[Federal Register Volume 61, Number 128 (Tuesday, July 2, 1996)]
[Notices]
[Pages 34466-34468]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 96-16689]


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SOCIAL SECURITY ADMINISTRATION


Social Security Ruling (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

AGENCY: Social Security Administration.

ACTION: Notice of Social Security Ruling.

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SUMMARY: In accordance with 20 CFR 422.406(b)(1), the Commissioner of 
Social Security gives notice of Social Security Ruling SSR 96-6p. This 
Ruling clarifies Social Security Administration policy regarding the 
consideration of findings of fact by State agency medical and 
psychological consultants and other program physicians and 
psychologists by adjudicators at the administrative law judge and 
Appeals Council levels. Also, the Ruling restores to the Rulings and 
clarifies policy interpretations regarding administrative law judge and 
Appeals Council responsibility for obtaining opinions of physicians or 
psychologists designated by the Commissioner of Social Security 
regarding equivalence to listings in the Listing of Impairments 
(appendix 1, subpart P of 20 CFR part 404) formerly in SSR 83-19, 
``Titles II and XVI: Finding Disability on the Basis of Medical 
Considerations Alone--The Listing of Impairments and Medical 
Equivalency.'' SSR 83-19 was rescinded without replacement by SSR 91-7c 
(C.E. 1990-1991, p. 92) as a result of the Supreme Court's decision in 
Sullivan v. Zebley, 493 U.S. 521 (1990), which invalidated the use of a 
medical ``listings only'' approach to evaluating disability claims of 
individuals under 18 years of age under the supplemental security 
income program. That decision has no bearing on the aspects of SSR 83-
19 that we are restoring in this Ruling.

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

[[Page 34467]]

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)

    Dated: June 7, 1996.
Shirley S. Chater,
Commissioner of Social Security.

Policy Interpretation Ruling--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

    Purpose: To clarify Social Security Administration policy regarding 
the consideration of findings of fact by State agency medical and 
psychological consultants and other program physicians and 
psychologists by adjudicators at the administrative law judge and 
Appeals Council levels. Also, to restore to the Rulings and clarify 
policy interpretations regarding administrative law judge and Appeals 
Council responsibility for obtaining opinions of physicians or 
psychologists designated by the Commissioner regarding equivalence to 
listings in the Listing of Impairments (appendix 1, subpart P of 20 CFR 
part 404) formerly in SSR 83-19. In particular, to emphasize the 
following longstanding policies and policy interpretations:
    1. Findings of fact made by State agency medical and psychological 
consultants and other program physicians and psychologists regarding 
the nature and severity of an individual's impairment(s) must be 
treated as expert opinion evidence of nonexamining sources at the 
administrative law judge and Appeals Council levels of administrative 
review.
    2. Administrative law judges and the Appeals Council may not ignore 
these opinions and must explain the weight given to these opinions in 
their decisions.
    3. An updated medical expert opinion must be obtained by the 
administrative law judge or the Appeals Council before a decision of 
disability based on medical equivalence can be made.
    Citations (Authority): Sections 216(i), 223(d) and 1614(a) of the 
Social Security Act (the Act), as amended; Regulations No. 4, sections 
404.1502, 404.1512(b)(6), 404.1526, 404.1527, and 404.1546; and 
Regulations No. 16, sections 416.902, 416.912(b)(6), 416.926, 416.927, 
and 416.946.
    Introduction: Regulations 20 CFR 404.1527 and 416.927 set forth 
detailed rules for evaluating medical opinions about an individual's 
impairment(s) offered by medical sources \1\ and the medical opinions 
of State agency medical and psychological consultants and other 
nonexamining sources. Paragraph (a) of these regulations provides that 
``medical opinions'' are statements from physicians and psychologists 
or other acceptable medical sources that reflect judgments about the 
nature and severity of an individual's impairment(s), including 
symptoms, diagnosis and prognosis, what the individual can still do 
despite his or her impairment(s), and the individual's physical or 
mental restrictions. Paragraph (b) provides that, in deciding whether 
an individual is disabled, the adjudicator will always consider the 
medical opinions in the case record together with the rest of the 
relevant evidence. Paragraphs (c), (d), and (e) then provide general 
rules for evaluating the record, with particular attention to medical 
and other opinions from acceptable medical sources.
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    \1\ ``Medical sources'' are defined in 20 CFR 404.1502 and 
416.902 as ``treating sources,'' ``sources of record'' (i.e., 
medical sources that have provided an individual with medical 
treatment or evaluation, but do not have or did not have an ongoing 
treatment relationship with the individual), and ``consultative 
examiners'' for the Social Security Administration.
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    Paragraph (f) provides that findings of fact made by State agency 
medical and psychological consultants and other program physicians and 
psychologists become opinions at the administrative law judge and 
Appeals Council levels of administrative review and requires 
administrative law judges and the Appeals Council to consider and 
evaluate these opinions when making a decision in a particular case.
    State agency medical and psychological consultants are highly 
qualified physicians and psychologists who are experts in the 
evaluation of the medical issues in disability claims under the Act. As 
members of the teams that make determinations of disability at the 
initial and reconsideration levels of the administrative review process 
(except in disability hearings), they consider the medical evidence in 
disability cases and make findings of fact on the medical issues, 
including, but not limited to, the existence and severity of an 
individual's impairment(s), the existence and severity of an 
individual's symptoms, whether the individual's impairment(s) meets or 
is equivalent in severity to the requirements for any impairment listed 
in 20 CFR part 404, subpart P, appendix 1 (the Listing of Impairments), 
and the individual's residual functional capacity (RFC).
    Policy Interpretation: Because State agency medical and 
psychological consultants and other program physicians and 
psychologists are experts in the Social Security disability programs, 
the rules in 20 CFR 404.1527(f) and 416.927(f) require administrative 
law judges and the Appeals Council to consider their findings of fact 
about the nature and severity of an individual's impairment(s) as 
opinions of nonexamining physicians and psychologists. Administrative 
law judges and the Appeals Council are not bound by findings made by 
State agency or other program physicians and psychologists, but they 
may not ignore these opinions and must explain the weight given to the 
opinions in their decisions.
    Paragraphs 404.1527(f) and 416.927(f) provide that the rules for 
considering medical and other opinions of treating sources and other 
sources in paragraphs (a) through (e) also apply when we consider the 
medical opinions of nonexamining sources, including State agency 
medical and psychological consultants and other program physicians and 
psychologists. The regulations provide progressively more rigorous 
tests for weighing opinions as the ties between the source of the 
opinion and the individual become weaker. For example, the opinions of 
physicians or psychologists who do not have a treatment relationship 
with the individual are weighed by stricter standards, based to a 
greater degree on medical evidence, qualifications, and explanations 
for the opinions, than are required of treating sources.
    For this reason, the opinions of State agency medical and 
psychological consultants and other program physicians and 
psychologists can be given weight only insofar as they are supported by 
evidence in the case record, considering such factors as the 
supportability of the opinion in the evidence including any evidence 
received at the administrative law judge and Appeals Council levels 
that was not before the State agency, the consistency of the opinion 
with the record as a

[[Page 34468]]

whole, including other medical opinions, and any explanation for the 
opinion provided by the State agency medical or psychological 
consultant or other program physician or psychologist. The adjudicator 
must also consider all other factors that could have a bearing on the 
weight to which an opinion is entitled, including any specialization of 
the State agency medical or psychological consultant.
    In appropriate circumstances, opinions from State agency medical 
and psychological consultants and other program physicians and 
psychologists may be entitled to greater weight than the opinions of 
treating or examining sources. For example, the opinion of a State 
agency medical or psychological consultant or other program physician 
or psychologist may be entitled to greater weight than a treating 
source's medical opinion if the State agency medical or phychological 
consultant's opinion is based on a review of a complete case record 
that includes a medical report from a specialist in the individual's 
particular impairment which provides more detailed and comprehensive 
information than what was available to the individual's treating 
source.
    The following additional guidelines apply at the administrative law 
judge and Appeals Council levels to opinions about equivalence to a 
listing in the Listing of Impairments and RFC assessments, issues that 
are reserved to the Commissioner in 20 CFR 404.1527(e) and 416.927(e). 
(See also SSR 96-5p, ``Titles II and XVI: Medical Source Opinions on 
Issues Reserved to the Commissioner.'')

Medical Equivalence to an Impairment in the Listing of Impairments.

    The administrative law judge or Appeals Council is responsible for 
deciding the ultimate legal question whether a listing is met or 
equaled. As trier of the facts, an administrative law judge or the 
Appeals Council is not bound by a finding by a State agency medical or 
psychological consultant or other program physician or psychologist as 
to whether an individual's impairment(s) is equivalent in severity to 
any impairment in the Listing of Impairments. However, longstanding 
policy requires that the judgment of a physician (or psychologist) 
designated by the Commissioner on the issue of equivalence on the 
evidence before the administrative law judge or the Appeals Council 
must be received into the record as expert opinion evidence and given 
appropriate weight.
    The signature of a State agency medical or psychological consultant 
on an SSA-831-U5 (Disability Determination and Transmittal Form) or 
SSA-832-U5 or SSA-833-U5 (Cessation or Continuance of Disability or 
Blindness) ensures that consideration by a physician (or psychologist) 
designated by the Commissioner has been given to the question of 
medical equivalence at the initial and reconsideration levels of 
administrative review. Other documents, including the Psychiatric 
Review Technique Form and various other documents on which medical and 
psychological consultants may record their findings, may also ensure 
that this opinion has been obtained at the first two levels of 
administrative review.
    When an administrative law judge or the Appeals Council finds that 
an individual's impairment(s) is not equivalent in severity to any 
listing, the requirement to receive expert opinion evidence into the 
record may be satisfied by any of the foregoing documents signed by a 
State agency medical or psychological consultant. However, an 
administrative law judge and the Appeals Council must obtain an updated 
medical opinion from a medical expert <SUP>2 in the following 
circumstances:
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    \2\ The term ``medical expert'' is being used to refer to the 
source of expert medical opinion designated as a ``medical advisor'' 
in 20 CFR 404.1512(b)(6), 404.1527(f), 416.912(b)(6), and 
416.927(f). This term is being used because it describes the role of 
the ``medical expert'' as an expert witness rather than an advisor 
in the course of an administrative law judge hearing.
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    <bullet> When no additional medical evidence is received, but in 
the opinion of the administrative law judge or the Appeals Council the 
symptoms, signs, and laboratory findings reported in the case record 
suggest that a judgment of equivalence may be reasonable; or When 
additional medical evidence is received that in the opinion of the 
administrative law judge or the Appeals Council may change the State 
agency medical or psychological consultant's finding that the 
impairment(s) is not equivalent in severity to any impairment in the 
Listing of Impairments.
    When an updated medical judgment as to medical equivalence is 
required at the administrative law judge level in either of the 
circumstances above, the administrative law judge must call on a 
medical expert. When an updated medical judgment as to medical 
equivalence is required at the Appeals Council level in either of the 
circumstances above, the Appeals Council must call on the services of 
its medical support staff.

Assessment of RFC

    Although the administrative law judge and the Appeals Council are 
responsible for assessing an individual's RFC at their respective 
levels of administrative review, the administrative law judge or 
Appeals Council must consider and evaluate any assessment of the 
individual's RFC by a State agency medical or psychological consultant 
and by other program physicians or psychologists. At the administrative 
law judge and Appeals Council levels, RFC assessments by State agency 
medical or psychological consultants or other program physicians or 
psychologists are to be considered and addressed in the decision as 
medical opinions from nonexamining sources about what the individual 
can still do despite his or her impairment(s). Again, they are to be 
evaluated considering all of the factors set out in the regulations for 
considering opinion evidence.
    Effective Date: This Ruling is effective on the date of its 
publication in the Federal Register.
    Cross-References: SSR 96-5p, ``Titles II and XVI: Medical Source 
Opinions on Issues Reserved to the Commissioner;'' Program Operations 
Manual System, section DI 24515.007; and Hearings, Appeals, and 
Litigation Law Manual, section I-5-310.

[FR Doc. 96-16689 Filed 7-1-96; 8:45 am]
BILLING CODE 4190-29-P