What Medical Evidence Is Required by Social Security Disability?

Social Security disability needs timely, accurate, and sufficient medical evidence. Here's what that means.

By , M.D. | Updated by Nicole Moberg, Attorney
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For a Social Security disability (or SSI) case, medical evidence takes many forms, including physician examination and treatment notes, mental health records, bloodwork panels, and reports of imaging studies (MRI, CT scan, and X-rays). Timely, accurate, and sufficient medical evidence from your treating doctors can eliminate the need for the Social Security Administration (SSA) to obtain additional medical evidence, which means you can get a faster determination on your disability claim.

What's the Best Type of Evidence to Give to Social Security?

Social Security wants to see information in your medical records that's timely, accurate, and sufficient. Here's what this means.

Timely Records

Timely records are recent enough to be relevant to your current medical condition. How recent is a matter of medical judgment, depending on the disorder. A condition that is rapidly changing requires more up-to-date information than one that is slowly progressive or unchanged for years. Generally, the SSA likes to have records no older than six months, though for some conditions, they'll want to see doctor's treatment notes that are no older than three or four months. That doesn't mean older records aren't important. Records dating back for many years may help provide the medical big picture.

Accurate Records

Accurate records correctly describe your condition according to the standards of "acceptable medical sources". (Acceptable medical sources are medical doctors, osteopaths, physician assistants, nurse practitioners, and in some cases, licensed psychologists, audiologists, and optometrists.)

To use a common example, a chiropractor can describe subluxation (slippage) of your spine on X-rays, but Social Security won't consider this opinion as accurate if an acceptable medical source reports the X-rays are normal. (Social Security doesn't consider a chiropractor's records and notes as evidence of an impairment because chiropractors are not medical doctors, but the X-rays taken by a chiropractor can be admissible as evidence.)

Also, if Social Security has objective evidence that conflicts with your doctor's medical opinion, the agency won't consider that opinion to be accurate. For instance, if your doctor's records that say you can't walk one block because of chest pain, but you've had specific exercise testing shows that you can do much more exercise, Social Security will reject your doctor's opinion.

Sufficient Medical Records

Sufficient medical records contain enough accurate information from acceptable medical sources to allow the SSA to make an independent medical judgment regarding the nature and severity of your medical condition. For example, simply having a doctor's note with an allegation and diagnosis of cancer is not sufficient. The SSA will want to know:

  • Did a biopsy prove the cancer's presence?
  • What is the exact type of cancer?
  • Where in the body is the cancer?
  • When did symptoms fisrt appear?
  • What did a physical examination show?
  • What did X-rays and other imaging tests show?
  • What did blood tests show?
  • Did you have surgery?
  • Did the surgery remove all of the cancer?
  • Did you have chemotherapy?
  • What side effects did you suffer form the chemo, if any?
  • Did you have radiation therapy?
  • What were the results of the radiation therapy?

(Read more about the medical evidence required for disability based on cancer. Similarly, the evidence requirements for HIV-AIDS disability are specific and involved.)

Social Security will also consider the effects of your symptoms, so your medical records should include evidence of:

  • your daily activities—what you can and can't do
  • the location, duration, frequency, and intensity of your pain or other symptoms
  • "precipitating factors" (things that cause or trigger symptoms)
  • "exacerbating factors" (things that make your symptoms worse)
  • the type of medication you're taking, including the dosage, whether or not the medication helps your symptoms, and whether you experience any side effects
  • anything that you do to relieve pain or other symptoms, and
  • any other factors about your symptoms that limit your ability to function.

"Longitudinal" Medical Records

It isn't enough for your doctor to start keeping detailed records when you apply for disability. The SSA would like to see "longitudinal" records—that is, records that include your medical history over a number of months or year, especially if you hope to get retroactive disability benefits.

For example, say you were sick for six months before you applied for disability and were unable to work during that time. You could be eligible for a retroactive award of benefits for the six months you couldn't work. But if your doctor doesn't have detailed medical records for the entire time period you were sick, you might not be able to prove you were unable to work during those six months.

How Far Back Does Social Security Look at Medical Records?

Social Security will generally consider all medical records for disability that are relevant to your claim and the medical conditions that you claim are disabling. Relevant records are records that cover the period of time you're claiming you've been disabled. The time period starts with your "alleged onset date" (AOD) and remains ongoing, unless the medical condition got better. (To learn more, see our article about impairments that get better before a hearing is conducted.)

For example, if you tell Social Security that your onset date is January 1, 2019, you're telling Social Security that, as of January 1, 2019, you were no longer able to work—this is the "start date" of your disability, your AOD. To be found disabled back to the date your AOD, you must have medical records going back that far. Even if that means the medical records are several years old, Social Security will review them.

Are There Types of Records That Aren't Helpful to My Claim?

The SSA can't evaluate medical records that are scribbled and unreadable, nor can they evaluate medical records that lack significant information about your condition.

Unfortunately, many records don't contain enough information for Social Security to determine disability. For example, many people apply for disability benefits based on their arthritis. When the disability examiners review the records provided by the treating doctor, often the file contains a few scribbles that the patient has joint pains and arthritis, and further notes that some form of treatment has been given. The medical records might contain no description of diseased joints, no range of motion test results, and no x-rays. The SSA spends extensive time and money each year obtaining data by sending applicants to consultative examinations, X-rays, and other lab tests.

Here's another example. To qualify for disability based on epilepsy, you must have had a certain number of seizures during a specified time period, and your medical records must include a description of a typical seizure. But physicians—even neurologists who specialize in treating epileptics—often don't record the number of seizures a patient has had between visits, even though they should, in the event an adjustment of medication might be needed. Nor do physicians usually describe a seizure in detail in their records, though they will note the type of seizure involved and the drugs given. Medical records are often missing a number of other items that the SSA requires to evaluate the severity of epilepsy, such as whether or not you cooperate in taking medication and the blood levels of the drugs used to treat the epilepsy. (Read more about the disability requirements for epilepsy.)

What Medical Records Are the Most Helpful to Disability Claims?

The best medical records for disability are those from your doctor that are typed, mention all of your complaints, show the results of examinations, note what treatment was given, state your response to treatment, and mention future plans and a prognosis.

The medical records that often carry the most weight with Social Security are "medical source statements" from your treating physician. Your treating physician (a doctor you see regularly) will generally know your medical condition better than any other source. RFC forms are an ideal way for your doctor to let the SSA know what your symptoms and limitations are.

If you know your medical evidence is lacking, you may want to learn about how a disability attorney can develop the medical evidence that will best help your case.

Updated January 28, 2022

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