I-5-3-30.Revisions to Rules Regarding the Evaluation of Medical Evidence

I. Purpose

On January 18, 2017, the Social Security Administration (SSA) published revisions to the rules regarding the evaluation of medical evidence (82 FR 5844). These revisions became effective on March 27, 2017 (see IV below). These instructions explain why SSA revised its rules regarding the evaluation of medical evidence and when the Office of Hearings Operations (OHO) and the Office of Analytics, Review, and Oversight (OARO) will apply the revised rules.

II. Background

In 1991, SSA adopted new rules creating a uniform national policy about how to consider medical opinions from treating physicians. Based on the state of healthcare at that time, SSA determined that opinions from a claimant's treating physician tended to have a special intrinsic value, because the treating physician was likely to be the medical professional most able to provide a detailed, longitudinal picture of a claimant's impairments. Accordingly, the “treating physician rule” allowed adjudicators to give controlling weight to treating source opinions under certain circumstances. In 1996 and 2006, SSA issued Social Security Rulings (SSR) that provide further instructions on how to evaluate evidence from medical and non-medical sources, including treating physicians (SSRs 96-2p, 96-5p, 96-6p, and 06-3p, all of which were rescinded effective March 27, 2017).

However, since adopting these rules more than twenty-five years ago, changes in healthcare delivery and SSA's adjudicative experience necessitated revision of the rules. Healthcare delivery has changed dramatically since the 1991 rules were implemented. Many people now receive healthcare from coordinated and managed care organizations instead of from a single treating physician. People typically visit multiple medical professionals, including primary physicians, specialists, and nurse practitioners, and they do so in a variety of medical settings, such as managed care and specialty clinics, hospitals, ambulatory care centers, and public healthcare centers. As a result, people are less likely to develop a sustained relationship with a single treating physician. Additionally, due to changes in the national healthcare workforce, people now receive medical care from a wider range of medical sources with rigorous state licensure and extensive education and training requirements, such as Advanced Practice Registered Nurses, audiologists, and physician assistants.

Further, SSA's remand data from both the Appeals Council (AC) and Federal courts revealed that consideration and evaluation of opinion evidence has consistently remained one of the highest reasons for remand at both levels. The Federal courts differed in how strictly they have interpreted the articulation requirements for evaluating opinion evidence, and they developed varying standards for determining what constitutes a treating physician relationship and how SSA must address multiple opinions from multiple treating sources. The various approaches moved SSA's adjudication away from the content of medical opinions and toward weighing treatment relationships against each other. Consequently, the reviewing courts have focused more on whether SSA sufficiently articulated the weight we gave treating source opinions rather than on whether substantial evidence supported a final decision.

In light of the changes in healthcare delivery and SSA's adjudicative experience, SSA requested that the Administrative Conference of the United States (ACUS) provide recommendations on how SSA could improve the process of considering medical opinion evidence in the disability and blindness claims evaluation process. In 2013, ACUS issued its final report. Additionally, the Bipartisan Budget Act (BBA) of 2015 amended the Social Security Act in several ways, including revising the requirements about medical consultants (MC) and psychological consultants (PC).

III. Revisions to the Rules for Evaluating Medical Evidence

Based on changes in healthcare delivery, ACUS's final report, the requirements of the BBA, and SSA's adjudicative experience, we updated our regulations to:

• Redefine and reorganize several key terms related to evidence;

• Revise the rules about acceptable medical sources (AMS);

• Revise the manner in which SSA considers and articulates consideration of medical opinions and prior administrative medical findings;

• Revise the rules about MCs and PCs; and

• Revise the rules about treating sources.

SSA expects these changes will simplify the rules and make them easier to understand and apply, and that these changes will allow SSA adjudicators to continue to make accurate and consistent disability determinations and decisions. SSA will apply most of these revisions only in claims filed on or after March 27, 2017. See subsection IV below for information on determining whether, for purposes of these rules, a claim was filed before March 27, 2017 or on or after that date, and for more information on which rules to apply depending on the filing date of a claim(s).

IV. Implementation of the Rules for Evaluating Medical Evidence

The revised rules became effective on March 27, 2017. While some of the revised rules apply in all claims, many of the most significant changes for evaluating evidence will apply only in claims filed on or after March 27, 2017 (see IV.A. below for instructions on how to determine the filing date). Accordingly, the filing date of a claim(s) determines which set of rules to apply when evaluating medical and nonmedical evidence in a claim.

The rules applicable in cases filed before March 27, 2017, but not applicable in cases filed on or after that date, include the following or similar language: “For claims filed before March 27, 2017, the rules in this section apply.” For simplicity, these rules are referred to as the “prior rules.” The rules applicable in cases filed on or after March 27, 2017, but not applicable in cases filed before that date, include the following or similar language: “For claims filed on or after March 27, 2017, the rules in this section apply.” For simplicity, these rules are referred to as the “current rules.”

The following chart highlights which rules depend on the filing date of a claim(s) and includes citations to applicable rules:

The following subsections provide information on which set of rules will apply in a given case. Importantly, even where different claims in a case have different filing dates, only one set of rules will apply in a claim, i.e., either the prior rules or the current rules, but never both. See IV.B. below for common filing date scenarios. For a more comprehensive overview of filing date scenarios, see Program Operations Manual System (POMS) DI 24503.050.

V. Inquiries

Hearing office staff will direct all program-related and technical questions through appropriate management channels. OHO regional offices may refer questions or unresolved issues to the appropriate headquarters contact.

In the Office of Appellate Operations, staff and adjudicators will direct any program-related or technical questions to the Executive Director's Office.