Social Security Ruling (SSR) 17-2p: Titles II and XVI: Evidence Needed by Adjudicators at the Hearings and Appeals Council Levels of the…

Social Security Ruling (SSR) 17-2p: Titles II and XVI: Evidence Needed by Adjudicators at the Hearings and Appeals Council Levels of the Administrative Review Process To Make Findings About Medical Equivalence

SUMMARY: We are providing notice of SSR 17-2p. This SSR provides guidance about how adjudicators at the hearings and Appeals Council (AC) levels of the administrative review process make findings about medical equivalence in disability claims under titles II and XVI of the Social Security Act.

DATES: Effective Date: March 27, 2017.

FOR FURTHER INFORMATION CONTACT: Joshua Silverman, Office of Disability Policy, Social Security Administration, 6401 Security Boulevard, Baltimore, MD 21235-6401, (410) 594-2128. For information on eligibility or filing for benefits, call our national toll-free number 1-800-772, 1213, or TTY 1-800-325-0778, or visit our Internet site, Social Security Online, at http://www.socialsecurity.gov.

SUPPLEMENTARY INFORMATION: Although 5 U.S.C. 552(a)(1) and (a)(2) do not require us to publish this SSR, we are doing so in accordance with 20 CFR 402.35(b)(1).

Through SSRs, we make available to the public precedential decisions relating to the Federal old-age, survivors, disability, supplemental security income, and special veterans benefits programs. We may base SSRs on determinations or decisions made at all levels of administrative adjudication, Federal court decisions, Commissioner's decisions, opinions of the Office of the General Counsel, or other interpretations of the law and regulations.

Although SSRs do not have the same force and effect as statutes or regulations, they are binding on all components of the Social Security Administration. 20 CFR 402.35(b)(1).

This SSR will remain in effect until we publish a notice in the Federal Register that rescinds it, or we publish a new SSR that replaces or modifies it.

(Catalog of Federal Domestic Assistance, Programs Nos. 96.001, Social Security--Disability Insurance; 96.002, Social Security--Retirement Insurance; 96.004, Social Security--Survivors Insurance; 96.006--Supplemental Security Income.)

Nancy A. Berryhill,

Acting Commissioner of Social Security.

POLICY INTERPRETATION RULING

Social Security Ruling, SSR 17-2p: Titles II and XVI: Evidence Needed by Adjudicators at the Hearings and Appeals Council Levels of the Administrative Review Process to Make Findings about Medical Equivalence.

This Social Security Ruling (SSR) rescinds and replaces 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."

PURPOSE: This SSR provides guidance on how adjudicators at the hearings and Appeals Council (AC) levels of our administrative review process make findings about medical equivalence in disability claims under titles II and XVI of the Social Security Act (Act).

CITATIONS: Sections 216(i), 223(d), and 1614(a) of the Act, as amended; 20 CFR 404.1526 and 416.926.

BACKGROUND:

The Sequential Evaluation Process

We use a five-step sequential evaluation process to determine whether an adult is disabled under titles II or XVI of the Act. /1/ We use a different process to decide whether a child is disabled under title XVI of the Act. /2/ In both situations, if we can find an individual is disabled at a step, we make a determination or decision at that step and do not go on to the next step. /3/

FOOTNOTE 1 See 20 CFR 404.1520 and 416.920. END FOOTNOTE

FOOTNOTE 2 See 20 CFR 416.924. END FOOTNOTE

FOOTNOTE 3 See 20 CFR 404.1520(a)(4) and 416.920(a)(4). END FOOTNOTE

At step 3 of the sequential evaluation process for determining disability in adult and child claims, we make a medical assessment to determine whether an individual's impairment(s) meets a listing in the Listing of Impairments (listings). /4/ If an individual's impairment(s) meets all the criteria of any listed impairment in the listings, we will find that the individual is disabled. If an individual has an impairment(s) that does not meet all of the requirements of a listing, we then determine whether the individual's impairment(s) medically equals a listed impairment. An impairment is medically equivalent to a listed impairment if it is at least equal in severity and duration to the criteria of any listed impairment. We can find medical equivalence in three ways:

FOOTNOTE 4 20 CFR part 404, subpart P, Appendix 1. END FOOTNOTE

1. If an individual has an impairment that is described in the listings, but either:

a. the individual does not exhibit one or more of the findings specified in the particular listing, or

b. the individual exhibits all of the findings, but one or more of the findings is not as severe as specified in the particular listing,

then we will find that his or her impairment is medically equivalent to that listing if there are other findings related to the impairment that are at least of equal medical significance to the required criteria.

2. If an individual has an impairment(s) that is not described in the listings, we will compare the findings with those for closely analogous listed impairments. If the findings related to the impairment(s) are at least of equal medical significance to those of a listed impairment, we will find that the impairment(s) is medically equivalent to the analogous listing.

3. If an individual has a combination of impairments, no one of which meets a listing, we will compare the findings with those for closely analogous listed impairments. If the findings related to the impairments are at least of equal medical significance to those of a listed impairment, we will find that the combination of impairments is medically equivalent to that listing. /5/

FOOTNOTE 5 See 20 CFR 404.1526 and 416.926. END FOOTNOTE

If we determine an individual's impairment(s) does not meet or medically equal a listed impairment, we continue evaluating the claim using the sequential evaluation process. /6/

FOOTNOTE 6 In adult claims, we will determine the individual's residual functional capacity and then go to step 4 of the sequential evaluation process. See 20 CFR 404.1520 and 416.920. In a child's claim under Title XVI, we will determine whether the child's impairment(s) functionally equals the Listings at step 3. See 20 CFR 416.926a. END FOOTNOTE

Who decides whether an individual's impairment medically equals a listing?

At the initial and reconsideration levels of the administrative review process, Federal or State agency Medical Consultants (MC) or Psychological Consultants (PC) consider the evidence and make administrative medical findings about medical issues, including whether an individual's impairment(s) meets or medically equals a listing. /7/ MCs and PCs are highly qualified medical sources who are also experts in the evaluation of medical issues in disability claims under the Act. In most situations, /8/ we require adjudicators at the initial and reconsideration levels to obtain MC or PC administrative medical findings about medical equivalence.

FOOTNOTE 7 In some States, we are testing modifications to the disability determination procedures that allow disability examiners to decide whether an individual's impairment(s) medically equals a listing without requiring consultation with an MC or PC, although such consultation is permissible. One modification authorizes specialized State agency disability examiners called "single decisionmakers" (SDM) to make initial and reconsideration determinations without consulting an MC or PC in some types of claims. See 20 CFR 404.906(b)(2) and 416.1406(b)(2). The other modification being tested allows disability examiners to make fully favorable determinations in quick disability determinations (QDD) and compassionate allowance (CAL) claims without requiring consultation with an MC or PC because those types of claims involve the most obviously disabling impairments. See 20 CFR 404.1615(c)(3) and 416.1015(c)(3). In those States using the testing modifications, there may not be an MC or PC medical assessment in the file. Both of these testing modifications are scheduled to end by the end of calendar year 2018. See 81 FR 73027 (2016) and 81 FR 58544 (2016). END FOOTNOTE

FOOTNOTE 8 As stated in the prior footnote, disability examiners are not required to obtain MC or PC input about medical equivalence in certain SDM claims and in QDD and CAL claims. In those States using the testing modifications, there may not be a MC or PC medical assessment in the file. END FOOTNOTE

At the hearings level of the administrative review process, administrative law judges (ALJ) and some attorney advisors /9/ determine whether an individual's impairment(s) meets or medically equals a listing at step 3 of the sequential evaluation process. To assist in evaluating this issue, adjudicators at the hearings level may ask for and consider evidence from medical experts (ME) about the individual's impairment(s), such as the nature and severity of the impairment(s).

FOOTNOTE 9 See 20 CFR 404.942 and 416.1442. END FOOTNOTE

At the AC level of the administrative review process, when the AC exercises its authority to issue a decision, /10/ it determines whether an individual's impairment(s) meets or medically equals a listing. The AC may ask its medical support staff to help decide whether an individual's impairment(s) medically equals a listing.

FOOTNOTE 10 The Appeals Council issues decisions in cases after it grants a request for review or takes own motion review of a hearing decision. See 20 CFR 404.969-970 and 416.1469-1470. The Appeals Council may also make a decision after a Federal court remands a case. See 20 CFR 404.983 and 416.1483. END FOOTNOTE

POLICY INTERPRETATION

Evidentiary requirements

--This is a summary of a Federal Register article originally published on the page number listed below--

Notice of Social Security Ruling (SSR).

Citation: "82 FR 15263"

Document Number: "Docket No. SSA-2012-0035"

Federal Register Page Number: "15263"

"Notices"