TN 13 (04-13)

DI 22510.006 When Not to Purchase a Consultative Examination (CE)

IMPORTANT: This section includes most, but not all, situations where CE purchase is inappropriate.

Do not purchase a CE:

A. When case evidence is sufficient and consistent enough to adjudicate the claim

See DI 24515.001B.

REMINDER: For continuing disability reviews (CDRs), the nature of the impairment determines whether you need recent medical evidence. Do not order a CE in CDR cases where the impairment:

  • Meets a listing and will always meet the listing.

  • Meets the requirement for certain Medical Improvement Not Expected (MINE) or MINE-equivalent cases. (See DI 28040.005.)

B. When other sources have available evidence

Do not request a CE for diagnostic tests or procedures already performed by a medical source. If you need a test, evaluation, or procedure that a medical source has already performed, request the results of the test or procedure from the appropriate source.

C. When the test or procedure involves significant risk

Do not order diagnostic tests or procedures such as myelograms, arteriograms, or cardiac catheterizations that involve significant risk to the claimant. If you are uncertain about whether a diagnostic test or procedure poses significant risk, obtain the approval of a disability determination services (DDS) medical consultant prior to ordering the CE.

IMPORTANT: The medical source designated to do the CE is responsible for deciding whether to perform a requested test or procedure that may involve significant risk to a claimant.

D. For issues of potential malingering

Do not purchase symptom validity tests (SVT) to address symptom evaluation or issues of potential malingering as part of a CE. Tests cannot prove whether a claimant is malingering because there is no test that, when passed or failed, conclusively determines the claimant’s motivation. Malingering requires a deliberate attempt to deceive.

Examples of SVT include, but are not limited to:

  • Rey 15 Item Memory Test (Rey-II),

  • Miller Forensic Assessment of Symptoms Test (M-FAST),

  • Millon Clinical Multiaxial Inventory,

  • Minnesota Multiphasic Personality Inventory (MMPI),

  • Malingering Probability Scale,

  • Structured Interview of Reported Symptoms,

  • Test of Memory Malingering, and

  • Validity Indicator Profile.

EXCEPTION: The Office of Disability Programs may approve rare exceptions to this prohibition on a case-by-case basis (for example, testing ordered pursuant to a court order). When necessary, the Office of Hearing Operations will email ^ODP Controls for preapproval and copy both ^ODP OMLI Controls and ||DCO ODD.

REMINDER: Consider referring a case with evidence suggestive of fraud or similar fault to the Office of Inspector General for investigation. See DI 23025.015.

NOTE: When the results of SVT are part of the medical evidence of record, we consider them along with all of the relevant evidence in the case record.

E. For drug or alcohol testing

Do not purchase drug or alcohol testing to evaluate an issue of drug addiction or alcoholism (DAA). A single drug or alcohol test is not sufficient to establish DAA as a medically determinable impairment, nor does it provide pertinent information that can help us determine whether DAA is material to a finding of disability. For details on evaluating cases involving DAA, see SSR13-2p.

F. When a substantial gainful activity (SGA) issue precludes entitlement

Resolve any outstanding SGA issue that could preclude entitlement before ordering a CE.

G. When a technical factor precludes entitlement

These situations include, but are not limited to:

1. Disability insurance benefits claims (DIB)

Date last insured (DLI) is in the past and there is no possibility of establishing an established onset date (EOD) prior to the DLI.

2. Widow's or widower's benefits based on disability (DWB)

The prescribed period has ended and there is no possibility of establishing an EOD prior to the date the prescribed period ended.

3. Child's benefits based on disability (CDB)

There is no possibility of establishing an EOD before the date the claimant attained age 22.