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).

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.

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."

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.

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;

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

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  Factors that precipitate and aggravate the symptoms;

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

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

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  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

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

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:

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     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;

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     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

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     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.

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.

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