[Federal Register Volume 61, Number 128 (Tuesday, July 2, 1996)]
[Notices]
[Pages 34489-34492]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 96-16685]
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SOCIAL SECURITY ADMINISTRATION
[Social Security Ruling (SSR) 96-2p.]
Titles II and XVI: Giving Controlling Weight To Treating Source
Medical Opinions
AGENCY: Social Security Administration.
ACTION: Notice of Social Security Ruling.
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SUMMARY: In accordance with 20 CFR 422.406(b)(1), the Commissioner of
Social Security gives notice of Social Security Ruling 96-2p. This
Ruling explains terms used in the Social Security Administration
regulations on evaluating medical opinions concerning when treating
source medical opinions are entitled to controlling weight, and
clarifies how the policy is applied.
EFFECTIVE DATE: July 2, 1996.
FOR FURTHER INFORMATION CONTACT: Joanne K. Castello, Division of
Regulations and Rulings, Social Security Administration, 6401 Security
Boulevard, Baltimore, MD 21235, (410) 965-1711.
SUPPLEMENTARY INFORMATION: Although we are not required to do so
pursuant to 5 U.S.C. 552 (a)(1) and (a)(2), we are publishing this
Social Security Ruling in accordance with 20 CFR 422.406(b)(1).
Social Security Rulings make available to the public precedential
decisions relating to the Federal old-age, survivors, disability,
supplemental security income, and black lung benefits programs. Social
Security Rulings may be based on case decisions made at all
administrative levels of adjudication, Federal court decisions,
Commissioner's decisions, opinions of the Office of the General
Counsel, and other policy interpretations of the law and regulations.
Although Social Security Rulings do not have the force and effect
of the law or regulations, they are binding on all components of the
Social Security Administration, in accordance with 20 CFR
422.406(b)(1), and are to be relied upon as precedents in adjudicating
cases.
If this Social Security Ruling is later superseded, modified, or
rescinded, we will publish a notice in the Federal Register to that
effect.
(Catalog of Federal Domestic Assistance, Programs 96.001 Social
Security--Disability Insurance; 96.002 Social Security--Retirement
Insurance; 96.004 Social Security--Survivors Insurance; 96.005
Special Benefits for Disabled Coal Miners; 96.006 Supplemental
Security Income)
Dated: June 7, 1995.
Shirley S. Chater,
Commissioner of Social Security.
Policy Interpretation Ruling
Titles II and XVI: Giving Controlling Weight To Treating Source Medical
Opinions
Purpose: To explain terms used in our regulations on evaluating
medical opinions concerning when treating source medical opinions are
entitled to controlling weight, and to clarify how the policy is
applied. In particular, to emphasize that:
1. A case cannot be decided in reliance on a medical opinion
without some reasonable support for the opinion.
2. Controlling weight may be given only in appropriate
circumstances to medical opinions, i.e., opinions on the issue(s) of
the nature and severity of an individual's impairment(s), from treating
sources.
3. Controlling weight may not be given to a treating source's
medical opinion unless the opinion is well-supported by medically
acceptable clinical and laboratory diagnostic techniques.
4. Even if a treating source's medical opinion is well-supported,
controlling weight may not be given to the opinion unless it also is
``not inconsistent'' with the other substantial evidence in the case
record.
5. The judgment whether a treating source's medical opinion is
well-supported and not inconsistent with the other substantial evidence
in the case record requires an understanding of the clinical signs and
laboratory findings and what they signify.
6. If a treating source's medical opinion is well-supported and not
inconsistent with the other substantial evidence in the case record, it
must be given controlling weight; i.e., it must be adopted.
7. A finding that a treating source's medical opinion is not
entitled to controlling weight does not mean that the opinion is
rejected. It may still be entitled to deference and be adopted by the
adjudicator.
Citations (Authority): Sections 205(a), 216(i), 223(d), 1614(a)(3),
and 1631(d) of the Social Security Act, as amended; Regulations No. 4,
sections 404.1502 and 404.1527, and Regulations No. 16, sections
416.902 and 416.927.
Pertinent History: Our regulations at 20 CFR 404.1502, 404.1527,
416.902, and 416.927 were revised on August 1, 1991, to define who we
consider to be a ``treating source'' and to set out detailed rules for
evaluating treating source medical opinions and other opinions. Among
the provisions of these rules is a special provision in 20 CFR
404.1527(d)(2) and 416.927(d)(2) that requires adjudicators to adopt
treating source medical opinions (i.e., opinions on the issue(s) of the
nature and severity of an individual's impairment(s)) in one narrowly
defined circumstance. As we stated in the preamble to the publication
of the final rules:
The provision recognizes the deference to which a treating
source's medical opinion should be entitled. It does not permit us
to substitute our own judgment for the opinion of a treating source
on the issue(s) of the nature and severity of an impairment when the
treating source has offered a medical opinion that is well-supported
by medically acceptable clinical and laboratory diagnostic
techniques and is not inconsistent with other substantial evidence.
56 FR 36932, 36936 (1991).
Policy Interpretation: Explanation of Terms
Controlling weight. This is the term used in 20 CFR 404.1527(d)(2)
and 416.927(d)(2) to describe the weight we give to a medical opinion
from a treating source that must be adopted. The rule on controlling
weight applies when all of the following are present:
1. The opinion must come from a ``treating source,'' as defined in
20 CFR 404.1502 and 416.902. Although opinions from other acceptable
medical sources may be entitled to great weight, and may even be
entitled to more weight than a treating source's opinion in appropriate
circumstances, opinions from sources other than treating sources can
never be entitled to ``controlling weight.''
2. The opinion must be a ``medical opinion.'' Under 20 CFR
404.1527(a) and 416.927(a), ``medical opinions'' are opinions about the
nature and severity of an individual's impairment(s) and are the only
opinions that may be entitled to controlling weight. (See SSR 96-5p,
``Titles II and XVI: Medical Source Opinions on Issues Reserved to the
Commissioner.'')
3. The adjudicator must find that the treating source's medical
opinion is ``well-supported'' by ``medically acceptable'' clinical and
laboratory diagnostic techniques. The adjudicator cannot decide a case
in reliance on a medical opinion without some reasonable support for
the opinion.
4. Even if well-supported by medically acceptable clinical and
laboratory diagnostic techniques, the treating source's medical opinion
also must be ``not inconsistent'' with the other ``substantial
evidence'' in the individual's case record.
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If any of the above factors is not satisfied, a treating source's
opinion cannot be entitled to controlling weight. It is an error to
give an opinion controlling weight simply because it is the opinion of
a treating source if it is not well-supported by medically acceptable
clinical and laboratory diagnostic techniques or if it is inconsistent
with the other substantial evidence in the case record. However, when
all of the factors are satisfied, the adjudicator must adopt a treating
source's medical opinion irrespective of any finding he or she would
have made in the absence of the medical opinion.
For a medical opinion to be well-supported by medically acceptable
clinical and laboratory diagnostic techniques, it is not necessary that
the opinion be fully supported by such evidence. Whether a medical
opinion is well-supported will depend on the facts of each case. It is
a judgment that adjudicators must make based on the extent to which the
opinion is supported by medically acceptable clinical and laboratory
diagnostic techniques and requires an understanding of the clinical
signs and laboratory findings in the case record and what they signify.
It is not unusual for a single treating source to provide medical
opinions about several issues; for example, at least one diagnosis, a
prognosis, and an opinion about what the individual can still do.
Although it is not necessary in every case to evaluate each treating
source medical opinion separately, adjudicators must always be aware
that one or more of the opinions may be controlling while others may
not. Adjudicators must use judgment based on the facts of each case in
determining whether, and the extent to which, it is necessary to
address separately each medical opinion from a single source.
Medically acceptable. This term means that the clinical and
laboratory diagnostic techniques that the medical source uses are in
accordance with the medical standards that are generally accepted
within the medical community as the appropriate techniques to establish
the existence and severity of an impairment. The requirement that
controlling weight can be given to a treating source medical opinion
only if it is well-supported by medically acceptable clinical and
laboratory diagnostic techniques helps to ensure that there is a sound
medical basis for the opinion.
Not inconsistent. This is a term used to indicate that a well-
supported treating source medical opinion need not be supported
directly by all of the other evidence (i.e., it does not have to be
consistent with all the other evidence) as long as there is no other
substantial evidence in the case record that contradicts or conflicts
with the opinion.
Whether a medical opinion is ``not inconsistent'' with the other
substantial evidence is a judgment that adjudicators must make in each
case. Sometimes, there will be an obvious inconsistency between the
opinion and the other substantial evidence; for example, when a
treating source's report contains an opinion that the individual is
significantly limited in the ability to do work-related activities, but
the opinion is inconsistent with the statements of the individual's
spouse about the individual's actual activities, or when two medical
sources provide inconsistent medical opinions about the same issue. At
other times, the inconsistency will be less obvious and require
knowledge about, or insight into, what the evidence means. In this
regard, it is especially important to have an understanding of the
clinical signs and laboratory findings and any treatment provided to
determine whether there is an inconsistency between this evidence and
medical opinions about such issues as diagnosis, prognosis (for
example, when deciding whether an impairment is expected to last for 12
months), or functional effects. Because the evidence is in medical, not
lay, terms and information about these issues may be implied rather
than stated, such an inconsistency may not be evident without an
understanding of what the clinical signs and laboratory findings
signify.
Substantial evidence. This term describes a quality of evidence.
Substantial evidence is ``* * * 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),
SSR 71-53c, C.E. 1971-1975, p. 418.) The term is intended to have this
same meaning in 20 CFR 404.1527(d)(2) and 416.927(d)(2). It is intended
to indicate that the evidence that is inconsistent with the opinion
need not prove by a preponderance that the opinion is wrong. It need
only be such relevant evidence as a reasonable mind would accept as
adequate to support a conclusion that is contrary to the conclusion
expressed in the medical opinion.
Depending upon the facts of a given case, any kind of medical or
nonmedical evidence can potentially satisfy the substantial evidence
test. For example, a treating source's medical opinion on what an
individual can still do despite his or her impairment(s) will not be
entitled to controlling weight if substantial, nonmedical evidence
shows that the individual's actual activities are greater than those
provided in the treating source's opinion. The converse is also true:
Substantial evidence may demonstrate that an individual's ability to
function may be less than what is indicated in a treating source's
opinion, in which case the opinion will also not be entitled to
controlling weight.
When a Treating Source's Medical Opinion Is Not Entitled to Controlling
Weight
Adjudicators must remember that a finding that a treating source
medical opinion is not well-supported by medically acceptable clinical
and laboratory diagnostic techniques or is inconsistent with the other
substantial evidence in the case record means only that the opinion is
not entitled to ``controlling weight,'' not that the opinion should be
rejected. Treating source medical opinions are still entitled to
deference and must be weighed using all of the factors provided in 20
CFR 404.1527 and 416.927. In many cases, a treating source's medical
opinion will be entitled to the greatest weight and should be adopted,
even if it does not meet the test for controlling weight.
Also, in some instances, additional development required by a
case--for example, to obtain more evidence or to clarify reported
clinical signs or laboratory findings--may provide the requisite
support for a treating source's medical opinion that at first appeared
to be lacking or may reconcile what at first appeared to be an
inconsistency between a treating source's medical opinion and the other
substantial evidence in the case record. In such instances, the
treating source's medical opinion will become controlling if, after
such development, the opinion meets the test for controlling weight.
Conversely, the additional development may show that the treating
source's medical opinion is not well-supported by medically acceptable
clinical and laboratory diagnostic techniques or may create an
inconsistency between the medical opinion and the other substantial
evidence in the case record, even though the medical opinion at first
appeared to meet the test for controlling weight. Ordinarily,
development should not be undertaken for the purpose of determining
whether a treating source's medical opinion should receive controlling
weight if the case record is otherwise adequately developed. However,
in cases at the administrative law judge (ALJ) or Appeals Council (AC)
level, the ALJ or the AC may need to
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consult a medical expert to gain more insight into what the clinical
signs and laboratory findings signify in order to decide whether a
medical opinion is well-supported or whether it is not inconsistent
with other substantial evidence in the case record.
Explanation of the Weight Given to a Treating Source's Medical Opinion
Paragraph (d)(2) of 20 CFR 404.1527 and 416.927 requires that the
adjudicator will always give good reasons in the notice of the
determination or decision for the weight given to a treating source's
medical opinion(s), i.e., an opinion(s) on the nature and severity of
an individual's impairment(s). Therefore:
When the determination or decision:
--Is not fully favorable, e.g., is a denial; or
--is fully favorable based in part on a treating source's medical
opinion, e.g., when the adjudicator adopts a treating source's opinion
about the individual's remaining ability to function;
the notice of the determination or decision must contain specific
reasons for the weight given to the treating source's medical opinion,
supported by the evidence in the case record, and must be sufficiently
specific to make clear to any subsequent reviewers the weight the
adjudicator gave to the treating source's medical opinion and the
reasons for that weight.
When the determination or decision is fully favorable and
would be even without consideration of a treating source's medical
opinion, the notice of the determination or decision must contain an
explanation of the weight given to the treating source's medical
opinion. This explanation may be brief.
Effective Date: This Ruling is effective on July 2, 1996.
Cross-References: SSR 96-5p, ``Titles II and XVI: Medical Source
Opinions on Issues Reserved to the Commissioner;'' Program Operations
Manual System, sections DI 22505.001, and DI 24515.001-24515.003;
Hearings, Appeals, and Litigation Law manual, sections I-2-530, I-2-
532, I-2-534, I-2-539, I-2-540, I-2-825, I-3-111, I-3-712, I-3-812, and
Temporary Instruction 5-310.
[FR Doc. 96-16685 Filed 7-1-96; 8:45 am]
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