Medical evidence is the foundation of a successful disability case, and many disability claimants believe their medical record will speak for itself.
After all, if you’ve been dealing with a condition that prevents you from working, you’ve likely seen multiple providers and had dozens of tests. You’ve probably taken different medications, and maybe you’ve had other courses of treatment, such as chemotherapy, physical therapy or even surgery.
It’s all there in your medical record. Or is it?
In this post, we’ll take a look at how the Social Security Administration uses medical evidence, the kinds of evidence it will accept, and problems with medical evidence that can derail a claim.
How does the Social Security Administration use medical evidence?
Social Security makes disability determinations based on a five-step sequential evaluation process. Medical evidence comes into play at Steps 2 and 3.
In Step 1, you proved that you are not engaged in substantial gainful activity. That is, your earnings from work are not more than the SSA’s designated limit.
At Step 2, a claims examiner looks for a medically determinable impairment — or a combination of impairments — that is severe enough to interfere with work-related activities and will last at least 12 months or result in your death. SSA considers both physical and mental impairments.
Step 3 is a closer examination of the severity of your condition. An adjudicator looks to see if your medically determinable impairment meets or exceeds a listing in its Listing of Impairments, also called the “Blue Book.” The Blue Book is maintained by the SSA and lists medical criteria that are considered to be so severe that an individual with a condition that meets or exceeds the criteria is found to be disabled.
It’s important to understand that just because your condition is included in the Listing of Impairments does not mean your claim will be approved. The listings are extremely restrictive, and most claims are won at Steps 4 or 5.
If you are not found to be disabled at Step 3 because your condition does not meet or exceed a listing, the medical evidence will be used to assess your residual functional capacity — basically, your ability to engage in substantial gainful activity.
What kind of medical records do I need?
Gathering medical records can be a huge source of stress, even if you’re not already dealing with a disability. A member of the Joyce & Bary Law team will work with you to identify your medical providers and collect the medical records we need to assemble your case.
We will be looking for items in your medical record that help us establish:
- The specific diagnosis related to the condition that prevents you from working
- The date of your diagnosis
- The severity of your symptoms
- Your prognosis — that is, how your medical provider expects your condition to progress, including whether it is expected to last for more than a year or result in your death
- The treatments you’ve tried and the results of those treatments
- Your current list of medications
- Physical or mental limitations you’ve experienced as a result of your condition.
The Social Security Administration will be looking for objective medical evidence from acceptable medical sources to evaluate your claim in Steps 2 and 3.
Here’s what the SSA means by those terms:
Objective medical evidence
These are records of findings from tests and assessments. They may include:
- Medical imaging such as x-ray, MRI, CT scan, ultrasound, or mammography
- Cardiac tests such as ECG or EKG
- Nerve conduction studies such as EMG
- Lab findings, including blood tests, spinal taps, pulse rate, blood pressure
- Pathology tests such as biopsies
- Tests of brain activity, such as EEG
Acceptable medical sources
Social Security’s acceptable medical sources include:
- Physicians
- Psychiatrists
- Psychologists
- Optometrists
- Podiatrists
- Speech pathologists
- Audiologists
- Physician assistants
- Advanced registered nurse practitioners
You may also work with other healthcare professionals who are not on this list as you seek treatment. While they can provide information that may help establish the severity of your condition and the lengths you’ve gone to to seek treatment, evidence from these sources cannot replace evidence from acceptable medical sources. If the only evidence you have is from one or more of these non-acceptable sources, your case will not be successful.
But objective medical findings are not usually enough to win your case. Some conditions are not detectable using medical testing — fibromyalgia and migraines fall into that category. While testing may rule out other conditions, it will not confirm a diagnosis. And while objective medical evidence might prove that you have a certain condition, it doesn’t always speak to its severity or intensity.
Other kinds of medical evidence
Clinical notes
Your medical providers take notes each time you visit. During an intake at your doctor’s office, you might speak to a nurse who takes your vital signs and asks you about the reasons for your visit. When the doctor (or other provider) takes over, they will take more notes about their observations and the symptoms you report. We’ll talk more about these notes when we discuss problems with medical records. These notes are critical to your case.
Journals and logs
We often advise clients to keep a journal of their symptoms, especially those symptoms that are intermittent such as seizures, muscle spasms or panic attacks. If you have chronic pain, you can take note each day of how you rate your pain. If you are experiencing mental health symptoms, your journal might be where you keep track of your moods or side effects of your medication.
You can also track in your journal the limitations you experience as you live your life. If you try to lift your arms to take a shower and can’t do it one day, write that down. If you’re out of breath by the time you get from one end of your house to the other, take note.
The journal serves several purposes. First, it will help you remember all the things you need to report to your doctor. Also, knowing more about the frequency, duration and intensity of your symptoms will give your provider insight into your condition that could help your treatment. In addition, your doctor can add your report to your medical record so it is submitted to the SSA when your records are requested. Sometimes, we even submit the journal in its entirety as part of your case.
As we evaluate your medical evidence, we might decide that a medical source statement would help your case. A medical source statement is a form completed by your doctor that gives an overview of your condition and how it limits your daily and work-related activities.
If your medical record doesn’t contain enough information about your condition or an SSA examiner has reason to question information contained in your medical record, you may be required to have a consultative examination with a doctor chosen by Social Security.
Problems with medical records
When submitted as evidence in your SSD claim, your medical record is only as good as the information it contains. Often, applicants who have been denied disability benefits are surprised to find that the evidence in their medical record doesn’t spell things out quite as clearly as they might have assumed.
“I’m fine.”
Over time, individuals who are dealing with disabilities learn to tolerate the very symptoms that keep them from being able to work.
For example, maybe you’ve injured your back and you experience pain on a daily basis. After weeks or months, your pain may be just as severe as it was after your initial injury, but if it’s not any worse, you tell your doctor you’re fine. You still can’t sit or stand for more than a few minutes at a time, and the pain is so severe that it makes it difficult to concentrate, but you don’t complain if it’s not worse than it was the last time you were at the doctor’s office.
Or maybe you’re following up with your psychiatrist about the serious anxiety you’ve been experiencing. Because you feel OK on the day of your appointment, you don’t think to mention the panic attack you had while standing in line at the grocery store or that your appetite has been sluggish since you started your new medication.
When this happens, the SSA can use your own statements to your doctor against you when denying your case.
The most important thing you can do to help your disability case is to be open and honest with your provider every time you have an appointment. Here are some examples:
- Talk about any symptoms you are having, even if you’ve reported the same symptoms in the past.
- Discuss side effects of your medication and whether or not it is providing the intended relief.
- Rate your pain and talk about whether or not you have noticed any improvement.
- Relate any new symptoms you’ve had — even if they seem unrelated or like a one-time occurrence.
- If your condition restricts your movement, show that to the doctor.
And don’t save all of this information up just for the doctor. If your appointment begins with a nurse taking vitals and doing an intake, be sure to be specific and thorough when answering questions and talking about the reason for your visit. If you feel like you’re telling the same story over and over, you’re probably doing it right.
Missing medical recommendations
Sometimes providers will make recommendations that don’t make it into the medical record. For example, your doctor might tell you to try walking with a cane or not to lift over 10 pounds. Or if you’re struggling with a mental health issue, you might be told to retreat to a quiet place when you identify certain triggers.
Unfortunately, if this advice doesn’t get into your exam notes, it’s difficult to use such limitations to support your case. Ask your provider for these instructions in written form to ensure they are added to your case file.
Non-compliance and gaps in treatment
If your doctor prescribes medicine or another treatment and you never take the medication or seek out the additional treatment, this can be used against you in your disability case. SSA will say that your condition might have improved had you followed doctor’s orders.
If you’re experiencing medication side effects that you can’t tolerate, don’t just stop taking the medication. Call your provider and report the side effects. Not only might there be a different medication you can take, but stopping a medication without any explanation in your medical record can weaken your case.
Missed appointments that are never rescheduled are also problematic. They make it look as though your condition either isn’t as bad as you say it is or that you aren’t interested in pursuing treatment to get better.
Even if you’ve been told that a certain course of treatment is no longer beneficial or that there are no other treatment options, be sure to continue to receive whatever treatment and follow-up are appropriate. Also, ask your doctor to clearly document the reasons for ending treatment.
Supplemental and alternative treatments
Many individuals suffering from a disabling condition have tried supplemental or alternative treatment, and some report finding relief.
As long as a supplemental or alternative treatment does not detract from the treatment your doctor prescribes, SSA will not hold it against you. But if you stop going to the doctor because you feel you’re getting better results from a naturopathic practitioner (who does not also happen to be an approved medical source), you will jeopardize your case.
Other damaging information
Social Security might deny a disability claim based on seemingly irrelevant information contained in the medical record. For example, if while chatting with your doctor you mention a recent family vacation, the doctor might jot that into your record. And while being disabled doesn’t mean you can never take another vacation, an adjudicator could take it as a sign that you’re doing better than you might actually be. The same can be said about activities of daily living such as childcare, hobbies and meal preparation.
How can I obtain my medical records?
If you’ve ever requested your medical records, you might realize that while it sounds easy, it usually isn’t. Sometimes it takes your provider a long time to respond only to find out you’re going to have to contact someone else.
Don’t worry about that. Our team will track down and request your medical records on your behalf. We will follow up as many times as needed to get your records from the providers you’ve seen.
What if I can’t afford to see the doctor?
If you haven’t been working, you’ve probably lost your health insurance and seeking treatment is a financial burden. Our team will help you connect with free or low-cost providers who can continue your treatment for the time you are without coverage.
Joyce & Bary Law can help
Don’t try to navigate the Social Security Disability process alone. Our team takes your case seriously, from start to finish, and we can help you no matter where you are in the claims process. Contact us today to schedule your free consultation.