How Important Are Medical Records And Specialist Opinion In A Disability Claim?

by | Published on Dec 29, 2021 | Healthcare /Disability Insurance

Medical records are most important when it comes to winning a disability claim or getting a disability application granted by the Social Security Administration (SSA). That is what makes medical record review for social security disability firms a very important consideration. The medical evidence required can be physical exam and treatment notes, bloodwork results, mental health records, and imaging studies such as X-rays, MRI and CAT scans. Typically, if the applicant submits accurate, timely and sufficient medical evidence from the treating physicians and healthcare facilities, the SSA will not need to seek additional medical evidence. This in turn translates to getting a speedy determination on the applicant’s disability claim. So, disability attorneys always focus on gathering and presenting all of the medical evidence necessary to get the claim approved.

In this post, we will look at the importance of medical records first and then go on to discuss the significance of specialist opinion in a disability case. As a medical claims review firm assisting social security disability attorneys, we review the following types of medical records.

  • Medical records of historical visits that contain clinical examinations and physicians’ notes
  • Records related to prescribed treatments
  • Imaging studies and lab tests
  • Surgical notes, records of hospital visits, emergency room visits
  • Pharmacy records showing the list of prescriptions
  • Physical/mental functional capacity reports
  • Medical records related to specific tests prescribed for specific disabilities

When a claimant first applies for benefits, he/she has to include a copy of their medical records along with the application. While it is a fact that the state agency Disability Determination Services (DDS) collects the disability claimant’s medical records, the problem is that they may not collect all the relevant records which may be important to the claim.

The SSA looks for the following features in the claimant’s medical records:

  • Timeliness: The medical records must be relevant to the claimant’s present medical condition. They must be up-to-date and not older than 6 months. However, older records that are relevant to the claim are also important.
  • Accuracy: The medical records must accurately describe the claimant’s condition according to acceptable medical sources’ standards. As a article points out, a chiropractor can describe slippage or subluxation of the spine on X-rays but this will not be considered accurate if an acceptable medical source reports normal X-rays. The SSA does not consider chiropractors as medical doctors and so the chiropractor’s records and notes are not considered as evidence. Nevertheless, the X-rays taken by a chiropractor are admissible as evidence. Similarly, a medical opinion that cannot be substantiated by objective evidence may not be considered accurate.
  • Adequacy: The medical records must contain sufficient accurate information from accepted medical sources. For instance, in the case of a cancer diagnosis, the SSA will want to look at the biopsy results, the location of the tumor in the body, medical records showing symptoms, physical examination records, blood test results, imaging studies, surgical records, treatments such as chemotherapy provided, side effects, radiation therapy and so on.

Coming to specialist opinion regarding the claimant’s disability, the SSA has issued new and significant changes to the disability program. According to these, the claimant’s own doctor’s opinion may not carry the weight it carried earlier, that is, before March 27, 2017 when the changes were introduced. As per the new regulations, the SSA will no longer give a specific weight to any medical opinions, including from the claimant’s own treating doctors. The SSA removed the term “treating source” from the regulations and substituted it with the term “your medical source.”

A claim adjudicator can however, consider a claimant’s own medical providers’ medical opinion to be the most persuasive if it is supported by objective medical evidence, the treating doctors’ explanation, and is consistent with other evidence presented.

As per the old rules, the SSA gave special weight to the claimant’s treating sources. The new regulations allow the SSA to consider the persuasiveness of opinions from all medical sources, and not assign special weight to any one source. To determine persuasiveness of the evidence, the SSA would consider factors such as supportability, consistency, relationship with the claimant, specialization, and other related aspects.

A claimant’s medical records should show the progress of the medical condition over time. There should be clear evidence regarding when the conditions became disabling. The records should also have documentation of the claimant’s reported symptoms and their severity. Objective test results such as X-rays, EMGs, MRIs, CT scans and bloodwork should substantiate the disability and its impact. The medical records should clearly highlight the claimant’s restrictions and functional capacity.

As providers of medical record review for social security disability firms, we understand that medical opinions that are best supported by the medical records will carry more weight.

Discover our medical record review solutions and partner with us for your next case.

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