TN 1 (02-01)

Citations:

20 CFR 416.908 20 CFR 416.912 20 CFR 416.913

A. Policy

A medically determinable physical or mental impairment must result from anatomical, physiological, or psychological abnormalities which can be shown by medically acceptable clinical and laboratory diagnostic techniques. The impairment must be established by objective medical evidence (signs, laboratory findings, or both) from an acceptable medical source, not on an individual’s statement of symptoms (see DI 24501.020). See DI 22505.003A.2.

B. Procedure

If the evidence does not include objective medical evidence from an acceptable medical source sufficient to establish the existence of a medically determinable impairment (MDI) , follow the procedure below.

1. Insufficient or conflicting evidence

If the evidence from acceptable medical sources is insufficient to establish the existence of an impairment or contains a material conflict, undertake additional development (e.g., recontact medical sources, order a CE), per DI 22505.008 and DI 22510.001.

2. Development complete

After development is complete, decide the nature of the child's impairment(s) based on all the evidence of record.

3. Evidence from acceptable medical sources

Do not establish the existence of an impairment(s) on the basis of information from a source(s) that is not an acceptable medical source (although such information may be valuable when assessing the severity of an impairment(s).

Example 1: A school psychologist, who is the only source of evidence, concludes that the claimant, a 9-year-old child, has a developmental reading disorder. Based on the school psychologist's report and on the child's parents' statements, the DDS medical consultant/psychological consultant (MC/PC) believes that the child's more significant impairment may be a disruptive behavior disorder. The MC/PC cannot establish that a disruptive behavior disorder exists because the record does not include medical evidence about the disruptive behavior disorder from an acceptable medical source. (Per DI 22505.003A, a school psychologist is an acceptable medical source only with respect to intellectual disability, learning disabilities, and borderline intellectual functioning.) The DDS should not establish the existence of a disruptive behavior disorder without additional evidence from an acceptable medical source.

Example 2: A CE provider indicates that a child was somewhat oppositional in the test situation, but the provider does not provide sufficient medical evidence to establish the existence of an oppositional defiant disorder (ODD). It would be incorrect to combine anecdotal information with reports from the child's mother and teacher to conclude that the child has ODD. Recontact with the CE provider is required.

Example 3: A psychological evaluation indicates that a 10-year-old child has full scale, verbal, and performance IQs in the low 60's, but the report does not discuss deficits of adaptive functioning nor does it provide a diagnosis of intellectual disability. The consultant cannot be recontacted for clarification. However, the child's mother describes activities typical of mild intellectual disability. In this case, the DDS should not establish the existence of intellectual disability without additional evidence about adaptive functioning from an acceptable medical source.