DI 24503.035 Evaluation and Articulation Requirements for Medical Opinions, Opinions, and Prior Administrative Medical Findings - Claims Filed before March 27, 2017
A. When to use this section
For claims with a filing date before March 27, 2017, follow the guidance in this section. For claims with a filing date on or after March 27, 2017, follow the guidance in:
DI 24503.025 Evaluating Medical Opinions and Prior Administrative Medical Findings – Claims filed on or after March 27, 2017, and
DI 24503.030 Articulation Requirements for Medical Opinions and Prior Administrative Medical Findings – Claims Filed on or after March 27, 2017.
For more information about how to determine the filing date of a claim, see DI 24503.050 Determining the Filing Date for Evaluating Evidence.
For the definition of a medical opinion, prior administrative findings, and opinion, see 24503.005 Categories of Evidence.
C. Sources of medical opinions, opinions, and prior administrative medical findings
Acceptable medical sources (AMSs) can make evidence we categorize as medical opinions. Medical consultants (MC) and psychological consultants (PC) can make evidence we categorize as prior administrative medical findings. Medical sources who are not AMSs and nonmedical sources can make evidence we categorize as opinions.
D. When we evaluate this evidence
Do not consider medical opinions, opinions, or prior administrative medical findings when establishing a medically determinable impairment (MDI). However, once an MDI is established, consider medical opinions, opinions, and prior administrative medical findings for all other findings in a claim, as appropriate.
E. How we evaluate medical opinions
Consider the factors listed in DI 24503.035E.1-6 when weighing medical opinions. See DI 24503.035F for when it is appropriate to give controlling weight to a medical opinion.
1. Examining relationship
Generally, give more weight to the medical opinion of a source who has examined the claimant than to the medical opinion of a source who has not examined him or her.
2. Treatment relationship
a. General policy
Generally, give more weight to medical opinions from the claimant’s own medical sources because they are likely to be able to:
provide a detailed, longitudinal picture of the claimant’s medical impairment(s), and
bring a unique perspective to the medical evidence that cannot be obtained from the objective medical findings alone or from reports of individual examinations, such as consultative examinations or brief hospitalizations.
b. Length of the treatment relationship and frequency of examination
Generally, the longer a medical source has treated a claimant and the more times the claimant has seen the medical source, the more weight we will give to the medical source's medical opinion. When the medical source has seen the claimant a number of times and long enough to have obtained a longitudinal picture of the impairment, give the medical source's medical opinion more weight than if it were from a non-treating source.
c. Nature and extent of the treatment relationship
Generally, the more knowledge a medical source has about a claimant’s impairment(s), the more weight we will give to the medical source's medical opinion. Look at the nature of the treatment, the extent of examinations, and testing performed or ordered from specialists and independent laboratories.
EXAMPLE: If an ophthalmologist notes the claimant complained of neck pain during an eye examination, consider the ophthalmologist’s medical opinion with respect to the individual’s neck pain, but give it less weight than a medical opinion from a physician who has treated him or her for neck pain.
Give more weight to a medical source opinion that presents relevant evidence to support it, particularly when it is supported by objective medical evidence.
Give more weight to a well-explained medical opinion than one than is not explained as well.
Because nonexamining sources have no examining or treating relationship with the claimant, consider the supporting explanations they provide for their opinions when determining the weight to assign to them.
Generally, the more consistent a medical opinion is with the record as a whole, the more weight we will give to that medical opinion.
Generally, give more weight to the medical opinion of a specialist about medical issues related to his or her area of specialty than to the medical opinion of a medical source who is not a specialist.
6. Other factors
Consider any factors that support or contradict the opinion when deciding the weight to give to a medical opinion. This includes, but is not limited to:
The amount of understanding of our disability programs and their evidentiary requirements that a medical source has, regardless of the source of that understanding, and
The extent to which a medical source is familiar with the other evidence in the claim.
F. Giving controlling weight
For claims with a filing date before March 27, 2017, give controlling weight to (adopt) the medical opinion of a treating source only when it is both well supported by objective medical evidence and is consistent with the other substantial evidence in the claim.
2. Determining whether a medical source is a treating source
A treating source is a claimant’s own AMS who has provided the claimant with medical treatment or evaluation and who has had an ongoing treatment relationship with the claimant.
The AMS and the claimant have established an ongoing treatment relationship when the claimant has seen the AMS with a frequency consistent with accepted medical practice for the type of treatment and evaluation required for the medical condition(s).
Do not consider a medical source to be a treating source if the claimant’s has only seen the medical source to obtain a report(s) in support of a claim for disability.
G. How to evaluate opinions and prior administrative medical findings
We consider the same factors listed in DI 24503.035E.1-6 when we determine how to weigh opinions and evaluate prior administrative medical findings. However, never assign controlling weight to an opinion or prior administrative medical finding.
H. Articulation requirements
1. Medical opinions
a. When you give controlling weight to a medical opinion
Explain why you gave the treating source’s medical opinion controlling weight. Include a discussion of why the objective medical evidence supports the opinion and the consistency of the opinion with the other substantial evidence in the claim.
Ensure that the claim analysis is consistent with the treating source’s medical opinion given controlling weight.
EXAMPLE: A shoulder injury, confirmed by a magnetic resonance imaging (MRI), and consistent with activities, range of motion exam, and physical therapy records supports giving controlling weight to the treating source opinion that the claimant has a limit on overhead reaching.
b. When you do not give controlling weight to a medical opinion
Explain how you considered all of the treating source’s medical opinion(s) and all of the other acceptable medical sources’ medical opinions in the claim.
c. Analysis of opinions from sources who are not acceptable medical sources
You should generally provide a written analysis of how you considered opinions to provide the claimant and subsequent reviewers with a full understanding of your analysis of the evidence. In claims that are less than fully favorable, if you find an opinion is entitled to more weight than a medical opinion of a treating source, you must explain why you gave it the weight you did.
2. Prior administrative medical findings
For claims filed before March 27, 2017, there is no articulation requirement for prior administrative medical findings at the reconsideration level.