[Federal Register Volume 61, Number 128 (Tuesday, July 2, 1996)]
[Notices]
[Pages 34471-34474]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 96-16688]
-----------------------------------------------------------------------
SOCIAL SECURITY ADMINISTRATION
Social Security Ruling (SSR) 96-5p. Titles II and XVI: Medical
Source Opinions on Issues Reserved to the Commissioner
AGENCY: Social Security Administration.
ACTION: Notice of Social Security Ruling.
-----------------------------------------------------------------------
SUMMARY: In accordance with 20 CFR 422.406(b)(1), the Commissioner of
Social Security gives notice of Social Security Ruling 96-5p. This
Ruling clarifies Social Security Administration policy on how we
consider medical source opinions on issues reserved to the Commissioner
of Social Security, including whether an individual's impairment(s)
meets or is equivalent in severity to the requirements of any
impairment(s) in the Listing of Impairments in appendix l, subpart P of
20 CFR part 404 of the Social Security Administration regulations; what
an individual's residual functional capacity is; whether an
individual's residual functional capacity prevents him or her from
performing past relevant work; how the vocational factors of age,
education, and work experience apply; and whether an individual is
``disabled'' under the Social Security Act.
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.)
[[Page 34472]]
Dated: June 7, 1996.
Shirley S. Chater,
Commissioner of Social Security.
Policy Interpretation Ruling
Titles II and XVI: Medical Source Opinions on Issues Reserved to the
Commissioner
Purpose: To clarify Social Security Administration (SSA) policy on
how we consider medical source opinions on issues reserved to the
Commissioner, including whether an individual's impairment(s) meets or
is equivalent in severity to the requirements of any impairment(s) in
the Listing of Impairments in appendix 1, subpart P of 20 CFR part 404
(the listings); what an individual's residual functional capacity (RFC)
is; whether an individual's RFC prevents him or her from doing past
relevant work; how the vocational factors of age, education, and work
experience apply; and whether an individual is ``disabled'' under the
Social Security Act (the Act). In particular, to emphasize:
1. The difference between issues reserved to the Commissioner and
medical opinions.
2. That treating source opinions on issues reserved to the
Commissioner are never entitled to controlling weight or special
significance.
3. That opinions from any medical source about issues reserved to
the Commissioner must never be ignored, and that the notice of the
determination or decision must explain the consideration given to the
treating source's opinion(s).
4. The difference between the opinion called a ``medical source
statement'' and the administrative finding called a ``residual
functional capacity assessment.''
Citations (Authority): Sections 205(a) and (b)(1), 216(i),
221(a)(1) and (g), 223(d), 1614(a), 1631(c)(1) and (d)(1), and 1633 of
the Social Security Act, as amended; Regulations No. 4, sections
404.1503, 404.1504, 404.1512, 404.1513, 404.1520, 404.1526, 404.1527,
and 404.1546; Regulations No. 16, sections 416.903, 416.904, 416.912,
416.913, 416.920, 416.924, 416.924d, 416.926, 416.926a, 416.927, and
416.946.
Introduction: 1 On August 1, 1991, SSA published regulations
at 20 CFR 404.1527 and 416.927 that set out rules for evaluating
medical opinions. The regulations provide general guidance for
evaluating all evidence in a case record and provide detailed rules for
evaluating medical opinion evidence. They explain the significance
given to medical opinions from treating sources on the nature and
severity of an individual's impairment(s). They also set out factors
used to weigh opinions from all types of medical sources, including
treating sources, other examining sources, and nonexamining physicians,
psychologists, and other medical sources. In addition, the regulations
provide that the final responsibility for deciding certain issues, such
as whether an individual is disabled under the Act, is reserved to the
Secretary of Health and Human Services (the Secretary).
---------------------------------------------------------------------------
\1\ Note: For clarity, the following discussions refer only to
claims of individuals claiming disability benefits under title II
and individuals age 18 or older claiming disability benefits under
title XVI. However, the same principles regarding medical source
opinions apply in determining disability for individuals under age
18 claiming disability benefits under title XVI. Therefore, it
should be understood that references in this Ruling to the ability
to do gainful activity, RFC, and other terms and rules that are
applicable only to title II disability claims and title XVI
disability claims of individuals age 18 or older, are also intended
to refer to appropriate terms and rules applicable in determining
disability for individuals under age 18 under title XVI.
---------------------------------------------------------------------------
On March 31, 1995, SSA became an independent agency under Public
Law 103-296. As a result of this legislative change, the Commissioner
of Social Security (the Commissioner) replaced the Secretary as the
official responsible for making determinations of disability under
titles II and XVI of the Act.
Policy Interpretation: The regulations at 20 CFR 404.1527(a) and
416.927(a) define medical opinions as ``statements from physicians and
psychologists or other acceptable medical sources that reflect
judgments about the nature and severity of your impairment(s),
including your symptoms, diagnosis and prognosis, what you can still do
despite impairment(s), and your physical or mental restrictions.'' The
regulations recognize that treating sources are important sources of
medical evidence and expert testimony, and that their opinions about
the nature and severity of an individual's impairment(s) are entitled
to special significance; sometimes the medical opinions of treating
sources are entitled to controlling weight. Paragraphs (b), (c), (d),
and (f) of 20 CFR 404,1527 and 416.927 explain how we weigh treating
source and other medical source opinions. (See, also, SSR 96-2p,
``Titles II and XVI: Giving Controlling Weight to Treating Source
Medical Opinions,'' and 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.'')
Under 20 CFR 404.1527(e) and 416.927(e), some issues are not
medical issues regarding the nature and severity of an individual's
impairment(s) but are administrative findings that are dispositive of a
case; i.e., that would direct the determination or decision of
disability. The following are examples of such issues:
1. Whether an individual's impairment(s) meets or is equivalent in
severity to the requirements of any impairment(s) in the listings;
2. What an individual's RFC is;
3. Whether an individual's RFC prevents him or her from doing past
relevant work;
4. How the vocational factors of age, education, and work
experience apply; and
5. Whether an individual is ``disabled'' under the Act.
The regulations provide that the final responsibility for deciding
issues such as these is reserved to the Commissioner.
Nevertheless, our rules provide that adjudicators must always
carefully consider medical source opinions about any issue, including
opinions about issues that are reserved to the Commissioner. For
treating sources, the rules also require that we make every reasonable
effort to recontact such sources for clarification when they provide
opinions on issues reserved to the Commissioner and the bases for such
opinions are not clear to us.
However, treating source opinions on issues that are reserved to
the Commissioner are never entitled to controlling weight or special
significance. Giving controlling weight to such opinions would, in
effect, confer upon the treating source the authority to make the
determination or decision about whether an individual is under a
disability, and thus would be an abdication of the Commissioner's
statutory responsibility to determine whether an individual is
disabled.
However, opinions from any medical source on issues reserved to the
Commissioner must never be ignored. The adjudicator is required to
evaluate all evidence in the case record that may have a bearing on the
determination or decision of disability, including opinions from
medical sources about issues reserved to the Commissioner. If the case
record contains an opinion from a medical source on an issue reserved
to the Commissioner, the adjudicator must evaluate all the evidence in
the case record to determine the extent to which the opinion is
supported by the record.
[[Page 34473]]
In evaluating the opinions of medical sources on issues reserved to
the Commissioner, the adjudicator must apply the applicable factors in
20 CFR 404.1527(d) and 416.927(d). For example, it would be appropriate
to consider the supportability of the opinion and its consistency with
the record as a whole at the administrative law judge and Appeals
Council levels in evaluating an opinion about the claimant's ability to
function which is from a State agency medical or psychological
consultant who has based the opinion on the entire record (see Findings
of State Agency Medical and Psychological Consultants, below). However,
pursuant to paragraph (e)(2) of 20 CFR 404.1527 and 416.927, the
adjudicator is precluded from giving any special significance to the
source; e.g., giving a treating source's opinion controlling weight,
when weighing these opinions on issues reserved to the Commissioner.
The following discussions provide additional policy interpretations
and procedures for evaluating opinions on issues reserved to the
Commissioner.
Opinions About Whether an Individual's Impairment Meets the
Requirements of a Listed Impairment
Whether the findings for an individual's impairment meet the
requirements of an impairment in the listings is usually more a
question of medical fact than a question of medical opinion. Many of
the criteria in the listings relate to the nature and severity of
impairments; e.g., diagnosis, prognosis and, for those listings that
include such criteria, symptoms and functional limitations. In most
instances, the requirements of listed impairments are objective, and
whether an individual's impairment manifests these requirements is
simply a matter of documentation. To the extent that a treating source
is usually the best source of this documentation, the adjudicator looks
to the treating source for medical evidence with which he or she can
determine whether an individual's impairment meets a listing. When a
treating source provides medical evidence that demonstrates that an
individual has an impairment that meets a listing, and the treating
source offers an opinion that is consistent with this evidence, the
adjudicator's administrative finding about whether the individual's
impairment(s) meets the requirements of a listing will generally agree
with the treating source's opinion. Nevertheless, the issue of meeting
the requirements of a listing is still an issue ultimately reserved to
the Commissioner.
Opinions on Whether an Individual's Impairment(s) Is Equivalent in
Severity to the Requirements of a Listed Impairment
In 20 CFR 404.1526 and 416.926, equivalence is addressed as a
``decision * * * on medical evidence only'' because this finding does
not consider the vocational factors of age, education, and work
experience. A finding of equivalence involves more than findings about
the nature and severity of medical impairments. It also requires a
judgment that the medical findings equal a level of severity set forth
in 20 CFR 404.1525(a) and 416.925(a); i.e., that the impairment(s) is
``* * * severe enough to prevent a person from doing any gainful
activity.'' This finding requires familiarity with the regulations and
the legal standard of severity set forth in 20 CFR 404.1525(a),
404.1526, 416.925(a), and 416.926. Therefore, it is an issue reserved
to the Commissioner.2
---------------------------------------------------------------------------
\2\ See the section below entitled ``Findings of State Agency
Medical and Psychological Consultants'' for an explanation of how
administrative law judges and the Appeals Council must evaluate
State agency medical and psychological consultant findings about
equivalence. See also 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.''
---------------------------------------------------------------------------
Residual Functional Capacity Assessments and Medical Source Statements
The regulations describe two distinct kinds of assessments of what
an individual can do despite the presence of a severe impairment(s).
The first is described in 20 CFR 404.1513(b) and (c) and 416.913(b) and
(c) as a ``statement about what you can still do despite your
impairment(s)'' made by an individual's medical source and based on
that source's own medical findings. This ``medical source statement''
is an opinion submitted by a medical source as part of a medical
report. The second category of assessments is the RFC assessment
described in 20 CFR 404.1545, 404.1546, 416.945, and 416.946 which is
the adjudicator's ultimate finding of ``what you can still do despite
your limitations.'' Even though the adjudicator's RFC assessment may
adopt the opinions in a medical source statement, they are not the same
thing: A medical source statement is evidence that is submitted to SSA
by an individual's medical source reflecting the source's opinion based
on his or her own knowledge, while an RFC assessment is the
adjudicator's ultimate finding based on a consideration of this opinion
and all the other evidence in the case record about what an individual
can do despite his or her impairment(s).
Medical Source Statement
Medical source statements are medical opinions submitted by
acceptable medical sources 3, including treating sources and
consultative examiners, about what an individual can still do despite a
severe impairment(s), in particular about an individual's physical or
mental abilities to perform work-related activities on a sustained
basis. Adjudicators are generally required to request that acceptable
medical sources provide these statements with their medical reports.
Medical source statements are to be based on the medical sources'
records and examination of the individual; i.e., their personal
knowledge of the individual. Therefore, because there will frequently
be medical and other evidence in the case record that will not be known
to a particular medical source, a medical source statement may provide
an incomplete picture of the individual's abilities.
---------------------------------------------------------------------------
\3\ The term ``acceptable medical sources'' is defined in 20 CFR
404.1513(a) and 416.913(a).
---------------------------------------------------------------------------
Medical source statements submitted by treating sources provide
medical opinions which are entitled to special significance and may be
entitled to controlling weight on issues concerning the nature and
severity of an individual's impairment(s). Adjudicators must remember,
however, that medical source statements may actually comprise separate
medical opinions regarding diverse physical and mental functions, such
as walking, lifting, seeing, and remembering instructions, and that it
may be necessary to decide whether to adopt or not adopt each one.
RFC Assessment
The term ``residual functional capacity assessment'' describes an
adjudicator's finding about the ability of an individual to perform
work-related activities. The assessment is based upon consideration of
all relevant evidence in the case record, including medical evidence
and relevant nonmedical evidence, such as observations of lay witnesses
of an individual's apparent symptomatology, an individual's own
statement of what he or she is able or unable to do, and many other
factors that could help the adjudicator determine the most reasonable
findings in light of all the evidence.
[[Page 34474]]
Medical Source Statement vs. RFC Assessment
A medical source's statement about what an individual can still do
is medical opinion evidence that an adjudicator must consider together
with all of the other relevant evidence (including other medical source
statements that may be in the case record) when assessing an
individual's RFC. Although an adjudicator may decide to adopt all of
the opinions expressed in a medical source statement, a medical source
statement must not be equated with the administrative finding known as
the RFC assessment. Adjudicators must weigh medical source statements
under the rules set out in 20 CFR 404.1527 and 416.927, providing
appropriate explanations for accepting or rejecting such opinions.
From time-to-time, medical sources may provide opinions that an
individual is limited to ``sedentary work,'' ``sedentary activity,''
``light work,'' or similar statements that appear to use the terms set
out in our regulations and Rulings to describe exertional levels of
maximum sustained work capability. Adjudicators must not assume that a
medical source using terms such as ``sedentary'' and ``light'' is aware
of our definitions of these terms. The judgment regarding the extent to
which an individual is able to perform exertional ranges of work goes
beyond medical judgment regarding what an individual can still do and
is a finding that may be dispositive of the issue of disability.
At steps 4 and 5 of the sequential evaluation process in 20 CFR
404.1520 and 416.920, the adjudicator's assessment of an individual's
RFC may be the most critical finding contributing to the final
determination or decision about disability. Although the overall RFC
assessment is an administrative finding on an issue reserved to the
Commissioner, the adjudicator must nevertheless adopt in that
assessment any treating source medical opinion (i.e., opinion on the
nature and severity of the individual's impairment(s)) to which the
adjudicator has given controlling weight under the rules in 20 CFR
404.1527(d)(2) and 416.927(d)(2).
Opinions on Whether an Individual Is Disabled
Medical sources often offer opinions about whether an individual
who has applied for title II or title XVI disability benefits is
``disabled'' or ``unable to work,'' or make similar statements of
opinions. In addition, they sometimes offer opinions in other work-
related terms; for example, about an individual's ability to do past
relevant work or any other type of work. Because these are
administrative findings that may determine whether an individual is
disabled, they are reserved to the Commissioner. Such opinions on these
issues must not be disregarded. However, even when offered by a
treating source, they can never be entitled to controlling weight or
given special significance.
Findings of State Agency Medical and Psychological Consultants
Medical and psychological consultants in the State agencies are
adjudicators at the initial and reconsideration determination levels
(except in disability hearings--see 20 CFR 404.914 ff. and 416.1414
ff.). As such, they do not express opinions; they make findings of fact
that become part of the determination. However, 20 CFR 404.1527(f) and
416.927(f) provide that, at the administrative law judge and Appeals
Council levels of the administrative review process, medical and
psychological consultant findings about the nature and severity of an
individual's impairment(s), including any RFC assessments, become
opinion evidence. Adjudicators at these levels, including
administrative law judges and the Appeals Council, must consider these
opinions as expert opinion evidence of nonexamining physicians and
psychologists and must address the opinions in their decisions. In
addition, under 20 CFR 404.1526 and 416.926, adjudicators at the
administrative law judge and Appeals Council levels must consider and
address State agency medical or psychological consultant findings
regarding equivalence to a listed impairment.
At the administrative law judge and Appeals Council levels,
adjudicators must evaluate opinion evidence from medical or
psychological consultants using all of the applicable rules in 20 CFR
404.1527 and 416.927 to determine the weight to be given to the
opinion. For additional detail regarding these policies and policy
interpretations, see 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.''
Requirements for Recontacting Treating Sources
Because treating source evidence (including opinion evidence) is
important, if the evidence does not support a treating source's opinion
on any issue reserved to the Commissioner and the adjudicator cannot
ascertain the basis of the opinion from the case record, the
adjudicator must make ``every reasonable effort'' to recontact the
source for clarification of the reasons for the opinion.
Explanation of the Consideration Given to a Treating Source's Opinion
Treating source opinions on issues reserved to the Commissioner
will never be given controlling weight. However, the notice of the
determination or decision must explain the consideration given to the
treating source's opinion(s).
Effective Date: This Ruling is effective on the date of its
publication in the Federal Register.
Cross-References: 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,'' SSR 96-2p,
``Titles II and XVI: Giving Controlling Weight to Treating Source
Medical Opinions;'' and Program Operations Manual System, section DI
24515.010.
[FR Doc. 96-16688 Filed 7-1-96; 8:45 am]
BILLING CODE 4190-29-P
