The Social Security Administration, or SSA, considers medical findings, treatment records, diagnostic testing, medical opinions, symptoms, and other evidence when deciding whether someone meets the requirements for Social Security Disability Insurance (SSDI). When reviewing an SSDI claim, Social Security looks for medical evidence that establishes an impairment and shows how that condition affects a person’s ability to function.
A diagnosis alone is not enough. Good medical records do more than identify a condition. They show how the condition developed, what treatment has been tried, how the condition has responded to treatment, and what physical or mental limitations remain.
SSA generally develops a claimant’s medical history for at least the 12 months prior to the month that the application is filed, under Title 20 Code of Federal Regulations (CFR) § 404.1512(b)(1). The agency may need to develop an earlier or different period when the circumstances require it. This 12-month medical-history rule does not mean a claimant must have exactly 12 months of treatment before applying.
What Medical Evidence Does Social Security Consider?
SSA considers several types of evidence when reviewing an SSDI claim. The evidence that matters most will depend on the medical condition and the questions SSA needs answered about it.
Treatment Records and Clinical Findings
Treatment records can show the history and progression of a medical condition. They may come from primary care doctors, specialists, hospitals, therapists, rehabilitation providers, and other medical sources. These records can include physical examinations, clinical findings, diagnoses, treatment notes, medication histories, surgical records, therapy notes, and information about treatment response.
A series of records can tell a much clearer story than a single appointment because it may show whether symptoms and limitations continued over time. For example, records documenting recurring back pain, restricted range of motion, medication changes, physical therapy, and ongoing work restrictions may provide more useful information than a single record that simply lists back pain as a diagnosis.
Diagnostic Tests and Objective Findings
Objective medical evidence includes medical signs and laboratory findings. Under 20 CFR § 404.1521, SSA requires objective medical evidence from an acceptable medical source to establish the existence of a medically determinable physical or mental impairment.
The relevant testing depends on the condition. It may include imaging studies, laboratory tests, pulmonary or cardiac testing, neurological findings, physical examination results, or other medically appropriate testing. For example, an MRI may document structural changes related to a spinal condition, while laboratory testing may help establish certain systemic diseases. Mental health claims may involve clinical observations, mental status findings, treatment records, and other evidence appropriate to the condition.
A test result does not automatically establish disability. SSA looks at the findings along with the rest of the record to determine the severity and functional effects of the impairment.
Medical Opinions About Functional Limitations
Medical opinions can help explain what a person can still do despite a medical impairment. An opinion may address physical abilities such as sitting, standing, walking, lifting, carrying, reaching, or handling objects. It may also address mental abilities such as understanding, remembering, concentrating, following instructions, maintaining pace, responding to supervision, or interacting with others.
Specific limitations generally provide more useful information than a brief statement that someone is “disabled” or “unable to work.” For example, a medical source might explain how long a person can sit before needing to change positions, whether frequent breaks are necessary, or whether symptoms interfere with concentration.
For claims filed on or after March 27, 2017, 20 CFR § 404.1520c(a), (c)(1)-(2) provides that SSA does not automatically give greater weight to an opinion simply because it comes from a treating physician. Instead, SSA considers the supportability and consistency of the opinion as the most important factors, along with other applicable factors such as specialization and the relationship with the claimant.
Symptoms and Medication Side Effects
Symptoms such as pain, fatigue, dizziness, or shortness of breath can’t establish an impairment on their own. Once objective evidence shows a medically determinable impairment, though, SSA looks at how intense and persistent the symptoms are and how much they limit the person’s ability to work. Under 20 CFR § 404.1529(c)(3), the factors SSA considers include how often symptoms occur and how severe they are, what brings them on or makes them worse, and the type, dosage, effectiveness, and side effects of any medication.
Side effects are easy to overlook, but they can matter. A medication that controls pain may also cause drowsiness or slowed thinking. Those limitations won’t show up in a diagnosis or a test result, yet they can affect whether someone can stay alert and on task through a workday.
SSA also won’t reject a person’s statements about their symptoms just because the objective findings don’t fully back them up (§ 404.1529(c)(2)). That’s why it helps when treatment notes record reported symptoms and side effects over time.
How Does Social Security Use Medical Evidence in an SSDI Decision?
Medical evidence is considered throughout SSA’s disability evaluation process. First, SSA determines whether the claimant has a medically determinable impairment established by objective medical evidence from an acceptable medical source. A diagnosis, symptom statement, or medical opinion alone does not establish the existence of that impairment. Records are examined to see how a condition developed, how it has responded to treatment, and what limitations remain.
SSA then considers whether the impairment is severe and whether it meets or medically equals the requirements of a condition in the Listing of Impairments. A diagnosis by itself cannot satisfy a Listing. The evidence must meet the applicable medical criteria and the duration requirement under 20 CFR § 404.1509. Unless an impairment is expected to result in death, SSA generally requires it to have lasted or be expected to last for a continuous period of at least 12 months.
If the impairment does not meet or medically equal a Listing, SSA evaluates the claimant’s residual functional capacity, commonly called RFC. RFC describes what a person can still do despite medically established impairments and related symptoms. It can include physical abilities, mental abilities, environmental restrictions, and other work-related functions.
What Should Medical Evidence Show in an SSDI Claim?
The medical record should give SSA enough information to evaluate the impairment and how it affects functioning. Different parts of the record can help establish that picture.
The medical condition should be documented. Objective findings from appropriate medical sources help establish that a medically determinable impairment exists.
The severity should be documented. Examination findings, testing, treatment notes, and other medical evidence can show how significantly the impairment affects functioning.
The duration should be supported. Records from different points in time can help show whether the condition lasted, or is expected to last, for the required period.
Functional limitations should be described. Evidence about sitting, standing, walking, lifting, using the hands, concentrating, following instructions, interacting with others, or adapting to workplace conditions can help SSA evaluate RFC.
Treatment and response should be documented. Records showing medications, therapy, surgery, rehabilitation, specialist treatment, and the results or side effects of those treatments can put the medical condition in context.
A statement that someone cannot work does not necessarily answer the questions SSA must decide. More specific information about what the person can and cannot do can be more useful when SSA evaluates functional capacity.
SSA also considers evidence from nonmedical sources, including information about daily activities and functioning. That evidence can supplement the medical record, but it does not replace the objective medical evidence required to establish a medically determinable impairment.
What If Medical Evidence Is Missing or Conflicting?
Medical records may contain gaps in treatment, different descriptions of functional abilities, limited objective findings, or incomplete information about the period when disability is alleged to have begun. Missing or conflicting medical evidence does not automatically end an SSDI claim, but it may leave questions that SSA needs to resolve. SSA considers the evidence as a whole when addressing these issues.
When the existing evidence is not sufficient to make a disability determination, SSA may seek additional information. In appropriate cases, the agency may require a claimant to attend a consultative examination at SSA’s expense. A consultative examination is used to obtain additional medical information when the existing evidence does not provide enough information for SSA to decide. A consultative examination does not replace a person’s regular medical care. Records from doctors, specialists, hospitals, therapists, and other medical sources can remain important parts of the disability record. The goal is to give SSA enough information to evaluate the medically determinable impairment, its severity and duration, and its effect on the claimant’s ability to function.
What Happens to Medical Evidence After an SSDI Denial?
Updated medical evidence can become important after an SSDI claim is denied. A claimant may have received additional treatment, undergone new testing, received another diagnosis, or experienced changes in symptoms since the original decision. After an initial denial, a claimant can request reconsideration. If reconsideration results in another unfavorable determination, the claimant can request a hearing before an Administrative Law Judge, or ALJ.
A request for an ALJ hearing generally must be filed within 60 days after the claimant receives notice of the reconsideration determination or decision, under 20 CFR § 404.933(b)(1). SSA presumes that the notice was received five days after the date shown on the notice unless a later receipt date is established, under 20 CFR § 404.901. SSA may extend the deadline when good cause is shown.
There is also a separate deadline for evidence at the hearing stage. Under 20 CFR § 404.935(a)-(b), claimants generally must inform SSA about or submit written evidence no later than five business days before the scheduled hearing. An ALJ may decline to consider late evidence unless an applicable exception exists. The principal exceptions include situations where SSA’s actions misled the claimant; where a physical, mental, educational, or linguistic limitation prevented earlier submission; or an unusual, unexpected, or unavoidable circumstance beyond the claimant’s control prevented timely submission. SSA also considers situations such as serious illness of the claimant, a death or serious illness in the immediate family, damaged records, or medical records that were diligently requested but not received until shortly before the hearing.
Medical offices can take time to provide records, so waiting until shortly before a hearing to request updated evidence can create avoidable problems.
How Bailey & Galyen Can Help With an SSDI Claim
An SSDI claim may involve records from several doctors, specialists, hospitals, therapists, and testing facilities, and pulling those records together while identifying gaps can be difficult, especially while dealing with an ongoing medical condition. Bailey & Galyen helps individuals and families understand the Social Security disability process and the role medical evidence can play in a claim, including reviewing medical records, identifying missing documentation, and connecting medical findings and functional limitations to how SSA evaluates a claim through its Social Security Disability practice. If you have questions about the medical evidence in your SSDI claim, Call Bailey & Galyen to schedule a free consultation, or contact the firm online.
Hablamos español en nuestra oficina.
Bailey & Galyen – Solving Your Legal Puzzle®
