I-5-3-30.Revisions to Rules Regarding the Evaluation of Medical Evidence

Table of Contents
I Purpose
II Background
III Revisions to the Rules for Evaluating Medical Evidence
IV Implementation of the Rules for Evaluating Medical Evidence
V Inquiries

I. Purpose

On January 18, 2017, the Social Security Administration (SSA) published revisions to the rules regarding the evaluation of medical evidence (82 FR 5844). These revisions became effective on March 27, 2017 (see IV below). These instructions explain why SSA revised its rules regarding the evaluation of medical evidence and when the Office of Disability Adjudication and Review (ODAR) will apply the revised rules.

II. Background

In 1991, SSA adopted new rules creating a uniform national policy about how to consider medical opinions from treating physicians. Based on the state of healthcare at that time, SSA determined that opinions from a claimant's treating physician tended to have a special intrinsic value, because he or she was likely to be the medical professional most able to provide a detailed, longitudinal picture of a claimant's impairments. Accordingly, the “treating physician rule” allowed adjudicators to give controlling weight to treating source opinions under certain circumstances. In 1996 and 2006, SSA issued Social Security Rulings (SSR) that provide further instructions on how to evaluate evidence from medical and non-medical sources, including treating physicians (SSRs 96-2p, 96-5p, 96-6p, and 06-3p, all of which were rescinded effective March 27, 2017).

However, since adopting these rules over twenty-five years ago, changes in healthcare delivery and SSA's adjudicative experience necessitated revision of the rules. Healthcare delivery has changed dramatically since the 1991 rules were implemented. Many people now receive healthcare from coordinated and managed care organizations instead of a single treating physician. People typically visit multiple medical professionals, including primary physicians, specialists, and nurse practitioners, and they do so in a variety of medical settings, such as managed care and specialty clinics, hospitals, ambulatory care centers and public healthcare centers. As a result, people are less likely to develop a sustained relationship with a single treating physician. Additionally, due to changes in the national healthcare workforce, people now receive medical care from a wider range of medical sources with rigorous state licensure and extensive education and training requirements, such as Advanced Practice Registered Nurses, audiologists, and physician assistants.

Further, SSA's remand data from both the Appeals Council (AC) and Federal courts revealed that consideration and evaluation of opinion evidence has consistently remained one of the highest reasons for remand at both levels. The Federal courts differed in how strictly they have interpreted the articulation requirements for evaluating opinion evidence and developed varying standards for determining what constitutes a treating physician relationship and how SSA must address multiple opinions from multiple treating sources. The various approaches moved SSA's adjudication away from the content of medical opinions and towards weighing treatment relationships against each other. Consequently, the reviewing courts have focused more on whether SSA sufficiently articulated the weight we gave treating source opinions rather than on whether substantial evidence supported a final decision.

In light of the changes in healthcare delivery and SSA's adjudicative experience, SSA requested that the Administrative Conference of the United States (ACUS) provide recommendations on how SSA could improve considering medical opinion evidence in the disability and blindness claims evaluation process. In 2013, ACUS issued its final report. Additionally, the Bipartisan Budget Act (BBA) of 2015 amended the Social Security Act in several ways, including revising the requirements about medical consultants (MC) and psychological consultants (PC).

III. Revisions to the Rules for Evaluating Medical Evidence

Based on changes in healthcare delivery, ACUS's final report, the requirements of the BBA, and SSA's adjudicative experience, we updated our regulations to:

  • Redefine and reorganize several key terms related to evidence;

  • Revise the rules about acceptable medical sources (AMS);

  • Revise the manner in which SSA considers and articulates consideration of medical opinions and prior administrative medical findings;

  • Revise the rules about MCs and PCs; and

  • Revise the rules about treating sources.

SSA expects these changes will simplify the rules and make them easier to understand and apply, and allow SSA adjudicators to continue to make accurate and consistent disability determinations and decisions. SSA will apply most of these revisions only in claims filed on or after March 27, 2017. See subsection IV below for information on determining whether, for purposes of these rules, a claim was filed before March 27, 2017 or on or after that date, and for more information on which rules to apply depending on the filing date of a claim(s).

IV. Implementation of the Rules for Evaluating Medical Evidence

The revised rules became effective on March 27, 2017. While some of the revised rules apply in all claims, many of the most significant changes for evaluating evidence will apply only in claims filed on or after March 27, 2017 (see IV.A. below for instructions on how to determine the filing date). Accordingly, the filing date of a claim(s) determines which set of rules to apply when evaluating medical and nonmedical evidence in a claim.

The rules applicable in cases filed before March 27, 2017, but not applicable in cases filed on or after that date, include the following or similar language: “For claims filed before March 27, 2017, the rules in this section apply.” For simplicity, these rules are referred to as the “prior rules.” The rules applicable in cases filed on or after March 27, 2017, but not applicable in cases filed before that date, include the following or similar language: “For claims filed on or after March 27, 2017, the rules in this section apply.” For simplicity, these rules are referred to as the “current rules.”

The following chart highlights which rules depend on the filing date of a claim(s) and includes citations to applicable rules:

Topic

Prior Rule Citation

Current Rule Citation

AMS

20 CFR 404.1502(a)(1)-(5) and 416.902(a)(1)-(5)

20 CFR 404.1502(a)(1)-(8) and 416.902(a)(1)-(8)

Medical Opinion Definition

20 CFR 404.1527(a) and 416.927(a)

20 CFR 404.1513(a)(2) and 416.913(a)(2)

Other Medical Evidence Definition

20 CFR 404.1513(a)(3) and 416.913(a)(3)

20 CFR 404.1513(a)(3) and 416.913(a)(3)

Consideration and Articulation of Opinion Evidence and Prior Administrative Medical Findings

20 CFR 404.1513a, 404.1527, 416.913a and 416.927

20 CFR 404.1513a, 404.1520c, 416.913a and 416.920c

Statements on Issues Reserved to the Commissioner

20 CFR 404.1527(d) and 416.927(d)

20 CFR 1520b(c)(3), and 416.920b(c)(3)

Decisions by other Governmental and Nongovernmental Entities

20 CFR 404.1504 and 416.904

20 CFR 404.1504, 1520b(c)(1), 416.904, and 416.920b(c)(1)

The following subsections provide information on which set of rules will apply in a given case. Importantly, even where different claims in a case have different filing dates, only one set of rules will apply in a claim, i.e., either the prior rules or the current rules, but never both. See IV.B. below for common filing date scenarios. For a more comprehensive overview of filing date scenarios, see Program Operations Manual System (POMS) DI 24503.050.

A. Determining the Filing Date – Generally

The Office of Disability Policy has established policies for determining whether to use the prior rules or the current rules in a given case. See POMS DI 24503.050 for filing date scenarios and GN 00204.007 for more information about how we determine when a claim is filed. Both the hearing level and the AC will follow these policies to determine whether to apply the prior rules or the current rules in an individual case.

To assist adjudicators in determining when a claim(s) was filed and which rules to apply, the eView header contains a Medical Evidence indicator identifying whether the claim(s) was filed before March 27, 2017, or on or after March 27, 2017. For claims filed before March 27, 2017, the eView header will show the following indicator: “MedEv: Prior Rules.” For claims filed on or after March 27, 2017, the eView header will show the following indicator: “MedEv: Current Rules.”

NOTE:

The eView indicator is first set at the initial level before the field office transfers the claim to the State agencies. There are situations where the filing date may change after the indicator is first set (see IV.C. below for an example). Accordingly, it is important in all cases to verify the claim(s) filing date by reviewing relevant information in the file.

B. Determining Which Rules Apply – Common Scenarios

With exceptions noted in POMS DI 24503.050, use the earliest possible filing date of a claim(s) to determine which set of rules to follow. The following chart displays common filing date scenarios and which rules to apply in a given case:

Filing Scenario

Rules to Apply

Single claim (title II or title XVI) with a filing date before March 27, 2017

Prior rules

Single claim (title II or title XVI) with a filing date on or after March 27, 2017

Current rules

Title II or title XVI concurrent, with a filing date(s) before March 27, 2017

Prior rules for both claims

Title II or title XVI concurrent, with a filing date(s) on or after March 27, 2017

Current rules for both claims

Title II claim with a filing date before March 27, 2017, and a title XVI claim filed on or after March 27, 2017

Prior rules for both claims

Title XVI claim with a filing date before March 27, 2017, and a title II claim filed on or after March 27, 2017

Prior rules for both claims

NOTE:

The filing date of an age 18 redetermination is the date the individual attains age 18, which is one day before the calendar date of their 18th birthday. If the claimant attains age 18 before March 27, 2017, the prior rules apply, and if the claimant attains age 18 on or after March 27, 2017, the current rules apply.

C. Determining Which Rules Apply – Protective Filing Dates

In certain situations, the AC will advise the claimant that if he or she files a new application within 6 months of the date of the AC's notice in a title II claim, or within 60 days of the AC's notice in a title XVI claim, then the agency will use the date of the request for review as the filing date for the new application. See 20 CFR 404.970(c) and 416.1470(c) and Hearings, Appeals and Litigation Law (HALLEX) manual I-3-4-3 D, I-3-5-20 A , I-3-8-1 C, and I-4-8-25 C.

The prior rules will apply when:

  • the AC issues a protective filing date that is before March 27, 2017, and

  • the claimant files the new application(s) within 6 months of the date of the AC's notice containing the protective filing date (in a title II claim), or within 60 days of the date of the AC's notice containing the protective filing date (in a title XVI claim).

The prior rules will also apply when a claimant files new concurrent claims even if only one of the claims has a protective filing date before March 27, 2017, provided the claim(s) is filed within the required time period(s).

D. Determining Which Rules Apply – Subsequent Applications

Adjudicators occasionally have to consolidate a subsequent application(s) with a pending application(s) when there are overlapping periods. In ODAR, this most often happens when an exception to file a subsequent application has been granted under SSR 11-1p or when a case is remanded from Federal court and the claimant filed a subsequent application(s). See HALLEX I-1-10 for detailed information about subsequent applications.

If the subsequent application(s) is filed on or after March 27, 2017, and is an allowance, adjudicators will use the current rules to evaluate the subsequent application(s) to determine if reopening is appropriate (see HALLEX I-1-10-30). If the subsequent application(s) is not reopened and instead is affirmed, adjudicators should continue to adjudicate the pending claim(s) using the filing date of the pending claim.

If the subsequent application(s) is filed on or after March 27, 2017, involves an overlapping period on the same title, and is pending, denied, or reopened, then consolidation of the pending and subsequent applications is necessary for further adjudication (see HALLEX I-1-10-25). If the subsequent and pending applications were filed on or after March 27, 2017, adjudicators will apply the current rules to the consolidated case. If the subsequent application(s) is filed on or after March 27, 2017 and the pending application(s) is filed before March 27, 2017, adjudicators will apply the prior rules to the consolidated case.

For example, a Federal court remands concurrent claims with filing dates of January 12, 2014. Subsequent concurrent applications with filing dates of March 27, 2017, were denied at the reconsideration level. The AC will remand the pending court claims to the administrative law judge (ALJ) and, in the remand order, instruct the ALJ to consolidate the pending court claims with the subsequent applications and adjudicate them under the prior rules.

E. Determining Which Rules Apply – Continuing Disability Reviews (CDR)

Adjudicators must apply the rules in effect at the time of the application filing date (not the most recent comparison point decision (CPD)) for the final favorable determination or decision in the claim when adjudicating a CDR. For example, the claimant filed an application for benefits on May 1, 2010, and the claimant was found disabled in a decision dated December 20, 2013. The agency initiated a CDR and found the claimant's disability continued in a CPD dated February 23, 2015. The agency initiated another CDR on April 13, 2017. In adjudicating the second CDR, the prior rules must be applied, because the original application filing date for the favorable decision was May 1, 2010, which is before March 27, 2017.

F. Applying the “Prior Rules” in Claim(s) Filed Before March 27, 2017

For claim(s) filed before March 27, 2017, adjudicators must use the prior rules throughout the entire appeals process. While the prior rules are similar to the regulations as they existed before March 27, 2017, the agency made some changes.

Most importantly, the agency rescinded the following four SSRs and incorporated the policies in those SSRs into the rules applicable in claim(s) filed before March 27, 2017:

  • SSR 96-2p: Titles II and XVI: Giving Controlling Weight to Treating Source Medical Opinions.

  • SSR 96-5p: Titles II and XVI: Medical Source Opinions on Issues Reserved to the Commissioner.

  • SSR 96-6p: Titles II and XVI: Consideration of Administrative Findings of Fact by State Agency Medical and Psychological Consultants and Other Program Physicians and Psychologists at the Administrative Law Judge and Appeals Council Levels of Administrative Review; Medical Equivalence.

  • SSR 06-03p: Titles II and XVI: Considering Opinions and Other Evidence from Sources Who Are Not “Acceptable Medical Sources” in Disability Claims; Considering Decisions on Disability by Other Governmental and Nongovernmental Agencies.

For claim(s) filed before March 27, 2017, cite the following authorities instead of the four rescinded SSRs:

  • 404.1527(d) and 416.927(d) provide guidance on how to consider medical source opinions on issues reserved to the Commissioner, which was previously provided in SSR 96-5p.

  • 404.1527(e) and 416.927(e) provide guidance on considering administrative findings of fact by State agency medical and psychological consultants and other program physicians and psychologists, which was previously provided in SSR 96-6p.

  • SSR 17-2p: Titles II and XVI: Evidence Needed by Adjudicators at the Hearings and Appeals Council Levels of the Administrative Review Process to Make Findings about Medical Equivalence, provides guidance on issues relating to medical equivalence, which was previously provided in SSR 96-6p.

  • 404.1527(f) and 416.927(f) provide guidance on considering opinions and other evidence from sources who are not AMSs and on considering decisions on disability by other governmental and nongovernmental agencies, which was previously provided in SSR 06-03p.

V. Inquiries

Hearing office staff will direct all program-related and technical questions through appropriate management channels. ODAR regional offices may refer questions or unresolved issues to the appropriate headquarters contact.

In the Office of Appellate Operations, staff and adjudicators will direct any program-related or technical questions to the Executive Director's Office.