DI 24501: General - Medical Evaluation
TN 12 (03-18)
Citations:
Social Security Act §§ 205(a) & (b) Evidence, procedure, and certification for payment, 221(k) Disability determinations, 223 Disability insurance benefit payments, 1614(a) Meaning of terms for aged, blind, or disabled individual, 1631(c) & (e) Payment of benefits, and 1633 Administration;
20 CFR §§ 404.1502 Definitions for this subpart, 404.1503 Who makes disability and blindness determinations, 404.1504 Decisions by other governmental agencies and nongovernmental entities, 404.1512 Responsibility for evidence through 404.1523 Multiple impairments, 404.1527 Evaluating opinion evidence for claims filed before March 27, 2017, 416.902 Definitions for this subpart, 416.903 Who makes disability and blindness determinations, 416.904 Decisions by other governmental agencies and nongovernmental entities, 416.912 Responsibility for evidence through 416.924(b) Age as a factor of evaluation in the sequential evaluation process for children, 416.927 Evaluating opinion evidence for claims filed before March 27, 2017, and 416.1013 Disability determinations the State makes.
A. Introduction to evidence evaluation
Evaluate all the evidence in the case record before making a disability determination.
For additional information:
on medical evaluation, see DI 24501.002;
about the categories of evidence that may be in the case record, see DI 24503.005;
to evaluate medical opinions and prior administrative medical findings for claims filed on or after March 27, 2017, see DI 24503.030; and
to evaluate medical opinions, opinions, and prior administrative medical findings for claims filed before March 27, 2017, see DI 24503.035.
Consider the claimant’s residual functional capacity to evaluate:
the claimant’s ability to do past relevant work at step 4 of the sequential evaluation process (see subchapter DI 25005.000); and
the claimant’s ability to do other work at step 5 of the sequential evaluation (in conjunction with the claimant’s vocational factors (see subchapter DI 22515.000).
REMINDER: When appropriate, consider an expedited vocational assessment at steps 4 and 5, per DI 25005.005.
B. Definitions for evidence evaluation
Use the definitions in this section to evaluate the evidence.
1. Evidence
Evidence is any medical or non-medical information the claimant or anyone else submits to us, or that we obtain, that relates to the claim.
For additional information about what is and is not evidence, see DI 24503.001.
2. Relevant evidence
Relevant evidence is a type of essential material related to the issues in the claim, including, but not limited to the following:
Establishing one or more medically determinable impairments, see DI 24501.020;
Assessing the severity of the impairment, see DI 24505.000;
Determining the duration of the impairment, see DI 25505.000;
Establishing the onset date of disability, see DI 25501.000; and
Documenting fraud or similar fault, see DI 23025.000.
For a definition of essential material and relevant evidence, see DI 20503.001.
3. Sufficient evidence
Evidence is sufficient when it contains all the information we need to make the determination. For additional information on completeness of medical and non-medical evidence, see DI 22501.001.
4. Inconsistent evidence
Evidence is inconsistent if it:
conflicts with other evidence;
contains an internal conflict;
contains ambiguities; or
is medical evidence that does not appear to be based on medically acceptable clinical or laboratory diagnostic techniques.
For additional information on purchasing a consultative examination to resolve a conflict, inconsistency, or ambiguity, see DI 22510.005B.5.
For additional information on using supplemental evidence to resolve an inconsistency or insufficiency, see DI 22505.008.
IMPORTANT: If the file contains a material conflict, inconsistency, or ambiguity in the evidence, the case evidence is insufficient. Evidence is materially inconsistent only if the inconsistency presents an issue that:
makes a difference between the decision to allow or deny; or
affects the determination of established onset date.
C. Procedure to evaluate the evidence
Follow the steps in this section to evaluate the evidence.
1. Compare the evidence with the claimant’s allegations
Analyze each piece of evidence and consider the evidence for the following:
completeness;
relevance;
internal consistency;
interrelationship with other evidence; and
consistency with other evidence.
IMPORTANT: When determining the persuasiveness of medical opinions or prior administrative medical findings in cases with filing dates on or after March 27, 2017, consider the five factors listed in DI 24503.025E:
Supportability;
Consistency;
Relationship with the claimant;
Specialization; and
Other factors.
2. Case evidence is complete and consistent
If the case evidence is consistent and contains sufficient evidence to make a disability determination:
make the required findings based on all of the evidence; and
complete the determination.
REMINDERS:
Case evidence must be complete and detailed enough to permit an independent determination about whether the claimant is disabled or blind. For details on case development, see DI 22501.001.
The case development summary worksheet must document initial and follow-up requests for medical evidence of record (MER) and non-MER. For further information about the case development summary worksheet, see DI 20503.001E.
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Before making a determination that is not fully favorable to the claimant, make every reasonable effort to develop the claimant’s complete medical history.
For details on every reasonable effort requirements, see DI 22505.001A.2.
For details on complete medical history, see DI 22505.001A.3.
3. Case evidence is inconsistent but sufficient
If any of the case evidence is inconsistent, but there is sufficient evidence to make a determination, consider all the evidence and make a determination supported by the case evidence.
Document how you resolved any inconsistencies in the evidence in:
the electronic claims analysis tool (eCAT) disability determination claims communication section;
an SSA-5002 (Report of Contact); or
the Case Development Summary Worksheet.
4. Case evidence is insufficient or inconsistent
Consider evidence insufficient when it does not contain all the information to make a determination.
Consider evidence inconsistent when it conflicts with other evidence, contains an internal conflict, is ambiguous, or the medical evidence does not appear to be based on medically acceptable clinical or laboratory diagnostic techniques.
If the case evidence contains any material inconsistencies, or is otherwise insufficient, follow these procedures:
a. Complete supplemental development
Complete supplemental development to resolve material inconsistencies or insufficiencies in the case evidence.
For supplemental development requirements, see DI 22505.008.
b. Evaluate the supplemental evidence with the other evidence in the file
Make determination findings supported by the case evidence.
REMINDER: Do not make a fully favorable determination if unable to resolve an insufficient evidence situation through supplemental development.
c. Document the medical evaluation
Document the medical evaluation to include:
the appropriate period;
substantive findings supported by the case evidence; and
an explanation of the evidentiary insufficiency (i.e., unresolved conflict or missing essential information), and all related supplemental development efforts if evidence is insufficient to complete the medical evaluation. Do not make findings substantiating impairment-related limitations during any period in which evidence is insufficient to support the finding.
For additional details on documenting the medical evaluation, see DI 24501.002.
5. Document evidentiary development and follow up efforts
For details on documenting the folder, see DI 20503.001.
In all cases, document the details of all developmental efforts in either:
the eCAT claims communication section;
an SSA-5002 (Report of Contact); or
the Case Development Summary Worksheet.
D. When to stop certain evidentiary development and follow-up activities
The three findings in this section allow you stop certain development activities.
1. Sufficient evidence for an allowance
If the case contains sufficient evidence to make a fully favorable determination, discontinue development. Do not await receipt of, or follow-up on, outstanding medical evidence requests.
For details on curtailing development on fully favorable claims, see DI 24515.020.
2. Medical source clearly will not provide evidence
If the medical source cannot or will not provide the requested MER, discontinue development from the source.
For information on when not to make a request for medical information to a source, see DI 22505.006A.3.
For information on when to discontinue follow-up activities when the medical source cannot or will not provide the requested medical evidence, see DI 22505.035.
3. Insufficient evidence furnished
Once you make a reasonable effort to get the claimant to comply with our requests for evidence or action, discontinue development that requires his or her cooperation. Ensure that you made a reasonable effort to develop a complete medical history that does not require the claimant’s cooperation. Make a determination based on all of the evidence in the file.
E. References
DI 22505.001 Medical and Nonmedical Evidence
DI 22505.003 Evidence from an Acceptable Medical Source (AMS)
DI 22505.006 Requesting Evidence - General
DI 22505.008 Developing Supplemental Evidence
DI 22505.035 Follow-up on Requests for Medical Evidence of Record (MER)
DI 22510.005 When to Purchase a Consultative Examination (CE)
DI 22515.000 Vocational Evidence Table of Contents
DI 23025.000 Fraud or Similar Fault Table of Contents
DI 24501.002 Introduction to Medical Evaluation
DI 24501.020 Establishing a Medically Determinable Impairment (MDI)
DI 24503.001 Evaluating Evidence - Basic Policy
DI 24503.005 Categories of Evidence
DI 24503.010 Evaluating Objective Medical Evidence
DI 24503.015 Evaluating Other Medical Evidence
DI 24503.020 Evaluating Evidence from Nonmedical Sources
DI 24503.025 Evaluating Medical Opinions and Prior Administrative Medical Findings – Claims filed on or after March 27, 2017
DI 24503.030 Articulation Requirements for Medical Opinions and Prior Administrative Medical Findings – Claims filed on or after March 27, 2017
DI 24503.035 Evaluation and Articulation Requirements for Medical Opinions, Opinions, and Prior Administrative Medical Findings - Claims Filed before March 27, 2017
DI 24505.000 Impairment Severity Table of Contents
DI 24515.012 Evaluating Lay Evidence
DI 24515.020 Curtailing Development of Fully Favorable Claims
DI 25005.000 Capacity to Do Past Relevant Work Table of Contents
DI 25005.005 Expedited Vocational Assessment at Steps 4 and 5 of Sequential Evaluation
DI 25025.000 Medical-Vocational Guidelines Table of Contents
DI 25501.000 Onset Table of Contents
DI 25505.000 Duration Table of Contents