Consultative Examinations: A Guide for Health Professionals
Part II - Evidence Requirements
Under both the title II and title XVI programs, medical evidence is the cornerstone for the determination of disability.
Each person who files a disability
claim is responsible for providing medical evidence showing that he or
she has an impairment (s) and how severe the impairment (s) is. However,
SSA will help claimants get medical reports from their own medical sources
when the claimants gives SSA permission to do so. This medical evidence
generally comes from sources that have treated or evaluated the claimant
for his or her
Acceptable Medical Sources
Documentation of the existence of a claimant's impairment must come from medical professionals defined by SSA's regulation as "acceptable medical sources." Once the existence of an impairment is established, all of the medical and non-medical evidence is considered in assessing impairment severity.
"Acceptable medical sources" are:
- Licensed physician (medical or osteopathic doctor).
- Licensed psychologist, which includes:
- A licensed or certified psychologist at the independent practice level; and
- A licensed or certified school psychologist, or other licensed or certified individual with another title who performs the same function as a school psychologist in a school setting, for impairments of intellectual disability, learning disabilities, and borderline intellectual functioning only.
- Licensed optometrist for impairments of visual disorders, or measurement of visual acuity and visual fields only, depending on the scope of practice in the State in which the optometrist practices.
- Licensed podiatrist for impairments of the foot, or foot and ankle only, depending on whether the State in which the podiatrist practices permits the practice of podiatry on the foot only, or the foot and ankle.
- Qualified speech-language pathologist for speech or language impairments only. For this source, qualified means that the speech-language pathologist must be licensed by the State professional licensing agency, or be fully certified by the State education agency in the State in which he or she practices, or hold a Certificate of Clinical Competence in Speech-Language Pathology from the American Speech-Language-Hearing Association.
- Licensed audiologist for impairments of hearing loss, auditory processing disorders, and balance disorders within the licensed scope of practice only.
NOTE: Audiologists scope of practice generally includes evaluation, examination, and treatment of certain balance impairments that result from the audio-vestibular system. However, some impairments involving balance involve several body systems that are outside the scope of practice for audiologists, such as those involving muscles, bones, joints, vision, nerves, heart, and blood vessels.
- Licensed advanced practice registered nurse (APRN), also known in some States as advanced practice nurse (APN), and advanced registered nurse practitioner (ARNP) for impairments within his or her licensed scope of practice. There are four types of APRNs with a handful of State variations:
- Certified nurse midwife (CNM);
- Nurse practitioner (NP);
- Certified registered nurse anesthetist (CRNA); and
- Clinical nurse specialist (CNS).
- Licensed physician assistant for impairments within his or her licensed scope of practice only.
Medical Evidence from Treating
Currently, many disability claims are decided on the basis of medical evidence from "treating sources." ”Treating source” means the claimant’s own “acceptable medical source” who provides, or has provided, the claimant with medical treatment or evaluation and who has, or has had, an ongoing treatment relationship with the claimant. SSA regulations place special emphasis on evidence from treating sources because they are likely to be the medical professionals most able to provide a detailed longitudinal picture of the claimant's impairments and they may bring a unique perspective to the medical evidence that cannot be obtained from the medical findings alone or from reports of individual examinations or brief hospitalizations. Therefore, timely, accurate, and adequate medical reports from treating sources may accelerate the processing of the claim because they can greatly reduce or eliminate the need for additional medical evidence to complete the claim.
Other Evidence Sources
Information from other sources may also help show the extent to which a person's impairment(s) affects his or her ability to function. Other sources include public and private social welfare agencies, non-medical sources such as teachers, day care providers, social workers and employers, and other health care professionals such as naturopaths, chiropractors, and audiologists.
SSA frequently asks physicians, psychologists, and other health care professionals to submit reports about an individual's impairment. Therefore, it is important to know what evidence SSA needs. Medical reports should include:
- Medical history;
- Clinical findings (such as the results of physical or mental status examinations);
- Laboratory findings (such as blood pressure, x-rays);
- Treatment prescribed with response and prognosis; and a
- Statement providing an opinion about what
the claimant can still do despite his or her impairment(s) based on
the medical source's findings on the above factors. This statement should
describe, but is not limited to, the individual's ability to perform
work-related activities, such as sitting, standing, walking, lifting,
carrying, handling objects, hearing, speaking, and traveling. In cases
involving mental impairments, it should describe the individual's ability
to understand, to carry out and remember instructions, and to respond
appropriately to supervision, coworkers, and work pressures in a work
setting. For a child, the statement should describe the child's ability
to function in an age-appropriate manner in the areas of functioning
appropriate for the child's age.
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 information provided by treating and other sources regarding:
- The claimant's daily activities;
- 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, the decision-maker(s) must give full consideration to all of the above-mentioned factors. It is important that medical sources address these factors in the reports they provide.