TN 5 (09-16)
DI 24501.021 Evaluating Symptoms
CITATIONS: 20 CFR 404.1529 and 416.929, SSR 16-3p TITLES II AND XVI: Evaluation of Symptoms in Disability Claims, and SSR 96-3p TITLES II AND XVI: Considering Allegations of Pain and Symptoms in Determining Whether a Medically Determinable Impairment is Severe,
A. Policy for Evaluating Symptoms
Findings about the existence, intensity, and persistence of impairment-related symptoms may be a determinative factor in a disability evaluation. An individual’s statements of symptoms are not, by themselves, enough to establish the existence of a physical or mental impairment or disability. However, if an individual alleges, or evidence documents, impairment-related symptoms, we must evaluate those symptoms using the two-step process in our regulations and in DI 24501.021B in this section.
1. What symptoms we consider
We consider all symptoms alleged or documented in the evidence, for example pain, fatigue, shortness of breath, weakness, nervousness, and the side effects of medication.
2. When we evaluate symptoms
We consider symptoms throughout the medical evaluation of a claim:
We evaluate symptoms at step 2 of the sequential evaluation process to help determine whether an established impairment is severe.
We evaluate symptoms at step 3 of the sequential evaluation process for listings that require consideration of symptoms, for example listings 7.18 or 14.10B.
We evaluate symptoms when we evaluate residual functional capacity for adult disability claims, or when we evaluate functional domains for child disability claims under title XVI.
EXCEPTION: Symptom evaluation is not required if you can make a fully favorable determination based solely on the objective medical findings. See details in DI 24515.020.
3. What findings we make
We find the existence, intensity, and persistence of symptoms is supported when the alleged symptoms are consistent with the evidence in the case. We will not find the individual’s alleged symptoms to be inconsistent with the evidence in the case based on consideration of the objective medical evidence alone.
IMPORTANT: Symptom evaluation is not an evaluation of an individual’s credibility, character, or truthfulness.
B. Two-Step Procedure for Symptom Evaluation
Symptom evaluation occurs as part of the medical evaluation process.
1. Step one of the symptom evaluation procedure
Does the individual have a medically determinable impairment (MDI) that could reasonably be expected to produce the alleged symptoms?
a. If YES
Consider the symptoms as you proceed with medical evaluation of the claim. Go to step two of the symptom evaluation procedure in DI 24501.021B.2 in this section.
b. If NO
1. Do not consider the alleged symptoms in the disability determination.
IMPORTANT: The individual may allege multiple symptoms where some symptoms are reasonably related to an MDI and others are not. Continue to step two of the symptom evaluation procedure for any symptom(s) that can be reasonably linked to an MDI.
2. Document the finding.
· In the Electronic Claims Analysis Tool (eCAT), document your finding in the text box found below the question, “Can one or more of the individual’s medically determinable impairment(s) (MDI(s)) reasonably be expected to produce the individual’s pain or other symptoms? Explain why the medically determinable impairment(s) (MDIs) could not reasonably be expected to produce the symptoms.”
· If the case is an eCAT exclusion, document your findings on the appropriate medical assessment form.
c. Examples for step one of the symptom evaluation procedure
1. EXAMPLE 1
An individual has an MDI established by objective medical evidence - a knee x-ray - from an acceptable medical source (AMS) showing mild degenerative changes. He or she alleges extreme pain that limits his or her ability to stand and walk. The adjudicator documents that the individual has an MDI that could reasonably be expected to produce the symptom of pain. At the next step of symptom evaluation, the adjudicator will determine the extent to which the symptoms limit the individual’s ability to perform work-related activities.
2. EXAMPLE 2
Due to alleged knee pain, an individual alleges extreme symptoms that limit his or her ability to stand and walk; however, the case record does not contain objective medical evidence of a medically determinable knee impairment from an AMS that could reasonably be expected to produce the alleged symptoms. If after an attempt to develop additional evidence, the record does not establish an MDI that could be reasonably linked to the alleged symptoms, the adjudicator will determine that the alleged symptoms do not affect the individual’s ability to perform work activities.
2. Step two of the symptom evaluation procedure
Are the individual’s statements about the intensity, persistence, and limiting effects of the alleged symptoms consistent with the objective medical evidence?
a. If Yes
Determine the extent to which the symptoms reduce the individual’s capacity to perform work-related activities (or reduce a child’s ability to function, independently, appropriately, and effectively in an age-appropriate manner, in a child’s title XVI disability claim) in the manner consistent with the individual’s allegations.
b. If No
In addition to the objective medical evidence, the adjudicator will consider the following when evaluating intensity, persistence, and limiting effects of an individual's symptoms:
The individual’s daily activities;
The location, duration, frequency, and intensity of the individual’s pain or other symptoms;
Factors that precipitate and aggravate the symptoms;
The type, dosage, effectiveness, and side effects of any medication the individual takes or has taken to alleviate pain or other symptoms;
Treatment, other than medication, the individual receives or has received for relief of pain or other symptoms;
Any measures other than treatment the individual uses or has used to relieve pain or other symptoms (e.g., lying flat on his or her back, standing for 15 to 20 minutes every hour, or sleeping on a board); and
Any other factors concerning the individual’s functional limitations and restrictions due to pain or other symptoms.
IMPORTANT: Consider only the factors relevant to assessing the intensity, persistence, and limiting effects of the individual’s symptoms. Keep in mind that some individuals may experience symptoms differently and may be limited by symptoms to a greater or lesser extent than other individuals with the same medical impairments, the same objective medical evidence, and the same non-medical evidence.
3. Considerations for step two of symptom evaluation
Evaluate the consistency of all the evidence with the individual’s alleged intensity and persistence of the reported symptoms, such as pain, and determine the extent to which the symptoms limit the individual’s ability to perform work-related activities (or function independently, appropriately, and effectively, for a child with a title XVI disability claim).
The symptom evaluation must reflect the evaluator’s findings when alleged symptoms and their effects are reasonably related to an MDI but somewhat inconsistent with the objective medical evidence. The evaluation must show the extent to which the allegations are consistent with all the evidence of record.
C. Relevant Evidence for Symptom Evaluation
1. Items to always consider
Signs and laboratory findings as defined in DI 24501.020. Signs are anatomical, physiological, or psychological abnormalities established by medically acceptable clinical diagnostic techniques that can be observed apart from an individual’s symptoms. Laboratory findings are anatomical, physiological, or psychological phenomena that can be shown by the use of medically acceptable laboratory techniques.
The clinical observations in the medical evidence. The intensity, persistence, and limiting effects of many signs and symptoms can be clinically observed and recorded in the medical evidence. Examples: reduced joint motion, muscle spasm, sensory deficit, or motor disruption.
The individual’s statements about the intensity, persistence, and limiting effects of symptoms. This evidence may address the frequency, duration, and intensity of symptoms, as well as the impact of the symptoms on the individual’s ability to perform activities of daily living. The statements may include activities that precipitate or aggravate the symptoms, medications and treatments used, and other methods used to alleviate the symptoms.
The individual’s attempts to seek treatment to minimize symptoms that he or she alleges are the source of distress. Persistent attempts to obtain relief of symptoms such as increasing dosages and changing medications, trying a variety of treatments, referrals to specialists, or changing treatment sources may indicate that an individual’s symptoms are a source of distress and may show that symptoms are intense and persistent.
2. Also consider other relevant evidence in the file
If available, consider:
Statements and other information provided by medical sources;
Statements and other information provided by other sources, including non-medical sources and agency personnel;
Statements made in connection with claims for other types of disability, such as workers’ compensation, private insurance benefits, or benefits under programs of the Department of Veterans Affairs;
A description of the symptoms from a person familiar with the individual and his or her symptoms, especially if an impairment prevents the individual from adequately describing his or her symptoms;
For a child with a title XVI disability claim, evidence submitted by educational institutions and personnel, parents and other relatives, social welfare agencies, therapists, and other practitioners with information regarding the child’s symptoms; and
Any other relevant evidence in the case record.
3. Issues to consider when analyzing the evidence related to symptoms
a. Consistency of statements
Consider the consistency of the statements regarding the symptoms throughout the case record. Keep in mind:
Symptoms may vary with different types and frequency of treatment.
Frequent attempts to obtain treatment of symptoms may indicate that the symptoms are intense and persistent.
Lack of treatment seeking may indicate symptoms are less intense and persistent. For example, the condition may be effectively treated with over-the-counter medication.
Lack of treatment may also indicate something else, for example, the individual may have:
Reduced or structured activities in order to minimize symptoms;
Received only periodic treatment or evaluation for prescription refills because the symptoms reached a plateau;
Refused to take medications due to side effects that are less tolerable than the symptoms;
Been unable to access medical services;
Been advised by a medical source indicating that further treatment would not be beneficial;
Religious beliefs prohibiting medical treatment;
Limitations (such as language or mental limitations) preventing him or her from understanding the appropriate treatment or need for consistent treatment;
A mental impairment that affects his or her judgment, reality testing, or orientation, that causes the individual to be unaware that he or she has a disorder that requires treatment; or
If the individual is a child, he or she may have disregarded the level and frequency of treatment needed to maintain or improve functioning because it interferes with participation in activities typical of other children his or her age without impairments.
IMPORTANT: When necessary, contact the individual and obtain additional information regarding the lack of treatment. Explain in your rationale how you considered the individual’s reasons in your evaluation of the individual’s symptoms.
IMPORTANT: Do not find an individual’s symptoms inconsistent with the evidence in the record without considering possible reasons he or she may not comply with treatment or seek treatment consistent with the degree of his or her complaints.
NOTE: If prescribed treatment is expected to result in the individual no longer meeting the medical requirements to be found disabled, and he or she fails to follow prescribed treatment, see the details in DI 23010.000 regarding failure to follow prescribed treatment.
D. Documenting Symptom Evaluation Step Two Findings in the Case Record
1. Where to document the symptom evaluation
Be sure to document your analysis in the proper location.
If evaluating a claim in eCAT, put the symptom evaluation explanation in the text box found in the Symptoms Evaluation section, below the question, “What is your assessment of the consistency of the individual’s statements regarding symptoms considering the total medical and non-medical evidence in file? Explain the assessment of consistency regarding symptom related limitations.”
If the case is an eCAT exclusion, document the symptom evaluation findings on the appropriate medical assessment form.
2. What to document for symptom evaluation
Provide specific reasons for the assessment of intensity, persistence, and limiting effects of the individual’s symptoms, consistent with and supported by the evidence.
Provide specific reasons for the assessment of intensity, persistence, and limiting effects of the individual’s symptoms, consistent with and supported by the evidence. Do not make a single, conclusory statement regarding the consideration or consistency of an individual’s reported symptoms.
Clearly explain how you analyzed the relevant case evidence and what findings you made.
IMPORTANT: If you decided some of the individual’s alleged symptoms were consistent with all of the evidence in the file and some were not, you must explain which were, which were not, and why.
DI 22505.001A What Evidence do we consider?
DI 22505.008 Developing Supplemental Evidence
DI 23010.000 Failure to Follow Prescribed Treatment
DI 24501.020 Establishing a Medically Determinable Impairment (MDI)
DI 24510.006 Assessing Residual Functional Capacity (RFC) in Initial Claims (SSR 96-8p)
DI 24510.050 Completion of the Physical RFC Assessment Form
DI 24510.060 Mental Residual Functional Capacity Assessment
DI 24515.020 Curtailing Development of Fully Favorable Claims
DI 24515.062 Your Residual Functional Capacity
DI 24515.064 Evaluation of Specific Issues – Environmental Illness
DI 24515.065 Symptoms, Medically Determinable Physical and Mental Impairments, and Exertional and Nonexertional Limitations (SSR 96-4p).