When updated evidence (e.g., from a follow-up medical exam, test, or procedure that has already taken place) is available from an existing medical source, and the evidence is relevant to the determination (see DI 24501.016B.2.), request the updated medical evidence. If the DDS does not receive the available medical evidence within 10-20 days follow standard follow-up procedures in DI
1: Helen alleged chronic obstructive pulmonary disease (COPD). The DDS requested medical evidence from Helen’s pulmonologist, which was received on 3/3/2021. On 3/8/2021, Helen called the DDS to report having a pulmonary function test (PFT) at the pulmonologist's office on 3/7/2021. In this situation, request the additional medical evidence from Helen’s office visit, to obtain the physical examination and the results and tracings from the PFT.
EXAMPLE 2: John alleges major depressive disorder and general anxiety. On the SSA-3373 (Function Report - Adult) John reports difficulty concentrating and following simple instructions. The DDS receives medical evidence from John’s psychiatrist on 7/15/2022 which shows the doctor prescribed Prozac and Cymbalta in November of 2021. After increased medication dosage over several months, examinations from February 2022 to July 2022 show that John is stable and has not experienced any breakthrough symptoms. The most recent exam is from 7/8/2022. The DDS sends the claim to the DDS psychological consultant (PC) for review on 7/18/2022 and the PC completes a mental residual functional capacity assessment form (MRFC) on 8/1/2022. There are no physical impairments to assess.
John calls the DDS on 8/3/2022 to report an upcoming psychiatric appointment on 8/31/2022. John explains that this appointment is a regularly scheduled medication check. The DDS confirms that John has not been to the emergency room, hospital, or psychiatrist since the last visit on 7/8/2022. The DDS already obtained all available and relevant evidence, which is consistent and complete enough to make a determination. The DDS makes the determination using the available MRFC.