The Common Sense Medical Review:

The evaluation of a claimant’s medical evidence is an extremely important part of the Social Security disability process.  However, most individuals who enter this field have no medical training.  Many assume that if you’re not a medical professional, you cannot be an effective disability advocate.  This assumption is incorrect! 

To address this issue, Disability Associates has developed a unique method that enables a vigilant advocate to produce highly effective arguments without a background in medicine or training in medical terminology.  We call our approach the “common sense medical review.”

Look for the Relationship:

There is a common sense relationship between every medical disorder and its symptoms. You can name any serious medical disorder and determine the common symptoms caused by that disorder.  Once you identify the symptoms of a disease, you can use those symptoms to identify physical or mental limitations.  This simple action enables you to create rationale arguments for a reduced residual functional capacity.

The above example has provided you with an enormous amount of valuable information that can be used to argue for a reduced RFC for this claimant.  I want you to note that all genuine medical conditions will almost always have symptoms. If the condition is more severe, you can expect the symptoms to be more severe.  Usually, the more severe the symptom, the more restrictive the limitation caused by the symptom.  Symptoms cause limitations that can be used to reduce a person’s perceived ability to perform work.  It’s this not so subtle relationship between a diagnosis and a symptom that makes it unnecessary for an astute advocate to be a medical professional. 

In many common but serious medical conditions, it takes little more than common sense and a little bit of reading, to determine how the condition will limit the claimant.  If you keep this common sense relationship between a diagnosis and symptom in mind, you’re well on your way to becoming a successful disability advocate regardless of your background.

The Medical Evaluation:

After you have assessed, accepted and developed a case, it's time to evaluate the evidence you have obtained.  This process is called a case evaluation.  To help you to better understand the medical aspects of a case, we have provided two important tools.  The first is the Social Security Disability Guide.  This book is provided to all students regardless of training level.  The other medical tool is the Systems Explorer.  Access to the Systems Explorer is provided free with our Executive level training program.  

Evidence is the Key!

Learning to evaluate medical evidence in a disability claim is an important skill that must be mastered in order to function successfully as a disability advocate.  Many of you do not have medical backgrounds and are not familiar with medical terminology.  For this reason, this lesson has been written in a manner that assumes that you are not experienced in evaluating medical records of any type.

If you happen to be a medical professional, you’ll find this lesson to be much easier to comprehend.  Regardless of your background, this lesson is critical to your understanding of Social Security case evaluation.

Common Sense Evidence Evaluation:

When evaluating medical evidence, look at the claimant's impairment from a functional standpoint.  Note how the claimant's impairment affects his ability to function within a normal home and working environment.  Most Social Security disability decisions are based on how the claimant's symptoms affect his ability to work.  The more medically supportable signs and symptoms suffered by the claimant, the more likely he will be found disabled. 

Quality of Evidence:

The quality of supporting medical evidence is also important!  Good quality evidence addresses from the perspective of a disability advocate is any and all evidence that directly addresses the claimant’s alleged primary and secondary reasons for disability.  The date of the evidence should be no older than six months prior to the date of the Alleged Onset Date (AOD).  If possible, the evidence should show the progression and treatment of the claimant’s disorder over time, leading to the most current date. Good quality evidence should also be legible, acceptable by Social Security standards and is signed by the appropriate health professional that provided the evidence. 

Purpose for evaluating medical evidence:

The purpose for evaluating a claimant's medical evidence is to extract from the evidence specific findings that can be used as the basis to support your argument. An argument for disability must be supported by the medical evidence.  If it’s not supported by the evidence, the argument will not hold up under close analysis by the DDS examiner or the administrative law judge.  Any medical finding that makes the claimant appear functionally impaired is from the advocate's standpoint a positive finding.

Medical Evidence of Record:

Any evidence used in the evaluation of a Social Security disability claim is referred to as “Evidence of Record.”  On all application levels, medical evidence is requested or purchased by Social Security to cover all allegations made by the claimant. The process of acquiring these records is called case development.

Social Security is required to make sure that each of the claimant's alleged impairments are addressed by the medical evidence before a decision is made.  The advocate and the DDS examiner will both be involved in case development.  On the appeal levels, the majority of evidence will already have been collected by the claimant or the DDS examiner.  This would limit your request for evidence to that generated after the decision.

It is always a good idea to have the claimant acquire copies of his evidence regardless of the adjudicative level.  Both the claimant and the advocate will have greater flexibility if the claimant’s evidence is readily available.  Having the evidence on hand also allows for faster case processing.  When you take a case at the reconsideration or ALJ levels, you will also have legal access to all accumulated evidence from the initial application. The medical information gathered on the initial or reconsideration level can be used by an advocate to formulate an argument at any other adjudicative level.

Sources of Medical Evidence:

The claimant in any given case may allege disability due to a physical or mental impairment and in many cases both. There is also no limit to the number of impairments a claimant can allege.  Therefore, it is possible to have medical evidence from many different professional sources. A typical disability case may contain medical records from the claimant’s attending physician, specialist, psychologists, hospital records, surgical summaries, outpatient records, nurse’s notes, etc.  You should only request records that directly address the claimant’s primary or secondary diagnosis.  The dates of the records requested should cover the period of disability. 

Types of Medical Evidence:

A typical disability case will contain some or all of the following types of medical evidence of record.

1. Narrative reports from a medical doctor:

This is a common type of medical evidence of record that can come from many different types of physicians. This form of evidence usually provides specific information about the claimant's disease state. Often a physician may also offer his opinion as to the extent of the claimant's disability.

2. Questionnaires:

A questionnaire is a pre-developed form that is sent to the claimant or his physician by Social Security in order to extract information about a given medical or mental disorder. A questionnaire is also sent to the claimant to extract detailed information about his daily activities or to determine characteristics of a given symptom such as chest pain.

If a claimant is sent a questionnaire, you may wish to assist the claimant in filling it out. Social Security will use an activity or symptom description provided by the claimant or family member, as proof that the claimant can perform a certain level of activity. If the claimant admits to a higher level of activity than is alleged in his application, this will be used by Social Security to justify a denial of benefits.

3. Hospital Records Inpatient:

Inpatient hospital records are another common type of medical evidence. Most inpatient hospital records will contain an admission and discharge summary. This summary is useful because it will describe the claimant’s hospital stay in a couple of pages.  Sending for the summary can significantly reduce the number of pages within the claimant’s folder.  Inpatient hospital records may also contain information such as laboratory tests, pathology reports, surgical reports, special procedure reports, x-ray findings and any important events that may have occurred during the hospital stay.  Hospital records will can be one of your best sources of specific medical ammunition.

4. Hospital Reports Outpatient:

Hospital outpatient records can also be valuable to a case.  If a claimant is treated at a hospital outpatient clinic, there may be one or more clinic notes in file. These clinic notes should be treated the same as any other doctor's reports. 

5. Consultative Examinations (CE):

A consultative medical examination, lab test or any other test ordered and paid for by Social Security is referred to as a consultative examination. These examinations are only ordered when the medical evidence of record is insufficient or too old to establish the claimant's current medical status. You can use Social Security's own medical source for a consultative examination or you can use the claimant’s family doctor.  We suggest you use the claimant’s family physician if he is a strong believer in the claimant’s inability to work as a result of his impairment.  Also, if you feel that an examination is not needed in order to make a favorable decision, it is your right to point this out to SSA.  However, if Social Security orders the claimant to attend a CE, make sure he attends or the case will be denied based on the claimant’s failure to cooperate.

6. Special procedure reports:

Usually found in hospital records, these special procedure reports include test like angiography, CAT scans, biopsies, etc. These types of reports can be invaluable in arguing a case because some of them are capable of pinpointing very obscure findings that support the claimant's complaints. Any abnormal findings gleaned from these reports should be incorporated into your argument.

7. Military or VA. Hospital reports:

Information from these facilities should be treated the same as any other hospital evidence of record.  Look for the same findings in these reports as you would in any other hospital report.

8. Activities of Daily Living (ADL):

These reports are seen both in physical and mental cases, ADL are extremely important. An examiner will send out a questionnaire to a friend or relative of the claimant asking them to describe the claimant's daily activities. The purpose of this action is to see if the claimant is as restricted as claimed.  If it is determined that the claimant is not restricted as claimed via a third party report, the claim will be denied.  Social Security must accept third party reports like ADL as a means of determining the claimant's level of limitation.  If used properly, these third party reports can help you to win cases. 

9.  Chiropractic reports:

A Chiropractic report is not considered to be an acceptable form of medical evidence by Social Security.  However, this medical source should not be completely ignored.  Although no chiropractic report can be used to establish a disabling condition or be the sole basis for a final decision under SSA regulations, it can be used as supportive evidence.  The claimant’s condition will need to have been previously diagnosed by a medical doctor in order to use Chiropractic evidence.

Confidentiality of Medical Records:

As the claimant's authorized representative, you have the same right of access to case information as the claimant himself.  Federal law clearly states that all case information is to be kept strictly confidential and should not be available to anyone except those with authorized access to these materials. Even if you were to inadvertently break the confidentiality rule, Social Security could still bar you from performing as a representative.  So be careful!  Do not share information about a claimant or his case with anyone outside of your firm.  Also make sure that your staff understands and abides by Social Security’s confidentiality rules.

Extracting Key Points:

Key points are simply those findings within the body of a claimant’s medical evidence that specifically support a particular allegation or limitation.  Extracting key points from the medical evidence can be a relatively simple procedure if you follow a few rules of thumb.

A.  Consider all positive medical findings, those that make the claimant appear disabled, as potential ammunition to support your argument on behalf of the claimant.

B.  Use your common sense when choosing evidence for your argument. If the evidence does not support or strengthen your attempt to show the claimant as being totally disabled, don't use it!  Look for and use any and all restrictive symptoms documented within the medical evidence.

Examples of restrictive symptoms are:

Pain
Fatigue
Dizziness and Vertigo
Loss of physical coordination
Inability to ambulate
Blurred vision
Muscular weakness
Memory loss
Lack of concentration
Inability to interact with others.
Extreme hostility

Individually or collectively, the above symptoms may support a more restricted RFC, improving your chances of winning the case.

C.   Don't hesitate to use doctor's quotes that support your argument or conclusions. Example: Dr. Good states that the claimant should not be on his feet for more than an hour a day as a result of his impairment. Statements like this are powerful tools for restricting the claimant's RFC.

D.   Pay close attention to the dates of the medical evidence.  Try to avoid evidence that is not related to the claimant’s primary or secondary conditions unless the additional impairment causes additional physical or mental limitations.  You want to review all available evidence that is relevant for the time period claimed as the period of disability by the claimant. Unless there is a DLI in the past, you should always try to acquire medical reports from the onset date to the present. The term “present” is defined as evidence dated within three months of the date of the current disability decision.

Extracting Evidence Continued:

The actual act of extracting key findings from the medical evidence can be described as a step-by-step procedure. The act itself is only the beginning of the case analysis process. Once the medical facts are identified and summarized, you can then begin to evaluate the vocational evidence. Once this is done, you would bring the medical and vocational data together to form your argument on behalf of the claimant.

In order to make this process easier to understand, let's create a hypothetical case on a Mr. Katz and extract the key medical findings using the step method below. We’ll summarize both the findings and the steps at the end of this lesson.

Step One:  The Telephone Interview:

At the beginning of a case, you will initiate an interview with the claimant to acquire specific information about his disability case. Your first act must be to determine if the case is worth taking.  This is done by performing a manual or digital assessment.

After determining that the case is worth accepting, you would discuss the case further with the claimant to extract key points that might help you to better understand his circumstance.  The following is an example of what the claimant might tell you in the interview.  All important key information will be highlighted to give you a feel for extracting useful data.

Sample Interview:

The claimant Mr. Katz states the he suffered a heart attack on 10/01/05 and has not been able to work since.  He applied for benefits on 4/01/06 and was denied four months later. He has asked you to represent him on 9/01/06, which is within his sixty-day limit for applying for a reconsideration appeal.  The claimant also states that he continues to suffer from chest pain on exertion and an inability to stand and walk for more than thirty minutes without rest.  He feels physically weak and he has a high level of anxiety and fears for his future.

Since his heart attack, he has been seen by two doctors: Dr. Jones and Dr. Smith. The client was hospitalized twice.  Once at the time of the heart attack an again six months later for unstable angina.  Both hospitalizations were at St. John's Hospital. The claimant also states that he is age fifty-one, has eleven years of education and has worked for fifteen years as a carpenter.

Analysis of above information:

From the interview above you now know that the claimant's primary diagnosis is heart disease. Onset date or the date the disability began is 10/01/05 or the date of his original heart attack. You also know when he applied for benefits 04/1/06 and the outcome of the case, which was a denial on or around 8/1/06.  You also know that the claimant is now applying for a reconsideration of his previous denial ad that he is within his sixty-day appeal limit for requesting an appeal. 

You have also been made aware of a series of continuing complaints from the claimant that if medically documented, could be used as ammunition in your case argument. You also know what doctors your client has seen over time. Since the case is at the reconsideration level, you can instruct Social Security to get any new evidence at no cost or you can save time by requesting any new evidence yourself.

Step Two: Extracting info from PDN

The claimant has a copy of his personalized denial notice which indicates the reason for the denial decision.  The information within the PDN can help you to quickly determine why the case was denied.  

The PDN Reads as Follows:

Analysis of above PDN

The information in the 4268 or PDN has given us much useful data. The PDN tells us the primary diagnosis is a myocardial infarction. The PDN also takes us through step five of the sequential analysis process, which indicates he is capable of performing his past work.  He has also been given a light RFC by the examiner.  The claimant's past work must have an accepted exertion level of light which would coincide with the claimant’s RFC.   

The PDN has also told us exactly at what step in the sequential analysis process the case was denied.  In this case it would be step five of the sequential analysis process. We must now argue that the claimant has a lower RFC than that given the SSA and that he is not capable of performing his past work.  Once this argument is made, we must then argue that the claimant cannot do other less demanding work if we expect to win the case.

This sample PDN has also given us a new concept called the vocational rule 202.12.  The vocational rule concept will be discussed in lesson five.

Step Three:  Evaluating the Medical Evidence:

You have just received your client's medical records from the SSA District Office or the DDS. You have a number of reports from a Dr. Smith, Dr. Jones and records from St. John's Hospital.  Now let's take a closer look at the claimant’s medical evidence.

The St. John's Hospital records tell us what occurred during the claimant's hospitalization for an acute heart attack. To simplify matters, let's just sum up this reports.

The records from St. John’s contain a physical exam, EKG and lab test that show a fifty one year old man in acute cardiac distress. He is treated appropriately and is recovering without complication. There have been no surgical procedures in this case. A cardiac catherization was done showing partial blockage of a major coronary artery. Claimant was placed on nitroglycerin for chest pain and was discharged six days later in stable condition.

Analysis:

The St. John's hospital records are important because they establish the claimant’s diagnosis and the seriousness of the underlying condition. The heart catherization report showed a significant blockage of a coronary artery. The vessel blockage verifies the claimant's primary diagnosis of coronary artery disease. Even though there is little else in the way of outstanding findings from these records, they still act to support the validity of the physical limitations alleged by the claimant.  This report also establishes the onset date of this claimant's disorder.

Claimant was hospitalized at St. John’s six months after his heart attach for unstable angina (chest pain).  He was sent home four days later with nitroglycerin and instructions to rest.

Now let's review Dr. Smith's Report:

In our hypothetical case, Dr. Smith is the claimant's cardiologist.  He has supplied a narrative report on the claimant's cardiac condition since his hospitalization in 2005. Dr. Smith states that “Mr. Katz suffered an acute MI and since that time he has been experiencing chest pain exertion.  Mr. Katz has complained of occasional chest discomfort that is relieved by sublingual nitroglycerin tablets. Although it has been months since his original heart attack, Mr. Katz is not as yet able to return to any type of work activity at this time. The patient continues to suffer from exertion related chest pain that is giving us some concern. We are slowly increasing his exercise tolerance, but we do not want to push him to hard due to his poor physical conditioning.  Mr. Katz has also shown some signs of situational depression that may be associated with his current financial problems.”

Analysis: of Dr. Smith’s Report

Here is what we have learned from Dr. Smith's report that we did not know from previous reports.  Dr. Smith has verified the claimant's continuing problem with chest pain and poor exercise tolerance. He has also given a personal opinion concerning the patient's inability to work.  He ahs also added a new diagnosis which appears to be situational depression. This additional diagnosis verifies claimant's allegation of anxiety associated with his concerns about the future.

Now let's review Dr. Jones' Report:

Dr. Jones is the claimant's family doctor who has taken care of Mr. Katz for years. Dr. Jones' report gives essentially the same information as Dr. Smith's concerning the claimant’s heart condition.  However, Dr. Jones' report alerts us to an additional medical problem that we previously knew nothing about. According to Dr. Jones, our claimant also has a history of diabetes.  The claimant’s diabetes is insulin dependent and has cause poor circulation and pain in both lower extremities.  Dr. Jones also confirms the claimant’s continuing problem with chest pain.

Analysis:

We have learned from Dr. Jones' report that the claimant has diabetes with poor circulation and pain in the lower extremities.  This information is important because it can be used to further reduce this claimant’s RFC. 

Step Four:  List and summary the evidence.

The medical findings should be summarized in order to make it easier for you to create your final argument.  This is a good habit to follow when reviewing any disability case because it will make it easier to recall the key supportive facts when writing your argument. Here is the summation of all the evidence so far reviewed.

• Claimant suffered an acute myocardial infarction (heart attack), EKG, lab and cardiac catherization has verified this condition..
   

• Onset date 10.01/05, the day of the heart attack.
   

• Additional diseases suffered by claimant are diabetes, poor circulation and pain in both legs.
   

• Claimant has chest pain on exertion.
   

• The cardiologist Dr. Smith says claimant is unable to work due to unstable chest pain.
   

• Claimant adds that cannot stand or walk for extended periods of time due his chest pain, weakness and pain in legs.  His anxiety has also made it difficult for him to concentrate.   
   

• You have entered this case on the reconsideration appeal level.
   

• SSA has determined that claimant can do his past work.   

There are other facts within this case that we could list here, but I think you get the point. 

Step Five:  Identify all physical & mental limitations

The fifth step in the process of extracting key points from the medical evidence involves identifying all of the claimant's limitations.  Before this can be accomplished, you must take the time to learn about the disease state your dealing with. It is not critical that you understand every aspect of every disease you may encounter.  However, to improve your evidence reviewing skills and overall knowledge of a disease, we do recommend that you read a little about each impairment.  This action will help build your evaluation skills and shorten the time it takes you to produce an argument.

The Merck Manual online, see ACM Software for link, the Systems Explorer, the Social Security Guide, and any medical text that discusses disease states in layman's terms, will act as an excellent source in furthering your understanding of disease states.  The purpose for using a medical text such as the Merck manual is to help you to identify physical or mental limitations that are common or possible for a particular disorder.

It is more important that you understand how a disease can physically or mentally restrict a person's functioning than it is to understand the disease itself.  Mr. Katz is suffering from a number of diseases, each of which can cause a number of physical limitation.  It is these physical limitations and not the disease itself that will be used to argue for a reduced RFC.

If you understand how a disease can physically or mentally restrict an individual and you can prove that the restrictions are reasonable via the medical evidence, you’ll have the required ingredients for creating a winning argument. 

Conclusion:

In the case of Mr. Katz, it appears that his stated restrictions are indeed reasonable and supported by the medical evidence.  In order to win this case, all we need do is use the available evidence to argue for a reduced RFC.  If we reduce Mr. Katz RFC to less than sedentary, the case would result in an allowance.  Of course, Social Security must agree with our assertion that the claimant is incapable of performing any type of work, including work of a sedentary nature.   

You must allow the claimant and the medical evidence to tell you what the relevant restrictions are.  Then you must attempt to prove that the alleged restrictions are reasonable and consistent with the claimant’s medical condition. Then you must present the restrictions and their supporting evidence as part of your argument for a total disability.  These actions are the basic steps in the case evaluation process.

How to Use the Merck Manual:

The Merck Manual is a diagnostic reference book widely used by consultants, medical professionals and many Social Security agencies. The text is broken into segments, each covering a category of disease.  To use the manual, take the name of the disease state such as myocardial infarction, lay term heart attack, and turn to the index in the back of the book.  Look up the diagnosis.  It should be listed in alphabetical order. The number that appears by the name of the disorder is the page number where you will find the information about the disease.  The Merck Manual will provide you with a wealth of information about any disease state you may encounter.  It also provides information on common signs and symptoms found in a disease state.

Understanding Signs:

I have used the term “sign” several times in your training.  A sign is a medical term used to describe evidence derived from physical examinations or laboratory testing.  For example, if I were to take a sharp needle and use it to stick Mr. Katz in his lower extremity, I would be looking to extract a sign.  If Mr. Katz does not feel the needle, this is a sign that he may be suffering from severe nerve damage in that area. Medical professionals use signs as a means of formulating a diagnosis.  Signs are used in disability as a means of reinforcing the existence of an alleged disorder.  If a person alleges a disorder, claims symptoms but has not sign of the disease, the disorder might be considered non-severe by Social Security.

Example: Mr. Katz has a secondary diagnosis of diabetes.  Our needle test indicates a neurological reduction that may indicate a possible peripheral neuropathy.  Peripheral neuropathy (destruction of nerves) is a sign of a progressive diabetic condition. This sign, reduction in neurological response, provides an important hint as to the extent of Mr. Katz diabetic condition.  The lack of this sign would indicate a less serious diabetic disorder unless of course there are other serious diabetic signs.


Summation:

The following is a summation of the five steps in evaluating a disability claim.  Each step will help you to extract key findings from the medical evidence.

Step one:  Interview client for relevant information.

Step two:  Extract information from the claimant’s PDN if available.

Step three:  Review the claimant’s medical evidence.

Step four:  List the key findings and use them to support client's alleged limitations.

Step five:  Identify all physical and mental restrictions caused by the claimant’s disease states.

Once the above five steps are performed, you must now consider the claimant’s work history.  Evaluating a claimant’s work history is a process called vocational analysis.
 

Lesson Five Preview:

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