HOW THE SSA WEIGHS MEDICAL EVIDENCE
HOW THE SSA WEIGHS MEDICAL EVIDENCE IN YOUR DISABILITY CASE
If you file an application for Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI), then your medical evidence will determine whether you receive benefits. Many people believe the SSA only looks at your diagnosis. However, that is not how the five step SSA review process works. Instead, the SSA carefully reviews your medical records to decide how your condition affects your ability to work.
The rules that govern medical evidence changed a few years ago. The SSA now reviews medical opinions differently than it did in the past. As a result, understanding these rules can help you build a better disability case.
At our SSD law firm, we talk to many people who assume that they will win their case if they have a statement from their doctor that says they are disabled. Unfortunately, that is not true. Instead, the SSA looks at the entire medical record to decide whether the evidence supports your claim. If your medical evidence is consistent over time, then you have the best chance of an award of SSD benefits.
MEDICAL EVIDENCE CAN COME FROM A VARIETY OF TREATING PROVIDERS
For many years the SSA only accepted statements about your health from your treating doctor. However, this did not reflect the reality that most people get treatment from medical providers other than their main doctor. For example, many people see nurse practitioners, physician assistants, and other professionals. In fact, most doctors use these providers for much of the routine medical care for their patients.
Because of these changes, the SSA updated its rules to reflect how people receive medical treatment. The agency also wanted to make SSD decisions that were consistent from one case to another. As a result, the SSA issued new medical evidence regulations. These rules apply to every disability application filed today.
The SSA reviews everything in your medical file to understand how your condition affects your daily life and your ability to perform work activities. Your treatment records tell the story of your illness over time. They show how often you seek treatment, how your symptoms change, what medications you take, and whether your condition is betting better or worse.
Medical evidence also includes physical exams, imaging studies, lab tests, treatment notes, hospital records, therapy records, and opinions from all of your medical providers. Together, these records help the SSA understand the severity of your medical condition.
THE FIVE TYPES OF EVIDENCE THE SSA REVIEWS
The SSA organizes evidence into different categories during their case review. First, they review objective medical evidence. Next, the SSA reviews medical opinions. These opinions describe the physical or mental symptoms that prevent you from working.
The SSA also reviews other medical evidence found throughout your treatment records. This may include descriptions of your symptoms, treatment, medications, and observations made during office visits. That is why it is important for you to explain all of your symptoms at your doctor visits. If you say you are “fine,” then that is what appears in your records.
Additionally, the SSA considers evidence from family members, friends, and employers. These opinions are not medical opinions. But sometimes, the SSA gives these opinions weight when they appear consistent with the rest of the evidence. Even providers who do not qualify as acceptable medical sources may still provide useful information. For example, your chiropractor could provide records and an opinion. As long as it was consistent, the SSA might consider it.
Finally, the SSA reviews opinions from their SSA doctors who review your records during earlier stages of the application process. Each type of evidence plays a different role in your SSD case. Therefore, building a complete medical record is the most important part in proving your case.
A DIAGNOSIS ALONE IS NOT ENOUGH
Many people feel surprised when they learn that having a diagnosis does not automatically qualify them for SSD benefits. Think of it this way. Millions of people have a diagnosis of depression. They take medication which helps their symptoms and then, they go to work. In other words, they have a diagnosis, but it doesn’t keep them from working. Simply having a doctor diagnose you with a condition does not help you win benefits.
First, the SSA must determine that you have a medical condition proven by objective medical evidence. Next, they will examine whether you are getting the proper treatment and if that alleviates your symptoms. After that, they must decide whether your condition limits your ability to perform full time work.
For example, two people may receive the same diagnosis. One person may continue working without significant problems. The other may experience severe symptoms that prevent any substantial gainful activity. The diagnosis remains the same, but the level of impairment differs greatly.
Because of this, the SSA focuses heavily on how your medical condition affects your ability to function rather than simply looking at the name of your illness.
YOU MUST FILE AN APPLICATION TO WIN SSD BENEFITS
If you have a severe medication condition that prevents work, then you must file an application to win benefits. There are two types of benefits you can file for under the Social Security program: Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI) benefits. You can file an application on the Social Security’s website. You can also file an application over the phone with the SSA.
Social Security Disability Insurance (SSDI):
SSDI benefits are for those who have worked in the recent past and can no longer work at any job due to a medical condition. The amount of money you will receive from SSDI benefits every month is based on how much Social Security tax you have paid during your work history.
To qualify for SSDI, you must have earned enough work credits. You can earn up to 4 work credits per year. The amount of work credits you need depends on how old you are when you apply. If you haven’t earned enough work credits for your age at the time you apply, then you can only apply for Supplemental Security Income benefits.
Supplemental Security Income (SSI):
SSI is a needs based benefit and it is for those people with little to no income, such as children and the elderly. An individual with greater than $2000 saved cannot receive SSI benefits. The SSA counts the income of those you share expenses with, not just your income. You cannot qualify for SSI benefits, no matter how severe your anxiety, if you do not meet the income and asset rules for SSI.
OBJECTIVE MEDICAL EVIDENCE MATTERS
Objective medical evidence is one of the most important parts of every SSD claim. It is medical evidence that comes from physical exams, blood tests, X-rays, MRIs, CT scans, nerve conduction studies, heart tests, and other procedures.
Your symptoms are also important. However, the SSA usually cannot approve your claim based only on what you tell your doctor. Instead, your medical records should show objective findings that support your symptoms and explain why you cannot work.
That is why regular medical treatment is so important. Regular does not mean twice a year. At a minimum it means once a month. Each doctor appointment creates another record of your condition, your symptoms, and your treatment. Over time, your progress notes build a clear picture of how your medical condition limits your ability to work. Your medical records provide the evidence the SSA needs to approve your SSD benefits.
THE MEDICAL OPINION FROM YOUR DOCTOR DOES NOT CARRY THE MOST WEIGHT
For many years, the SSA followed what people often called the treating physician rule. Under those rules, the opinion of your treating doctor received controlling weight if it met certain legal requirements. Many SSD cases depend heavily on what a long term treating physician says about your ability to work.
That rule no longer applies to SSD claims. Since 2017, the SSA does not automatically give greater weight to the opinion of your treating doctor. Instead, the SSA evaluates every medical opinion using the same standards. It is unfortunate that they changed the rule because your treating doctor certainly knows about you. Additionally, your doctor has better insight into your medical conditions than a doctor who simply reviews your records.
You may believe your family doctor knows your condition better than anyone else. While that may be true, the SSA still compares the opinion of your doctor to the rest of your medical evidence before deciding how much weight to give it. Your treating doctor can still help you win benefits, but their medical opinion must be supported and consistent with the entire medical record.
THE SSA FOCUSES ON PERSUASIVENESS OF MEDICAL EVIDENCE
Instead of giving different weight to medical opinions, the SSA now decides how persuasive each opinion is. This means the SSA reviews the quality of the opinion rather than the title of the medical provider.
A medical opinion should explain your limitations clearly and point to medical findings that support those limitations. For example, if your doctor explains that severe degenerative disc disease limits your ability to stand, then refers to treatment records, then the opinion is persuasive.
On the other hand, a short statement that simply says you cannot work carries very little value. The SSA wants to understand what your limitations are. Medical opinions that include detailed explanations usually receive greater consideration than opinions that only contain conclusions.
This is one reason why working closely with your doctor can make a difference. Your attorney can request letters and information from your doctor that supports your case. If you attorney does this, then it is easier for the SSA to understand how your condition limits your ability to work.
SUPPORTABILITY IS ONE OF THE MOST IMPORTANT FACTORS
Supportability is another important factors the SSA uses when deciding how much weight to give a medical opinion. It means the opinion from your doctor is backed up by medical evidence. The SSA looks to see whether your doctor explains the opinion with physical exam findings, imaging studies, lab results, treatment notes, and other objective medical evidence.
For example, your neurologist may say that you cannot use your hands for a full eight hour workday. That opinion becomes stronger if your medical records also show muscle weakness, reduced grip strength, abnormal nerve studies, or loss of balance.
On the other hand, if your doctor checks boxes on a form but provides no explanation that sites the medical records, then the SSA may find the opinion has no support. That is why detailed treatment notes and objective medical evidence are so important. The stronger the medical evidence, the better your case.
CONSISTENCY IS IMPORTANT IN MEDICAL EVIDENCE
Another major factor when the SSA weighs your medical evidence is consistency.
Consistency means the SSA compares one medical opinion to the rest of the evidence in your file. The agency wants to see whether the opinion of your doctor agrees with your treatment records, imaging studies, and hospital records. The opinion should also be similar to opinions from other medical providers.
If your records consistently show severe pain, reduced strength, limited range of motion, frequent treatment, and ongoing symptoms, then the SSA should accept the medial opinion from your doctor. Everything works together to support your claim.
However, problems arise when the records tell a different story. If your doctor says you cannot walk fifty feet but the treatment notes repeatedly describe a normal gait and normal strength, then the SSA may question that opinion. For this reason, consistency throughout your medical record is extremely important.
REGULAR MEDICAL TREATMENT STRENGTHENS YOUR CASE
Regular medical treatment plays a major role in the outcome of your Social Security Disability claim.
One of the most common mistakes people make is waiting too long between doctor visits. When months pass without treatment, the SSA questions whether your condition is as severe as you claim. While there are many valid reasons for gaps in treatment, such as losing insurance or being unable to afford care, long breaks in your medical records makes your claim harder to prove.
Seeing your doctor on a regular basis creates a consistent medical history. Each visit documents your symptoms, your treatment, and how your condition changes over time. These records help show whether your condition improves, remains the same, or continues to worsen despite following your treatment plan.
It is also important to tell your doctors about every symptom you experience. Do not focus only on your primary diagnosis. Tell your doctor about pain, fatigue, weakness, and medication side effects. If you have mental issues, then tell the doctor about memory problems, anxiety, or any other symptoms that affect your ability to work. If these problems are not in your medical records, then the SSA may not have enough medical evidence to grant your SSDI and SSI benefits.
HOW THE SSA CONSIDERS EVIDENCE FROM FAMILY & FRIENDS
Medical records are the foundation of your SSD claim. Even so, they do not always capture how your medical condition affects your everyday life. That is why the SSA also considers statements from family members, friends, employers, and others who have knowledge of your symptoms.
For example, your spouse may state that you need help getting dressed because of inflammatory arthritis. A family member can describe how your tremors make it unsafe to prepare meals. A friend may write that you are exhausted after walking even a short distance. A former employer may report that you miss work frequently because of your symptoms or have difficulty with your job duties. These observations show how your condition affects your ability to function outside of a medical setting.
Although statements from family and friends cannot prove you have a medically condition, they can support the medical evidence in your file. When these observations are consistent with your treatment records and the other evidence in your claim, then they support the argument that you cannot work.
THE SSA REVIEWS YOUR ENTIRE MEDICAL RECORD
The SSA does not base its decision on one medical record. Instead, they review your complete medical history to understand how your condition affects your ability to work.
The SSA looks at office visits, hospital records, emergency room records, imaging studies, mental health treatment, medication history, and many other types of medical evidence. They also evaluate how your condition changes throughout your treatment.
That is why every medical appointment is important. Even a routine follow up visit can document your symptoms, response to treatment, or changes in your condition. Each record adds another piece to the overall picture of your health. The SSA looks at all of your conditions, even the conditions that are not severe.
When your medical records document the same symptoms and limitations over months or years, they provide strong evidence that your condition affects your ability to work. Consistent medical records carry significant weight when the SSA evaluates your case.
THE SSA DOES NOT HAVE TO FOLLOW DECISIONS FROM OTHER AGENCIES
Many people receive benefits from another government agency before filing for Social Security disability benefits. For example, you may be getting veteran benefits from the Department of Veterans Affairs. You may also receive workers compensation benefits or money from another state or federal program.
While the SSA reviews the evidence behind those decisions, it does not have to agree with the findings or conclusions of any other agency. A finding that you are disabled under another program does not automatically mean you qualify for SSDI or SSI benefits.
This is frustrating for most people who file for SSD benefits. Every disability program follows its own rules and regulations. Therefore, the SSA makes its own independent decision using Social Security’s rules.
Even so, the medical records that support a decision from another agency may still provide valuable medical evidence. If those records document severe limitations and ongoing treatment, they can help support your SSD claim.
COMMON MISTAKES THAT CAN HURT YOUR SSD CLAIM
Many SSD applications receive denials because important evidence is missing. Fortunately, many of these problems can be avoided.
One common mistake is failing to seek regular medical treatment. If large gaps appear in your medical records, then the SSA may question your condition. While financial problems or lack of insurance sometimes explain missed treatment, you need to get consistent medical care. We have resources if you need free or low cost medical treatment.
Another mistake involves failing to report every symptom to your medical provider. Many people mention only their primary diagnosis and forget to discuss chronic pain, fatigue, side effects from medication, anxiety, or memory problems. If your symptoms never appear in your medical records, then the SSA may not consider them.
Some people also stop following their treatment plan without discussing the reasons with their doctor. In certain situations, the SSA may question whether your condition would improve if you followed your treatment plan. If you cannot afford treatment or experience serious side effects, then make sure those issues appear in your medical records.
Finally, some people assume that one strong medical opinion is enough to win benefits. In reality, the SSA reviews your entire medical record. Every office visit, test result, imaging study, therapy note, and hospital record contributes to the overall picture of your health. One medical opinion is not enough medical evidence to prove your case.
THE SSA MAKES THE FINAL DECISION
Your doctor plays an important role in your disability case, but your doctor does not decide whether you qualify for benefits.
Likewise, your employer, insurance company, or another government agency cannot make that decision either. The SSA alone decides whether you meet the legal definition of disability under the Social Security Act.
Because of this, statements that simply say you are disabled usually do not carry much weight. Instead, the SSA focuses on the medical evidence that explains your limitations.
The agency wants to understand exactly how your condition affects your ability to perform work related activities. Can you sit for long periods or lift objects throughout the day? Are you able to stay focused long enough to complete simple tasks? Can you interact with other workers and your boss? These are the types of questions the SSA must answer before deciding your claim.
BUILDING STRONGER MEDICAL EVIDENCE
The best SSD cases tell one consistent story from beginning to end. Your medical evidence, test results, treatment notes, and medical opinions should all support one another.
You should attend your medical appointments as regularly as you can. At your visits, you should discuss every symptom that affects your daily activities and your ability to work. Your treating providers cannot document problems they do not know about. If you think you will forget to talk about your symptoms, then make a list of topics you want to discuss before you go to the doctor.
You should also make sure your doctors understand how your condition affects your daily life. Explain if you cannot stand long enough to prepare a meal. Tell them if you need frequent breaks during the day. Describe problems with concentration, fatigue, balance, or pain. These details often become important medical evidence in the SSA’s review process.
When your medical records consistently document your limitations over time, then the SSA has a clear picture of why you cannot work.
WHY AN SSD ATTORNEY WITH EXPERIENCE MAKES A DIFFERENCE
The SSA follows detailed regulations when they review your medical evidence. Therefore, hiring an attorney who understands those rules can improve your chances of success.
An experienced SSD attorney understands what evidence the SSA finds persuasive. Your attorney can identify missing records, obtain supportive medical opinions, and review your file for weaknesses. They can also develop a strategy that presents the best possible case. Additionally, when you hear an SSD law firm who has decades of legal experience, they know what the SSA is wants to see. They will also know your SSA judge and what that judge is looking for.
At our SSD law firm, we know that every case is unique. We carefully review your medical evidence to make sure it accurately reflects your limitations. If important records are missing, then we work to obtain them. If additional medical opinions would strengthen your case, then we explain what information would be most helpful.
We also prepare you for every stage of the review process, including your hearing before an SSA judge. Finally, throughout your case, we work to ensure that the evidence clearly explains why your medical condition prevents you from working.
HIRE US. PUT OUR LEGAL EXPERIENCE TO WORK FOR YOU
Winning SSDI and SSI benefits often depends on the quality of your medical evidence. While a diagnosis is important, the SSA wants much more than the name of your condition. The SSA wants reliable medical evidence, objective findings, and consistent treatment. They also want medical opinions that explain how your condition limits your ability to work.
Understanding how the SSA evaluates medical evidence can help you avoid common mistakes and build a stronger disability claim. However, gathering the right evidence and presenting it effectively can feel overwhelming, especially when you are already dealing with serious health problems.
At our SSD law firm, we help people throughout Utah, Nevada, Idaho, Colorado, and across the country win their SSD case. In the past 35 years, we have won over 20,000 SSD cases for our clients.
We know what the SSA looks for, and we work hard to build the best case possible for every client. If you cannot work because of a serious medical condition, then contact us for a free case review. We are ready to help you win the SSD benefits you deserve.
