5.2 Developing Medical Evidence

DEVELOPING MEDICAL EVIDENCE

Doctor Patient Discussing Health Examination

The most important factor in winning your disability claim is your medical evidence. The strength of your case is determined primarily by (1) your medical treatment records and diagnostic evidence, including evidence such as X-rays, MRI’s and blood work results, or, in the cases of psychiatric impairments, your treatment and progress notes; and (2) the medical opinions from your doctors and therapists that describe the limitations caused by your medical impairments, as well as the opinions of Social Security medical personnel. For this reason, it is important that you seek regular treatment for your conditions. It is also important that you get opinions from your doctors indicating why it is your symptoms prevent you from working. It is not enough to establish that you have depression, back pain, asthma, or diabetes; you must prove that these conditions cause symptoms that are severe enough to keep you from working. Having notes and opinions from the doctors who know you will help tremendously here.

When your case is under review, federal law requires that the SSA gives your treatment providers “controlling weight” if their opinions are well supported by the medical evidence you provide1. Your treatment providers should thoroughly and accurately identify serious limitations that keep you from working effectively. Single statements from your doctor that you are “disabled,” or “unable to work,” can help, but they probably won’t win your case.

Whether your disability is physical or mental, your treatment providers can fill out special forms to ensure your complete and accurate disability story is being told. These forms are extremely important to your case.

In some cases your doctors may not want to fill out forms. Instead, many doctors will write brief paragraphs that detail your medical conditions and the symptoms and limitations caused by these conditions.

Code of Federal Regulations 404.1527 (ssa.gov)

It’s important to get regular treatment and documentations from your medical providers early and often. Whether in the form of opinions, notes, or completed forms, the treatment records from your doctors and therapists are the most important factors in your claim. The more records you can gather from across your disability journey, the more likely you are to win your disability case.

Finally, get letters from the people close to you, i.e. spouses, children, siblings and neighbors. They can speak to how your condition has affected the “ activities of daily living ” things like cleaning, laundry, shopping, and childcare. These letters are not nearly as important as the opinions from your doctors and therapists, but they can help your case.

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