[Federal Register Volume 61, Number 128 (Tuesday, July 2, 1996)]
[Notices]
[Pages 34466-34468]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 96-16689]
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SOCIAL SECURITY ADMINISTRATION
Social Security Ruling (SSR) 96-6p. Titles II and XVI:
Consideration of Administrative Findings of Fact by State Agency
Medical and Psychological Consultants and Other Program Physicians and
Psychologists at the Administrative Law Judge and Appeals Council
Levels of Administrative Review; Medical Equivalence
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 SSR 96-6p. This
Ruling clarifies Social Security Administration policy regarding the
consideration of findings of fact by State agency medical and
psychological consultants and other program physicians and
psychologists by adjudicators at the administrative law judge and
Appeals Council levels. Also, the Ruling restores to the Rulings and
clarifies policy interpretations regarding administrative law judge and
Appeals Council responsibility for obtaining opinions of physicians or
psychologists designated by the Commissioner of Social Security
regarding equivalence to listings in the Listing of Impairments
(appendix 1, subpart P of 20 CFR part 404) formerly in SSR 83-19,
``Titles II and XVI: Finding Disability on the Basis of Medical
Considerations Alone--The Listing of Impairments and Medical
Equivalency.'' SSR 83-19 was rescinded without replacement by SSR 91-7c
(C.E. 1990-1991, p. 92) as a result of the Supreme Court's decision in
Sullivan v. Zebley, 493 U.S. 521 (1990), which invalidated the use of a
medical ``listings only'' approach to evaluating disability claims of
individuals under 18 years of age under the supplemental security
income program. That decision has no bearing on the aspects of SSR 83-
19 that we are restoring in this Ruling.
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
[[Page 34467]]
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, 1996.
Shirley S. Chater,
Commissioner of Social Security.
Policy Interpretation Ruling--Titles II and XVI: Consideration of
Administrative Findings of Fact by State Agency Medical and
Psychological Consultants and Other Program Physicians and
Psychologists at the Administrative Law Judge and Appeals Council
Levels of Administrative Review; Medical Equivalence
Purpose: To clarify Social Security Administration policy regarding
the consideration of findings of fact by State agency medical and
psychological consultants and other program physicians and
psychologists by adjudicators at the administrative law judge and
Appeals Council levels. Also, to restore to the Rulings and clarify
policy interpretations regarding administrative law judge and Appeals
Council responsibility for obtaining opinions of physicians or
psychologists designated by the Commissioner regarding equivalence to
listings in the Listing of Impairments (appendix 1, subpart P of 20 CFR
part 404) formerly in SSR 83-19. In particular, to emphasize the
following longstanding policies and policy interpretations:
1. Findings of fact made by State agency medical and psychological
consultants and other program physicians and psychologists regarding
the nature and severity of an individual's impairment(s) must be
treated as expert opinion evidence of nonexamining sources at the
administrative law judge and Appeals Council levels of administrative
review.
2. Administrative law judges and the Appeals Council may not ignore
these opinions and must explain the weight given to these opinions in
their decisions.
3. An updated medical expert opinion must be obtained by the
administrative law judge or the Appeals Council before a decision of
disability based on medical equivalence can be made.
Citations (Authority): Sections 216(i), 223(d) and 1614(a) of the
Social Security Act (the Act), as amended; Regulations No. 4, sections
404.1502, 404.1512(b)(6), 404.1526, 404.1527, and 404.1546; and
Regulations No. 16, sections 416.902, 416.912(b)(6), 416.926, 416.927,
and 416.946.
Introduction: Regulations 20 CFR 404.1527 and 416.927 set forth
detailed rules for evaluating medical opinions about an individual's
impairment(s) offered by medical sources \1\ and the medical opinions
of State agency medical and psychological consultants and other
nonexamining sources. Paragraph (a) of these regulations provides that
``medical opinions'' are statements from physicians and psychologists
or other acceptable medical sources that reflect judgments about the
nature and severity of an individual's impairment(s), including
symptoms, diagnosis and prognosis, what the individual can still do
despite his or her impairment(s), and the individual's physical or
mental restrictions. Paragraph (b) provides that, in deciding whether
an individual is disabled, the adjudicator will always consider the
medical opinions in the case record together with the rest of the
relevant evidence. Paragraphs (c), (d), and (e) then provide general
rules for evaluating the record, with particular attention to medical
and other opinions from acceptable medical sources.
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\1\ ``Medical sources'' are defined in 20 CFR 404.1502 and
416.902 as ``treating sources,'' ``sources of record'' (i.e.,
medical sources that have provided an individual with medical
treatment or evaluation, but do not have or did not have an ongoing
treatment relationship with the individual), and ``consultative
examiners'' for the Social Security Administration.
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Paragraph (f) provides that findings of fact made by State agency
medical and psychological consultants and other program physicians and
psychologists become opinions at the administrative law judge and
Appeals Council levels of administrative review and requires
administrative law judges and the Appeals Council to consider and
evaluate these opinions when making a decision in a particular case.
State agency medical and psychological consultants are highly
qualified physicians and psychologists who are experts in the
evaluation of the medical issues in disability claims under the Act. As
members of the teams that make determinations of disability at the
initial and reconsideration levels of the administrative review process
(except in disability hearings), they consider the medical evidence in
disability cases and make findings of fact on the medical issues,
including, but not limited to, the existence and severity of an
individual's impairment(s), the existence and severity of an
individual's symptoms, whether the individual's impairment(s) meets or
is equivalent in severity to the requirements for any impairment listed
in 20 CFR part 404, subpart P, appendix 1 (the Listing of Impairments),
and the individual's residual functional capacity (RFC).
Policy Interpretation: Because State agency medical and
psychological consultants and other program physicians and
psychologists are experts in the Social Security disability programs,
the rules in 20 CFR 404.1527(f) and 416.927(f) require administrative
law judges and the Appeals Council to consider their findings of fact
about the nature and severity of an individual's impairment(s) as
opinions of nonexamining physicians and psychologists. Administrative
law judges and the Appeals Council are not bound by findings made by
State agency or other program physicians and psychologists, but they
may not ignore these opinions and must explain the weight given to the
opinions in their decisions.
Paragraphs 404.1527(f) and 416.927(f) provide that the rules for
considering medical and other opinions of treating sources and other
sources in paragraphs (a) through (e) also apply when we consider the
medical opinions of nonexamining sources, including State agency
medical and psychological consultants and other program physicians and
psychologists. The regulations provide progressively more rigorous
tests for weighing opinions as the ties between the source of the
opinion and the individual become weaker. For example, the opinions of
physicians or psychologists who do not have a treatment relationship
with the individual are weighed by stricter standards, based to a
greater degree on medical evidence, qualifications, and explanations
for the opinions, than are required of treating sources.
For this reason, the opinions of State agency medical and
psychological consultants and other program physicians and
psychologists can be given weight only insofar as they are supported by
evidence in the case record, considering such factors as the
supportability of the opinion in the evidence including any evidence
received at the administrative law judge and Appeals Council levels
that was not before the State agency, the consistency of the opinion
with the record as a
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whole, including other medical opinions, and any explanation for the
opinion provided by the State agency medical or psychological
consultant or other program physician or psychologist. The adjudicator
must also consider all other factors that could have a bearing on the
weight to which an opinion is entitled, including any specialization of
the State agency medical or psychological consultant.
In appropriate circumstances, opinions from State agency medical
and psychological consultants and other program physicians and
psychologists may be entitled to greater weight than the opinions of
treating or examining sources. For example, the opinion of a State
agency medical or psychological consultant or other program physician
or psychologist may be entitled to greater weight than a treating
source's medical opinion if the State agency medical or phychological
consultant's opinion is based on a review of a complete case record
that includes a medical report from a specialist in the individual's
particular impairment which provides more detailed and comprehensive
information than what was available to the individual's treating
source.
The following additional guidelines apply at the administrative law
judge and Appeals Council levels to opinions about equivalence to a
listing in the Listing of Impairments and RFC assessments, issues that
are reserved to the Commissioner in 20 CFR 404.1527(e) and 416.927(e).
(See also SSR 96-5p, ``Titles II and XVI: Medical Source Opinions on
Issues Reserved to the Commissioner.'')
Medical Equivalence to an Impairment in the Listing of Impairments.
The administrative law judge or Appeals Council is responsible for
deciding the ultimate legal question whether a listing is met or
equaled. As trier of the facts, an administrative law judge or the
Appeals Council is not bound by a finding by a State agency medical or
psychological consultant or other program physician or psychologist as
to whether an individual's impairment(s) is equivalent in severity to
any impairment in the Listing of Impairments. However, longstanding
policy requires that the judgment of a physician (or psychologist)
designated by the Commissioner on the issue of equivalence on the
evidence before the administrative law judge or the Appeals Council
must be received into the record as expert opinion evidence and given
appropriate weight.
The signature of a State agency medical or psychological consultant
on an SSA-831-U5 (Disability Determination and Transmittal Form) or
SSA-832-U5 or SSA-833-U5 (Cessation or Continuance of Disability or
Blindness) ensures that consideration by a physician (or psychologist)
designated by the Commissioner has been given to the question of
medical equivalence at the initial and reconsideration levels of
administrative review. Other documents, including the Psychiatric
Review Technique Form and various other documents on which medical and
psychological consultants may record their findings, may also ensure
that this opinion has been obtained at the first two levels of
administrative review.
When an administrative law judge or the Appeals Council finds that
an individual's impairment(s) is not equivalent in severity to any
listing, the requirement to receive expert opinion evidence into the
record may be satisfied by any of the foregoing documents signed by a
State agency medical or psychological consultant. However, an
administrative law judge and the Appeals Council must obtain an updated
medical opinion from a medical expert 2 in the following
circumstances:
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\2\ The term ``medical expert'' is being used to refer to the
source of expert medical opinion designated as a ``medical advisor''
in 20 CFR 404.1512(b)(6), 404.1527(f), 416.912(b)(6), and
416.927(f). This term is being used because it describes the role of
the ``medical expert'' as an expert witness rather than an advisor
in the course of an administrative law judge hearing.
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When no additional medical evidence is received, but in
the opinion of the administrative law judge or the Appeals Council the
symptoms, signs, and laboratory findings reported in the case record
suggest that a judgment of equivalence may be reasonable; or When
additional medical evidence is received that in the opinion of the
administrative law judge or the Appeals Council may change the State
agency medical or psychological consultant's finding that the
impairment(s) is not equivalent in severity to any impairment in the
Listing of Impairments.
When an updated medical judgment as to medical equivalence is
required at the administrative law judge level in either of the
circumstances above, the administrative law judge must call on a
medical expert. When an updated medical judgment as to medical
equivalence is required at the Appeals Council level in either of the
circumstances above, the Appeals Council must call on the services of
its medical support staff.
Assessment of RFC
Although the administrative law judge and the Appeals Council are
responsible for assessing an individual's RFC at their respective
levels of administrative review, the administrative law judge or
Appeals Council must consider and evaluate any assessment of the
individual's RFC by a State agency medical or psychological consultant
and by other program physicians or psychologists. At the administrative
law judge and Appeals Council levels, RFC assessments by State agency
medical or psychological consultants or other program physicians or
psychologists are to be considered and addressed in the decision as
medical opinions from nonexamining sources about what the individual
can still do despite his or her impairment(s). Again, they are to be
evaluated considering all of the factors set out in the regulations for
considering opinion evidence.
Effective Date: This Ruling is effective on the date of its
publication in the Federal Register.
Cross-References: SSR 96-5p, ``Titles II and XVI: Medical Source
Opinions on Issues Reserved to the Commissioner;'' Program Operations
Manual System, section DI 24515.007; and Hearings, Appeals, and
Litigation Law Manual, section I-5-310.
[FR Doc. 96-16689 Filed 7-1-96; 8:45 am]
BILLING CODE 4190-29-P