The primary evidence for establishing entitlement to Social Security Disability (“SSD”) benefits is a Medical Source Statement (“MSS”). An MSS summarizes the doctor’s medical findings and conclusions, including an opinion about the claimant’s functional abilities. Many administrative law judges (“ALJs”) used to accept an MSS to approve an SSD application.
Section 404.1512 of the Social Security (“SS”) regulations addresses the evidence that a claimant must furnish in order to establish entitlement to SSD benefits, but does not require treatment records. Similarly, the POMS list treatment notes as just one of the many types of evidence that may be submitted, but the POMS also does not provide that treatment notes are required. Nor is there any other written SS rule or regulation that requires the submission of treatment records.
About a year ago, there were discussions about how SS was implementing procedures to reduce the number of SSD applications that were being granted. Coincidentally, it was about that same time that the ALJ who had routinely accepted a MSS to approve an application stopped doing so unless treatment records were also obtained.
So although there is no written rule or regulation that requires treatment notes to establish entitlement to SSD benefits, it is pretty obvious that SS has instituted an unwritten policy to require treatment records. I represent a 50 year old librarian whose SSD application was approved today by an ALJ, but only after the ALJ insisted on receiving treatment records post hearing. Since the treatment records were silent on the issue of functional limitations, it appears that they are being required solely as a credibility test, to confirm that claimant are actually being treated.