Disability Evaluation Under Social Security
Part II - Evidentiary Requirements
Medical evidence is the cornerstone of the disability determination under both the title II and title XVI programs.
Each person who files a disability claim is responsible for providing medical evidence showing he or she has an impairment(s) and the severity of the impairment(s). However, the Social Security Administration (SSA), with the claimant’s permission, will help the claimant get medical evidence from his or her own medical sources who have evaluated, examined, or treated the claimant for his or her impairment(s). SSA also requests copies of medical evidence from hospitals, clinics, or other health facilities when appropriate.
Claimants who provide SSA with timely, accurate, and complete information and evidence can help accelerate the processing of their claims.
Existence of an impairment
By law, SSA needs specific medical evidence to establish that a claimant has an impairment. SSA regulations require “objective medical evidence” from an “acceptable medical source” to establish that a claimant has a medically determinable impairment. The regulations define these terms.
Once the existence of an impairment is established, SSA considers all evidence from all medical and nonmedical sources to assess the extent to which a claimant's impairment(s) affects his or her ability to function in a work setting; or in the case of a child, the ability to function compared to that of children the same age who do not have impairments. Nonmedical sources include, but are not limited to: the claimant, educational personnel, public and private social welfare agency personnel, family members, caregivers, friends, neighbors, employers, and clergy.
A claimant must inform SSA about or submit all evidence known to him or her that relates to whether or not he or she is blind or disabled. This duty is ongoing and requires the claimant to disclose any additional related evidence about which he or she becomes aware throughout the administrative review process. The evidence must be complete and detailed enough for SSA to determine:
- The nature and severity of the claimant’s impairment(s),
- How long the claimant has experienced the impairment(s), and
- Whether the claimant can still do work-related physical and mental activities with the impairment(s).
If the evidence provided by the claimant's own medical sources is inadequate to determine if he or she is disabled, additional medical information may be sought by recontacting the medical source for additional information or clarification, or by arranging for a consultative examination (CE). Generally, a claimant’s own medical source(s) is the preferred source to perform the needed examination or test, and SSA will pay the authorized fee for the CE. However, SSA may use an independent medical source other than the claimant’s own medical source(s) to conduct the CE in several situations, such as:
- the claimant’s own medical source(s) prefers not to perform the examination;
- the claimant’s own medical source(s) does not have the equipment to provide the specific data needed;
- there are conflicts or inconsistencies in the file that cannot be resolved by going back to the claimant’s own medical source(s);
- the claimant prefers another source and has good reason for doing so;
- SSA knows from prior experience that the claimant’s own medical source(s) may not be a productive source; or
- the claimant’s own medical source(s) is not qualified, as is defined by regulation.
Consultative Examination Report Content
A complete CE report will involve all the elements of a standard examination in the applicable medical specialty and should include the following elements:
- the claimant's major or chief complaint(s);
- a detailed description, within the area of specialty of the examination, of the history of the major complaint(s);
- a description, and disposition, of pertinent "positive" and "negative" detailed findings based on the history, examination, and laboratory tests related to the major complaint(s), and any other abnormalities or lack thereof reported or found during examination or laboratory testing;
- results of laboratory and other tests (for example, X-rays) performed according to the requirements stated in the Listing of Impairments (see Part III of this guide);
- the diagnosis and prognosis for the claimant's impairment(s);
- in claims for adults, a statement about what a claimant can still do despite his or her impairment(s) and whether the claimant has one or more impairment-related limitations or restrictions in the following abilities:
- The ability to perform physical demands of work activities, such as sitting, standing, walking, lifting, carrying, pushing, pulling, or other physical functions (including manipulative or postural functions, such as reaching, handling, stooping, or crouching);
- The ability to perform mental demands of work activities, such as understanding; remembering; maintaining concentration, persistence, or pace; carrying out instructions; or responding appropriately to supervision, co-workers, or work pressures in a work setting;
- The ability to perform other demands of work, such as seeing, hearing, or using other senses; and
- The ability to adapt to environmental conditions, such as temperature extremes or fumes;
- in claims for children under age 18, a statement about the child’s impairment-related limitations and restrictions (as compared to children his or her age who do not have impairments) in:
- acquiring and using information;
- attending and completing tasks;
- interacting and relating with others;
- moving about and manipulating objects;
- caring for yourself; and
- heath and physical well-being; and
- the consultant 's consideration, and some explanation or comment on, the claimant's major complaint(s) and any other abnormalities found during the history and examination or reported from the laboratory tests. The history, examination, evaluation of laboratory test results, and the conclusions will represent the information provided by the consultant who signs the report.
Evidence Relating to Symptoms
In developing evidence of the effects of symptoms, such as pain, shortness of breath, or fatigue, on a claimant's ability to function, SSA investigates all avenues presented that relate to the complaints. These include evidence about:
- the claimant's daily activities;
- the location, duration, frequency, and intensity of the pain or other symptom;
- precipitating and aggravating factors;
- the type, dosage, effectiveness, and side effects of any medication;
- treatments, other than medications, for the relief of pain or other symptoms;
- any measures the claimant uses or has used to relieve pain or other symptoms; and
- other factors concerning the claimant's functional limitations due to pain or other symptoms.
In assessing the claimant's pain or other symptoms, SSA considers all of the above-mentioned factors. It is important that medical sources address these factors in the reports they provide.