFR §404.935 – Evidence submission deadlines.

Key Takeaway:
New evidence can be considered at an ALJ hearing if submitted timely or with good cause for late submission.

Question 11

Scenario:
Lisa misses the 60-day deadline to request Appeals Council review, claiming she never received her ALJ denial letter.

Question:
What determines whether Lisa’s late request is accepted?

Answer 11

Answer:
Lisa must prove good cause for missing the deadline, such as non-receipt of the denial letter.

Explanation:
SSA presumes claimants receive decisions within five days of mailing. Lisa must provide evidence, such as incorrect address records, to rebut this presumption.
Key Resource: CFR §404.968(b) – Good cause for late filing at the Appeals Council.

Key Takeaway:
Claimants must demonstrate good cause, such as non-receipt of a decision, to file late Appeals Council requests.

Question 12

Scenario:
Tom requests Appeals Council review after his ALJ denial. The Council finds no significant procedural errors or abuse of discretion but disagrees with the ALJ’s RFC determination.

Question:
Can the Appeals Council reverse the ALJ’s decision based on disagreement with the RFC?

Answer 12

Answer:
Yes, the Appeals Council can review and reverse ALJ decisions based on errors in factual findings, including RFC assessments.

Explanation:
The Appeals Council reviews cases for procedural errors, abuse of discretion, or unsupported factual findings. RFC errors fall under this scope.
Key Resource: CFR §404.970(a)(3) – Grounds for Appeals Council review.

Key Takeaway:
The Appeals Council can review and reverse ALJ decisions for factual errors, including incorrect RFC findings.

Question 13

Scenario:
Sara files a federal court appeal after exhausting SSA’s internal appeals process. She introduces new medical evidence not previously submitted.

Question:
Can the federal court consider Sara’s new evidence?

Answer 13

Answer:
No, the federal court cannot consider new evidence unless the case is remanded to SSA under Sentence Six of 42 U.S.C. §405(g).

Explanation:
Federal court review is limited to the administrative record. New evidence may only be considered if it is material and there was good cause for not submitting it earlier.
Key Resource: 42 U.S.C. §405(g) – Sentence Six remand for new evidence.

Key Takeaway:
Federal courts review only the administrative record unless a remand is granted for new evidence under Sentence Six.

Question 14

Scenario:
What is the first level of appeal for a denied SSDI claim?

Question:
Where does a claimant begin the appeals process?

Answer 14

Answer:
Reconsideration.

Explanation:
The reconsideration stage involves a new review of the claim by a different SSA official who was not involved in the initial decision.
Key Resource: CFR §404.907 – Reconsideration process.

Key Takeaway:
The first level of appeal for a denied SSDI claim is reconsideration.

Question 15

Scenario:
What is the deadline for filing an appeal at each stage of the SSA process?

Question:
How long do claimants have to file an appeal after receiving a denial?

Answer 15

Answer:
60 days from the date of receipt of the denial letter.

Explanation:
SSA presumes claimants receive decisions five days after mailing, giving them 65 days from the decision date to file appeals.
Key Resource: CFR §404.909 – Appeal deadlines.

Key Takeaway:
Claimants have 60 days from receipt of a denial to file an appeal.

Question 16

Scenario:
John’s SSDI claim is denied at the ALJ level because his RFC allows for sedentary work. He files an appeal with the Appeals Council, arguing that his vocational factors were not properly considered.

Question:
What vocational factors can the Appeals Council evaluate in John’s case?

Answer 16

Answer:
The Appeals Council can review John’s age, education, and transferable skills to determine if vocational factors were misapplied.

Explanation:
The Appeals Council evaluates whether the ALJ applied vocational rules correctly, especially when assessing transferable skills for older claimants.
Key Resource: CFR §404.970(a) – Appeals Council scope of review.

Key Takeaway:
The Appeals Council reviews vocational factors to ensure ALJs apply them correctly in disability determinations.

Question 17

Scenario:
Emma’s SSDI claim is denied at Step 4. At the ALJ hearing, her representative fails to present key vocational evidence. Emma files a federal court appeal citing ineffective representation.

Question:
Can federal court reverse the ALJ decision based on ineffective representation?

Answer 17

Answer:
No, federal court cannot reverse an ALJ decision solely for ineffective representation but can remand for procedural errors affecting the fairness of the hearing.

Explanation:
Federal courts evaluate whether procedural errors compromised due process. Ineffective representation alone does not meet this standard unless it caused a denial of fair hearing rights.
Key Resource: 42 U.S.C. §405(g) – Federal court review and remand.

Key Takeaway:
Federal court evaluates procedural fairness, not representative effectiveness, when reviewing SSA decisions.