Obtaining helpful medical documentation for Huntington, West Virginia Social Security disability claimants and claimants throughout the Tri-State region

Whether through its office in Huntington, West Virginia or Huntington Ashland Ironton, the Social Security Administration requires a lot of medical documentation for disability cases. And the Social Security Administration in West Virginia and nationwide wants to see medical test results not just conclusions from your treating doctor. Doctor’s conclusions alone are usually insufficient.

Why obtaining medical documentation is so important for West Virginia Social Security disability cases

The West Virginia Social Security Administration has two sets of regulations that are very important in determining disability. One set, called the Listing of Impairments, consists of medical findings for many common physical and mental impairments (and some that are not so common), which, if present, require that a claimant be found disabled even without looking at whether a claimant can do his or her past relevant work. The Listings are available on the Internet at http://www.socialsecurity.gov/disability/professionals/bluebook/index.htm. When a claimant’s impairment meets the criteria set forth in the Listing of Impairments, the claimant is said to “meet the Listings” and is found disabled.

The other set of regulations, called the Medical-Vocational Guidelines, are used only when a claimant cannot be found disabled using the Listing of Impairments and only after a claimant shows that he or she cannot do any past relevant work. The Medical-Vocational Guidelines directly apply only to physical impairments that cause exertional limitations, but they are to be used as a framework for decision-making in other cases, as well. These rules state whether a claimant is or is not disabled when a claimant has certain combinations of age, education, work experience and residual functional capacity.

Objective medical findings are very important in Huntington, West Virginia Social Security disability cases because, for the Social Security Administration, the issue of meeting the Listings is one more of medical fact than medical opinion. When dealing with the Listings, the Social Security Administration in West Virginia and nationwide regards the treating doctor mostly as a source of medical evidence. However, the Social Security Administration will not ignore a treating doctor’s opinion, and, in practice, many administrative law judges will carefully consider any well-supported opinion that a claimant’s impairment meets or equals the Listings. However, the determination of whether or not a claimant meets the Listings is an issue reserved to the Social Security Administration not the treating doctor. To make these determinations, the Social Security Administration carefully considers your file’s medical documentation.

What medical documentation to obtain for your West Virginia disability claim

Because of its importance, we work hard to obtain medical documentation for all our Huntington, West Virginia Social Security disability cases. However, not all medical documentation is helpful for a case.

The following are some examples of medical documentation that is often not useful:

records concerning routine medical care for matters having nothing to do with your disability (such as gynecological records);
nurse’s notes, doctors’ orders and other miscellaneous records from a hospitalization; and
records from more than a year before the alleged onset date (except in cases where the impairment is a slowly progressing impairment and/or a worsening episodic impairment).

The above items seldom add anything to a case. We will often not obtain or submit these types of items.

However, there are West Virginia disability cases where we will need to obtain absolutely every piece of medical evidence that exists. For example, if you have chronic fatigue or fibromyalgia, we will need to prove that you are disabled by an impairment that has few objective signs or you will lose. In these cases, we collect all the medical records, including records that include statements from you about activities of daily living, work activity and work capacity, and treatment records (even those involving gynecological records, etc.). For every record we submit, we will explain how it relates to our theory for the case.

Helpful medical documentation for Huntington, West Virginia disability cases

The medical records we obtain will depend on our theory of the case. For example, hospital records concerning an acute illness are less important than the records generated after a claimant has been stabilized from the illness. This is because the issue in most cases is whether the claimant can work after recovering from the acute phase of an illness rather than whether the claimant can work when hospitalized.

Depending on your disability case’s theory, we will gather:

admission histories and physicals;
all reports by medical consultants;
physical therapy evaluations and reports;
surgical/operative reports;
emergency room records;
pathologist’s reports; and
discharge summaries and test results pertaining to the claimant’s impairment, such as a lab reports, radiologist reports, nerve condition/EMG reports, and nuclear medicine reports.

For your case, we also collect copies of your medical records and documentation such as a complete list of your medical providers.

We will make sure that your case file contains the actual test results for all significant positive tests, and that those results are consistent with the Social Security Administration’s specific requirements for particular kinds of medical evidence. For example, the Social Security Administration in West Virginia requires copies of the electrocardiogram tracings in addition to the cardiologist’s interpretation of them for a cardiac case.

If negative records exist in your case, we will also submit those and will refine our case theory to account for the existence of such records.

Medical sources of medical documentation

There are various medical sources that provide medical documentation, and the Social Security Administration in Huntington, West Virginia and nationally classify some medical sources as “acceptable medical sources” and others as “other” medical sources.

Documentation from “acceptable” medical sources

“Acceptable” medical sources include: physicians, osteopaths, podiatrists, optometrists, and psychologists. Acceptable medical sources, such as your treating doctor, can provide information about the nature, severity, extent and duration of your impairments, including observations and opinions about how well you are able to function, the effects of any treatment, including side effects, and how long the impairments are expected to limit your ability to function.

For acceptable medical sources, when the examination or treatment by such healthcare provider is pertinent to your case, we will obtain copies of such provider’s notes in addition to the medical reports. In addition, for mental impairment cases, when we obtain office records from a psychologist we also request copies of all test results, as required by the mental impairment Listings.

Documentation from “other” medical sources

Medical sources that are not on the list of “acceptable medical sources” include: chiropractors, physical and occupational therapists, nurse-practitioners, physicians’ assistants, audiologists, and therapists. These sources are on the Social Security Administration’s list of “other” medical sources; and they are limited to showing the severity of your impairment(s) and how it affects your ability to work.

Chiropractors

Included in the Social Security Administration’s list of “other” medical sources are chiropractors. For a chiropractor’s records and opinions, a few courts will treat a chiropractor’s opinion with the same importance as a physician’s opinion. However, most courts follow the Social Security Administration’s regulation that opinions from “other” medical sources should be used only to show the severity of a claimant’s impairment. Thus, administrative law judges will generally give less weight to a chiropractor’s opinion than an opinion given by a treating physician or even some other medical professionals listed with chiropractors as “other medical sources.”

Therefore, if we have a Huntington, West Virginia disability client with a back problem, we would obtain an opinion concerning his or her back problem from an “acceptable” medical source. We cannot solely rely on a chiropractor’s explanation that a client’s back problem is the result of a spinal misalignment or some other condition. Nonetheless, we will not ignore chiropractor records because, if nothing else, they demonstrate that a claimant was in enough pain to go see a chiropractor.

Physical and occupational therapists

Even though physical and occupational therapists are on the Social Security Administration’s list of “other” medical sources, they can provide invaluable medical documentation. Their summaries, evaluations and notes of treatment, if properly interpreted, may provide the best description of a client’s symptoms and be the best source of information about a client’s range of motion for particular joints.

In addition, sometimes occupational therapists’ records contain a detailed evaluation of a client’s former job and explain why he or she is not now capable of performing that job.

Opinions from “other” medical sources

It is important to note that the Social Security Administration has recognized that depending on the particular facts in a case, and after applying the factors for weighing opinion evidence, an opinion from a medical source who is not an “acceptable” medical source may outweigh the opinion of an acceptable medical source, including the medical opinion of a source who treats the claimant. However, while a treating doctor’s opinion may be given “controlling weight” in a disability case, an opinion from an “other source” can never be given controlling weight.

For example, it may be appropriate to give more weight to the opinion of an “other” medical source if he or she has seen the individual more often than the treating “acceptable” medical source and has provided better supporting evidence and a better explanation for his or her opinion. Giving more weight to the opinion from an “other” medical source than to the opinion from a treating “acceptable” medical source does not conflict with the Social Security Administration’s medical source rules.

Assistance from experienced West Virginia disability lawyers

Two of the ways we help Huntington, West Virginia disability claimants is by making sure that their case files contain the right medical documentation, and by uncovering and presenting the strongest way to present their claims to the Social Security Administration in West Virginia.

If you are not already represented by a West Virginia disability attorney and you want our assistance with your claim, please give us a brief description of your claim using the form to the right.

Huntington Ashland Ironton disability lawyers