The statutory definition of disability for both adults and children requires a “medically determinable” impairment or impairments as a starting point. There are a limited number of sources that may establish a medically determinable impairment.
However, once there is evidence of a medically determinable impairment, evidence from medical, other professional, and lay sources should be considered to show impairment severity and the resulting functional limitations.
§ 1.9.1 Acceptable Medical Sources to Establish Medically Determinable Impairments
Medical determinable impairments must be diagnosed by “acceptable medical”
sources. 20 C.F.R. 404.1513, 416.913, as published at 65 Fed. Reg. 34,950 (June 1, 2000). Generally, an acceptable medical source must be a licensed physician, osteopath, or psychiatrist. The term also includes licensed or certified psychologists. In addition, the following are acceptable sources for limited diagnoses:
optometrists for visual acuity and visual field measurements;
podiatrists for foot and ankle impairments;
licensed or certified school psychologists for mental retardation, learning disabilities, and borderline intellectual function; and
qualified speech and language pathologists for speech and language impairments.
§ 1.9.2 Evidence to Establish the Nature and Severity of the Impairment
Evidence of the impact of the medical determinable impairment or impairments on the individual’s ability to function may be provided by physicians, other medical sources, other professional sources, and lay sources. 20 C.F.R. 404.1513,
416.913. Physician evidence tends to be preferred, but it is often the case that other sources have more information on the individual’s day-to-day experience with the impairment. Non-physicians and other professionals who see the individual in their professional capacities for reasons related to the impairment can provide very helpful and credible information on the individual’s ability to function. These sources include nurse practitioners, physicians’ assistants, chiropractors, therapists, teachers, and counselors. For individuals who have worked recently, information from
employers can be valuable in establishing the impact of medically determinable impairments on the ability to function at work. See SSR 06-3p for SSA’s helpful instructions on considering evidence other than acceptable medical sources in evaluating disability claims.
Finally, lay evidence should not be overlooked. Family and friends can also be a valuable source of information about daily functioning. The importance of these sources that are not medically acceptable sources will be determined in individual cases by the nature of the impairment and the individual’s ability to be a good historian.
The form taken by evidence of impairments and function may vary greatly. Because the formal rules of evidence do not apply, any type of information will be accepted for the record. However, greater weight and credibility will be assigned to certain types of information. Generally, the SSA prefers documentation prepared in the normal course of treatment, e.g., treatment notes. However, treatment records often do not include all the information needed because they are prepared for a different purpose. It is often necessary to ask the treating source for additional information to clarify, fill in gaps, or explain.
Practice Note: Medical Records Laws
In Massachusetts, medical providers must furnish a copy of existing records free of charge when the request is made in connection with an application
for federal or state disability benefits. See G.L. c. 111, 70 (hospitals, clinics);
G.L. c. 12, 12CC (physicians).
§ 1.9.3 Weighing Evidence
It is worth the effort to ensure that the record contains sufficient evidence from treating sources. Treating source evidence is often entitled more weight than that from other sources, e.g., the doctors hired by the SSA to review claims and provide an opinion or to provide a consultative examination and report. This is due to the treating source’s greater familiarity with the individual and the impairment, based on examinations of the individual and longitudinal perspective. The SSA’s criteria for the contents of a complete medical report are at 20 C.F.R. 404.1513(d),
416.913(d).
To qualify as a treating source, a medical provider must be an “acceptable medical source” and have a sufficient treating relationship with the individual. 20 C.F.R.
404.1502, 416.902. The length of the treating relationship and the frequency of examination necessary to qualify as a treating source depends of the nature of the impairment. Generally, however, the longer the relationship and the greater the frequency of examination, the better. Another important factor is whether the treating source is a specialist in the area of the individual’s impairment.
If the treating source’s opinion is well supported and not inconsistent with other substantial evidence in the record, the opinion must be given controlling weight on the issues of diagnosis and severity of the individual’s impairment. 20 C.F.R.
404.1527, 416.927. Certain conclusions, e.g., whether the individual’s medical criteria equal the severity of a listed impairment or whether the individual has a residual functional capacity (RFC) for light or sedentary work, are issues reserved for the SSA. But the underlying facts necessary to establish those conclusions may be established by treating sources. SSR 96-5p—Policy Interpretation Ruling—Titles II and XVI—Medical Source Opinions on Issues Reserved to the Commissioner.
20 C.F.R. 416.927(e) provides that whether an individual is disabled or whether an impairment meets or equals a listing is one of the issues reserved to the SSA. This means that the SSA will not give controlling weight to the opinions of treating physicians on the ultimate issue of equivalence. 20 C.F.R. 416.927(e)(2). Note, however, that the regulation does not specifically refer to functional equivalence.
Social Security Rulings 96-2p (Giving Controlling Weight to Treating Source Opinions) and 96-5p (Medical Source Opinions on Issues Reserved to the
Commissioner) also address the weight to be given to medical opinions concerning meeting or equaling a listing. The rulings basically repeat the language of the regulations cited above. Some ALJs have interpreted these rulings to prevent them from considering opinions on the issue of listing equivalence. However, both of the rulings remind adjudicators that the prohibition only concerns controlling weight or special significance. Treating source opinions are always to be considered and carefully evaluated. In fact, Social Security Ruling 96-5p states that, where a treating source provides medical evidence that demonstrates that the claimant’s impairment meets a listing and where that opinion is consistent with the evidence, the adjudicator’s finding on this issue will generally agree with the treating source’s opinion.
Even if a treating source’s opinion is not entitled to controlling weight, it may still be given great weight or deference when compared against other medical evidence in the record. Further, when the treating source has provided an opinion on an issue reserved for the SSA, it may not be ignored. Instead, the SSA must explain the consideration given to the treating source opinion. Evidence from other sources, including nonmedical sources, will also be weighed and judged for credibility, but is not entitled to controlling weight or any particular deference. See Social Security Ruling 96-2p.
Practice Note
In an amendment to the evidence weighing rules, the SSA added the following other factors for consideration:
the amount of understanding that an acceptable medical source has of our disability programs and their evidentiary requirements, regardless of the source of that understanding, and the extent to which an acceptable medical source is familiar with the other information in your case record;
and
state agency medical and psychological consultants and other program physicians and psychologists are highly qualified physicians and
psychologists who are also experts in Social Security disability evaluation.
20 C.F.R. 404.1527(d)(6), 416.927(d)(6), published at 65 Fed. Reg.
11,866 (Mar. 7, 2000). These revisions would appear to favor agency doctor opinion, at least on opinions reserved for the SSA. See also Social Security Ruling 96-2p, SSR 96-6p—Policy Interpretation Ruling—
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