The Appeals Council (AC) will grant review and may remand for further development when the evidence in the claim(s) file is insufficient to support a conclusion that may affect the outcome of the decision. For example, if the medical evidence itself has a material conflict that involves medical facts, and the administrative law judge (ALJ) did not attempt to obtain additional evidence to resolve the conflict, the AC may decide to remand the claim(s) for further development of the issue.

The AC will grant review and may remand to obtain existing evidence, including hospital reports or medical source records, when the record indicates the ALJ did not attempt to obtain needed existing evidence (even if the ALJ was not at fault). For example, the AC may remand a claim to the ALJ to obtain additional evidence if:

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  The most recent evidence in the claim(s) file was dated more than a year before the ALJ decision;

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  The claimant has a progressive impairment that likely affects his or her ability to function;

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  There is an indication that the impairment worsened during the period at issue; and

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  Additional evidence exists.

Prior to considering a remand for a CE or medical test(s), the AC will consider whether obtaining an opinion from medical support staff (MSS) may resolve the issue without a remand. See HALLEX HA 01320.011. In addition to providing opinions, and subject to the limitations described above regarding specialists or specific testing, MSS can advise the AC on the type of medical information the AC should direct the ALJ to obtain on remand.

When requesting a MSS report is not appropriate, the AC may remand a case to obtain a CE(s) or medical test(s) when additional evidence is necessary to establish the nature, severity, or duration of a claimant's impairment(s) during the period at issue, and the information is not available from the claimant's medical sources. The AC will not remand a case for this reason if the period at issue was limited (e.g., a closed period of benefits or a title II case involving a date last insured (DLI) issue) and the ALJ would not be able to obtain the CE or medical test within a few months of the period at issue. Situations where it may be appropriate for the AC to remand for CE or additional medical testing include the following:

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  Additional information is needed to establish onset in accordance with Social Security Rulings 18-1p, Titles II and XVI: Determining the Established Onset Date (EOD) in Disability Claims and 18-2p, Determining the Effective Onset Date (EOD) in Blindness Claims;

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  The medical findings (symptoms, signs, and laboratory findings) and claimant's functional limitations may demonstrate medical equivalence to the criteria required for a listed impairment (see 20 CFR 404.1526 and 416.926);

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  A medical opinion may resolve problems identified by the AC or would complete necessary development of the record to resolve problems identified by the AC; or

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  A court ordered the agency to obtain the information.

Generally, the AC will not direct an ALJ to obtain a specialist or a particular medical diagnostic test because a particular specialist or test may not be available. For example, when evaluating a claim involving a mental impairment, the AC will not direct an ALJ to obtain a psychiatric CE because it may limit an ALJ's flexibility to obtain a mental status examination by a psychologist in an area where psychiatrists are not readily available. Rather, the AC will describe the purpose of the CE or needed medical information in its remand order. If there is a compelling reason for specific instructions, the AC will qualify the order by specifically stating “if available” or “if possible” because further development may obviate the need for such evidence.

Additionally, the AC will request only development that is essential for a legally sufficient decision on the claim. For example, the AC will not order a full CE if only X-rays are needed. Further, the AC will not direct the ALJ to obtain diagnostic tests or procedures that involve significant risk to the claimant, such as myelograms, arteriograms, or cardiac catheterizations.