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SSR 16-3p – Evaluation of Symptoms in Disability Claims Explained

Osterhout Berger Disability Law > Social Security Disability > SSR 16-3p – Evaluation of Symptoms in Disability Claims Explained

When you’re looking for a way to pay for your bills when you can’t work due to injury, illness, or another type of medical condition that makes it impossible for you to work, you might apply for disability benefits through the Social Security Administration. Knowing how the symptoms will be evaluated will help you better understand the entire process and determine what you should do to ensure your optimal chances that you’ll get the disability insurance you need. Recently, the SSR 16-3p ruling has changed the way that the SSA evaluates symptoms.

Step 1: Determining If the Individual Has an MDI

An ‘MDI’ is a medically determinable impairment. The first step of determining whether or not an individual is eligible for disability insurance through the Social Security Administration is to determine whether or not they have signs that indicate that they have a covered condition under disability insurance through the SSA. (We have a guide to many conditions here.)

The signs that the Social Security Administration is looking for can be anatomical, psychological, or physiological in nature. They also need to be signs that have been observed by medical professionals using medically acceptable clinical techniques other than the symptoms that the patient reports.

During this step, the SSA isn’t concerned with whether or not the severity of the symptoms, such as pain, are in proportion with what you might expect given the medical evidence for the specific type of condition. The SSA only cares about whether or not the type of signs are consistent with what you would expect to see for the claimed condition and whether or not that condition is in the Blue Book.

Step 2: Determining the Extent That the MDI Prevents Work

The first step of the process solely determines whether or not the applicant has a medically determinable impairment that would qualify them for disability insurance. The second step takes this further, so the SSA wants to determine whether or not the symptoms are severe enough to help them qualify for disability insurance under the Blue Book requirements.

The SSA recognizes that different individuals might experience symptoms, such as pain, to different extents. Furthermore, their experience of the symptoms might limit one person more or less than another.

When looking at the intensity, limiting effects, and duration of the symptoms, the SSA will consider everything in the case record. Additionally, the SSA will make reasonable efforts to obtain a full medical record unless they have enough information to determine that the applicant is disabled, given the amount of information that they have even if it’s not an entirely complete medical record.

Medical Sources of Evidence

Additionally, this stage is also when the SSA will look at the persistency and intensity of the symptoms as well as the degree to which they put limitations on the applicant. When looking at the medical evidence, they’re determining whether the symptoms are consistent with what could reasonably be expected to be found with the particular disease the claim is being made under. The SSA also looks at whether or not the severity is in line with what you could reasonably expect.

If an applicant was complaining of not having the ability to walk or stand but still had leg muscle tone, the objective medical evidence wouldn’t support the applicant’s claim. If the applicant had actually not been standing or walking very much, they should also have atrophied muscles upon evaluation because they had not been using them by standing and walking.

On the other hand, there are also times when the symptoms that the applicant is claiming are supported by medical evidence. For instance, muscle spasms, reduced joint motion, and motor disruption can all be observed by a clinician, and the presence of these symptoms can lend greater credence to claims of pain by the applicant.

Medical evidence isn’t the only thing that is considered during an evaluation. Medical evidence is just one factor that’s considered when the SSA is looking at a claim.

Non-Medical Sources of Evidence

If, after reviewing the medical evidence, the applicant doesn’t meet the listing favorably through objective medical evidence, then the SSA will start considering other sources of evidence, including individual applicants’ reports and reports from people that the applicant knows, such as colleagues at work, educational personnel, family, and friends. Additionally, the SSA will look at the intensity, limiting factors, and persistence of the claimant’s symptoms. For instance, the SSA will consider the types of activities that aggravate the symptoms. It will also consider any medications that the applicant is taking along with the side effects that it causes and the frequency and dose that the applicant has to take the medication.

Some of the factors that the SSA might consider when looking at any statements made by the individual include the intensity, limiting effects, and persistence of the symptoms they experience. Additionally, the SSA will consider any statements that the applicant makes directly to them or another source.

The SSA will also consider the information obtained by other non-medical sources, including colleagues, educational personnel, agency personnel, friends, and family. For instance, a colleague might have information about an incident that happened to the applicant that lends further credence to the applicant’s claims of disability.

Determining the extent to which the symptoms actually affect the person’s ability to work and do daily activities will have a process. If the symptoms are consistent with the medical evidence, then it’s fairly likely that the SSA will find that the applicant has a disability.

At this stage, the SSA will also consider the consistency of the applicant’s own statements by comparing various accounts that the applicant has made on a particular subject concerning the persistence, intensity, and effects of their symptoms. While this factor is considered, the SSA recognizes that inconsistencies in reporting don’t always indicate untruthfulness as symptoms can change over time.

The SSA also looks at the degree to which an applicant sought medical help for their condition and the degree to which they followed the course of treatment prescribed to them. There are also several factors that can play into whether or not it makes sense if the applicant chose not to follow a prescribed treatment plan. For instance, if the applicant’s religious beliefs are in contradiction to the prescribed treatment plan, this might be a reasonable reason why the applicant chose not to follow the plan despite having severe symptoms. Some other possible reasons why an applicant might choose to not seek treatment or follow the prescribed course of treatment include the applicant’s inability to pay for treatment, the applicant’s inability to understand the importance of treatment due to mental or language limitations, and medical personnel telling the patient that there are no further courses of treatment necessary or possible for them.

Five Steps of Adjudication

There are five steps of adjudication when determining whether or not someone is eligible for disability benefits through the Social Security Administration. The first step is to determine whether or not the applicant is currently doing activities that are gainful and substantial.

Step two of the adjudication process involves determining whether or not the applicant has a condition that will last at least 12 continuous months or has already lasted at least 12 months or will result in death. The condition must result in a severe impairment that has more than small implications on the ability of the adult to work. If the objective medical evidence alone establishes that the condition and symptoms are severe enough to qualify the applicant for disability benefits, that will be enough. But if it’s not, then the SSA will look at the applicant’s symptoms and functional limitations that are caused by the condition. If the applicant doesn’t have a severe medically determinable impairment, the SSA will find the applicant to not be disabled at this point. If they do meet these requirements, then they move forward to step three.

The third step is when the SSA will evaluate whether or not the symptoms are severe enough to qualify. If the symptoms are part of the evaluation process, the SSA will look at the documentation of the severity of the symptoms, but some listings don’t require an evaluation of the symptoms, so they won’t be used in every impairment evaluation.

Step four comes after the SSA determines whet residual functional capacity the applicant has and what their limitations entail. During this fourth step, the SSA looks at the applicant’s previous work history to better understand what they’re trained to do. Then, the SSA compares the job requirements as the applicant previously did them and how they’re typically done throughout the country. Then, the SSA compares them with the applicant’s residual functional capacity. If there are jobs that the person has done in the past that don’t have activities that overlap with their current limitations, then the applicant won’t be considered disabled. If the applicant is considered to be disabled at this point, they’ll continue to the next step.

The fifth and final step is where the SSA looks at whether or not there are jobs that the applicant could transition to even though they’ve never done the job in the past. During this phase, the SSA will look at the applicant’s previous work history and education to determine whether or not there are available jobs for the applicant to transfer into. The SSA will also look at the supply of these jobs.

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