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Evidence From Sources Who Are Not Acceptable Medical Sources In Social Security Disability Claims

Note: SSR 06-03p was Rescinded by Federal Register Notice Vol. 82, No. 57, page 15263, effective March 27, 2017

SSR 06-03p is a Policy Interpretation Ruling in SSDI and SSI disability claims titled ‘Considering Opinions and Other Evidence from Sources Who Are Not “Acceptable Medical Sources” in Disability Claims; Considering Decisions on Disability by Other Governmental and Nongovernmental Agencies.

The purpose of the ruling is to clarify how Social Security considers opinions from sources who are not “acceptable medical sources” and how Social Security considers decisions by other governmental and nongovernmental agencies on the issue of disability or blindness.

Social Security uses medical and other evidence to reach conclusions about an individual’s impairments to make a disability determination or decision. When Social Security makes a determination or decision of disability, it will consider all of the available evidence in the individual’s case record. This includes but is not limited to, objective medical evidence; other evidence from medical sources, including their opinions; statements by the individual and others about the impairment(s) and how it affects the individual’s functioning; information from other “non-medical sources” and decisions by other governmental and non-governmental agencies about whether an individual is disabled or blind.

RELATED POST: What Is a Medically Determinable Impairment

Medical Sources

The term “medical sources” refers to both “acceptable medical sources” and other health care providers who are not “acceptable medical sources.”

Under the SSA’s current regulations, “acceptable medical sources” are:

  • Licensed physicians (medical or osteopathic doctors);
  • Licensed or certified psychologists. Included are school psychologists or other licensed or certified individuals with other titles who perform the same function as a school psychologist in a school setting for purposes of establishing mental retardation, learning disabilities, and borderline intellectual functioning only;
  • Licensed optometrists, for the measurement of visual acuity and visual fields (for claims under title II, Social Security may need a report from a physician to determine other aspects of eye disease);
  • Licensed podiatrists, for purposes of establishing impairments of the foot, or foot and ankle only, depending on whether the State in which the podiatrist practices permits the practice of podiatry on the foot only or the foot and ankle; and
  • Qualified speech-language pathologists for purposes of establishing speech or language impairments only.

See 20 CFR 404.1513(a) and 416.913(a).

Medical Source Distinction

For three reasons, the distinction between “acceptable medical sources” and other healthcare providers who are not “acceptable medical sources” is necessary:

  • First, Social Security needs evidence from “acceptable medical sources” to establish the existence of a medically determinable impairment.
  • Second, only “acceptable medical sources” can give us medical opinions.
  • Third, only “acceptable medical sources” can be considered treating sources, as defined in 20 CFR 404.1502 and 416.902, whose medical opinions may be entitled to controlling weight.

See 20 CFR 404.1527(d) and 416.927(d).

Making a distinction between “acceptable medical sources” and medical sources who are not “acceptable medical sources” facilitates the application of the SSA’s rules on establishing the existence of an impairment, evaluating medical opinions, and who can be considered a treating source.

“Other Sources”

In addition to evidence from “acceptable medical sources,” Social Security may use evidence from “other sources,” as defined in 20 CFR 404.1513(d) and 416.913(d), to show the severity of the individual’s impairments and how the impairments affect the individual’s ability to function. These sources include, but are not limited to:

  • Medical sources who are not “acceptable medical sources,” such as nurse practitioners, physician assistants, licensed clinical social workers, naturopaths, chiropractors, audiologists, and therapists; and
  • “Non-medical Sources” including, but not limited to:
  • Educational personnel, such as school teachers, counselors, early intervention team members, developmental center workers, and daycare center workers;
  • Public and private social welfare agency personnel, rehabilitation counselors; and
  • Spouses, parents and other caregivers, siblings, other relatives, friends, neighbors, clergy, and employers.

Information from these “other sources” cannot establish the existence of a medically determinable impairment. Instead, there must be evidence from an “acceptable medical source” for this purpose. However, information from such “other sources” may be based on special knowledge of the individual and may provide insight into the severity of the impairment(s) and how it affects the individual’s ability to function.

Evaluating Opinions and Other Evidence

Sections 404.1527 and 416.927 of Social Security’s regulations provide general guidance for evaluating all relevant evidence in a case record and provide detailed rules for evaluating medical opinions from “acceptable medical sources.”

Medical opinions are statements from physicians and psychologists or other “acceptable medical sources” that reflect judgments about the nature and severity of an individual’s impairments, including symptoms, diagnosis, and prognosis, what the individual can still do despite the impairments and physical and mental restrictions. See 20 CFR 404.1527(a)(2) and 416.927(a)(2).

The regulations set out factors Social Security considers in weighing medical opinions from treating sources, non-treating sources, and non-examining sources. See 20 CFR 404.1527(d) and 416.927(d).

These factors include:

  • The examining relationship between the individual and the “acceptable medical source”;
  • The treatment relationship between the individual and a treating source, including its length, nature, and extent as well as the frequency of examination;
  • The degree to which the “acceptable medical source” presents an explanation and relevant evidence to support an opinion, particularly medical signs and laboratory findings;
  • How consistent the medical opinion is with the record as a whole;
  • Whether the opinion is from an “acceptable medical source” who is a specialist and is about medical issues related to his or her area of specialty; and
  • Any other factors brought to Social Security’s attention, or of which Social Security is aware, which tend to support or contradict the opinion. For example, the amount of understanding of Social Security’s disability programs and their evidentiary requirements that an “acceptable medical source” has, regardless of the source of that understanding, and the extent to which an “acceptable medical source” is familiar with the other information in the case record, are all relevant factors that Social Security will consider in deciding the weight to give to a medical opinion.

In addition, these regulations provide that the final responsibility for deciding certain issues, such as whether an individual is disabled under the Act, is reserved to the Commissioner.

These regulations provide specific criteria for evaluating medical opinions from “acceptable medical sources”; however, they do not explicitly address how to consider relevant opinions and other evidence from “other sources” listed in 20 CFR 404.1513(d) and 416.913(d). With the growth of managed health care in recent years and the emphasis on containing medical costs, medical sources who are not “acceptable medical sources,” such as nurse practitioners, physician assistants, and licensed clinical social workers, have increasingly assumed a greater percentage of the treatment and evaluation functions previously handled primarily by physicians and psychologists. Opinions from these medical sources, who are not technically deemed “acceptable medical sources” under Social Security’s rules, are important and should be evaluated on key issues such as impairment severity and functional effects, along with the other relevant evidence in the file.

“Non-medical sources” who have had contact with the individual in their professional capacity, such as teachers, school counselors, and social welfare agency personnel who are not health care providers, are also valuable sources of evidence for assessing impairment severity and functioning. Often, these sources have close contact with the individuals and have personal knowledge and expertise to make judgments about their impairment(s), activities, and level of functioning over a period of time. Consistent with 20 CFR 404.1513(d)(4) and 416.913(d)(4), Social Security also considers evidence provided by other “non-medical sources” such as spouses, other relatives, friends, employers, and neighbors.

Although 20 CFR 404.1527 and 416.927 do not explicitly address how to evaluate evidence (including opinions) from “other sources,” they do require consideration of such evidence when evaluating an “acceptable medical source’s” opinion.

For example, SSA’s regulations include a provision that requires adjudicators to consider any other factors brought to Social Security’s attention or of which Social Security is aware, which tend to support or contradict a medical opinion. Information, including opinions, from “other sources”–medical and “non-medical sources”–can be important in this regard. In addition, and as already noted, the Act requires the SSA to consider all of the available evidence in the individual’s case record in every case.

Accordingly, Ruling SSR 06-03p clarifies how Social Security considers opinions and other evidence from medical sources that are not “acceptable medical sources” and from “non-medical sources,” such as teachers, school counselors, social workers, and others who have seen the individual in their professional capacity, as well as evidence from employers, spouses, relatives, and friends. This ruling also explains how Social Security considers decisions on disability made by other governmental and non-governmental agencies.

Policy Interpretation

I. Evidence From “Other Sources”

Social Security considers all relevant evidence in the case record when it makes a determination or decision about whether the individual is disabled. Evidence includes, but is not limited to, opinion evidence from “acceptable medical sources,” medical sources who are not “acceptable medical sources,” and “non-medical sources” who have seen the individual in their professional capacity. The weight to which such evidence may be entitled will vary according to the case’s particular facts, the source of the opinion, including that source’s qualifications, the issue(s) that the opinion is about, and many other factors, as described below.

Factors for Considering Opinion Evidence

Although the factors in 20 CFR 404.1527(d) and 416.927(d) explicitly apply only to the evaluation of medical opinions from “acceptable medical sources,” these same factors can be applied to opinion evidence from “other sources.” These factors represent basic principles that apply to the consideration of all opinions from medical sources that are not “acceptable medical sources” as well as from “other sources,” such as teachers and school counselors, who have seen the individual in their professional capacity.

These factors include:

  • How long the source has known and how frequently the source has seen the individual;
  • How consistent the opinion is with other evidence;
  • The degree to which the source presents relevant evidence to support an opinion;
  • How well the source explains the opinion;
  • Whether the source has a specialty or area of expertise related to the individual’s impairment(s), and
  • Any other factors that tend to support or refute the opinion.

Opinions from Medical Sources Who Are Not “Acceptable Medical Sources”

Opinions from “other medical sources” may reflect the source’s judgment about some of the same issues addressed in medical opinions from “acceptable medical sources,” including symptoms, diagnosis, and prognosis, what the individual can still do despite the impairment(s), and physical and mental restrictions.

Not every factor for weighing opinion evidence will apply in every case. Evaluating an opinion from a medical source who is not an “acceptable medical source” depends on the particular facts in each case. Each case must be adjudicated on its own merits based on a consideration of the probative value of the opinions and weighing all the evidence in that particular case.

The fact that a medical opinion is from an “acceptable medical source” is a factor that may justify giving that opinion greater weight than an opinion from a medical source who is not an “acceptable medical source” because, as Social Security previously indicated in the preamble to its regulations at 65 FR 34955, dated June 1, 2000, “acceptable medical sources” “are the most qualified health care professionals.”

However, depending on the particular facts in a case, and after applying the factors for weighing opinion evidence, an opinion from a medical source who is not an “acceptable medical source” may outweigh the opinion of an “acceptable medical source,” including the medical opinion of a treating source. For example, it may be appropriate to give more weight to the opinion of a medical source who is not an “acceptable medical source” if he or she has seen the individual more often than the treating source and has provided better-supporting evidence and a better explanation for his or her opinion. Giving more weight to the opinion from a medical source who is not an “acceptable medical source” than to the opinion from a treating source does not conflict with the treating source rules in 20 CFR 404.1527(d)(2) and 416.927(d)(2) and SSR 96-2p, “Titles II and XVI: Giving Controlling Weight To Treating Source Medical Opinions.”

Evidence from “Non-Medical Sources”

Opinions from “non-medical sources” who have seen the individual professionally should be evaluated by using the applicable factors listed above in the section “Factors for Weighing Opinion Evidence.” Not every factor for weighing opinion evidence will apply in every case. The evaluation of an opinion from a “non-medical source” who has seen the individual in a professional capacity depends on the particular facts in each case. Each case must be adjudicated on its own merits based on a consideration of the probative value of the opinions and weighing all the evidence in that particular case.

For opinions from sources such as teachers, counselors, and social workers who are not medical sources, and other non-medical professionals, it would be appropriate to consider such factors as the nature and extent of the relationship between the source and the individual, the source’s qualifications, the source’s area of specialty or expertise, the degree to which the source presents relevant evidence to support his or her opinion, whether the opinion is consistent with other evidence, and any other factors that tend to support or refute the opinion.

An opinion from a “non-medical source” who has seen the claimant in his or her professional capacity may, under certain circumstances, properly be determined to outweigh the opinion from a medical source, including a treating source. For example, this could occur if the “non-medical source” has seen the individual more often and has greater knowledge of the individual’s functioning over time and if the “non-medical source’s” opinion has better-supporting evidence and is more consistent with the evidence as a whole.

In considering evidence from “non-medical sources” who have not seen the individual in a professional capacity in connection with their impairments, such as spouses, parents, friends, and neighbors, it would be appropriate to consider such factors as the nature and extent of the relationship, whether the evidence is consistent with other evidence, and any other factors that tend to support or refute the evidence.

Explanation of the Consideration Given to Opinions from “Other Sources”

Since there is a requirement to consider all relevant evidence in an individual’s case record, the case record should reflect the consideration of opinions from medical sources who are not “acceptable medical sources” and from “non-medical sources” who have seen the claimant in their professional capacity. Although there is a distinction between what an adjudicator must consider and what the adjudicator must explain in the disability determination or decision, the adjudicator generally should explain the weight given to opinions from these “other sources,” or otherwise ensure that the discussion of the evidence in the determination or decision allows a claimant or subsequent reviewer to follow the adjudicator’s reasoning, when such opinions may have an effect on the outcome of the case. In addition, when an adjudicator determines that an opinion from such a source is entitled to greater weight than a medical opinion from a treating source, the adjudicator must explain the reasons in the notice of decision in hearing cases and in the notice of determination (that is, in the personalized disability notice) at the initial and reconsideration levels, if the determination is less than fully favorable.

II. Decisions On Disability By Other Governmental And Nongovernmental Agencies

The regulations at 20 CFR 404.1504 and 416.904 provide that:

“[a] decision by any nongovernmental agency or any other governmental agency about whether you are disabled or blind is based on its rules and is not our decision about whether you are disabled or blind. We must make a disability or blindness determination based on social security law. Therefore, a determination made by another agency [e.g., Workers’ Compensation, the Department of Veterans Affairs, or an insurance company] that you are disabled or blind is not binding on us.”

Under sections 221 and 1633 of the Act, only a State agency or the Commissioner can make a determination based on Social Security law that you are blind or disabled. Social Security’s regulations at 20 CFR 404.1527(e) and 416.927(e) make clear that the final responsibility for deciding certain issues, such as whether you are disabled, is reserved to the Commissioner of Social Security (see also SSR 96-5p, “Titles II and XVI: Medical Source Opinions on Issues Reserved to the Commissioner”). However, Social Security is required to evaluate all the evidence in the case record that may have a bearing on its determination or decision of disability, including decisions by other governmental and nongovernmental agencies (20 CFR 404.1512(b)(5) and 416.912(b)(5)). Therefore, evidence of a disability decision by another governmental or nongovernmental agency cannot be ignored and must be considered.

These decisions, and the evidence used to make these decisions, may provide insight into the individual’s mental and physical impairment(s) and show the degree of disability determined by these agencies based on their rules. Social Security will evaluate the opinion evidence from medical sources, as well as “non-medical sources” who have had contact with the individual in their professional capacity, used by other agencies, that are in the SSA’s case record, in accordance with 20 CFR 404.1527, 416.927, Social Security Rulings 96-2p and 96-5p, and the applicable factors listed above in the section “Factors for Weighing Opinion Evidence.”

Because the ultimate responsibility for determining whether an individual is disabled under Social Security law rests with the Commissioner, Social Security is not bound by disability decisions by other governmental and non-governmental agencies. In addition, because other agencies may apply different rules and standards than Social Security does for determining whether an individual is disabled, this may limit the relevance of a determination of disability made by another agency. However, the adjudicator should explain the consideration given to these decisions in the notice of decision for hearing cases and in the case record for initial and reconsideration cases.