We categorize all evidence from an AMS as objective medical evidence (signs, laboratory findings, or both), medical opinions, or other medical evidence. For more information, see Categories of Evidence in DI 24503.005.

NOTE: If a person who is a medical source provides evidence in his or her capacity as a friend or family member, evaluate that evidence as if from a nonmedical source. For more information, see Evaluating Evidence from Nonmedical Sources.in DI 24503.020.

We require objective medical evidence (signs, laboratory findings, or both) from an AMS to establish that an individual has an MDI(s) at step 2 of the sequential evaluation process. For instructions on Establishing a Medically Determinable Impairment (MDI) see DI 24501.020.

REMEMBER:

• •

  We cannot establish an MDI based on symptoms, a diagnosis, or a medical opinion.

• •

  An MDI must result from anatomical, physiological, or psychological abnormalities identified by medically acceptable clinical and laboratory diagnostic techniques.

• •

  If we need objective medical evidence from a consultative examination (CE) to establish the existence of an MDI, a qualified CE source who is also an AMS must personally examine the claimant, though qualified support staff may assist.

See details:

DI 22510.010 Selecting a Qualified Medical Source to Perform a Consultative Examination (CE).

Once we establish that a claimant has an MDI based on objective medical evidence from an AMS, we use all evidence from all sources for all other findings in the sequential evaluation process, including showing the severity of a claimant’s MDI at step 2. These sources include:

1. a. 

   Medical sources who are not AMSs but are legally permitted to provide healthcare, such as naturopaths, chiropractors, and therapists;

2. b. 

   Nonmedical sources such as:

   • •

     educational personnel (for example, school teachers, counselors, early intervention team members, developmental center workers, and daycare center workers);

   • •

     public and private social welfare agency personnel; and

   • •

     relatives (spouses, parents, siblings, etc.), caregivers, friends, neighbors, past employers, and clergy.

Consider medical evidence to be from an AMS, as described in DI 22505.003A in this section, if it shows the AMS’s:

• •

  role in the care or evaluation; and

• •

  connection to the evidence.

Evidence is not from an AMS if it shows only a non-AMS source(s) provided the medical care for the claimant without an AMS taking a role in the care and having a direct connection to the evidence.

If we cannot determine whether the evidence is from an AMS after reviewing the evidence, and the issue is material to the determination (for example, no other evidence in the file would establish the existence of an MDI), resolve the issue with subsequent development. You may, for example:

• •

  recontact the source for clarification; or

• •

  consult State licensing or credentialing agency official resources, such as an official website to determine if he or she is an AMS.

After recontact, if you still cannot verify that the source is an AMS, then you cannot consider that source to be an AMS.

NOTE: Clearly document efforts to resolve any medical source issues. Document additional information in a Case Note in the Disability Case Processing System (DCPS), or on the Case Development Worksheet (CDW).