I-2-5-34.When to Obtain Medical Expert Opinion

Last Update: 9/28/05 (Transmittal I-2-68)

A. When an ALJ May Need to Obtain ME Opinion

An ALJ may need to obtain an ME's opinion, either in testimony at a hearing or in responses to written interrogatories, when:

  • the ALJ is determining whether a claimant's impairment(s) meets a listed impairment(s);

  • the ALJ is determining the usual dosage and effect of drugs and other forms of therapy;

  • the ALJ is assessing a claimant's failure to follow prescribed treatment;

  • the ALJ is determining the degree of severity of a claimant's physical or mental impairment;

  • the ALJ has reasonable doubt about the adequacy of the medical record in a case, and believes that an ME may be able to suggest additional relevant evidence;

  • the medical evidence is conflicting or confusing, and the ALJ believes an ME may be able to clarify and explain the evidence or help resolve a conflict;

  • the significance of clinical or laboratory findings in the record is not clear, and the ALJ believes an ME may be able to explain the findings and assist the ALJ in assessing their clinical significance;

  • the ALJ is determining the claimant's residual functional capacity, e.g., the ALJ may ask the ME to explain or clarify the claimant's functional limitations and abilities as established by the medical evidence of record;

  • the ALJ has a question about the etiology or course of a disease and how it may affect the claimant's ability to engage in work activities at pertinent points in time, e.g., the ALJ may ask the ME to explain the nature of an impairment and identify any medically contraindicated activities; or

  • the ALJ desires expert medical opinion regarding the onset of an impairment.

B. When the ALJ Must Obtain ME Opinion

The ALJ must obtain an ME's opinion, either in testimony at a hearing or in responses to written interrogatories:

  • When the Appeals Council or a court so orders.

  • To evaluate and interpret background medical test data. (See I-2-5-14 D., Medical Test Data.)

  • When the ALJ is considering a finding that the claimant's impairment(s) medically equals a medical listing.