Medical Opinions on Issues Reserved for the Commissioner in SSDI & SSI
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Medical Opinions on Issues Reserved for the Commissioner in SSDI and SSI Cases

by Melvin Cook

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SSR 96-5 Summary and Commentary

Medical opinions are very important in social security disability cases, especially those from doctors who have a treating relationship with the claimant. Sometimes these opinions are even entitled to controlling weight.

However, medical opinions (even from a treating doctor) on issues reserved to the Commissioner of Social Security are never entitled to special significance or controlling weight.

This is not to say that such opinions can be ignored; far from it. But, to give them controlling weight or special significance would tend to invade the province of the Commissioner, whose responsibility it is to make disability determinations (obviously, of necessity, the Commissioner must act through agency adjudicators, such as Administrative Law Judges, of which there are currently 1,445 nationwide).

In effect, such opinions are not considered “medical” opinions. As I discussed in a prior post, treating source opinions regarding the nature and severity of a person’s impairments, such as diagnoses, prognoses, and what a person can still do despite his or her impairments, are entitled to special significance and sometimes even controlling weight.

The issues reserved to the Commissioner, however, are a different matter. They are administrative findings that are outcome determinative to a case. They are such things as:

  1.  Whether the person’s impairment(s) meets or is equivalent to the requirements in any of social security’s listings of impairments;
  2.  What a person’s residual functional capacity (RFC ) is;
  3.  Whether a person’s RFC prevents him or her from doing prior relevant work (work done in the past fifteen years prior to adjudication);
  4.  How the vocational factors of age, education and work experience apply; and
  5.  Whether a person is “disabled” under the definition of the Act.

Whether or not a person meets a listing is a question of medical fact more than opinion. It is primarily a matter of documentation and whether the medical documentation meets the criteria for a listing. If a treating source medical opinion also states that the person meets a listing, the adjudicator will generally agree with this opinion because it is well-documented by medical facts. But such an opinion is not per se entitled to any special significant. The ultimate decision on disability must be made by the adjudicator.

The same thing applies in determining whether or not a person’s impairment is equivalent in severity to one of the listings. This is a decision governed by the legal standard of severity and social security rules and regulations. Someone familiar with those rules and regulations must make the decision.

There are two types of assessments about what a person can still do despite his or her impairments. One is a medical source statement from a doctor regarding the person’s physical or mental abilities to do work-related activities on a sustained basis. This may encompass more than one opinion, and each must be considered on its own merits. So, for example, a treating source may offer an opinion on how much the person can lift or carry, how long they can stand, sit or walk, etc. Each of these must be considered and weighed individually considering all of the evidence of record.

The other assessment is an administrative finding known as a residual functional capacity assessment, or RFC assessment. This is an adjudicator’s finding about the ability of an individual to do work-related activities. It must be made considering all of the evidence in the file, including medical source opinions, statements of the individual about what her or she can still do despite his or her impairments, statements from third parties about the person’s apparent symptoms and all other relevant evidence in the file.

Sometimes medical sources will offer an opinion on what category of work a person can still do, such as “sedentary”, “light”, or “medium.” But adjudicators must not assume that the medical professional is aware of the agency’s definitions of these different categories of work.

A treating source opinion stating that a person is “disabled” is never entitled to controlling weight or given any special significance. This is an area reserved to the Commissioner. However, such opinions can never be disregarded.

State Agency Medical and Psychological Consultants are adjudicators at the initial and reconsideration levels of disability determination. However, their findings become expert opinion evidence at the Administrative Law Judge and Appeals Council levels of adjudication. Their findings regarding a person’s RFC or whether or not they meet or equal a listing are weighed as expert opinions according the the agency’s rules and regulations.

If a treating doctor offers an opinion on an issue reserved to the Commissioner and the adjudicator cannot ascertain the basis for that opinion, they must make every reasonable effort to recontact the treating source to obtain an explanation for the basis of their decision.

Although treating source opinions on issues reserved to the Commissioner are never entitled to controlling weight, the adjudicator must consider them and explain in his or her opinion the consideration given to such opinions.

In my opinion, it is difficult to underestimate the importance in disability cases of expert medical opinions from treating sources on the nature and severity of a person’s condition. These sources know the person and their functionality the best. However, their opinions on issues reserved to the Commissioner are not entitled to controlling weight or special significance just because they are treating sources.

So, opinions on the nature and severity of a person’s condition from a treating doctor seem to be the most important kind of evidence, other than the medical records themselves.

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.

Contact a Salt Lake City Attorney Committed to Protecting Your Rights

When it comes the family law and social security disability, each client and case is different. It is also important to select an attorney with the experience, skills and professionalism required to address your legal issues. To learn more, contact the Salt Lake City law offices of Melvin A. Cook and schedule an initial consultation to discuss your case.

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