DDS Medical Consultant's Case Development
As a state Disability Determination Services medical consultant, I performed thousands of Social Security disability claim reviews since 1998. During that time, I developed a structured and fair approach to case assessments.
I start by asking, “What is it going to take to allow the claimant?” Outside of a decision of meeting or equaling a Listing, this can be a tricky subject. The reason I start with this concept is because there may be enough medical evidence in file to adjudicate the claim with a favorable decision without further development of allegations. This proves to be an efficient and cost effective approach.
Examiners get so caught up in trying to develop all of a claimant’s allegations that they sometimes get side-tracked in case development despite the fact there is enough in file to allow the claimant. For example, a claimant alleges multiple impairments such as Congestive Heart Failure (CHF), Chronic Obstructive Pulmonary Disease (COPD) and Degenerative Disc Disease (DDD) of the lumbar spine. Say I know that a “Light” Residual Functional Capacity (RFC) assessment would allow that claimant based on Social Security’s medical-vocational rules, and there is enough evidence in file to support a “Light” RFC based on CHF alone. We can stop case development and allow the claimant even when the medical evidence does not address the other two allegations.
I review the 3368 and any “activities of daily living” or ADL forms in file for allegations, reported severity of symptoms and impact on function. I review the treatment reported, response to treatment and any medications used. Next I read the entire file and tab pertinent physical exams, emergency room visits, hospitalizations, diagnostic studies, and medical source opinions.
At this point, I know whether there is enough in file to make a fair decision. If the information is insufficient, I return the case to the examiner with directions for further development. Sometimes I call a medical source to clarify an issue. Many states use forms to clarify issues with claimants and medical sources.
Once there is enough evidence in file, I use a combination of medical knowledge of disease states and their physiologic impact on function, common sense, objectivity and sleuthing to make the best decision. By being objective, I don’t bias my assessment with personal opinions regarding such issues as substance abuse.
Depending on the allegation, I may need to factor in issues like pain and fatigue. The phenomenon of pain as it applies to the assessment of disability claims requires I take into account the Polaski Factors: (1) the claimant’s subjective complaints of pain; (2) the duration, frequency and intensity of pain; (3) the dosage, effectiveness, and side effects of medication; (4) precipitating and aggravating factors; and (5) functional restrictions.
We all experience pain and fatigue in our lives, but the point at which those factors become disabling under the rules of Social Security is individualized for each claimant. I take into consideration the consistency of subjective symptoms and how they relate to the objective medical evidence.
To support alleged subjective symptoms, there must be a medically determinable impairment (MDI) that could produce the symptoms. I look to see if the MDI could reasonably result in the alleged severity of the symptom and its reported impact on function and ability to work. This involves comparing objective diagnostic findings, such as imaging studies and labs with subjective complaints, reports of functional abilities, and objective physical findings.
Physical findings can be difficult to accurately assess. This is because many reported physical findings are subjective. For example, if I tested your grip, you could provide whatever grip strength you desired based on your degree of effort. The same goes for any other muscle strength testing. You can also resist a joint range of motion at whatever point you wish. You can act as if you are incredibly short of breath, even using accessory muscles of respiration, when you are truly comfortable breathing room air.
So how do I assess consistency? I look for objective physical and diagnostic findings to compare to the behavior shown. For instance, I look for any documented hand atrophy, deformity or synovitis, and any abnormality on a hand X-ray. For shortness of breath, I look at lung exams, heart exams, chest X-rays, ejection fractions on echocardiograms, and pulmonary function testing results.
I review the file for consistency to see if the alleged severity of symptoms and impact on function match the objective findings and reports in file. I always read the Field Office interview to see if the claimant’s behavior was reported at a face-to-face meeting. If so, I look for any difficulty sitting, standing, walking or using their hands. These observations can be compared to any other documented behaviors in file, including consultative exams (CE) and treating source exams.
If there is a mental consultative exam in file, I read it for any reported ADLs and any description of physical behaviors. Some mental CE doctors do a great job at teasing out a true level of function and describing the claimant’s physical behaviors.
Third party ADLs can be helpful in making an accurate determination based on true levels of function. If there is a major inconsistency in what a third party reports versus what the claimant reports, we contact the third party and claimant for clarification.
I look for statements from treating sources regarding levels of function, which range from comments at office visits to formal medical source opinions. In doing so, I have found instances where claimants have been working and did not report it to the DDS. I have seen cases where claimants tell the examiner that they can barely walk to the mailbox, but tell their doctor that they just returned from a three-month trip to Europe.
Why is sleuthing such an important part of the disability determination? Because “white lies,” exaggeration and fraud are not uncommon in Social Security disability claims. Not all claimants exaggerate their symptoms, but the fact that some do make me approach each case with caution when assessing the credibility of claimants.
My ultimate assessment is one of four: (1) no medically determinable impairment exits; (2) the impairment meets a Listing; (3) the impairment or combination of impairments equals a Listing; or (4) the medically determinable impairment is “severe” and requires completion of an RFC.
Upon completion of my assessment, I return the case to the examiner who makes the final determination of whether the claimant’s condition fulfills Social Security’s definition of disability.