Medical Evidence in SSDI claims: an overview

by | Jan 10, 2021 | Firm News

What kind of evidence do I need to win my claim?

One of the main tasks necessary to proving a Social Security claim is gathering evidence. In evaluating Social Security Disability and SSI claims, the claim mostly comes down to medical evidence. Occasionally evidence is needed for non-medical issues such as earnings or work history, but in most cases, it all comes down to medical evidence.

So, what is medical evidence? For the most part, it’s going to consist of medical records. We need to drill down further still and understand what constitutes “medical records.” Most people don’t tend to ever actually receive or possess their own medical records, at least not of the sort that the Social Security Administration considers useful. Patients themselves often receive paperwork that isn’t actually documentary medical records – things like discharge instructions and billing records. These are certainly useful papers in some contexts, but not when it comes to proving your condition in a disability claim. The government wants proof not just of the vague fact that treatment occurred, but the details of the medical providers’ findings and conclusions. This is often referred to as a “chart” or just “notes.” Lawyers call them “medical records” and doctors and hospitals generally know what lawyers are talking about when we ask them for their records. These documents serve different purposes than the billing and discharge papers given to patients routinely. Because of HIPAA, the privacy law that governs medical records, doctors are not casual with giving out copies of this stuff, so it is not routine for doctors to give copies to their patients. Unless you specifically ask for your complete records in writing and sign a release form documenting the authority to release the records, your doctor simply won’t release these notes.

These records tell the full story of your medical treatment. Every encounter with a health care provider should be documented in a certain way, identifying the names and credentials of who you interacted with, documenting their observations upon examining you and your statements about your experience of symptoms, what the provider believes is causing the problem, and what they intend to do about it, such as medical procedures or medications. Prescriptions are documented, along with the sometimes gory details of procedures like surgeries. Again, none of this is routinely given out to the patient, so people are sometimes surprised by what they see – or don’t see – when they first see their records.

Social Security wants to see these records to determine several of the key facts of your case. Your medical records will identify the diagnoses or names of the conditions that you are afflicted with. This information forms a part of the analysis at steps 2 and 3 of the sequential evaluation process under the law, determining what your “severe impairments” are and some of the conditions of meeting a medical listing. The identification of symptoms in these records, including what is reported to the provider by the patient, forms the foundation of several findings in a medical decision in a Social Security claim, primarily at step 2 and 3, but also in determining your residual functional capacity for steps 4 and 5. Understanding what treatment has been done goes toward determining your RFC as well. Finally, medical records will sometimes contain statements on what you can and cannot (or do and do not) actually do in light of your condition, such as when there are limitations to certain activities or those activities cause the onset of symptoms. That is why it is helpful to make sure you talk to your doctor about your disabling condition, at every visit, and routinely follow up with your provider, even if things seem somewhat stable. The more often you talk to your doctor, even by phone or video in the pandemic era, the more of a record there is to prove your medical condition.

Medical records also contain the results of objective tests and imaging such as x-rays and MRIs. In Social Security law, the actual images from x-rays and the like are not treated as meaningful evidence, because judges are not qualified to interpret them, and they cannot be cited in a written format. However, those examinations are always accompanied with a written note of impressions by a radiologist, who is qualified to interpret it. These findings can be considered in assessing your condition, particularly at step 3, the medical listings, where specific cookie-cutter criteria are laid out.

Finally, medical records can contain opinion statements. Medical opinions can be formed on all sorts of topics, including the question of whether a person is “disabled,” but only certain topics of opinion are considered relevant in a social security claim. Whether a person is “disabled,” believe it or not, is not one of them; in fact, the regulations say that judges are to essentially disregard doctors statements as to whether a person is disabled, except in rare cases when the doctor is considered an expert in social security law. Generally, the most useful topic of medical opinion is an opinion about what you can and cannot do in light of your impairments. Attorneys use different terms to refer to these opinions, but we will often call them an “RFC” or “Residual Functional Capacity” opinion, that being the term SSA used to describe this evidence. Unfortunately, it is relatively rare for doctors to organically state an RFC in the course of routine records, despite such evidence being so important to a disability claim. Many doctors, thinking they understand the law, try to help their patients by writing short letters saying that they are disabled, but these opinions are not useful. To deal with this deficit, most attorneys have prepared specific questionnaires covering common limitations that could keep someone from being able to work. Sometimes, though, it’s hard to capture the precise details for an individual case in a questionnaire, which is a good reason to get these opinions early in a case and leave time to get clarification later.

So there’s an overview of what constitutes medical evidence for a Social Security Disability claim, and some of the reasons it is helpful to have an experienced representative to help gather it. The process is not inherently difficult; it’s simply not a matter of common sense, and dealing with a system most people seldom interact with.