TN 22 (09-20)

DI 22510.113 Adult Consultative Examination (CE) Report Content Guidelines for Cancer

Use the following guidelines to provide minimum content for CE reports for adult claimants with cancer. Each Disability Determinations Service (DDS) will notify medical sources of any additional requirements.

A. General guidelines for CE report content for adult cancer

The CE report guidelines for adult cancer in this section are in addition to the general CE report content guidelines in DI 22510.100.

B. Report content specific to cancer

The CE provider will use the specific requirements below to complete the CE report for cancer.

1. Current medical history

The CE provider will describe and discuss, as appropriate:

a. Fatigue, malaise, affected organ systems;

b. Type of therapy received or planned;

c. Response to therapy – surgical, radiation, and chemotherapy (for each cancer condition if more than one). If multimodal therapy, dates each completed/scheduled and performed by which physician;

d. Effects of any post-therapeutic residuals;

e. Planned treatment;

f. Weight loss;

g. Prognosis, if available; and

h. Dates and results of relevant diagnostic procedures, such as biopsy or tissue pathologic examination and imaging studies.

2. Physical examination

The CE provider will describe and discuss, as appropriate:

a. Review any biopsy or tissue pathologic examination;

b. Imaging studies; and

c. Other body systems affected by adverse effects of treatment.

 


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0422510113
DI 22510.113 - Adult Consultative Examination (CE) Report Content Guidelines for Cancer - 09/25/2020
Batch run: 09/25/2020
Rev:09/25/2020