In a claim for Social Security disability benefits (SDD), medical evidence is the main player. There is a long list of what is considered medical evidence: physician examinations and treatment notes, mental health records, laboratory testing, imagining studies including MRIs, CT scans, X-rays, etc. The bottom line is simple; in order to win your SSD case, you need to have some sort of medical treatment documenting your condition and/or limitations.
Your medical evidence should be timely.
The Social Security Administration (SSA) only considers medical records relevant to your current medical condition as well as those obtained within a certain time period. If you are suffering from bipolar disorder and it was first diagnosed 30 years ago, Social Security will only consider your mental health records for the current time period. They will not go through your “entire” medical history. Typically, they will consider medical records one year prior to your alleged onset date.
Your records should be accurate.
This means, your treating physician should use standards of acceptable medical sources. Also, the records from your physician should be in line with the objective evidence in your case.
You need to have sufficient medical records.
Your records should contain enough information from an acceptable medical source that allows SSA to make a decision regarding the nature and severity of your condition. An acceptable medical source is typically a licensed physician, licensed psychologist, licensed optometrist, licensed podiatrist, or qualified speech-language pathologist. Social Security will give the greatest weight to medical evidence from an acceptable medical source. This is not to say they will not consider medical evidence from another source, but those sources may not be given as much significance as those that are considered authoritative.
Other sources include records from nurse practitioners, chiropractors and therapists. Whether your treating physician is an acceptable medical source or not, Social Security will evaluate the weight of those records based on the length of treatment and how consistent the medical opinion is with the rest of the file. They will also factor in whether or not the source is a specialist as well as other aspects that tend to support or contradict the opinion.
The best medical records are those that are typed, note the patients’ complaints, show the results of any examination, and present a diagnosis and/or plan. Many treating physicians handwrite their medical records, and oftentimes they are illegible. Thus, those records will not be evaluated.
If you are having difficulty obtaining medical treatment but think you have a condition that prevents you from working, call a knowledgeable attorney who can discuss your situation with you. If you qualify for SSD benefits, the attorney will help you obtain the necessary medical treatment to win your case.