TN 14 (06-13)

Citations:

20 CFR 404.1520b and 416.920b

A. Policy for developing supplemental evidence

As you evaluate the case evidence, you may identify material inconsistencies or insufficiencies in evidence received from a claimant’s medical source(s). After you complete initial development of the medical and other evidence, attempt to obtain supplemental evidence when necessary to adjudicate the case.

B. Options for supplemental development

Depending on its nature, there may be more than one way to resolve the insufficiency or inconsistency. Select the appropriate method(s) of supplemental development to obtain the specific additional evidence needed to adjudicate the case.

C. Procedure for supplemental development

REMINDER: Document all case development efforts in the disability folder; see DI 20503.001E.

1. Recontacting a medical source(s)

a. When we require recontacting

We require recontacting in the following situations:

• The needed evidence is only available from this medical source (for example, the claimant underwent an invasive procedure, such as an angiography and the treating physician did not send us results of that procedure).

• The medical source provided evidence that contains an internal material inconsistency, and you cannot tell from the existing evidence whether the claimant is disabled.

REMINDER: If you know from experience that the source either cannot or will not provide the needed evidence, do not recontact this medical source. However, explain why you did not recontact the source on the case development summary worksheet.

b. Procedure for recontacting a medical source

Recontact a medical source by telephone, fax, or mail.

1. If you recontact a medical source by telephone, follow the procedures in DI 22505.030.

   REMINDER: Recontacting by telephone may be the most expeditious method.

2. If you recontact a medical source by mail, send a letter explaining:

   • the nature of the missing evidence or inconsistency;

   • why we need clarification of the information; and

   • the type of evidence needed (or suggest the type of evidence necessary to resolve the inconsistency).

Include an SSA-827 (Authorization to Disclose Information to the Social Security Administration (SSA)), if needed.

3. Use follow-up procedures in DI 22505.035, if needed.

2. Requesting additional existing medical records

a. When to request updated medical evidence

When additional records (e.g., from a follow-up medical exam, test, or procedure) are available from a medical source that previously provided records, and the new evidence could be material to the determination, request the updated medical records.

EXAMPLE: Helen alleged disability due to chronic obstructive pulmonary disease. The Disability Determination Services (DDS) requested medical records from Helen’s treating physician and received the records on 3/3/2012. On 3/8/2012, Helen called the DDS to report that she underwent a pulmonary function test (PFT) at her treating physician’s office on 3/7/2012. In this situation, request additional medical records from Helen’s 3/7/2012 office visit, including the notes from her office visit and the results and tracings from her PFT.

b. When to request evidence from a new medical source

If you identify a new medical source when developing the case, request relevant medical records from that source. This is a new initial request. EXAMPLE: Sam’s medical records from Dr. Smith indicate Dr. Jones also treated Sam for the same condition. Sam did not identify Dr. Jones as one of his medical sources on his SSA-3368-BK (Disability Report - Adult). Dr. Jones’ records may be material to the determination. In this case, the DDS would request the relevant medical records from Dr. Jones.

REMINDER: Unless case evidence supports a fully favorable determination, you must make every reasonable effort to develop a complete medical history. See DI 22505.001A.3.

c. Procedure for requesting additional medical records

Request evidence, including diagnostic tests, from all sources identified by the claimant or discovered during development for the alleged or documented impairment(s) during the applicable period, see DI 22505.007.

Use follow-up procedures in DI 22505.035, if needed.

3. Purchasing a consultative examination (CE)

a. When to purchase a CE

If a claimant’s medical source(s) cannot or will not provide sufficient medical evidence about a claimant’s impairment(s), you may purchase one or more CEs. For examples of situations that generally require a CE, see DI 22510.005B. Do not purchase a CE if any of the conditions in DI 22510.006 exist.

b. Procedures for developing a CE

For more information on CE development, see DI 22510.000.

4. Requesting evidence from the claimant

a. When to request evidence from the claimant

The claimant is usually the best source of information about his or her medical care (medical sources), functional limitations, and past work. Generally, request this information from the claimant before considering third party requests. Consider requesting information from the claimant when:

• There is an indication that the claimant has not identified all evidence or impairments that may be material to the disability determination (e.g., a medical source with relevant information).

• The information the claimant provided about his or her functional limitations is inconsistent with other information in the file or needs clarification.

• You need work history information.

REMINDER: If the claimant fails or refuses to provide the requested evidence to perform the necessary action, or attend a needed CE, you may discontinue development that requires claimant action, see DI 23007.000.

b. Procedure for requesting evidence or action from the claimant

To request evidence or action from the claimant, follow the procedures in DI 23007.005C through DI 23007.005G.

5. Requesting evidence from other sources

You may contact third party sources by mail or phone, as appropriate. For examples of other sources, see DI 22505.003B.3.

REMINDER: Carefully consider requesting information from third parties and contact them only when necessary. Contacting a third party always involves disclosure, and our minimization policy applies, see GN 03316.005D.

D. References

• DI 24515.001 Evaluating the evidence

• DI 22505.006 Requesting evidence