Medical Records for Disability

by Tim Moore, Disability Representative in North Carolina

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What medical records mean for your disability case

Medical records are mainly what decide your case. Your work history is very important as well. But nothing happens without medical records. Social Security needs recent medical records to know if you are currently disabled, but also older records to prove when your disability started (this benefits you in terms of back pay that is owed to you).

(Read if you live in North Carolina)

Generally, Social Security will look at any medical records that address your disabling condition. Social Security Disability examiners like to have at least a 12 month treatment history to review your claim.

Records from a long-time doctor are important

All medical records provide some value to your case, but records from a physician who has a long history of treating you will usually carry more face value. Especially to a judge. And especially if they are consistent over time.

Social Security refers to your “regular doctor” as a treating physician. Social Security believes that treating physicians offer a unique perspective that cannot be gotten from acute medical treatment notes (i.e. urgent care). Most often, treating physicians provide a qualified diagnosis and treatment methods that address your condition. This provides, from Social Security’s point of view, objective information that can be used to make a Social Security Disability determination.

Generally, Disability examiners who make decisions on claims do not consider chiropractors to be an acceptable medical treatment source. Which makes sense if you consider the fact that they are not allowed to write prescriptions of any kind. Typically, the only information a disability examiner will find useful from a chiropractor will be any Xrays taken by a chiropractor in their office.

You need current medical records to get approved

Although Social Security guidelines stress the importance of records obtained from medical professionals, there must be current treatment information in order to make a determination. Social Security considers medical information within the prior ninety days to be current.

In other words, if none of your medical records are within 90 days of when Social Security tries to make a decision…they won’t be able to make a decision.

What happens then? This is a common situation where a disability examiner will need to get some kind of snapshot of your current medical condition. And if they cannot obtain it from recent medical records, they will try to get it by sending you to what is called a CE, or consultative exam. They schedule it, and pay for it, with a local physician.

Note: If a person has more than one condition and no current medical treatment, Social Security may require more than one consultative examination to make a disability decision.

Can going to a CE help your claim?

Well, first of all, you don’t really have a choice in going. If you don’t, your case can be denied for “failure to cooperate”.  As to whether or not they help, it is very debatable.

From my past experience as a Social Security Disability examiner, it is my opinion that consultative examinations do not lead to many disability cases being approved. There are many reasons why this may be true.

For instance, the medical professional examining you does not have to have an expertise or specialty in a medical field that deals with your disabling condition. Your disabling condition could be severe back problems but your examining consultative examination doctor may specialize in digestive problems, or even be a gynecologist.

Why does this happen? Frankly, Social Security has to take whoever they can find to do their exams. Social Security has to use medical professionals (doctors, psychiatrists, psychologists, etc) who are available in a local geographical area (local to where the claimant lives) to perform their consultative examinations. That means whoever they can get.

Complaints about consultative exams

Most disability applicants who attend these examinations complain that they are short and that they do not evaluate the severity of their disabling condition/s fairly. Disability applicants should remember these examinations are just to give Social Security Disability examiners something current to use in their disability determination. They are not meant provide an intense evaluation of their medical condition, nor are they meant as any kind of treatment.

For these reasons, very few consultative examinations lead to an approval for disability benefits unless they involve objective testing like memory testing, intelligence quotient (IQ) testing, or vision testing. The results of this kind of testing provide a fairly black and white picture of an individual’s current functional ability.

Consultative examinations can also be useful as a follow-up status for disability applicants filing for disability benefits on the basis of a cerebral accident (for example, stroke or traumatic brain injury) or myocardial infarction (heart attack)–although they are rarely needed in these cases due to ongoing medical treatment.

Disability applicants that have medical treatment for their condition, or conditions (both past and current) have a better chance of being approved for disability benefits than disability applicants with no current medical treatment history for their disabling condition or conditions, who are basically depending upon the results of a short and rarely thorough consultative examination performed by a medical professional whom they have never met.