Social Security Ruling (SSR) 96-6p sets forth Social Security’s policy for evaluating the findings and conclusions of state agency consultants at the administrative hearing and Appeals Council levels of adjudication.
At the initial and reconsideration levels of a social security disability claim, there are medical and psychological consultants who are deemed to be experts in evaluating social security disability claims. These consultants do a review of the entire medical file and render findings of fact at the initial and reconsideration levels of determination. They are part of a team of state agency adjudicators who make decisions at these levels of administrative decision making.
These consultants render findings of fact regarding a disability claimant’s medical impairments, such as diagnoses, prognoses, the nature and severity of a claimant’s symptoms, the nature and extent of a claimant’s work-related medical limitations, whether or not a claimant’s impairment(s), either singly or in combination, meet or equal one of Social Security’s listed impairments, and the claimant’s residual functional capacity (RFC), or the maximum amount of work-like activities an individual can still do despite his or her impairments. Social Security’s listings outline strict medical criteria for severe impairments of each major body system that are presumed debilitating enough to be totally disabling.
These consultants are part of a team of adjudicators at the initial and reconsideration levels of adjudication that render a decision on a claimant’s disability claim. The findings of these state agency consultants result in a decision of either “disabled” or “not disabled” at the initial and reconsideration levels of adjudication.
The signatures of these consultants on various forms, including a Disability Determination and Transmittal form (SSA 831-U5), or a Psychiatric Review Technique form, ensure that the issues of a case have been properly reviewed by expert medical consultants at the initial and reconsideration levels of adjudication.
However, at the Administrative Law Judge and Appeals Council levels of review, these findings are not binding upon adjudicators. But even though they are not binding, these findings cannot be ignored. They become opinions of acceptable medical sources that must be reviewed and weighed according to detailed criteria set forth in 20 C.F.R. § 404.1527 and § 416.927. Under these criteria, the findings of state agency medical and psychological consultants are treated as opinions from non-examining medical sources. This is because state agency consultants only do a review of records in a file and do not treat or examine a claimant.
Such opinions are not entitled to as much deference as those from a claimant’s treating medical sources, and they are weighed by stricter criteria. However, under certain circumstances, these opinions may be given more weight than the opinions of treating sources, such as when they are consistent with the medical evidence as a whole, and the treating source opinions are not.
When adjudicators at the hearing and Appeals Council levels of adjudication find that an individual’s impairment(s)j is not medically equivalent to one of the listings, the requirement to receive expert medical opinion evidence on this issue is satisfied by the state agency consultants’ findings.
However, there are two circumstances in which an Administrative Law Judge or the Appeals Council need to obtain an updated opinion from a medical expert. The first is when no new additional medical evidence is received after the initial or reconsideration decision, but the adjudicator believes that symptoms, signs, and laboratory findings in the record suggest that a finding of medical equivalence to one of the listings may be reasonable.
The second circumstance is where new medical evidence has been received which the adjudicator believes may change the finding of the state agency consultants that the claimant’s impairment(s) does not medically equal one of the listings.
In effect, this means that adjudicators at the hearing and Appeals Council levels of adjudication must obtain an updated opinion from a medical expert before a decision of medical equivalency to one of the listings can be made.
If you need help with a social security disability or Supplemental Security Income claim, please contact our office for a free evaluation of your claim. We are Social Security Disability and SSI lawyers serving all of Tooele County.
This material should not be construed as legal advice for any particular fact situation, but is intended for general informational purposes only. For advice specific to any individual situation, an experienced attorney should be contacted