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Medical evidence and winning a SSDI claim

Most disability applicants have no idea how the Social Security Administration (SSA) makes their disability determination. The claimant may assume that when they cannot work anymore they simply file their Social Security Disability Insurance (SSDI) application and send it to the SSA and wait for the money to start rolling in.

When their application is denied, however, they are even more incredulous to find that not only do they have to an appeal to challenge the denial, waiting months or years to be approved, but they may also have to hire a disability lawyer to help win benefits they believe are rightfully theirs.

Recently on our disability forum a user asked, “I have not been able to get medical care from my own doctor, but when I applied for SSDI they sent me to a consultative examination. I’ve heard that this may not help my claim. What do you think?” disability-legal-help Getting great medical care and medical evidence to prove that your condition is severe, it will last 12 continuous months, and has eliminated your functional ability to work is the most important thing you can do to increase your chances of winning benefits.

Unfortunately, going to a consultative examination does not always provide the necessary medical evidence.

Medical Evidence and winning your SSDI claim


Before discussing the negatives of a consultative examination, let’s first look at what medical evidence the SSA needs. First, it’s important to understand that the SSA makes their disability determination based almost entirely on the medical information provided to them by your treating sources.

Specifically, the SSA will review physician examinations and treatment notes, mental health records, lab results, and imaging studies including MRI, CAT scan, and X-rays.  The medical evidence should also be relevant for your condition.

For example, if you state that you have a severe back injury, the SSA would expect for you to have an MRI documenting your injury.

Next, the SSA will need recent medical information. If you do not have medical evidence about your condition within the last six months it may be time to get more up to date medical records.

Finally, the SSA will need enough information to make an independent medical judgment about your diagnosis, prognosis, and limitations to work. It is also best if the information provides historical evidence about your condition.

Consultative Examination and gathering more medical evidence


Given the high cost of medical care, many claimants have not received proper medical care for their condition. For this reason many claimants do not have sufficient information for the SSA to make a disability determination.

For example, if you have been diagnosed with arthritis, the SSA needs information about your diseased joints, x-rays, and range of motion tests. Unfortunately, what they may find when they review your medical files is nothing related to arthritis or a few scribbled notes documenting your treatment plan. If the SSA does not find enough information about your condition (assuming you meet the nonmedical requirements for SSDI) they will send you to a consultative examiner.

What is a consultative examination?

A consultative examination is a short cursory medical examination provided by a consultative examiner. Although this can be your primary care doctor, it could simply be a doctor that the SSA has contracted to perform this examination.

The consultative examiner (C.E.) will perform a short examination and provide medical evidence to the SSA concerning your condition. Although the medical statements from your primary care doctor are supposed to carry the most weight when the SSA is evaluating your condition, if you do not have a primary care doctor or they have not provided any information the SSA will have to rely solely on the information provided by the C.E.

Bottom Line: A consultative examination may not provide enough medical evidence that you are disabled.

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