BASIC (10-16)

DI 23060.030 Evaluating Evidence Furnished by Excluded Medical Sources of Evidence

Citations:

Soc. Sec. Act as amended in 2015, Secs. 223(d)(5)(C), 1614(a)(3)(H)(i), 42 U.S.C. §§ 423(d)(5)(C), 1382c(a)(3)(H)(i); P.L. 114-74, § 812; 20 CFR §§ 404.1503b, 416.903b

A. Evaluating evidence furnished by excluded medical sources of evidence

This section applies to initial and reconsideration determinations and continuing disability reviews (CDR) for disability claims under titles II and XVI of the Social Security Act (Act).

Do not consider evidence furnished by excluded medical sources of evidence unless a good cause exception(s) applies. See DI 23060.010B.1 for the definition of excluded medical sources of evidence.

To document the evaluation of evidence furnished by an excluded medical source of evidence, follow the instructions in section DI 23060.030D.

REMEMBER: Evaluating evidence furnished by an excluded medical source of evidence does not affect the Social Security Administration’s (SSA) fraud or similar fault (FSF) policy. See DI 23025.000 for instructions on FSF.

B. Good cause exceptions

There are five good cause exceptions. Apply a good cause exception if all of its criteria are met. If a good cause exception applies, consider the evidence furnished by the excluded medical source of evidence.

NOTE: There may be instances where some, but not all, of the evidence furnished by an excluded medical source of evidence meets the criteria of a good cause exception. Consider the evidence that meets the criteria of the exception and do not consider the evidence that does not.

The five good cause exceptions are:

  1. The evidence covers treatment that occurred before the source’s felony conviction under section 208 or 1632 of the Act;

  2. The evidence covers treatment that occurred when the source was not excluded from participating in any Federal health care program under section 1128 of the Act;

  3. The evidence covers treatment that occurred before the source received a final decision imposing a civil monetary penalty (CMP), assessment, or both, for submitting false evidence under section 1129 of the Act;

  4. The source is excluded solely because the source cannot participate in any Federal health care program under section 1128 of the Act, but the Office of Inspector General of the Department of Health and Human Services (HHS’ OIG) has waived that exclusion;

  5. The evidence is a laboratory finding(s) about a physical impairment(s) and there is no indication that the finding(s) is unreliable. See DI 24501.020 for a definition of laboratory findings.

NOTE: This exception applies to laboratory findings, not signs. A laboratory finding results from medically acceptable laboratory diagnostic techniques (e.g., x-rays, MRIs, biopsies, and blood tests). A sign is an abnormality that can be observed apart from a claimant’s statements (e.g., a medical source observes a claimant limping).

C. Evidence considered in a prior determination or CDR

1. Evidence considered in a prior determination or CDR made before November 2, 2016

If evidence furnished by an excluded medical source of evidence was considered in a prior determination or CDR made before November 2, 2016, continue to consider that evidence even if it is resubmitted on or after November 2, 2016.

EXAMPLE: A determination made before November 2, 2016, considered evidence furnished by an excluded medical source of evidence. During a subsequent CDR that occurred after November 2, 2016, the excluded medical source of evidence resubmitted the same evidence. Continue to consider that resubmitted evidence in the CDR because it was originally furnished by the excluded medical source of evidence before November 2, 2016.

2. Evidence considered in a prior determination or CDR made on or after November 2, 2016

If evidence furnished by an excluded medical source of evidence was considered in a prior determination or CDR made on or after November 2, 2016, ask yourself:

  • Did a written statement of exclusion accompany the evidence or did the prior adjudicator identify clear documentation (e.g., an email from the administrator or professional relations officer) that the source was an excluded medical source of evidence?

  • Did the prior adjudicator correctly apply a good cause exception(s)?

If the answer to both questions is yes, continue to consider the evidence.

If the answer to one or both questions is no, re-evaluate the evidence to decide whether it should continue to be considered.

NOTE: During a CDR, consider whether to apply the Prior Error Exception if the evidence should not continue to be considered, and should not have been considered in the prior determination or CDR. See DI 28020.350 for instructions.

EXAMPLE 1: A determination made on or after November 2, 2016, considered evidence furnished by an excluded medical source of evidence that did not include a written statement of exclusion. The source later submitted the same evidence and included a written statement of exclusion. Re-evaluate the evidence.

EXAMPLE 2: A determination made on or after November 2, 2016, considered evidence furnished by an excluded medical source of evidence that included a written statement of exclusion. The prior adjudicator, however, did not correctly apply a good cause exception(s). Re-evaluate the evidence.

EXAMPLE 3: A determination made on or after November 2, 2016, considered evidence furnished by an excluded medical source of evidence that included a written statement of exclusion. Additionally, the prior adjudicator correctly applied a good cause exception(s). Continue to consider the previously furnished evidence.

3. Evidence excluded from a prior determination or CDR made on or after November 2, 2016

If evidence furnished by an excluded medical source of evidence was not considered in a prior determination or CDR made on or after November 2, 2016, ask yourself:

  • Should the prior adjudicator have applied a good cause exception(s) to some or all of the evidence?

If the answer is no, continue to exclude the evidence.

If the answer is yes, determine which evidence the good cause exception(s) applies to and consider that evidence.

EXAMPLE 1: A determination made on or after November 2, 2016, excluded evidence furnished by an excluded medical source of evidence. That evidence includes a blood test and there is no indication the test results are unreliable. Apply the good cause exception (i.e., a laboratory finding about a physical impairment where there is no indication of unreliability) and consider the blood test.

EXAMPLE 2: A determination made on or after November 2, 2016, excluded evidence furnished by an excluded medical source of evidence. None of that excluded evidence meets a good cause exception. Continue to exclude the evidence.

D. Documenting the evaluation of evidence

Document the evaluation of evidence furnished by an excluded medical source of evidence. For electronic cases, document this in the electronic Claims Analysis Tool (eCAT) so that it appears in the Disability Determination Explanation (DDE). For paper cases, follow the instructions in DI 23060.020D.2. In all cases, ensure that the evaluation is explained in the appropriate determination or CDR notice to the claimant.

NOTE: The documentation requirements in this subsection apply only to cases where an excluded medical source of evidence has furnished evidence.

NOTE: If the excluded medical source of evidence does not include a written statement of exclusion, but an adjudicator receives clear documentation that the source is excluded (e.g., an email from the administrator or professional relations officer), the adjudicator must document that and identify the clear documentation the adjudicator relied upon in eCAT so that it appears in the DDE (electronic cases) or by following the instructions in DI 23060.020D.2 (paper cases).

1. Electronic cases

Document the evaluation of evidence furnished by an excluded medical source of evidence in eCAT so that it appears in the DDE. The documentation in the DDE should inform a subsequent adjudicator of:

  • The evidence furnished by an excluded medical source of evidence, and

  • How that evidence was evaluated, including whether any good cause exceptions were considered and applied.

2. Paper cases

Follow the instructions in DI 23060.020D.2.

3. Appropriate determination or CDR notice to the claimant

Document the evaluation of evidence furnished by an excluded medical source of evidence in the appropriate determination or CDR notice to the claimant.

NOTE: If all of the evidence furnished by the source is excluded, do not include the source’s evidence in the list of considered evidence in the determination or CDR notice. If some or all of the evidence furnished by the source is considered, include the source’s evidence in the list of considered evidence.

a. Language to include in all determinations or CDR notices that include evidence furnished by an excluded medical source of evidence

Unless we have good cause, the law prevents us from considering evidence furnished by medical sources that have been convicted of a felony under section 208 or 1632 of the Social Security Act (Act); excluded from participating in any Federal health care program under section 1128 of the Act; or imposed with a civil monetary penalty, assessment, or both, under section 1129 of the Act, for submitting false evidence.

b. Language and information to add if none of the evidence furnished by the excluded medical source of evidence is considered

Add the following language:

We were not able to consider certain evidence in your case because it was furnished by a medical source(s) who falls within one of these categories.

Add the following information:

  • Name(s) of the excluded medical source(s) of evidence, and

  • A brief description of the excluded evidence.

c. Language and information to add if all of the evidence furnished by the excluded medical source of evidence is considered

Add the following language:

Although certain evidence in your case was furnished by a medical source(s) who falls within one of these categories, we were able to consider it because we found that a good cause exception(s) applied.

Add the following information:

  • Name(s) of the excluded medical source(s) of evidence, and

  • A brief description of the considered evidence.

d. Language and information to add if some of the evidence furnished by the excluded medical source of evidence is considered

Add the following language:

Although certain evidence in your case was furnished by a medical source(s) who falls within one of these categories, we found that a good cause exception(s) applied to some of that evidence, so we were able to consider it. However, we found that a good cause exception(s) did not apply to certain other evidence. Thus, we were not able to consider that evidence.

Add the following information:

  • Name(s) of the excluded medical source(s) of evidence,

  • A brief description of the considered evidence, and

  • A brief description of the excluded evidence.

E. Reopening a determination or CDR involving an excluded medical source of evidence

Consider reopening a determination or CDR involving evidence furnished by an excluded medical source of evidence if:

  • The previous adjudicator incorrectly considered the evidence (e.g., incorrectly applied a good cause exception(s)), or

  • The previous adjudicator did not consider evidence furnished by a medical source