I-2-5-20.Consultative Examinations and Tests
Last Update: 9/28/05 (Transmittal I-2-68)
If the claimant does not provide adequate evidence about his or her impairment(s) for the ALJ to determine whether the claimant is disabled or blind, and the ALJ or the HO staff is unable to obtain adequate evidence from the claimant's treating source(s) or other medical source(s), the ALJ may request a CE(s) and/or test(s) through the State agency.
An ALJ should request only the specific examination(s) or test(s) that he or she needs to make a decision. For example, an ALJ should not request a complete medical examination if the only evidence needed is a special test (such as an x-ray, blood study or electrocardiogram) or a medical source statement of the claimant's ability to do work-related activities.
A. Requesting a CE
When requesting a CE, the ALJ or HO staff should provide the State agency with the following:
A “Request for DDS Assistance in Obtaining Consultative Examination(s)” (and other medical evidence as indicated) [HA-4489]. To access this document, go to the Document Generation System (DGS) and click on the tab “CE and Evidence Request” then click on the “Request for DDS Assistance in Obtaining a Consultative Examination” tab. The ALJ or HO staff should request a medical source statement by checking the appropriate block. Specific information, including the type of evaluation and any specific test(s), including any equivalent test(s), requested by the ALJ should be clearly stated.
Signed and dated Form SSA-827, Authorization to Disclose Information to the Social Security Administration (SSA).
The Form SSA-827 was revised in February 2003 to comply with the Health Insurance Portability and Accountability Act (HIPAA). The form carries an expiration date of 12 months from the date signed. If there is no signed and dated SSA-827 (2-2003 edition or later) in the claim file, or if there is one but the 12-month period has expired or will expire within 30 calendar days, annotate the Specific Information Requested section of the “Request for DDS Assistance” (Form HA-4489) with “Updated SSA-827 Needed”. This will alert the State agency to take steps to have the claimant provide a new authorization.
A medical exhibits folder which contains evidence relating to the type of examination ordered with instructions for the State agency to send the folder to the consultative examiner for review. (See I-2-5-22, Medical Exhibits Folder.)
A medical source statement form (i.e., HA-1151, Medical Assessment of Ability to Do Work-Related Activities (Physical), or HA-1152, Medical Assessment of Ability to do Work-Related Activities (Mental), but only if directed by the ALJ. To access these documents, go to DGS, click on the “CE and Evidence Request,” then click on the “Medical Source Physical” tab or the “Stand Alone Medical Source Statement” then you can choose either the physical or mental medical source statement.
The name, email address and telephone number of a person in the HO that the State agency may contact.
A postage-paid return envelope suitable for the evidence requested.
In the electronic environment, the provider will be given the number to the DDS fax scanner. DDS will electronically notify OHA when the evidence is received.
The HO staff will place a copy of the CE request in the CF and will add a development action to the CPMS record.
B. Requesting Specific Tests
If an ALJ decides that he or she needs the results of a specific medical test(s) to make a decision, the ALJ may request the State agency to arrange for the test(s) to be performed either in conjunction with a CE or alone. Whenever possible, the ALJ should indicate that an equivalent test(s) may be substituted for the specific test(s) requested.
Some diagnostic tests or procedures, such as treadmill exercise testing, may involve significant risk to the claimant. The State agency medical consultant will review the evidence and determine whether a requested diagnostic test or procedure involves significant risk. (See I-2-5-26, State Agency Physician Determines that Requested Tests Would Involve Significant Risk.)
When requesting a State agency to have a specific medical test(s) performed in conjunction with a CE or alone, the ALJ or HO staff should provide the State agency with the information described above in subsection A., and describe the specific medical test(s) in section 3 (Specific Information Requested) of the HA-4489.
The HO staff will place a copy of the request in the CF and will add a development action to CPMS.
Requesting Medical Test Data
See I-2-5-14.D., Medical Test Data, which discusses requesting background medical test data (e.g., X-ray films, and “raw” psychological test data such as answer sheets or drawings). Because consulting sources are, by regulation, subject to special oversight provisions, as described in 20 CFR §§ 404.1519p through 404.1519t and 416.919p through 416.919t, it should not be necessary to request background medical test data from consulting sources.
C. Selecting the Medical Source Who Is to Conduct the CE or Test(s)
The ALJ usually will not need to specify a particular medical source to conduct a CE or test. Because SSA considers a claimant's treating source(s) to be the primary source of medical information about a claimant's impairment, the State agency will, if possible, select a treating source who is qualified, equipped, and willing to perform the CE or test for the amount allowed under its fee payment schedule.
An ALJ may request that the State agency use a particular nontreating medical source or other medical source to conduct a CE or test only if the Appeals Council or a court has so ordered.
An ALJ may request that the State agency not use a particular treating, nontreating, or other medical source to conduct a CE or test if he or she has a good reason. If an ALJ requests a State agency to use or not use a particular treating or nontreating medical source to conduct a CE or test, the ALJ must:
provide the medical source's name, address, and telephone number, and explain the reason(s) for the special request; and
place a copy of the special request in the CF.
The State agency may decline to use a particular treating, nontreating, or other medical source to conduct a CE or test if it has a good reason, e.g., the medical source has a history of not providing timely or complete reports. When the State Agency declines to use a particular treating, nontreating or other medical source, the reason should be provided in writing to the ALJ or HO.
D. Follow-up Procedures
If the State agency does not provide the requested evidence by the end of the diary period, the HO staff should follow the procedures in I-2-5-14 C.2.
E. Problems with the State Agency's Response
1. CE Report is Inadequate or Incomplete
If the State agency does not provide a CE report, or provides a CE report that is inadequate or incomplete, the HO staff should follow the procedures in I-2-5-14 C.3.
2. CE Report is Unsigned or Improperly Signed
If the State agency provides a CE report that is unsigned or improperly signed, or if the CF contains such a CE report, which would otherwise be proposed as an exhibit, the HO staff should ask the State agency to obtain a properly signed CE report, and then follow the procedures in E.3., or E.4., below.
A CE source's signature on a report annotated “not proofed” or “dictated but not read” is not acceptable. A rubber stamp signature, or a signature entered by another person is also not acceptable.
In the electronic environment, DDS will scan the signature page of a CE report into the Electronic Folder. The CE report would contain a “wet signature”.
3. Decision Fully Favorable
The ALJ should not delay issuing a fully favorable disability decision pending receipt of a properly signed CE report. The ALJ should issue the fully favorable decision, and the HO staff should send the decision and CF to the appropriate component for effectuation.
4. Decision Less Than Fully Favorable
The ALJ should not use an unsigned or improperly signed CE report as basis for a decision that is less than fully favorable. If the ALJ needs a CE report to issue a decision, but the CE report is unsigned or improperly signed, and the State agency cannot obtain the proper signature on the report, the ALJ should not use the report, but rather should request the State agency to arrange for another CE or test with a different CE source.