Effective Dates: 9/19/2024 - Present

Identification Number:
DI 24501 TN 28
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. 28, 09/19/2024

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

This transmittal includes updated language for consistency with SSR 16-3p and changes we made to DI 22510.006, When Not to Request a Consultative Examination (CE).

In this revised POMS, we instruct adjudicators to use the two-step symptom evaluation process to address statements or alleged symptoms that may appear inconsistent with, or unsubstantiated by, the objective medical evidence. In addition, we explain that adjudicators may not make conclusive findings about an individual's motivation because there are multiple reasons why they may appear to over-endorse symptoms.

Summary of Changes

DI 24501.021 Evaluating Symptoms

We made the following changes:

  1. 1. 

    Removed references to the archived SSR 96-3p, Considering Allegations of Pain and Other Symptoms in Determining Whether a Medically Determinable Impairment is Severe;

  2. 2. 

    Reorganized content and omitted redundant information;

  3. 3. 

    In subsection A, we:

    • •

      Added a definition of "symptom,"

    • •

      Outlined the two-step symptom evaluation process,

    • •

      Clarified and revised subsection titles, and

    • •

      Removed reference to an individual's credibility, character, or truthfulness

  4. 4. 

    In subsection B., we:

    • •

      Clarified and revise subsection titles,

    • •

      Updated our examples to include non-binary pronouns,

    • •

      Added instructions concerning inconsistent statements, and

    • •

      Instructed adjudicators not to order certain tests which address symptom validity for consistency with DI 22510.006, When Not to Purchase a CE.

  5. 5. 

    In subsection C., we:

    • •

      Clarified, revised, and reorganized subsection titles, and

    • •

      Clarified how to consider medical and non-medical evidence during the symptom evaluation process.

  6. 6. 

    In subsection D., we:

    • •

      Clarified, revised, and reorganized subsection titles,

    • •

      Added information on what to document in the symptom evaluation explanation, and

    • •

      Added information on who may and how to document the symptom evaluation explanation in DCPS.

  7. 7. 

    Removed subsection E, References, because we include hyperlinks to POMS citations throughout the policy.

DI 24501.021 Evaluating Symptoms

CITATIONS: 20 CFR 404.1529 and 416.929 .

SSR 16-3p

A. Policy for evaluating symptoms

A symptom is an individual's description, in their own words, of a physical or mental impairment(s). Statements about pain, fatigue, shortness of breath, weakness, nervousness, side effects of medication, and other symptoms, all indicate the potential for a severe underlying impairment(s) that could also be disabling.

Symptom evaluation is a part of the medical evaluation process; however, symptoms alone are not enough to establish the existence of a physical or mental medically determinable impairment (MDI) or disability. Symptoms must be evaluated using the two-step process established in our regulations and as explained in DI 24501.021B, in this section.

For more information on establishing an MDI, see DI 24501.020.

1. Symptoms we consider

We consider all alleged or documented symptoms such as pain, fatigue, shortness of breath, weakness, nervousness, the side effects of medication, etc.

2. Symptoms in the sequential evaluation process

We consider symptoms during the medical evaluation of a claim using the sequential evaluation process, in accordance with DI 22001.001.

  • •

    At step two, when determining whether an MDI (or combination of MDIs) is severe and has lasted or is expected to last for 12 continuous months;

  • •

    At step three, when a symptom(s) is one of the criteria in the listing (e.g., listings 7.18 , 12.04 , or 14.10B ), or when a combination of symptoms, signs, and findings are equal in severity to the listed criteria; or

  • •

    When assessing residual functional capacity (RFC) for an adult disability claim, or functional domains for a Title XVI child disability claim.

EXCEPTION: When it is possible to make a fully favorable determination based solely on the objective medical findings, adjudicators do not need to consider symptoms in the medical evaluation unless they are identified as one or more criteria in the listing.

For more information on curtailing development for a fully favorable determination, see DI 24515.020.

3. Symptom evaluation

We will find an individual's alleged symptoms are supported when one or more of the claimant's MDIs can reasonably be expected to produce those symptoms and when the intensity, persistence, and limiting effects of the alleged symptoms can be accepted as generally consistent with the case evidence and objective findings. However, we will not reject an individual’s statements about the intensity and persistence of their symptoms, or about the effect of the symptoms on their ability to work, solely because the available objective medical evidence does not substantiate the individual’s statements. In addition to the objective medical evidence, we will consider the factors set forth in DI 24501.021.B.2.b in this section.

In the symptom evaluation explanation, analyze and discuss the extent to which the symptoms are consistent, or inconsistent, with all the case evidence, as explained in DI 24501.021B.3.a. in this section.

B. Two-step process for symptom evaluation

1. Step one of the symptom evaluation process

The adjudicator must review the medical evidence for the existence of one or more MDI(s) resulting from anatomical, physiological, or psychological abnormalities. Then, the adjudicator must determine whether the individual’s MDI(s) could reasonably produce their reported symptom(s).

a. The MDI(s) could reasonably produce the symptom(s)

Document these finding(s) in the Disability Case Processing System (DCPS) and proceed to step two of the symptom evaluation process for symptoms that are reasonably related to an MDI(s).

b. The MDI(s) could not reasonably produce the symptom(s), or no MDI(s)

Explain in DCPS why the MDI(s) could not reasonably be expected to produce the symptoms. Some symptoms might be reasonably related to an MDI, while others are not. Do not consider symptoms that are not reasonably related to an MDI in the medical evaluation of the claim.

c. Examples of step one of symptom evaluation

Example one:

On the SSA-3373-BK (Function Report – Adult), an individual says they can only walk a few blocks due to pain. The medical evidence includes a knee x-ray showing moderate degenerative changes and a physical exam indicating limited range of motion, joint effusion, and a mildly antalgic gait.

At step one of symptom evaluation process, the objective findings establish the individual has an MDI that could reasonably be expected to produce the symptom of pain.

Example two:

On the SSA-3368-BK (Disability Report – Adult), an individual alleges depression, problems concentrating, and difficulty getting along with others but they did not identify a healthcare provider who treats their mental allegations. The individual completed and returned the SSA-3373-BK and reports difficulties in multiple domains of mental functioning, such as self-care (needs reminders to shower) and social activities (i.e., no longer spends time with friends or family, communicates only by text message). The DDS schedules a consultative examination (CE) to establish a mental MDI.

At the CE, the individual reports isolating from friends and family during depressive episodes. The mental status exam indicates the individual has a flat affect with fair eye contact and limited insight and judgment.  Additionally, they struggled to perform serial 7's and recalled 1 out of 3 objects after a delay. The CE source diagnosed the individual with major depressive disorder.

At step one of the symptom evaluation process, the objective findings establish the individual has an MDI that could reasonably be expected to produce the individual's symptoms of "problems concentrating" and "difficulty getting along with others."

2. Step two of the symptom evaluation process

When the medical evidence establishes one or more MDIs that could reasonably be expected to produce the individual’s symptom(s), the adjudicator must:

  • •

    Consider the intensity and persistence of the symptom(s);

  • •

    Determine the extent to which their alleged functional limitations are supported by, and consistent with, the medical and non-medical evidence in the case record; and

  • •

    Recognize that some individuals experience symptoms and related functional limitations differently, even when their MDI(s) and the case evidence are similar.

The adjudicator must consider the degree to which the intensity, persistence, and limiting effects of the individual's symptom(s) are consistent with and supported by the objective signs, laboratory findings, and other medical and non-medical evidence.

a. Symptoms are consistent

Determine the extent to which the symptoms limit the individual's ability to work (for an adult); or, to function independently, appropriately, and effectively in an age-appropriate manner (for a TXI child). Document your analysis in accordance with DI 24501.021D of this section.

b. Symptoms are not consistent

Ensure that every reasonable effort was made to obtain a complete medical history before finding the individual’s alleged symptoms do not limit their ability to perform work-related activities (for an adult) or to function independently, appropriately, and effectively in an age-appropriate manner (for a Title XVI child).

In addition when the alleged symptoms are not substantiated solely by the objective medical evidence, consider the following factors and how they contribute to the intensity, persistence, and limiting effects of an individual's symptoms.

  • •

    The individual’s daily activities;

  • •

    The location, duration, frequency, and intensity of the individual’s pain or other symptoms;

  • •

    Factors that precipitate and aggravate the symptoms;

  • •

    The type, dosage, effectiveness, and side effects of any medication the individual takes or has taken to alleviate pain or other symptoms;

  • •

    Treatment, other than medication, the individual receives or has received for relief of pain or other symptoms;

  • •

    Any measures other than treatment the individual uses or has used to relieve pain or other symptoms (e.g., lying flat on their back, standing for 15 to 20 minutes every hour, or sleeping on a board); and

  • •

    Any other factors concerning the individual’s functional limitations and restrictions due to pain or other symptoms.

3. Other issues to address in the symptom evaluation explanation

a. Consistency of statements

Evaluate the consistency of the individual’s description of the intensity and persistence of their reported symptoms with all the case evidence and determine the extent to which the symptoms limit the individual’s ability to perform work-related activities (for an adult) or function independently and effectively in an age-appropriate manner (for a Title XVI child).

Compare statements made in connection with the individual's claim for disability benefits (e.g., SSA-3373-BK or a CE report) with any existing statements made under other circumstances (e.g., the individual's medical source).

Consider the following when evaluating symptoms for consistency:

  1. 1. 

    Symptoms may vary with different types and frequency of treatment.

  2. 2. 

    Frequent attempts to obtain treatment of symptoms may indicate that the symptoms are intense and persistent.

  3. 3. 

    Absence of treatment may indicate symptoms are less intense and persistent. For example, the condition may be effectively treated with over-the-counter medication.

  4. 4. 

    Absence of treatment may also indicate that the claimant:

    • •

      Reduced or restructured their activities in order to minimize symptoms;

    • •

      Received only periodic treatment or evaluation for prescription refills because the symptoms reached a plateau;

    • •

      Refused to take medications due to side effects that are less tolerable than the symptoms;

    • •

      Received advice from a medical source indicating that further treatment would not be beneficial;

    • •

      Has religious beliefs prohibiting medical treatment;

    • •

      Has limitations (e.g., English proficiency) preventing them from understanding the need for appropriate or consistent treatment;

    • •

      Has an impairment affecting their judgment, reality testing, or orientation, that causes the individual to be unaware that they have a disorder requiring treatment; or

    • •

      Is, or has been, unable to access or afford medical services;

    • •

      If the individual is a child, they might disregard the level and frequency of treatment needed to maintain or improve functioning because it interferes with participation in activities typical of other children their age without impairments.

b. When symptoms appear out of proportion with objective evidence

There are multiple reasons why individuals may exhibit behaviors that are inconsistent or appear out of proportion with the objective findings. Generally, step two of the symptom evaluation process provides an opportunity to fully evaluate inconsistent statements or behavior. When the medical evidence by itself does not support the intensity, persistence, or limiting effects of the individual's impairment-related symptoms, do not reject these statements or find them inconsistent without considering the factors listed above and other possible reasons, as discussed in DI 24501.021B.3.a. in this section.

Further, inconsistent or disproportionate statements are not necessarily a reason to suspect fraud or similar fault (FSF). If the case evidence gives reason to suspect the individual (or someone responsible for acting on their behalf) may be involved in potential FSF, see DI 23025.015 to determine whether a fraud referral is appropriate.

IMPORTANT: Do not purchase a symptom validity test (SVT) to address inconsistent symptoms or behavior. An SVT cannot prove whether a person is over-endorsing symptoms because there is no test that conclusively determines an individual's motivation.

When the results of an SVT are part of the evidence of record, consider them along with all the relevant case evidence. SVTs have limited usefulness in the disability program and adjudicators must use caution when considering these findings (DI 24583.050).

For information on when NOT to purchase a consultative examination (CE), see DI 22510.006D.

C. How to consider case evidence when evaluating symptoms

1. Objective medical evidence

Objective medical evidence is a useful indicator to help make reasonable conclusions about the intensity, persistence, and limiting effects of many symptoms on an individual's ability to work (for an adult), or function independently, effectively, and in an age-appropriate manner (for a Title XVI child). For example, pain may be the individual’s expression of reduced range of motion or muscle spasm. Similarly, a description of weakness may be observed as sensory deficit or motor disruption.

Other signs in the medical evidence that might indicate an individual's symptoms are a source of distress include, but are not limited to:

  • •

    Increased dosages and medication changes;

  • •

    Trying a variety of treatments;

  • •

    Referrals to specialists; and

  • •

    Changes in medical sources.

2. Other relevant evidence

If the objective medical evidence by itself does not warrant issuing a fully favorable determination, carefully consider other relevant case evidence to evaluate the intensity, persistence, and limiting effects of an individual's symptoms. Because symptoms sometimes suggest a greater severity of impairment than can be shown by objective medical evidence alone, we will carefully consider any other information the individual might submit about their symptoms.  For instance, the individual’s medical or non-medical sources might provide information about the individual’s symptoms, and such information is an important indicator of the intensity and persistence of those symptoms. In sum, we will consider all of the evidence presented, including information about the individual’s prior work record, the individual’s own statements about their symptoms, evidence submitted by medical sources, and observations by SSA employees and other persons.

For additional categories of evidence to consider during symptom evaluation, see DI 24503.005.

D. Documenting the symptom evaluation findings

Symptom evaluation is part of the medical assessment(s). The adjudicator may complete or assist with completing symptom evaluation, however once an MC or PC signs the appropriate medical assessment (i.e., SSA-416 (Medical Evaluation), SSA-2506-BK (Psychiatric Review Technique), SSA-4734-BK (Physical Residual Functional Capacity Assessment,) or SSA-4734-SUP (Mental Residual Functional Capacity Assessment)) the adjudicator may not alter the symptom evaluation unless they send the case back to the MC or PC with an explanation of the change and a request to reapply their signature.  When the MC or PC applies their signature, they are affirming the individual’s symptoms were considered and the medical evaluation is complete.

For more information about signature requirements and responsibilities of the adjudicative team, see DI 24501.001.

1. Where to document the symptom evaluation explanation

Fully document your analysis in DCPS, using the "Symptoms Evaluation" section of the Medically Determinable Impairments and Severity page in Claim Analysis.

IMPORTANT: The individual must have one or more MDI(s) that could reasonably be expected to produce the individual's symptoms. When the medical evidence does not establish one or more MDI(s) that could reasonably be expected to produce the individual’s alleged symptoms, document these findings on the SSA-416 (Medical Evaluation) following the instructions in DI 24501.006.

2. What to document in the symptom evaluation explanation

Explain the following, as applicable:

  • •

    Identify and select the individual's physical or mental symptoms;

  • •

    Evaluate the individual's statements about symptoms and their functional effects;

  • •

    Consider which of the individual's symptoms are consistent, or inconsistent, with certain case evidence and if the symptoms are more or less likely to limit the individual's capacity to perform work-related activities for an adult; or reduce a child's ability to function independently, appropriately, and effectively in an age-appropriate manner (for a Title XVI child); and

  • •

    Provide specific reasons when assessing the intensity, persistence, and limiting effects of the individual's symptoms and how evaluation of their symptoms led to these conclusions.


DI 24501 TN 28 - General - Medical Evaluation - 9/19/2024