Showing the legitimacy of subjective reports of medical symptoms in an SSDI claim can be challenging, but the Social Security Administration has published guidelines for analysis.
It is an age-old struggle. How does someone with a serious illness or injury who experiences pain or other subjective complaints like dizziness, fatigue, depression, difficulty breathing, weakness, nervousness, lack of concentration or others, prove the level of impact of those symptoms that no one can measure in a lab or observe with the eye?
After all, the only person who really knows how severe a symptom is is the sufferer.
Appropriately crediting subjective complaints and their effect on the ability to work has been a long-time challenge for the Social Security Administration or SSA in the processing of Social Security Disability Insurance (and Supplemental Security Income) claims.
(While SSDI and SSI have the same definition of disability, we will speak here only of SSDI for ease.)
In March 2016, the SSA issued SSR 16-3P, titled “Evaluation of Symptoms in Disability Claims”, an agency ruling that is not a law, but that is binding on SSA employees at all levels. One purpose of this SSR is to stop using the word “credibility” when analyzing an individual’s symptoms, which is not meant to be “an examination of an individual’s character.”
The ruling defines a symptom as the claimant’s “own description or statement of his or her physical or mental impairment.”
The SSR directs the evaluator to follow a two-step process. First, the evaluator must determine if the claimant has a medically determinable impairment (MDI) that could reasonably cause the reported symptoms. The MDI must be based on medical signs or laboratory findings, defined as objective medical evidence (OME), which must be from acceptable medical sources.
Medical signs are defined as “anatomical, physiological, or psychological abnormalities established by medically acceptable clinical diagnostic techniques” that are observable.
If there is not enough OME to establish an MDI, the SSA should develop the medical record further such as by sending the claimant to a consultative exam or by consulting medical experts.
If an MDI that could reasonably cause the reported symptoms is not established, the analysis ends and the symptoms are not considered.
Symptom impact on work ability
Second, the evaluator looks at the entire record of evidence in the agency file to analyze symptom intensity and persistence and how they limit the ability to work. This is a careful analysis of all evidence because different people can have different intensity of the same symptoms from the same condition.
At this step, the SSA considers these kinds of evidence:
- OME: Some objective findings can be associated with and support claims of pain (e.g. muscle spasms).
- Claimant statements: The claimant’s description of symptoms can help determine frequency, duration, location and limiting effects.
- Doctor and other medical professional statements: Medical sources may describe patient complaints, clinical observations, medication side effects, treatment and prognosis. Non-treating professionals like SSA medical consultants may provide analysis.
- Other relevant sources: Information from family members, agencies, friends and others may be helpful as well as observations of SSA personnel.
- Relevant factors: SSA regulations list factors like daily activities, medication, what brings on or worsens symptoms, symptom “location, duration, frequency, and intensity,” other treatments for symptoms, measures used to treat symptoms (body positioning, exercise and so on) and anything else relevant.
In addition, the SSA will look at whether the claimant follows treatment when prescribed and how persistent he or she is in seeking relief as well as the reasons for not doing these things. For example, before discounting complaints of pain because a patient did not take a prescribed medication, the reasoning behind the decision should be considered.
Very importantly, the adjudicator must explain in detail in the written decision why he or she discounted or credited certain evidence related to the intensity of symptoms. Without this level of detail, a reviewing court cannot tell whether the adjudicator followed the SSR standards throughout he analysis.
SSDI attorney Robyn Rebers has convenient appointments in Tualatin and Clackamas, Oregon, and represents SSDI and SSI claimants in their applications and appeals.