What are the Rules about Evaluating Medical Evidence in a Social Security Disability Claim?

Social Security published “Revisions to Rules Regarding the Evaluation of Medical Evidence” in the Federal Register and they became effective on March 27, 2017. (Refer to 82 FR 5844.) For claims filed before March 27, 2017, Social Security continues to use some of the prior policies to evaluate medical evidence. This article discusses at a high level new rules Social Security uses to evaluate medical evidence in claims filed on or after March 27, 2017.

What Medical Evidence do I Need to Prove my Social Security Disability Claim?
To be approved for disability benefits, you must submit medical evidence to prove you have a medically determinable impairment(s), show your impairment(s) have lasted or are expected to last for at least twelve months or will result in death, and prove that your impairments cause limitations that prevent you from working at a substantial gainful activity level. Be aware that Social Security can deny your disability claim due to insufficient medical evidence.

Medical evidence is critical to proving you are disabled. Otherwise, Social Security can deny your disability claim due to insufficient medical evidence. Your medical records should contain enough information that Social Security can make a decision regarding the nature and severity of your impairment(s). Only providing your allegation of an impairment along with your doctor’s diagnosis is not sufficient to prove disability. The medical evidence must show how long you have had your impairment(s) and be detailed enough to show the severity and functional limitations of those impairment(s).

You should provide medical records from at least around the time when you first became disabled to the present. Medical records include all of your hospital, clinic, and doctor visits and medical treatments, such as surgical procedures. Medical records are also blood tests, imaging studies (such as x-ray, MRI, CT scan) or other diagnostic testing or procedures (such as an exercise stress test). Make sure to include medical evidence to support your complaints of pain or other symptoms that affect your ability to function. When you provide complete medical records of your impairment(s), it may eliminate the need for Social Security to take additional time to obtain more medical evidence in your case.

Does Social Security Help Get My Medical Records?
Social Security will give some assistance once you have provided them with the contact information of your medical sources and have signed form SSA-827, Authorization to Disclose Information to the Social Security Administration. Social Security will then request medical records on your behalf.

According to Social Security rules, they will make “every reasonable effort” to obtain a “complete medical history”. Every reasonable effort means Social Security will make an initial request for medical records and will make one follow-up request if they don’t receive the medical records. You may need to follow-up with your medical providers if Social Security has not received the medical evidence.

Social Security defines a “complete medical history” to mean medical records covering at least twelve months prior to a certain date, which is often the protective filing date but may be another important date, such as the date last insured for SSDI claims. However, it is in the discretion of Social Security whether to request medical evidence outside of the twelve-month period based on the facts of the case. Since you are likely to have other medical records that Social Security did not request, you will need to are request that medical evidence and submit it to Social Security yourself. Ultimately, it is your responsibility to submit evidence to Social Security that you are disabled.

When Does Social Security Order a Consultative Examination?
Social Security orders a consultative examination when the medical evidence is insufficient to decide the disability claim. Examples of when Social Security may decide a consultative examination is necessary is when there is no medical evidence or very little medical evidence in the file, or when the evidence does not establish the current severity and functional limitations of the impairment(s), or when a conflict or inconsistency in the case record cannot be resolved by recontacting you or another source of information.

Social Security contracts with licensed physicians and psychiatrists, as well as qualified psychologists to perform consultative examinations. Usually, Social Security will select the doctor who is scheduled to do your consultative examination, but you have the right to request that your regular doctor perform this exam if he is willing to do it.

Who is a Medical Source and Who is an Acceptable Medical Source?
A medical source is a healthcare worker working within the scope of practice permitted under law and includes a certified speech-language pathologist or school psychologist. An acceptable medical source is a certain type of medical practitioner identified in the regulations see https://www.ssa.gov/OP_Home/cfr20/404/404-1502.htm. Included as an acceptable medical source are licensed physicians, licensed psychologists, physician assistants (PAs), advanced registered nurse practitioners (ARNPs), and licensed audiologists and optometrists.

What Medical Evidence Establishes a Medically Determinable Impairment?
To establish a medically determinable impairment, Social Security rules require objective medical evidence of signs, laboratory findings, or both. The objective medical evidence must be from an acceptable medical source. Once the medically determinable impairment(s) is established, other medical evidence can be considered.

How Does Social Security Evaluate Medical Evidence?
With regard to disability claims filed on or after March 27, 2017, Social Security considers the persuasiveness of the quality of the evidence by taking into account the following factors when evaluating the medical evidence:
Supportability: The explanations by a medical source are supported by the objective medical evidence.
Consistency: A medical opinion or prior medical finding(s) is consistent with the other evidence.
Relationship with the claimant considers:
Length of the treatment relationship
Frequency of examinations
Purpose of the treatment relationship
Extent of the treatment relationship
Examining relationship
Specialization: The medical opinion of a specialist may be more persuasive about medical issues in his area of specialty.
Other factors: Factors that tend to support or contradict a medical opinion or prior medical finding.

Social Security will consider whether you impairment(s) meet or equal the criteria in set out in the Listing of Impairments, and if so, your disability case will be allowed. Otherwise, Social Security will continue to evaluate your claim to determine your residual functional capacity based on all relevant evidence and decide whether you have the ability to perform your past relevant work or any other work. If you cannot perform any work, your disability case will be allowed. However, if you can perform any work, Social Security will deny your claim for disability.

Contact a Disability Lawyer for Help
If you need help proving you are disabled, contact a disability lawyer at Cardea Law Group, LLC. When we represent you, we will work with you to complete the application for disability and other necessary forms, as well as help you obtain the medical and non-medical evidence you need to prove your claim. We show our commitment by providing you with information, guidance, and support at every step. Call us at 334-440-6261.