In social security disability and SSI cases, it is very important for a claimant or his or her representative to solicit and obtain medical opinions from at least one treating doctor. This is because the person’s treating doctor or doctors, especially ones they have been seeing for a long time, are often in the best position to fully understand the nature and severity of the person’s medical conditions. These treating source opinions, if reasonably supported by the objective medical evidence, are almost always entitled to deference by adjudicators.
In fact, under certain defined circumstances, a treating doctor’s opinions are entitled to controlling weight. These circumstances are set forth in Social Security Ruling 96-2p. (I always wondered what the “p” on the end of these rulings stands for — I think it is “policy”, but don’t take that to the bank).
An opinion from a treating doctor regarding the nature and severity of an individual’s impairment(s) is entitled to controlling weight if it is well-supported by “medically acceptable” clinical and laboratory diagnostic techniques and is not inconsistent with other substantial evidence in the record.
So, let’s break this down. First of all, the opinion must come from a treating source, which is further defined in the regulations, in other words, it must come from a physician who has established a reasonably regular treating relationship with the individual. The treating source must be an “acceptable medical source”, that is, a medical doctor (MD), doctor of osteopathic medicine (DO), or psychologist with a PhD. Social Security is nothing if not traditional in its view of the practice of medicine. Opinions from other medical sources, such as chiropractors, nurse practitioners, licensed social workers, therapists, physician’s assistants and so forth must be considered and are oftentimes entitled to great weight where they are consistent with the evidence as a whole. Sometimes these opinions even trump those from acceptable medical sources, if they are better supported by the evidence, but they are not entitled to controlling weight.
It is understood that a treating source may offer more than one medical opinion about the same individual. For example, there may be a diagnosis, a prognosis, a statement about the severity of the condition as it affects that particular individual, and a statement about what the person can still do despite his or her impairments. Each of these opinions must be assessed in its own right to determine if it should be given controlling weight.
Next, the opinion must be apropos the nature and severity of the person’s impairments. As described above, this would include such things as diagnoses, prognoses, and an opinion on what the person can still do despite his or her impairments. Certain issues, such as the ultimate determination of whether the person is disabled, are reserved to the Commissioner of Social Security (who must, of necessity, act through agents such as Administrative Law Judges). Thus, a bare statement, such as “this individual is disabled”, even if it comes from a treating source, is not particularly helpful, as that issue is ultimately an administrative decision. Similarly, an opinion from a treating source regarding specific vocational information is not always particularly enlightening, as the medical source presumably is not a vocational specialist.
The adjudicator must understand what medically acceptable laboratory and diagnostic techniques signify. Sometimes in difficult cases, the adjudicator, whether an Administrative Law Judge or Appeals Council Judge, may determine to consult a medical expert to assist in deciding whether an opinion is well-supported by generally accepted clinical and laboratory diagnostic techniques.
The reason for the requirement that an opinion be well-supported by objective findings in order to be given controlling seems clear; namely, to ensure that there is a reasonable medical basis for a decision. Simply put, an unsupported opinion cannot be given controlling weight.
Finally, the opinion must be “not inconsistent” with other substantial evidence in the record. This does not mean that the opinion must be supported by all of the evidence in the record. Remember, the opinion must simply be well-supported by the generally acceptable objective medical evidence. But the opinion cannot be inconsistent with other substantial evidence if it is to be given controlling weight. Substantial evidence is defined as “more than a mere scintilla … It means such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.” Richardson v. Perales, 402 U.S. 389 (1971).
Thus, if a treating source is inconsistent with other substantial medical or non-medical evidence, it cannot be given controlling weight. So, for example, if a treating source opinion assigns functional limitations that are clearly inconsistent with the individual’s activities as reported by his or her spouse, it cannot be given controlling weight. Likewise if there are inconsistent medical opinions from different sources, these opinions would not be given controlling weight. Sometimes the other inconsistent substantial evidence may even show the individual to be more limited than what the treating source states. In either case, whether the other inconsistent evidence shows the person to be more limited or less limited than the treating source states, the inconsistency of such substantial other evidence removes the treating source opinion from the realm of controlling weight.
If, however, the treating source opinion is well-supported by generally acceptable clinical and laboratory techniques and is not inconsistent with the other medical evidence, it must be given controlling weight, regardless of what the adjudicator may otherwise think. In other words, if the standard for controlling weight is met, the adjudicator may not substitute his or her own judgment about the medical facts for those of the well-supported treating source (something that appellate courts have derisively referred to as “playing doctor”).
It is vitally important to note that even if the standard for controlling weight is not met, the treating source opinion may nevertheless be entitled to great weighht and should often be adopted by the adjudicator. This is again because of the unique position a treating source has in understanding their own patient’s condition.
To sum it up, opinions from treating doctors are, in my opinion, the gold standard in proving an SSDI or SSI case. The opinions are not per se entitled to controlling weight, but they are entitled to such weight if they are well-supported by the objective medical evidence and not inconsistent with other substantial evidence in the record. If they do not strictly meet the test for controlling weight, they still must be weighed and considered, and are often entitled to great deference if well-supported by objective medical evidence.
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.