I-2-5-34.When to Obtain Medical Expert Opinion
Last Update: 4/1/16 (Transmittal I-2-170)
A. When to Obtain a Medical Expert (ME) Opinion
1. When an Administrative Law Judge (ALJ) Must Obtain an ME Opinion (Not Discretionary)
The ALJ must obtain an ME opinion, either in testimony at a hearing or in responses to written interrogatories in the following circumstances:
The Appeals Council or Federal court ordered an ME opinion.
There is a question about the accuracy of medical test results reported, requiring evaluation of background medical test data. For more information, see Hearings, Appeals and Litigation Law (HALLEX) manual I-2-5-14 E.
The ALJ is considering finding that the claimant's impairment(s) medically equals a listing.
2. When an ALJ May Obtain an ME Opinion (Discretionary)
An ALJ may need to obtain an ME opinion, either in testimony at a hearing or in responses to written interrogatories, when the ALJ:
Determines whether a claimant's impairment(s) meets a listed impairment(s);
Determines the usual dosage and effect of drugs and other forms of therapy;
Assesses a claimant's failure to follow prescribed treatment;
Believes a claimant's drug addiction or alcoholism may be material to finding a claimant disabled;
Determines the degree of severity of a claimant's physical or mental impairment;
Believes an ME may be able to suggest additional relevant evidence because there is reasonable doubt about the adequacy of the medical record;
Believes an ME may be able to clarify and explain the evidence or help resolve a conflict because the medical evidence is contradictory, inconsistent, or confusing;
Believes an ME may be able to assist the ALJ by explaining and assessing the significance of clinical or laboratory findings in the record that are not clear;
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;
Has a question(s) 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
Needs an expert medical opinion regarding the onset of an impairment.
An ALJ will never ask or permit an ME to perform an examination of a claimant. If an ALJ finds an examination is necessary because there is not enough evidence about an impairment(s) for the ALJ to make a finding, the ALJ will request a consultative examination. See HALLEX I-2-5-20.
B. Determining Medical Specialty and Manner of Receiving Opinion
If a staff designee is assigned to screen or perform a review of a case before the hearing and believes an ME opinion is necessary, the designee will make a recommendation to the ALJ regarding the need for an ME and the desired medical specialty of the ME. The designee will recommend the specialty whose expertise is most appropriate to the claimant's diagnosed impairment(s).
A National Adjudication Team (NAT) attorney advisor who is assigned a NAT case and has consulted with their NAT lead attorney or designee may obtain ME opinions through interrogatories if the requested opinion is likely to result in a fully favorable decision on the record.
If the ALJ agrees with a recommendation or independently determines that an ME opinion is needed, the ALJ will decide:
The medical specialty of the ME; and
The manner in which to receive the ME's opinion (i.e., whether to receive the opinion in testimony at the hearing in person, by video teleconferencing or telephone, or in response to written interrogatories).