Medical Evidence & Social Security Disability

July 5, 2022


When applying for Social Security Disability benefits, medical records play a crucial role in the evaluation of your claim. The core condition of being classified as disabled is having a “medically determinable impairment.”

Without proper medical documentation of your impairments, you have no way to prove the scope of your disability. Let’s break down key components of gathering solid medical records to help you complete the SSDI application process.

Treatment Dates

The Social Security Administration will collect medical records from the providers you list on your initial application. However, they often are not gathering the full and complete evidence from your providers. It is important to make sure that Social Security has records spanning before your alleged onset date. This ensures that they can document the progression of your impairments.

It is also important that you have current medical records. You have to be consistently treating for your alleged impairments to document the sustained nature of your medical issues. If you are not currently treating with a medical professional, not only is there no evidence that you are trying to get better, there is no evidence that your impairments are currently present.

Treatment History

Having the proper dates is of vital importance. But making sure that the records gathered properly document how your impairments have been treated can also make or break your Social Security claim.

Oftentimes, just having the diagnosis listed on chart notes isn’t enough. If you have, for example, degenerative disc disease in the lumbar spine, the professionals examining your file are looking for how you’ve attempted to treat it.

This could include:

  • Physical therapy
  • Steroid injections
  • Pain medications
  • Surgical interventions
  • Etc.

If there isn’t proper documentation of tried and failed attempts to mitigate your conditions, it is unlikely that your medical evidence will be sufficient for a favorable decision.

Medical Imaging

If you are suffering from a condition that can be documented with an x-ray, MRI, CT scan, etc., make sure those reports are included in your medical records, as this will benefit your case. These records are the most objective medical evidence your treating physicians can provide.

Treating Physician Opinions

Written statements from your physician can also hold a lot of weight in your Social Security claim. If you are seeing specialists, physical therapists, mental health counselors, or even your primary care physician, they can often shed light on how your impairments affect you functionally.

Oftentimes, these physicians have been treating you for a long period of time, so they have a better understanding of how your conditions have affected you in the long run, and how they interfere with your ability to sustain work.

Consultative Examinations

Social Security will sometimes schedule an appointment for you to be evaluated by a physician contracted by the Social Security Administration, regarding your specific impairments.

It is always a good idea to attend these evaluations, because it not only demonstrates your willingness to comply with an official evaluation of your disease, but these evaluations can carry a lot of weight with an administrative law judge.

Need Experienced Disability Lawyers in Your Area?

If you are in the process of applying for Social Security Disability benefits, or think you might qualify, consider talking with an attorney who has years of experience in Social Security claims.

At Kapor | Davis & Associates, we have over 40 years of combined experience serving those applying for Social Security Disability benefits. Working with our team can help ensure that the Social Security Administration has your full and complete medical history.

Not only will we be responsible for gathering all of your medical records, but we will also file your appeals, communicate with Disability Determination Services, keep all paperwork organized, and help ensure that you never miss a deadline.

Contact us today for a free consultation.