Identification Number:
DI 24501 TN 26
Intended Audience:See Transmittal Sheet
Originating Office:ORDP ODP
Title:General - Medical Evaluation
Type:POMS Full Transmittals
Program:Disability
Link To Reference:
 

PROGRAM OPERATIONS MANUAL SYSTEM

Part DI – Disability Insurance

Chapter 245 – Medical Evaluation

Subchapter 01 – General - Medical Evaluation

Transmittal No. 26, 02/07/2024

Audience

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

Originating Component

ODP

Effective Date

Upon Receipt

Background

The Office of Disability Policy issues this transmittal to provide clarification on evidence evaluation instructions.

Summary of Changes

DI 24501.016 Evidence Evaluation

In this section we:

  • Removed the titles from the Citations section; Updated language throughout for consistency with documentation requirements in the Disability Case Processing System (DCPS).

  • Subsection A Removed the language about residual functional capacity (RFC) and replaced it with cross references to the relevant POMS;

  • Subsection B.1. Changed the definition of evidence to align with 20 CFR 404.1513(a) and 416.913(a);

  • Subsection B.3. Retitled "Sufficiency of evidence" and added subsections for "Sufficient evidence" and "Insufficient evidence" with corresponding definitions;

  • Subsection B.4. Retitled "Inconsistency of evidence" and reorganized into B.4.a "Inconsistent evidence" and B.4.b "Materially inconsistent evidence" to emphasize when evidence is inconsistent and materially inconsistent;

  • Subsection C.3. Added a case example to demonstrate when evidence is inconsistent but sufficient;

  • Subsection D Moved subsection D.1. into C.2., subsection D.2. into C.4.a, and subsection D.3. into C.4.c;

  • Subsection E Removed

DI 24501.016 Evidence Evaluation

CITATIONS:

Social Security Act §§ 205(a) & (b), 221(k), 223 , 1614(a), 1631(c) & (e), and 1633.
20 CFR §§ 404.1502 , 404.1503 , 404.1504 , 404.1512 through 404.1523 , 404.1527 , 416.902 , 416.903 , 416.904 , 416.912 through 416.924b , and 416.927 .

A. Introduction to evidence evaluation

Evaluate all the evidence in the case record before completing the medical evaluation for a disability determination.

For more information on:

  • Medical evaluation, see DI 24501.002;

  • The categories of evidence that may be in the case record, see DI 24503.005;

  • Evaluating medical opinions and prior administrative medical findings for claims filed on or after March 27, 2017, see DI 24503.025 and DI 24503.030;

  • Evaluating medical opinions, opinions, and prior administrative medical findings for claims filed before March 27, 2017, see DI 24503.035;

  • Evidence the Disability Determination Services (DDS) considers when assessing whether an individual can do past relevant work, see DI 25005.000; and

  • Evidence the DDS considers when evaluating whether an individual can adjust to other work, see DI 25015.000.

B. Definitions for evidence evaluation

Use the definitions in this section to evaluate the evidence.

1. Evidence

Evidence is anything the claimant or anyone else submits to the Social Security Administration (SSA) or the DDS, or that SSA or the DDS obtains, that relates to their claim for benefits.

For more information about what is and is not evidence, see:

2. Relevant evidence

Relevant evidence is a type of essential material related to the issues in the claim. These issues include, but are not limited to the following:

  • Developing a complete medical history, see DI 22505.001A3;

  • Establishing one or more medically determinable impairments (MDI), see DI 24501.020;

  • Assessing the severity of the impairment, see DI 24505.000;

  • Determining the duration of the impairment, see DI 25505.000;

  • Establishing the onset date of disability, see DI 25501.000; and

  • Documenting fraud or similar fault (FSF), see DI 23025.000.

For a definition of essential material and relevant evidence in the disability folder, see DI 20503.001.

3. Sufficiency of evidence

a. Sufficient evidence

Sufficient evidence contains all the information needed to evaluate and make required findings for the issues relevant to the determination.

Sufficient evidence includes the information needed to resolve any insufficiency or material inconsistency in the evidence.

For development issues related to requirements for recency of evidence and completeness of medical and non-medical evidence, see DI 22505.008.

For development issues related to vocational evidence, see DI 22515.000.

b. Insufficient evidence

Insufficient evidence does not contain all of the information needed to make required findings for the issues relevant to the determination.

IMPORTANT: If the DDS makes a reasonable effort to complete the required initial and supplemental development but the case evidence is still insufficient, the DDS makes a determination based on the evidence in file using the sequential evaluation process, see DI 22505.008 and DI 23007.015.

4. Inconsistency of evidence

a. Inconsistent Evidence

Evidence is inconsistent if it:

  • Conflicts with other evidence;

  • Contains an internal conflict;

  • Contains ambiguities; or

  • Is medical evidence that does not appear based on medically acceptable clinical or laboratory diagnostic techniques.

b. Materially inconsistent evidence

Evidence is materially inconsistent only if the inconsistency presents an issue that:

  • Makes a difference between the decision to allow or deny the claim;

  • Affects the determination of the established onset date (EOD).

IMPORTANT: If the file contains a material inconsistency in the evidence that makes it impossible to make a determination on the claim, the case evidence is insufficient and supplemental development is generally required, see DI 22505.008.

For more information on:

  • Purchasing a consultative examination (CE) to resolve a conflict, inconsistency, or ambiguity, see DI 22510.005B5; and

  • Using supplemental development of evidence to resolve an inconsistency or insufficiency, see DI 22505.008.

C. Procedure to evaluate the evidence

Follow the steps in this section to evaluate the evidence.

1. Compare the evidence with the claimant’s allegations

Analyze each piece of evidence and consider the evidence for the following:

  • Completeness;

  • Relevance;

  • Internal consistency;

  • Interrelationship with other evidence; and

  • Consistency with other evidence and the longitudinal evidence.

REMINDER: When analyzing the relevance of the evidence, consider the relationship to the claimant's allegations and functioning, and the relevant time period for the claim or allegation. For more information on evaluating symptoms, see DI 24501.021.

IMPORTANT: When determining the persuasiveness of medical opinions or prior administrative medical findings in cases with application filing dates on or after March 27, 2017, consider the following factors listed in DI 24503.025E:

  • Supportability;

  • Consistency;

  • Relationship with the claimant;

  • Specialization; and

  • Other factors.

2. Evidence is complete and consistent

If the evidence in file is consistent and sufficient to make a disability determination:

  • Make the required findings based on all of the evidence; and

  • Complete the determination.

REMINDERS :

  • Evidence must be complete and detailed enough to permit an independent determination about whether the claimant is disabled or blind. For more information on case development, see DI 22501.001.

  • Document initial and follow-up requests for medical evidence of record (MER) and non-medical evidence in a Case Note in the Disability Case Processing System (DCPS), or on the Case Development Worksheet (CDW). For more information about the CDW, see DI 20503.001E.

  • If the case contains sufficient evidence to make a fully favorable determination, discontinue development. Do not wait for additional evidence or follow up on outstanding medical evidence requests. For details on curtailing development on fully favorable claims, see DI 24515.020.

  • Before making a determination that is not fully favorable to the claimant, make every reasonable effort to develop the claimant’s complete medical history, see DI 22505.001.

3. Evidence is inconsistent but sufficient

If any of the evidence is inconsistent, but there is sufficient evidence to make a determination, consider all the evidence and make a determination supported by the available evidence.

IMPORTANT: Document how any inconsistencies in the evidence were resolved in DCPS, or on the CDW.

EXAMPLE: Mark is a 35-year-old with complaints of left knee pain and difficulty walking during activities of daily living. The DDS obtained all available evidence. Medical evidence from Mark’s primary care physician noted left knee pain when walking, but the physical exam does not assess gait. Recent medical evidence from an orthopedist showed complaints of left knee pain, but normal range of motion, strength, and gait on exam. There are bilateral knee x-rays in file that are grossly normal. The DDS determines that while there are inconsistencies in the evidence, the evidence is sufficient for a determination as all available evidence has been obtained and supplemental development (in this case obtaining a CE) would not provide new evidence that is material to the determination. A residual functional capacity (RFC) is assessed with the evidence in file. There is not enough information on the form SSA-3369 (Work History Report) to determine whether Mark can return to past relevant work. Therefore, the DDS proceeds to step 5 of the sequential evaluation process with an expedited vocational assessment as all vocational rules direct a medical-vocational denial, see DI 25005.005.

4. Evidence is insufficient or materially inconsistent

If a fully favorable determination is not supported by the evidence in the file, consider whether the evidence is insufficient or materially inconsistent.

Supplemental development is generally required when the evidence is insufficient.

Supplemental development might not be required if the claimant has failed to comply with requests for evidence as outlined in DI 23007.015, and the DDS has made a reasonable effort to obtain all evidence available without the claimant's cooperation.

If the case evidence is materially inconsistent, the DDS must make a reasonable effort to resolve the material inconsistencies.

To resolve any insufficiencies or material inconsistencies in the case evidence follow these procedures:

a. Supplemental development of evidence

Complete supplemental development of evidence to resolve insufficiencies or material inconsistencies in the evidence. Supplemental development may also be necessary when a reasonable effort has not been made to develop a complete medical history and all available medical sources were not contacted during initial development or additional sources were identified in the process of development.

For supplemental development of evidence, see DI 22505.008.

REMINDER: If the medical source cannot or will not provide the requested evidence, discontinue development from the source.

For information on when not to make a request for medical information from a source, see DI 22505.006A3.

For information on when to discontinue follow-up activities because the medical source cannot or will not provide the requested medical evidence, see DI 22505.035.

b. Evaluate evidence from supplemental development with the other evidence in the file

Make determination findings supported by the evidence.

c. Document the medical evaluation

Document the medical evaluation as follows:

  • Identify the appropriate time period;

  • Include all the substantive findings supported by the evidence;

  • Describe the evidentiary insufficiency (i.e., unresolved conflict or missing essential information), and all related supplemental development efforts if evidence is insufficient to complete the medical evaluation. Do not find that a claimant has impairment-related limitations during any period in which evidence is insufficient to support the finding; and

  • Identify the correct Regulation Basis Code (RBC) that reflects the type of allowance or denial at the time of adjudication. For example, the claim is denied for insufficient evidence for failure to cooperate with a request for evidence or action, or a request to attend a CE. Choose N36, M5, or M6 depending on the claim type. For more information on RBC, see DI 26510.045.

For more details on documenting the medical evaluation, see DI 24501.002D.

REMINDER: Once a reasonable effort to get the claimant to comply with requests for evidence or action is made, the DDS should discontinue development that requires the claimant's cooperation. The DDS should also ensure that it made a reasonable effort to develop a complete medical history, and all available evidence through the adjudication date that does not require the claimant's cooperation, see DI 23007.015B.

5. Document evidentiary development and follow up efforts

For details on documenting evidentiary development, see DI 20503.001.

In all cases, document all developmental efforts in a Case Note in DCPS, or on the CDW.


DI 24501 TN 26 - General - Medical Evaluation - 2/07/2024