Medical Consultants and Specialties for Social Security Disability Claims

After you apply for Social Security disability, your application is sent to a state agency where your claim will be decided. These agencies are often called Disability Determination Services, or DDS. A disability examiner at DDS will request your medical records and complete a medical write-up of your claim, along with a tentative decision. A medical consultant who works for DDS will then review the medical issues in your file and confirm whether you should be approved for benefits.

This article will explain who medical consultants are and what medical consultants do, including the role they play in the Social Security disability determination process.

What Is the Role of the Medical Consultant in Social Security Disability Cases?

The SSDI medical consultant, who is sometimes called the state disability unit physician, is supposed to be the one deciding whether your impairment meets the requirements of a disability listing or whether your residual functional capacity (RFC) is too low to work any jobs. During the medical review process, the medical consultant should develop your RFC if your condition doesn't meet a listing.

Sometimes, however, the claims examiner creates your RFC instead. If this happens, the examiner should at least consult the doctor (medical consultant) on the nature and severity of your medical impairments, as well as what kind of additional medical evidence is needed to decide your claim. The examiner is not allowed to make decisions on medical eligibility without consulting the doctor on these points. The medical consultant must sign off on most claims before they're decided.

Who Are Social Security Medical Consultants?

Medical consultants work for Disability Determination Services, the state agency that makes the initial disability decisions. They usually work as part-time contractors, paid either on an hourly basis or per claim basis, though some medical consultants are paid as employees.

All medical consultants must be M.D.s or D.O.s. (20 CFR § 404.1616(b).) For claims that involve mental impairments, licensed psychologists may act as the medical consultant for the mental portion of the claim. For certain medical conditions, optometrists, podiatrists, or speech-language pathologists may weigh in as medical advisors, though they aren't able to sign off on a disability determination like a medical consultant.

Unfortunately, many DDS offices don't have a full range of specialists among their in-house medical consultants. Most medical consultants work in the fields of family medicine, internal medicine, or psychiatry/psychology. While these generalists are often able to properly evaluate the less complicated cases, more complicated cases require specialists or subspecialists. But some DDS offices don't have cardiologists, orthopedic specialists, neurologists, or ophthalmologists on their staff.

Rules on Medical Consultant Expertise

In claims involving cognitive or mental impairments, the evaluation of mental limitations and disorders must be done by a psychiatrist or psychologist, not a neurologist or internist. For instance, if you applied for disability for a traumatic brain injury, a consultant who is a neurologist can evaluate your diagnosis, but a psychiatrist or psychologist needs to weigh in on your resulting mental and cognitive impairments and limitations.

Another Social Security guideline is that children's claims for physical disabilities should be evaluated by a medical consultant who's a pediatrician, where possible. (The SSA must make "reasonable efforts" to ensure that a qualified pediatrician or specialist evaluates the claim.) (20 CFR § 416.903(e).)

In adult claims for physical impairments, the Social Security Administration (SSA) doesn't have any strict rules about which type of doctor should review your claim. The SSA places more importance on the training that medical consultants receive about the agency's regulatory standards and vocational concepts than it does on the physician's medical specialty.

But if your case is complex and a specialist or subspecialist didn't evaluate your claim, you can raise this issue on appeal. If you're denied disability benefits by Social Security, check your disability file to see if the medical consultant who reviewed your disability application was the appropriate type of doctor and if the consultant had a specialty. For instance, an orthopedic surgeon is the best one to evaluate a complex musculoskeletal disorder, and a cardiologist can best assess a serious heart condition.

How to Find the Medical Consultant's Field of Expertise

You can find the specialty code for the medical consultant who evaluated your claim on Form SSA-831, Disability Determination and Transmittal. This form is the official disability determination document used by Social Security. Your file will have a copy of Form 831, but you won't receive one. To see it, you need to request your disability file.

Most of the information on the front of the form will be of little use to you because of the number of codes used by the SSA. But the form should contain the name and signature of both the disability examiner and the DDS medical consultant who worked on your claim. The number of the medical consultant's specialty code should be near his or her name or signature. The specialty code information can tell you whether the wrong kind of doctor reviewed your claim.

If you find that the medical consultant didn't have a speciality or any medical background on your type of impairment, you or your lawyer can raise this issue on appeal.

Complete List of Social Security's Medical Consultants' Specialty Codes

Here's a list of the specialty codes for medical consultants and what type of doctor they refer to.

Difference Between Medical Consultants and Consultative Examiners

Medical consultants who work for Disability Determination Services are often a part of the decision-making on continuing disability reviews, where the SSA decides whether you've improved enough to go back to work. These reviews are called "consultative exams" or "disability re-evaluations."

But medical consultants who work for DDS are not the doctors who perform consultative exams. SSDI medical consultants only review your medical records (electronically or on paper). Social Security contracts with outside doctors to perform the in-person or virtual consultative exams and pays them for each exam.

Similarly, the medical experts who sometimes appear at ALJ hearings aren't Social Security employees either. They are usually retired doctors whom Social Security hires as expert witnesses. They are paid for each appearance.

This article was based on an excerpt from Nolo's Guide to Social Security Disability, by David Morton, M.D., a former Chief Medical Consultant for Social Security.