Identification Number:
DI 22505 TN 43
Intended Audience:See Transmittal Sheet
Originating Office:ORDP ODP
Title:Development of Medical Evidence of Record (MER)
Type:POMS Full Transmittals
Program:Disability
Link To Reference:
 

PROGRAM OPERATIONS MANUAL SYSTEM

Part DI – Disability Insurance

Chapter 225 – Case Development Procedures

Subchapter 05 – Development of Medical Evidence of Record (MER)

Transmittal No. 43, 02/07/2024

Audience

PSC: DE, DEC;
OCO-OEIO: CR, ERE, FCR, FDE, RECONE;
OCO-ODO: DE, DEC, DPS, DS, RECONE;
ODD-DDS: ADJ, DHU;

Originating Component

ODP

Effective Date

Upon Receipt

Background

The Office of Disability Policy is updating DI 22505.008 to provide guidance on supplemental development and the associated procedures.

Summary of Changes

DI 22505.008 Developing Supplemental Evidence

We changed the section title to "Supplemental Development of Evidence" and updated the language throughout for consistency with the disability case processing system (DCPS) procedures.

We made changes to the following subsections:

  • We retitled subsection A "Policy for supplemental development";

  • In subsection A, we defined supplemental development, provided specific issues that are material to a disability determination where supplemental development is needed, and provided cross-references for completeness of evidence, vocational development, and definitions of relevant and materially inconsistent evidence;

  • We removed the old subsection B;

  • The old subsection C became the new the subsection B "Procedure for supplemental development";

  • We provided an introduction in subsection B, describing when the DDS should consider supplemental development;

  • In subsection B, we provided cross-references about documentation for case development efforts, and electronic development procedures;

  • We retitled subsection B.1.a. "When to recontact a medical source", and provided case examples;

  • We retitled subsection B.1.b. "Procedure to recontact a medical source", and provided examples;

  • We retitled subsection B.2. "Requesting updated or new medical evidence";

  • We retitled subsection B.2.a. "When to request updated medical evidence from an existing medical source", added follow-up instructions, and added a second case example;

  • We clarified language in subsection B.2.b. about requesting available evidence from a new medical source identified during case development, and provided follow-up instructions and examples;

  • We retitled subsection B.2.c. "Procedure for requesting updated or new medical evidence", and added cross-references for development during the applicable period and follow-up procedures;

  • We provided cross-references for vocational development in subsection B.4.a.;

  • We provided cross-reference for failure to cooperate in subsection B.4.b.;

  • We restructured subsection B.5., added cross-references for examples of third-party sources and types of nonmedical development;

  • We removed the chart from subsection B.5.;

  • We added subsection B.6. "Recency of evidence"; and

  • We removed subsection D.

DI 22505.008 Supplemental Development of Evidence

CITATIONS:

A. Policy for supplemental development

Supplemental development refers to the additional development of evidence the Disability Determination Services (DDS) must undertake when basic initial development does not provide all of the information needed to make a determination.

The DDS completes supplemental development when additional evidence is needed to resolve an issue material to the sequential evaluation of a disability claim. Situations in which the DDS may need to complete supplemental development include, but are not limited to, when:

  • A new medical source(s) is identified;

  • New and relevant evidence becomes available from a new or current medical source(s);

  • A new allegation(s) is raised;

  • A potential new impairment(s) is discovered in the evidence;

  • Materially inconsistent or ambiguous evidence is received; or

  • Insufficient evidence is available to make a determination.

For information on completeness of medical and other evidence, see DI 22501.001D.

For information on vocational development, see DI 22515.000.

For the definitions of relevant evidence and materially inconsistent evidence, see DI 24501.016.

REMINDER: Supplemental development is not required when the evidence in the case already meets the requirement for duration and disabling level of severity.

B. Procedure for supplemental development

Once the DDS completes initial case development (including a review of any prior folder evidence) and makes every reasonable effort to obtain evidence from medical and nonmedical sources, the DDS must consider whether supplemental development is necessary.

IMPORTANT: Unless case evidence supports a fully favorable determination and any known outstanding evidence would not likely affect the allowance determination, make every reasonable effort to develop the claimant's complete medical history (see DI 22505.001A.3. and DI 22505.001B.2.).

REMINDER: Consider electronic case development procedures to expedite initial and supplemental development when applicable (see DI 81020.020). Document all case development efforts in the disability folder, in accordance with DI 20503.001E.

Supplemental development includes the following:

1. Recontacting a medical source(s)

a. When to recontact a medical source

The DDS is required to recontact a medical source when:

  • The evidence in the file is incomplete, and the needed evidence is only available from this source; or

    EXAMPLE: The claimant has a consultation with a treating orthopedist and undergoes magnetic resonance imaging (MRI). The medical source only sends the physical examination report and not the MRI report.

  • The medical source provided evidence that contains an internal inconsistency, and it is unclear from the existing evidence whether the claimant is disabled.

    EXAMPLE: Medical records from the claimant's orthopedist show normal gait on exam, but the medical records also mention that the claimant uses a walker for ambulation. This internal inconsistency should be resolved by recontacting the source for clarification. If this recontact does not resolve the inconsistency, a consultative examination (CE) may be needed to resolve the issue. For more information on inconsistent evidence, see DI 24501.016B.4.

REMINDER: For situations when the DDS should not make routine requests, see DI 22505.006A.3.

b. Procedure to recontact a medical source

Recontact a medical source by telephone, fax, or mail. Include an SSA-827 (Authorization to Disclose Information to the Social Security Administration (SSA)), if needed.

  1. 1. 

    To recontact a medical source by telephone, follow the procedures in DI 22505.030.

    REMINDER: The preferred method to recontact a medical source to request missing evidence or resolve inconsistencies is by telephone. After recontacting a medical source, it may be necessary to fax or mail additional letters to obtain the necessary information.

  2. 2. 

    To recontact a medical source by fax or mail, send a letter explaining:

    • The nature of the missing evidence or inconsistency;

    • Why the DDS needs clarification; and

    • The type of evidence needed.

  3. 3. 

    Use follow-up procedures in DI 22505.035, if needed.

  4. 4. 

    Stop follow-up procedures when the missing evidence is obtained, the inconsistency is resolved, or the medical source cannot or will not provide the requested information.

    EXAMPLE 1: The DDS receives a medical report from the claimant's nephrologist that references serum creatinine values above 4mg/dl over a period of several months. The medical report does not contain the actual lab reports. The medical report suggests that the claimant may meet listing 6.05A.1, but the lab reports are needed to make the determination. In this situation, the DDS should recontact the nephrologist by phone to explain what missing information is needed. If the nephrologist's office advises that the information will be sent without further action from the DDS, the DDS should document the conversation in the case file and set an appropriate follow-up date to receive the missing evidence. If the nephrologist's office asks the DDS for another evidence request, the DDS should fax or mail the request, along with an SSA-827, if needed, explaining what missing information is needed.

    EXAMPLE 2: The DDS receives a medical report from the claimant's orthopedist that references an x-ray showing degenerative disc disease. The medical report does not contain the x-ray report. The DDS needs the x-ray report to help establish the medically determinable impairment (MDI). The DDS attempts to recontact the orthopedist's office by phone and leaves a voicemail detailing what information is needed. The DDS does not receive a response to the voicemail. The DDS sends a request by mail with specific details about what information is needed. After waiting 10 days with no response to the phone call or mailed request, the DDS makes another phone call to follow-up on the mailed request and again leaves a voicemail that is not returned. At this point, the DDS should proceed with ordering a CE for an x-ray to obtain the missing information.

2. Requesting updated or new medical evidence

a. When to request updated medical evidence from an existing medical source

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 22505.035.

EXAMPLE 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.

b. When to request evidence from a new medical source

When the DDS discovers a new medical source during case development and the evidence could be relevant to the determination, request the available medical evidence from that source. Include an SSA-827 when the sending the request. If the DDS does not receive the available medical evidence within 10-20 days, follow standard follow-up procedures in DI 22505.035.

EXAMPLE 1: Dr. Smith, a rheumatologist, treats Sam for fibromyalgia. Medical evidence from Dr. Smith identifies Dr. Jones, a pain management specialist, who also treats Sam for fibromyalgia. Sam did not identify Dr. Jones as a medical source on the SSA-3368-BK (Disability Report - Adult). Dr. Jones’ records are relevant to the determination because this medical source treated Sam for an alleged impairment. In this case, the DDS must request the medical evidence from Dr. Jones.

EXAMPLE 2: The medical evidence from Dr. Jones mentions that Sam recently saw Dr. Phillips. The evidence does not mention the condition for which Dr. Phillips treats Sam. The DDS contacts Sam to get more information about Dr. Phillips. Sam explains that Dr. Phillips is a dentist that they see every six months for routine cleanings. The DDS does not request medical evidence from Dr. Phillips because it is not relevant to the claim.

c. Procedure for requesting updated or new medical evidence

Request updated evidence, including diagnostic tests, from all sources the claimant identified and request any new evidence discovered during development for the alleged or documented impairment(s) during the applicable period (see DI 22505.001). Send the request by mail, fax, or electronic method.

Use the follow-up procedures described in DI 22505.035 if needed.

3. Purchasing a consultative examination (CE)

If a claimant's medical source(s) cannot or will not provide sufficient medical evidence about a claimant's impairment(s), the DDS may purchase one or more CEs. For examples of situations that generally require a CE, see DI 22510.005B. Do not purchase a CE if any of the conditions in DI 22510.006 exist.

For more information on CE development, see DI 22510.000.

4. Requesting evidence or action from the claimant

a. When to request evidence or action from the claimant

The claimant is usually the best source of information about their medical history, medical sources, functional limitations, and past work. Generally, the DDS should request this information from the claimant before considering development from supplemental sources. Consider requesting information from the claimant when:

  • There is an indication that the claimant has not identified, on the SSA-3368, all potential impairments or medical sources that may be relevant to the disability determination (see DI 24505.030).

  • The DDS needs work history information (see DI 25005.000, DI 25015.000, DI 22515.003, and DI 22515.010); or

  • The information the claimant provided about their functional limitations is inconsistent with other information in the file or needs clarification (see DI 22511.011 and DI 24501.021).

b. Procedure for requesting evidence or action from the claimant

To request evidence or action from the claimant, follow the procedures in DI 22505.014. Contact the claimant, as discussed in DI 23007.005, by mail or telephone.

For more information about when the claimant fails to provide the requested evidence, take the necessary action, or attend a needed CE, see DI 22505.014 and DI 23007.000.

5. Requesting evidence from nonmedical sources

REMINDER: Carefully consider whether it is necessary to request information from a third party. Contacting a third party always involves disclosure, and our minimization policy applies (see GN 03313.001B). For information about when to make a reasonable effort to identify and involve a third party, see DI 23007.010.

You may contact nonmedical sources and third parties by telephone or mail, as appropriate (see DI 22505.014).

For examples of third parties and nonmedical sources, see DI 22505.001A.5.

For guidance on evaluating evidence from nonmedical sources, see DI 24503.020.

If the evidence in file shows that the claimant has an impairment(s) that could affect their ability to report their functioning accurately, the DDS should consider obtaining functional information from a third party who is familiar with the claimant's day-to-day activities. For more information on contacting nonmedical and collateral sources, see DI 22511.007E and DI 22511.011D.

6. Recency of evidence

In general, there is no recency requirement for evidence. Make the determination if:

  • A fully favorable determination is supported, or

  • The evidence is sufficient for a medical evaluation (see DI 24501.016), including evaluation of impairment severity and duration (see DI 24505.001 and DI 25505.025); and the DDS made a reasonable effort to develop a complete medical history (see DI 22505.001), or

  • There is insufficient evidence, the DDS has made a reasonable but unsuccessful effort to obtain the claimant's cooperation to comply with a request for evidence or action or to confirm or attend a CE, and a determination is made based on the evidence in file (see DI 23007.015).

REMINDER: To evaluate whether certain impairments meet or medically equal a listing, the DDS may require evidence from specific time frames. To determine whether a listing requires such evidence, see DI 34000.000. For more information on specific impairment evaluation issues, see DI 24500.000.


DI 22505 TN 43 - Development of Medical Evidence of Record (MER) - 2/07/2024