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 will then review the medical issues in your file and confirm whether you should be approved for benefits.
The 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. And the medical consultant should develop your RFC if your condition doesn't meet a listing. But sometimes the examiner creates your RFC. 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.
Medical consultants work for Disability Determination Services (DDS), the state agency that makes the initial disability decisions, usually as part-time contractors. All medical consultants must be M.D.s, D.O.s, or, for certain medical conditions, psychologists, optometrists, podiatrists, or speech-language pathologists.
Unfortunately, many DDS offices do not 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.
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 rule is that children's claims for physical disabilities should always be evaluated by a medical consultant who's a pediatrician.
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, 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. 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.
Under Social Security ruling SSR 96-6p, the administrative law judge (ALJ) hearing an appeal or the Appeals Council must take into account the specialization of the medical consultant who decided your claim at DDS.
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 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 any medical background on your type of impairment, you or your lawyer can raise this issue on appeal.
Here is a list of the specialty codes for medical consultants and what type of doctor they refer to.
|1 Anesthesiology||26 Occupational Medicine|
|2 Ambulatory Medicine||27 Oncology|
|3 Audiology||28 Ophthalmology|
|4 Cardiology||29 Orthopedics|
|5 Cardiopulmonary||30 Osteopathy|
|6 Dermatology||31 Pathology|
|7 E.E.N.T. (Eyes, Ears, Nose, & Throat)||32 Pediatrics|
|8 E.N.T. (Ear, Nose, & Throat)||33 Physiatry|
|9 E.T. (Ear & Throat)||34 Physical Medicine|
|10 Emergency Room Medicine||35 Plastic Surgery|
|11 Endocrinology||36 Preventive Medicine|
|12 Family or General Practice||37 Psychiatry|
|13 Gastroenterology||38 Psychology|
|14 Geriatrics||39 Public Health|
|15 Gynecology||40 Pulmonary|
|16 Hematology||41 Radiology|
|17 Industrial Medicine||42 Rehabilitative Medicine|
|18 Infectious Diseases||43 Rheumatology|
|19 Internal Medicine||44 Special Senses|
|20 Neurology||45 Surgery|
|21 Neuro-Ophthalmology||46 Urology|
|22 Neuro-Psychiatry||47 Other|
|23 Neonatology||48 Speech-Language Pathology|
|24 Nephrology||49 Child and Adolescent Psychiatry|
Medical consultants who work for DDS 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. Sometimes these reviews are called "disability re-evaluations."
But medical consultants who work for DDS don't handle "disability evaluations," or "consultative exams." Social Security contracts with outside doctors to perform these 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.
Updated December 1, 2022