Health Hippo: Evaluations of Social Security

 Disability

The Social Security Administration administers two programs that provide benefits based on disability: the Social Security disability program (Title II) and the supplemental security income program (Title XVI). Title II provides benefits to individuals who are insured under the Act by virtue of their contributions to the Social Security trust fund through tax on their earnings. Title XVI provides payments to individuals who are disabled and have limited income and resources.

What follows is a linked outline to legal resources organized under the Office of Hearings and Appeals five-step sequential evaluation process for reviewing social security disability claims, as set out in 20 CFR 404.1520. The rules under Title II and XVI are identical in most cases, so only Title II rules are linked below.

• Social Security Ruling 86-8: THE SEQUENTIAL EVALUATION PROCESS. The regulations state that a sequential evaluation process is followed whereby current work activity, severity and duration of the impairment(s), ability to do past work and vocational factors are considered in that order.

1. Substantial Gainful Activity

• Social Security Ruling 83-34: SELF-EMPLOYED PERSONS. In determining whether a self-employed individual is engaging in SGA, consideration must be given to the individual's activities and their value to his or her business.
• Social Security Ruling 83-35: AVERAGING OF EARNINGS. Method of averaging earnings for determinations as to whether work is substantial gainful activity (SGA) under the disability provisions of the law.
• Social Security Ruling 84-25: UNSUCCESSFUL WORK ATTEMPT. Determining whether substantial work activity that is discontinued or reduced below a specified level may be considered an unsuccessful work attempt (UWA) under the disability provisions of the law.
• Social Security Ruling 85-5c: AVERAGING EARNINGS FROM EMPLOYMENT. Claimant's employment at the department store, along with the evidence of her satisfactory work performance, showed that she had engaged in SGA.
• Social Security Ruling 94-1c: ILLEGAL ACTIVITY AS SUBSTANTIAL GAINFUL ACTIVITY. Finding that neither the Act nor the regulations recognizes a distinction between lawful and unlawful activity for purposes of determining SGA, the court of appeals concluded that illegal activity can constitute SGA.
• 20 CFR 404.429, Earnings; defined.
• 20 CFR 404.1571, General.
• 20 CFR 404.1572, What we mean by substantial gainful activity.
• 20 CFR 404.1573, General information about work activity.
• 20 CFR 404.1574, Evaluation guides if you are an employee.
• 20 CFR 404.1575, Evaluation guides if you are self-employed. , Impairment-related work expenses.

2. Severe Impairment

• BOWEN v. YUCKERT, 482 U.S. 137 (1987) The severity regulation increases the efficiency and reliability of the disability evaluation process by identifying at an early stage those claimants whose medical impairments are so slight that it is unlikely they would be found to be disabled even if their age, education, and experience were taken into account.
• Social Security Ruling 82-52: DURATION OF THE IMPAIRMENT. In considering "duration," it is the inability to engage in SGA because of the impairment that must last the required 12-month period.
• Social Security Ruling 85-28: MEDICAL IMPAIRMENTS THAT ARE NOT SEVERE. To clarify the policy for determining when a person's impairment(s) may be found "not severe" and, thus, the basis for a finding of "not disabled" in the sequential evaluation of disability, and thereby reflect certain circuit court decisions that have taken issue with the Secretary's previously stated definition of "not severe" impairments.
• Social Security Ruling 96-3p: CONSIDERING ALLEGATIONS OF PAIN AND OTHER SYMPTOMS IN DETERMINING WHETHER A MEDICALLY DETERMINABLE IMPAIRMENT IS SEVERE. An individual's symptoms may cause limitations and restrictions in functioning which, when considered at step 2, may require a finding that there is a "severe" impairment(s) and a decision to proceed to the next step of sequential evaluation.
• Social Security Ruling 96-4p: SYMPTOMS, MEDICALLY DETERMINABLE PHYSICAL AND MENTAL IMPAIRMENTS, AND EXERTIONAL AND NONEXERTIONAL LIMITATIONS.
• A "symptom" is not a "medically determinable physical or mental impairment" and no symptom by itself can establish the existence of such an impairment.
• In the absence of a showing that there is a "medically determinable physical or mental impairment," an individual must be found not disabled at step 2 of the sequential evaluation process. No symptom or combination of symptoms can be the basis for a finding of disability, no matter how genuine the individual's complaints may appear to be, unless there are medical signs and laboratory findings demonstrating the existence of a medically determinable physical or mental impairment.
• The terms "exertional" and "nonexertional" in the regulations describe types of functional limitations or restrictions resulting from a medically determinable physical or mental impairment; i.e., exertional limitations affect an individual's ability to meet the strength demands of jobs, and nonexertional limitations or restrictions affect an individual's ability to meet the nonstrength demands of jobs. Therefore, a symptom in itself is neither exertional nor nonexertional. Rather, it is the nature of the functional limitations or restrictions caused by an impairment-related symptom that determines whether the impact of the symptom is exertional, nonexertional, or both.
• The application of the medical-vocational rules in appendix 2 of subpart P of Regulations No. 4 depends on the nature of the limitations and restrictions imposed by an individual's medically determinable physical or mental impairment(s), and any related symptoms.
• Social Security Ruling 99-2p: EVALUATING CASES INVOLVING CHRONIC FATIGUE SYNDROME (CFS). This Ruling explains that CFS, when accompanied by appropriate medical signs or laboratory findings, is a medically determinable impairment that can be the basis for a finding of "disability." It also provides guidance for the evaluation of claims involving CFS.
• 20 CFR 404.1504, Determinations by other organizations and agencies. A decision by any nongovernmental agency or any other governmental agency about whether you are disabled or blind is based on its rules and is not our decision about whether you are disabled or blind. We must make a disability or blindness determination based on social security law. Therefore, a determination made by another agency that you are disabled or blind is not binding on us.
• 20 CFR 404.1508, What is needed to show an impairment.
• 20 CFR 404.1509, How long the impairment must last.
• 20 CFR 404.1512, Evidence of your impairment.
• 20 CFR 404.1513, Medical evidence of your impairment (acceptable sources).
• 20 CFR 404.1519, The consultative examination..
• 20 CFR 404.1519a, When we will purchase a consultative examination and how we will use it.
• 20 CFR 404.1521, What we mean by an impairment that is not severe.

3. Meets or Equals a Listing

• Listing of Impairments -- Appendix 1 to Subpart P of Part 404.
• Listing of Impairments — hyperlinked version.
• Social Security Ruling 96-6p: MEDICAL EQUIVALENCE. The administrative law judge or the Appeals Council must obtain an updated medical expert opinion before a decision of disability based on medical equivalence can be made. Equals = 1) missing a sign; 2) different impairment; 3) combination of impairments.
• Obesity: Revised Medical Criteria for Determination of Disability (Final Rule: August 24, 1999). Although many individuals with obesity are appropriately found "disabled" within the meaning of the Social Security Act (the Act), we have determined that the criteria in listing 9.09 were not appropriate indicators of listing-level severity because they did not represent a degree of functional limitation that would prevent an individual from engaging in any gainful activity.

3.5. Residual Functional Capacity

• Social Security Ruling 96-2p: GIVING CONTROLLING WEIGHT TO TREATING SOURCE MEDICAL OPINIONS. The provision recognizes the deference to which a treating source's medical opinion should be entitled. It does not permit us to substitute our own judgment for the opinion of a treating source on the issue(s) of the nature and severity of an impairment when the treating source has offered a medical opinion that is well-supported by medically acceptable clinical and laboratory diagnostic techniques and is not inconsistent with other substantial evidence.
• Social Security Ruling 96-5p: MEDICAL SOURCE OPINIONS ON ISSUES RESERVED TO THE COMMISSIONER. How we consider medical source opinions on issues reserved to the Commissioner, including whether an individual's impairment(s) meets or is equivalent in severity to the requirements of any impairment(s) in the Listing of Impairments in appendix 1, subpart P of 20 CFR part 404 (the listings); what an individual's residual functional capacity (RFC) is; whether an individual's RFC prevents him or her from doing past relevant work; how the vocational factors of age, education, and work experience apply; and whether an individual is "disabled" under the Social Security Act (the Act).
• Social Security Ruling 96-6p: 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. 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 non-examining sources at the administrative law judge and Appeals Council levels of administrative review. Administrative law judges and the Appeals Council may not ignore these opinions and must explain the weight given to these opinions in their decisions.
• Social Security Ruling 96-7p: ASSESSING THE CREDIBILITY OF AN INDIVIDUAL'S STATEMENTS.
• No symptom or combination of symptoms can be the basis for a finding of disability, no matter how genuine the individual's complaints may appear to be, unless there are medical signs and laboratory findings demonstrating the existence of a medically determinable physical or mental impairment(s) that could reasonably be expected to produce the symptoms.
• When the existence of a medically determinable physical or mental impairment(s) that could reasonably be expected to produce the symptoms has been established, the intensity, persistence, and functionally limiting effects of the symptoms must be evaluated to determine the extent to which the symptoms affect the individual's ability to do basic work activities. This requires the adjudicator to make a finding about the credibility of the individual's statements about the symptom(s) and its functional effects.
• Because symptoms, such as pain, sometimes suggest a greater severity of impairment than can be shown by objective medical evidence alone, the adjudicator must carefully consider the individual's statements about symptoms with the rest of the relevant evidence in the case record in reaching a conclusion about the credibility of the individual's statements if a disability determination or decision that is fully favorable to the individual cannot be made solely on the basis of objective medical evidence.
• In determining the credibility of the individual's statements, the adjudicator must consider the entire case record, including the objective medical evidence, the individual's own statements about symptoms, statements and other information provided by treating or examining physicians or psychologists and other persons about the symptoms and how they affect the individual, and any other relevant evidence in the case record. An individual's statements about the intensity and persistence of pain or other symptoms or about the effect the symptoms have on his or her ability to work may not be disregarded solely because they are not substantiated by objective medical evidence.
• It is not sufficient for the adjudicator to make a single, conclusory statement that "the individual's allegations have been considered" or that "the allegations are (or are not) credible." It is also not enough for the adjudicator simply to recite the factors that are described in the regulations for evaluating symptoms. The determination or decision must contain specific reasons for the finding on credibility, supported by the evidence in the case record, and must be sufficiently specific to make clear to the individual and to any subsequent reviewers the weight the adjudicator gave to the individual's statements and the reasons for that weight.
• Social Security Ruling 96-8p: ASSESSING RESIDUAL FUNCTIONAL CAPACITY IN INITIAL CLAIMS.
• Ordinarily, RFC is an assessment of an individual's ability to do sustained work-related physical and mental activities in a work setting on a regular and continuing basis. A "regular and continuing basis" means 8 hours a day, for 5 days a week, or an equivalent work schedule.
• The RFC assessment considers only functional limitations and restrictions that result from an individual's medically determinable impairment or combination of impairments, including the impact of any related symptoms. Age and body habitus are not factors in assessing RFC. It is incorrect to find that an individual has limitations beyond those caused by his or her medically determinable impairment(s) and any related symptoms, due to such factors as age and natural body build, and the activities the individual was accustomed to doing in his or her previous work.
• When there is no allegation of a physical or mental limitation or restriction of a specific functional capacity, and no information in the case record that there is such a limitation or restriction, the adjudicator must consider the individual to have no limitation or restriction with respect to that functional capacity.
• The RFC assessment must first identify the individual's functional limitations or restrictions and assess his or her work-related abilities on a function-by-function basis, including the functions in paragraphs (b), (c), and (d) of 20 CFR 404.1545 and 416.945. Only after that may RFC be expressed in terms of the exertional levels of work, sedentary, light, medium, heavy, and very heavy.
• RFC is not the least an individual can do despite his or her limitations or restrictions, but the most.
• Medical impairments and symptoms, including pain, are not intrinsically exertional or nonexertional. It is the functional limitations or restrictions caused by medical impairments and their related symptoms that are categorized as exertional or nonexertional.
• 20 CFR 404.1502, Definition of treating source.
• 20 CFR 404.1513, Medical evidence of your impairment.
• 20 CFR 404.1527, Evaluating medical opinions about your impairment or disability (examining, treating, nature & extent, support, consistency, specialization, issues reserved to the Commissioner and more).
• 20 CFR 404.1528, Symptoms, signs and laboratory findings.
• 20 CFR 404.1529, How we evaluate symptoms, including pain (includes the 7 pain factors).
• 20 CFR 404.1545, Your residual functional capacity.
• 20 CFR 404.1546, Responsibility for assessing and determining residual functional capacity.

4. Past Relevant Work

• Social Security Ruling 82-40: THE VOCATIONAL RELEVANCE OF THE PAST WORK PERFORMED IN A FOREIGN COUNTRY. The proper test in the fourth step of the sequential evaluation process is whether the individual can do his or her previous work, whether in the U.S. or in a foreign economy.
• Social Security Ruling 82-61: PAST RELEVANT WORK -- THE PARTICULAR JOB OR THE OCCUPATION AS GENERALLY PERFORMED. Under sections 404.1520(e) and 416.920(e) of the regulations, a claimant will be found to be "not disabled" when it is determined that he or she retains the RFC to perform: 1) The actual functional demands and job duties of a particular past relevant job; or 2) The functional demands and job duties of the occupation as generally required by employers throughout the national economy.
• Social Security Ruling 82-62: A DISABILITY CLAIMANT'S CAPACITY TO DO PAST RELEVANT WORK, IN GENERAL. Capacity to do past work may be indicative of the capacity to engage in SGA when that work experience constituted SGA and has current relevance considering duration and recency.
• 20 CFR 404.2(a)(4), Attainment of age.
• 20 CFR 404.1560, When your vocational background will be considered.
• 20 CFR 404.1562, If you have done only arduous unskilled physical labor.

5. Other Work

• The "Grids" -- Appendix 2 to Subpart P of Part 404--Medical-Vocational Guidelines. These rules reflect the analysis of the various vocational factors (i.e., age, education, and work experience) in combination with the individual's residual functional capacity (used to determine his or her maximum sustained work capability for sedentary, light, medium, heavy, or very heavy work) in evaluating the individual's ability to engage in substantial gainful activity in other than his or her vocationally relevant past work. Notes: 1) no need to discuss transferable skills for claimants under age 50; 2) age 50+, RFC of simple, unskilled work = no transferable skills; 3) unskilled work provides no transferable skills (duh?); 4) age 55+, light work w/o transferable skills = disabled; 5) age 50-54, sedentary work w/o transferable skills = disabled.
• Social Security Ruling 82-63: MEDICAL-VOCATIONAL PROFILES SHOWING AN INABILITY TO MAKE AN ADJUSTMENT TO OTHER WORK. There are two "medical-vocational profiles" which show an inability to make a vocational adjustment to other work (or any work) and which must be considered before a disability decision-maker refers to Appendix 2 of Subpart P of Regulations No. 4 to determine whether a claimant can do work which exists in significant numbers in the national economy, considering the interaction of the claimant's residual functional capacity (RFC), age, education, and work experience. The characteristics of these two profiles are: (1) marginal education and long work experience limited to arduous unskilled physical labor and (2) advanced age, limited education and no work experience.
• Social Security Ruling 83-10: THE MEDICAL-VOCATIONAL RULES OF APPENDIX 2. Addresses the issue of capability to do other work, and provides definitions of terms and concepts frequently used in evaluating disability under the medical-vocational rules.
• Social Security Ruling 83-11: CAPABILITY TO DO OTHER WORK -- THE EXERTIONALLY BASED MEDICAL-VOCATIONAL RULES MET
• Social Security Ruling 83-12: THE MEDICAL-VOCATIONAL RULES AS A FRAMEWORK FOR EVALUATING EXERTIONAL LIMITATIONS WITHIN A RANGE OF WORK OR BETWEEN RANGES OF WORK. Includes "significantly eroding the occupational base" explanation, "less than a full range", sit/stand option and more.
• Social Security Ruling 83-14: THE MEDICAL-VOCATIONAL RULES AS A FRAMEWORK FOR EVALUATING A COMBINATION OF EXERTIONAL AND NONEXERTIONAL IMPAIRMENTS. No table rule applies to direct a conclusion of "Disabled" or "Not disabled" where an individual has a nonexertional limitation or restriction imposed by a medically determinable impairment. However, a particular additional exertional or nonexertional limitation may have very little effect on the range of work remaining that an individual can perform. The person, therefore, comes very close to meeting a table rule that directs a conclusion of "Not Disabled."
• Social Security Ruling 85-15: THE MEDICAL-VOCATIONAL RULES AS A FRAMEWORK FOR EVALUATING SOLELY NONEXERTIONAL IMPAIRMENTS. (1) The potential job base for mentally ill claimants without adverse vocational factors is not necessarily large even for individuals who have no other impairments, unless their remaining mental capacities are sufficient to meet the intellectual and emotional demands of at least unskilled, competitive, remunerative work on a sustained basis; and (2) that a finding of disability can be appropriate for an individual who has a severe mental impairment which does not meet or equal the Listing of Impairments, even where he or she does not have adversities in age, education, or work experience. (dust & fumes don't significantly erode the base).
• Social Security Ruling 96-4p: SYMPTOMS, MEDICALLY DETERMINABLE PHYSICAL AND MENTAL IMPAIRMENTS, AND EXERTIONAL AND NONEXERTIONAL LIMITATIONS.
• The terms "exertional" and "nonexertional" in the regulations describe types of functional limitations or restrictions resulting from a medically determinable physical or mental impairment; i.e., exertional limitations affect an individual's ability to meet the strength demands of jobs, and nonexertional limitations or restrictions affect an individual's ability to meet the nonstrength demands of jobs. Therefore, a symptom in itself is neither exertional nor nonexertional. Rather, it is the nature of the functional limitations or restrictions caused by an impairment-related symptom that determines whether the impact of the symptom is exertional, nonexertional, or both.
• The application of the medical-vocational rules in appendix 2 of subpart P of Regulations No. 4 depends on the nature of the limitations and restrictions imposed by an individual's medically determinable physical or mental impairment(s), and any related symptoms.
• Social Security Ruling 96-9p: IMPLICATIONS OF A RESIDUAL FUNCTIONAL CAPACITY FOR LESS THAN A FULL RANGE OF SEDENTARY WORK. Guidelines for evaluating the ability to do less than a full range of sedentary work.
• 20 CFR 404.1512, Evidence of your impairment (burden of proof shift).
• 20 CFR 404.1563, Your age as a vocational factor.
• 20 CFR 404.1564, Your education as a vocational factor.
• 20 CFR 404.1565, Your work experience as a vocational factor.
• 20 CFR 404.1566, Work which exists in the national economy.
• 20 CFR 404.1567, Physical exertion requirements (sedentary, light, medium, etc., defined).
• 20 CFR 404.1568, Skill requirements.
• 20 CFR 404.1569, Listing of Medical-Vocational Guidelines in appendix 2.
• 20 CFR 404.1569a, Exertional and nonexertional limitations (defines both).

Continuing or Stopping Disability or Blindness

• 20 CFR 404.1579, How we will determine whether your disability continues or ends.
• 20 CFR 404.1594, How we will determine whether your disability continues or ends.
• 20 CFR 416.994, How we will determine whether your disability continues or ends.
• 20 CFR 404.1571, How we will determine whether your disability continues or ends.
• 20 CFR 404.1572, How we will determine whether your disability continues or ends.
• 20 CFR 404.1573, How we will determine whether your disability continues or ends.
• 20 CFR 404.1574, How we will determine whether your disability continues or ends.
• 20 CFR 404.1575, How we will determine whether your disability continues or ends.

• 20 CFR 416.988 Your responsibility to tell us of events that may change your disability or blindness status.
• 20 CFR 416.989 We may conduct a review to find out whether you continue to be disabled.
• 20 CFR 416.989a We may conduct a review to find out whether you continue to be blind.
• 20 CFR 416.990 When and how often we will conduct a continuing disability review.
• 20 CFR 416.991 If your medical recovery was expected and you returned to work.
• 20 CFR 416.992 The trial work period.
• 20 CFR 416.992a The reentitlement period.
• 20 CFR 416.993 Medical evidence in continuing disability review cases.
• 20 CFR 416.994 How we will determine whether your disability continues or ends.
• 20 CFR 416.994a How we will determine whether your disability continues or ends, and whether you are and have been receiving treatment that is medically necessary and available, disabled children.
• 20 CFR 416.995 If we make a determination that your physical or mental impairment(s) has ceased, did not exist or is no longer disabling (Medical Cessation Determination).

Medicare Part A - Disability Beneficiaries

• 20 CFR 406.12 Individual under age 65 who is entitled to social security or railroad retirement disability benefits (25-month requirement; deemed retroactive entitlement; duration; SGA).

SSR TABLE RELATED TO PARTICULAR LIMITATIONS