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What Evidence Is Required By Social Security? Understanding The Evidence Used To Evaluate Disability Claims

The key to success in Social Security disability claims lies in the evidence you provide. From medical records to personal testimonies, each piece plays a crucial role in determining the outcome of your case. Let’s delve into the essential medical evidence needed to navigate the Social Security Disability process successfully.

What Kind of Evidence Is Used to Evaluate and Decide Social Security Disability Claims?

The Foundation: Medical Evidence

Under both the Title II Social Security Disability Insurance (SSDI or SSD) and Title XVI Supplemental Security Income (SSI) programs, medical evidence is the cornerstone for the determination of disability. It showcases the extent and severity of your medical condition, providing concrete evidence of your limitations.

When applying for Social Security Disability benefits, be prepared to secure and submit your medical records. Each person who files a disability claim is responsible for providing medical evidence showing they have an impairment(s) and the severity of the impairment(s). However, with the claimant’s permission, the Social Security Administration (SSA) will help obtain medical evidence. This medical evidence generally comes from sources that have treated or evaluated the claimant for their impairment(s).

Acceptable Medical Sources

Documentation of a claimant’s impairment must come from medical professionals defined by SSA regulations as “acceptable medical sources.” Once an impairment is established, all the medical and non-medical evidence is considered in assessing impairment severity.

Acceptable medical sources are:

  • Licensed physicians (medical or osteopathic doctors);
  • Licensed or certified psychologists, including school psychologists (and other licensed or certified individuals with other titles who perform the same function as school psychologists in a school setting) only for purposes of establishing mental retardation, learning disabilities, and borderline intellectual functioning ;
  • Licensed optometrists only for purposes of establishing visual disorders (except in the US Virgin Islands, where licensed optometrists are acceptable medical sources only for the measurement of visual acuity and visual fields);
  • Licensed podiatrists only for purposes of establishing impairments of the foot, or foot and the ankle, depending on whether the State in which the podiatrist practices permits the practice of podiatry on the foot only or the foot and the ankle; and
  • Qualified speech-language pathologists are used only to establish speech or language impairments. For this source, “qualified” means that the speech-language pathologist must be licensed by the State education agency in the State in which they practice or hold a Certificate of Clinical Competence from the American Speech-Language-Hearing Association.

Your Medical Records

Medical Evidence from Treating Sources

Most disability claims are decided based on medical evidence from treating sources. SSA regulations place particular emphasis on evidence from treating sources because they are likely to be the medical professionals most able to provide a detailed longitudinal picture of the claimant’s impairment(s) and may bring a unique perspective to the medical evidence that cannot be obtained from the medical findings alone or reports of individual examinations or brief hospitalizations. Therefore, timely, accurate, and adequate medical reports from treating sources accelerate the processing of the claim because they can significantly reduce or eliminate the need for additional medical evidence to complete the claim.

Medical Evidence From Health Facilities

SSA also requests copies of medical evidence from hospitals, clinics, or other health facilities where a claimant has been treated. All medical reports received are considered during the disability determination process.

What Information Should Be Included In My Medical Records?

The SSA frequently asks physicians, psychologists, and other health professionals to submit reports about an individual’s impairment(s). Therefore, it is essential to know what evidence the SSA needs. Medical reports should include:

  • Medical history;
  • Clinical findings (such as the results of physical or mental status examinations);
  • Laboratory findings (such as blood pressure, x-rays);
  • Diagnosis;
  • The treatment prescribed with response and prognosis;
  • A statement about what the claimant can still do despite their impairment(s), based on the medical source’s findings on the above factors.
  • If the claimant is an adult age 18 or over, this statement should describe, but is not limited to, the claimant’s ability to perform work-related activities, such as sitting, standing, walking, lifting, carrying, handling objects, hearing, speaking, and traveling.
  • In adult cases involving mental impairments or mental functional limitations, this statement should describe the claimant’s capacity to understand, carry out, and remember instructions and respond appropriately to supervision, coworkers, and work pressures in a work setting.

If the claimant is a child under age 18, this statement should describe the child’s functional limitations compared to children their age who do not have impairments in acquiring and using information, attending and completing tasks, interacting and relating with others, moving about and manipulating objects, caring for yourself, and health and physical well-being.

Evidence Relating to Symptoms

In developing evidence of the effects of symptoms, such as pain, shortness of breath, or fatigue, on a claimant’s ability to function, SSA investigates all avenues presented that relate to the complaints. These include information provided by treating and other sources regarding:

  • The claimant’s daily activities.
  • The location, duration, frequency, and intensity of pain or other symptoms.
  • Precipitating and aggravating factors.
  • The type, dosage, effectiveness, and side effects of any medication.
  • Treatments, other than medications, for the relief of pain or other symptoms.
  • Any measures the claimant uses or has used to relieve pain or other symptoms and
  • Other factors concerning the claimant’s functional limitations due to pain or other symptoms.

Decision-makers must fully consider the above factors when assessing the claimant’s pain or other symptoms. Ensure your medical providers address these factors in their reports.

Consultative Examinations

If the evidence provided by the claimant’s medical sources is inadequate to determine if they are disabled, additional medical information may be sought by contacting the treating source for further information or clarification or arranging a consultative examination (CE). The treating source is preferred for a CE if qualified, equipped, and willing to examine the claimant for the authorized fee. Even if only a supplemental test is required, the treating provider is ordinarily preferred for this service.

However, SSA’s rules provide for using an independent source (other than the treating source) for a CE or diagnostic study if:

  • The treating source prefers not to perform the examination;
  • The treating source does not have the equipment to provide the specific data needed;
  • There are conflicts or inconsistencies in the file that cannot be resolved by going back to the treating source;
  • The claimant prefers another source and has good reason for doing so, or
  • Social Security knows from experience that the treating source may not be a productive source.
Consultative Examination Report Content

A complete CE report will involve all the elements of a standard examination in the applicable medical specialty and should include the following elements:

  • The claimant’s major or chief complaint(s);
  • A detailed description, within the area of specialty of the examination, of the history of the primary complaint(s);
  • A description and disposition of pertinent “positive” and “negative” detailed findings based on the history, examination, and laboratory tests related to the primary complaint(s) and any other abnormalities or lack thereof reported or found during examination or laboratory testing;
  • Results of laboratory and other tests (for example, X-rays) performed according to the requirements stated in the Listing of Impairments (see Part III of this guide);
  • The diagnosis and prognosis for the claimant’s impairment(s);
  • A statement about what the claimant can do despite impairment(s) unless the claim is based on statutory blindness.
    • If the claimant is an adult age 18 or over, this statement should describe the opinion of the consultant about the claimant’s ability, despite impairment(s), to do work-related activities, such as sitting, standing, walking, lifting, carrying, handling objects, hearing, speaking, and traveling;
    • In adult cases involving mental impairment(s) or mental functional limitations, this statement should also describe the consultant’s opinion about the claimant’s capacity to understand, carry out, and remember instructions and respond appropriately to supervision, coworkers, and work pressures in a work setting.
    • If the claimant is a child under age 18, this statement should describe the consultant’s opinion about the child’s functional limitations compared to children their age who do not have impairments in acquiring and using information, attending and completing tasks, interacting and relating with others, moving about and manipulating objects, caring for yourself, and health and physical well-being.
  • The consultant’s consideration and some explanation or comment on the claimant’s major complaint(s) and any other abnormalities found during the history and examination or reported from the laboratory tests. The history, examination, evaluation of laboratory test results, and conclusions will represent the information provided by the consultant who signs the report.

In addition to medical records, you must fill out forms detailing the challenges you face in your daily activities. These forms offer insights into how your medical condition impacts your life and are crucial in evaluating your case. The information you provide here will be instrumental in determining the level of support you may receive.

Your Hearing Testimony

Some cases may proceed to a hearing before an administrative law judge. During this process, you will be questioned not only about your medical issues but also about the limitations you experience due to your condition. Your testimony holds significant weight in the judge’s decision-making process and can significantly influence the outcome of your case.

Other Supporting Evidence

While medical records and personal testimonies are pivotal, additional evidence can further strengthen your case. This may include forms completed throughout the application process, letters of support from friends, family, or peers, and relevant school records. While these pieces of evidence may be considered smaller in scope, they can provide valuable insights into your situation and bolster your overall claim.

Information from other sources may also help show how much an individual’s impairment(s) affects their ability to function in a work setting or, in the case of a child, the ability to function compared to that of children the same age who do not have impairments. Other sources of supporting evidence include public and private agencies, non‑medical sources such as caregivers, social workers, and employers, and other practitioners such as naturopaths, chiropractors, and audiologists.

Submitting Evidence To Social Security

Submit the Evidence As Early in the Appeal Process as Possible

According to 20 CFR §§ 404.935 and 416.1435, Social Security Disability claimants should submit additional evidence for their claim with the Request for Hearing or within ten (10) days of submitting the request. Therefore, you should review your file and submit evidence as early in the hearing process as possible. Do not wait until the case is scheduled for a hearing to submit evidence. The hearing office is constantly screening cases for potential “on the record” decisions, and updated evidence will help identify cases that may be reversed without needing a hearing.

Do Not Submit Duplicate Records or Evidence That Is Already in the Record

According to Social Security, this is a big one: DO NOT SUBMIT DUPLICATIVE EVIDENCE or medical records that have already been provided. Social Security must constantly deal with this problematic and time-consuming issue at the hearing level. Hearing offices often spend several hours on any given claim sorting out duplicative evidence. This can significantly delay the preparation of a claim for hearing. Avoid submitting evidence that is already in the record.

Do You Need Help Proving Your Social Security Disability Claim?

Ortiz Law Firm can assist in completing your application and proving your Social Security Disability claim by gathering strong medical evidence, including reports from your doctors and specialists. The experienced legal team at Ortiz Law Firm will guide you through the appeals process if your initial claim is denied, representing you in hearings and advocating for your rights. With Ortiz Law Firm on your side, you can trust that your case will be handled efficiently and effectively, giving you the best chance of success in obtaining the benefits you deserve. Call (888) 321-8131 for a free case evaluation.

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