Can a Favorable ALJ Disability Decision Be Overturned by the Appeals Council?

Question: Can Social Security Overrule a Fully Favorable Decision by the Hearing Judge?

I had my disability hearing a few weeks ago, and I'm waiting to receive a decision letter. The hearing seemed to go well and the administrative law judge seemed sympathetic to my case. I've heard this judge approves most disability cases. If the judge decides I should get disability benefits, is that the end of it, or can the judge's decision be overruled by Social Security?

Answer: A Disability Judge's Favorable Decision Can Be Overturned

Technically, the Appeals Council can overturn a hearing judge's favorable ruling (one that grants benefits). But it's not likely to happen in your case.

The Social Security Administration's (SSA's) disability appeals process is intended to ensure that applicants with disabilities get the benefits they deserve and that no one who can work collects benefits they shouldn't receive. For some background, Social Security has three administrative appeal levels:

• reconsideration of your claim (by a new claims examiner at your state's Disability Determination Services (DDS) agency)
• appeal hearing before an administrative law judge (ALJ), and
• a review by the Social Security Appeals Council (AC).

Just as an ALJ can overturn a DDS claims examiner's decision, the Appeals Council can overturn a hearing judge's ruling.

How Cases Get on the Appeals Council's Agenda

Most cases before the Appeals Council are reviewed at the request of a disability applicant ("claimant") who's unhappy with an ALJ's decision.

You can request an Appeals Council review if you disagree with any part of the judge's ruling, like in any of the following situations:

• Your disability benefits are denied.
• The ALJ grants you disability benefits but moves up your onset date, reducing the amount of back pay you're entitled to receive.
• Your disability benefits are approved for a closed period, but you still can't work because of your impairments.

The Appeals Council is also required by law to review a small number of ALJ decisions "on its own motion." (Pub. L. 96-265 § 304(g).) This review process was created to ensure that all final claims decisions made by Social Security are consistent with the laws, regulations, and policies that govern the agency. The process is similar to how the Disability Quality Branch (DBQ) selects random cases for quality review of DDS decisions.

When the Appeals Council Is Required to Review a Claim

Because reviews on the Appeals Council's "own motion" aren't very common, it's unlikely that your case would be chosen for review, but it is possible.

Anytime within 60 days of the date the ALJ makes a decision in your case, the Appeals Council's Division of Quality can decide on its own motion to review that decision. (20 C.F.R. § 404.969(a).)

The Appeals Council can choose to review any type of ALJ decision, including:

• a fully favorable decision (approval back to your alleged onset date)
• a partially favorable decision (approval back to an established onset date)
• an unfavorable decision (a denial), and
• a dismissal (usually for fail to appear).

The Appeals Council uses random and selective sampling to identify potential cases for review, but the council won't generally take up a case where the outcome isn't likely to change, unless there's a compelling reason to do so. But the law requires the Appeals Council to review cases in four specific circumstances:

• The ALJ appears to have misinterpreted, misapplied, or failed to consider pertinent laws, regulations, or agency policies.
• There doesn't appear to be sufficient evidence (quantitatively or qualitatively) to support the ALJ's decision.
• A decision raises or addresses a question that could have far-reaching implications and could affect a significant number of claims.
• The ALJ appears to have abused their discretion, for instance, by:
  • not conducting a full and fair hearing
  • not allowing a hearing to be postponed for just cause (like a documented health emergency), or
  • failing to follow required procedures.

What Happens If the Appeals Council Reviews Your Case?

If the Appeals Council decides to review the ALJ's decision in your case, you'll be notified of its proposed action (to reverse the ALJ's decision, affirm it, or send it back to the ALJ), and you'll get the chance to offer your input. You'll receive this notice within 60 days of the ALJ's decision.

After reviewing the ALJ's decision, the Appeals Council can rule in one of four ways:

• affirm (uphold) the ALJ's decision or dismissal
• modify (change) the ALJ's decision
• reverse the ALJ's decision or dismissal, or
• remand (send back) the case to an ALJ for further action.

The Appeals Council can choose to reverse any ruling—including a fully favorable or partially favorable ALJ decision. But that's not very likely when you consider that the Appeals Council doesn't issue decisions (upholding or reversing claims) in very many cases. When the Appeals Council does act on a case, their most common action is to send the case back to the ALJ for another look.

How Long Does It Take for the Appeals Council to Decide an Own-Motion Review?

It's possible that an Appeals Council own-motion review could delay your benefits. It generally takes the AC at least two months or more to review a case on its own motion. Even if the council eventually upholds a favorable ALJ decision, your benefits generally can't begin until after the Appeals Council issues a ruling (if the council has chosen to review your claim).

But if the council takes too long to issue a final order (more than 110 days from the hearing decision), Social Security will pay you interim benefits (but not back pay) while you wait. The notice from the Appeals Council informing you that your case is under review will also notify you of your right to interim benefits.

Learn what you can expect once your SSDI or SSI claim is approved.

_{Updated April 2, 2024}