Identification Number:
DI 22510 TN 30
Intended Audience:See Transmittal Sheet
Originating Office:ORDP ODP
Title:Development of Consultative Examinations (CE)
Type:POMS Full Transmittals
Program:
Link To Reference:
 

PROGRAM OPERATIONS MANUAL SYSTEM

Part DI – Disability Insurance

Chapter 225 – Case Development Procedures

Subchapter 10 – Development of Consultative Examinations (CE)

Transmittal No. 30, 02/22/2023

Audience

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

Originating Component

ODP

Effective Date

Upon Receipt

Background

This transmittal includes updated language for consistency with SSR 16-3p, specifically that requesting a consultative examination (CE) is not appropriate for addressing issues of inconsistent behavior or potential malingering.

Summary of Changes

DI 22510.006 When Not to Purchase a Consultative Examination (CE)

We made the following changes:

  • Clarified where to find information on the sufficiency and consistency of evidence,

  • Clarified that we will not request a CE when the evidence does not indicate a change to the claimant's condition has occurred and the test or procedure was already performed,

  • Subsection D. - Revised the title to remove the reference to "malingering" and we clarified rare instances when Office of Disability Policy (ODP) may approve the purchase of a symptom validity test (SVT),

  • Subsection D. - Reorganized content, and

  • Clarified that we do not make adjudicative findings concerning potential malingering in the final determination.

Conversion Table
Old POMS ReferenceNew POMS Reference
DI 22510.006DI 22510.006

DI 22510.006 When Not to Purchase a Consultative Examination (CE)

This section includes most, but not all, situations where CE purchase is inappropriate.

A. Case evidence is sufficient and consistent enough to adjudicate the claim

Do not purchase a CE when the existing evidence is sufficient and consistent enough to adjudicate the claim. For information to evaluate the sufficiency and consistency of evidence, see DI 24501.016C.

For continuing disability reviews (CDRs), a CE is necessary only when the evidence as a whole, both medical and non-medical, is not sufficient to support a determination.

Do not purchase a CE in CDR cases when the impairment:

  • Continues to meets a listing (even when obsolete) as written at the comparison point decision (CPD) (DI 28030.020D.6).

  • Meets the requirement for certain Medical Improvement Not Expected (MINE) or MINE-equivalent cases, such as amputation of both hands or amputation of the leg at the hip (DI 28040.005 and DI 28040.125B.1).

B. Other sources have available evidence

Do not purchase a CE for diagnostic tests or procedures already performed by a medical source when there is no evidence to indicate a change to the claimant's condition.

When a test, evaluation, or procedure already performed by a medical source is needed, request the results of the test or procedure from the appropriate source. Only purchase a CE when the evidence is necessary to make a determination and every reasonable effort to obtain the evidence was made, but the attempt was unsuccessful (see DI 22510.005B.1).

C. Test or procedure involves significant risk

Do not purchase a CE for diagnostic tests or procedures such as myelograms, arteriograms, or cardiac catheterizations that involve significant risk to the claimant. When uncertain about whether a diagnostic test or procedure poses significant risk, obtain the approval of the appropriate Disability Determination Services (DDS) management or medical consultant prior to purchasing the CE.

IMPORTANT: The medical source designated to perform the CE is responsible for deciding whether to perform a requested test or procedure that may involve significant risk to a claimant.

D. Symptom validity tests (SVT)

Do not purchase an SVT or other metrics designed to address inconsistent symptoms or behavior as part of a CE. There is no test that, when passed or failed, conclusively determines the claimant’s motivation. Malingering requires a deliberate attempt to deceive.

Examples of an SVT include, but are not limited to:

  • Rey 15 Item Memory Test (Rey-II),

  • Miller Forensic Assessment of Symptoms Test (M-FAST),

  • Millon Clinical Multiaxial Inventory,

  • Minnesota Multiphasic Personality Inventory, Second Edition (MMPI-2),

  • Malingering Probability Scale,

  • Structured Interview of Reported Symptoms,

  • Test of Memory Malingering (TOMM), and

  • Validity Indicator Profile.

When results of an SVT are part of the medical evidence of record, consider them along with all of the relevant evidence in the case record (DI 24583.050D.9). Evaluate symptoms using the two-step symptom evaluation process explained in DI 24501.021. Do not make adjudicative findings or conclusory statements about potential malingering as part of the final determination.

EXCEPTION: In the rare case when an SVT is required at the Administrative Law Judge hearing level or appeal (e.g., testing ordered pursuant to a court order), the Office of Disability Policy (ODP) will approve SVT requests on a case-by-case basis. When necessary, the Office of Hearing Operations (OHO) will email ^ODP Controls for pre-approval and copy both ^ODP OMP Controls and ||DCO ODD.

REMINDER: Consider referring a case with evidence suggestive of fraud or similar fault to the servicing Cooperative Disability Investigations Unit (CDIU) or the Office of Inspector General (OIG) for investigation. For more information on how to make a referral for possible investigation, see DI 23025.015.

E. Drug or alcohol testing

Do not purchase a CE for drug or alcohol testing to evaluate an issue of drug addiction or alcoholism (DAA). A single drug or alcohol test is not sufficient to establish DAA as a medically determinable impairment (MDI), nor does it provide pertinent information that can help us determine whether DAA is material to a finding of disability. For details on evaluating cases involving DAA, see SSR13-2p.

F. Issues involving substantial gainful activity (SGA) which preclude entitlement

Do not purchase a CE without first resolving any outstanding SGA issue(s) that could preclude entitlement.

G. Technical factors preclude entitlement

Do not purchase a CE when a technical factor will preclude entitlement. These situations include, but are not limited to:

1. Disability insurance benefit(DIB) claims

Date last insured (DLI) is in the past and there is no possibility of establishing an established onset date (EOD) prior to the DLI.

2. Disabled widow(er)'s benefit (DWB) claims

The prescribed period has ended and there is no possibility of establishing an EOD prior to the date the prescribed period ended.

3. Childhood disability benefit (CDB) claims

There is no possibility of establishing an EOD before the date the claimant attained age 22.


DI 22510 TN 30 - Development of Consultative Examinations (CE) - 2/22/2023