The Social Security Administration (SSA) has issued a ruling regarding evaluation of symptoms. This ruling rescinds SSR 96-7p and eliminates the term “credibility” from policy.
In evaluating symptoms, SSA first determines whether there is an underlying medically determinable physical or mental impairment that is reasonably expected to produce the individual’s symptoms. Medical signs or laboratory findings must show a medically determinable impairment. SSA does not consider whether the severity of the alleged symptoms is supported by objective medical evidence.
If there an underlying physical or medical impairment, then SSA evaluates the intensity and persistence of the symptoms to determine the extent to which the symptoms limit an individual’s ability to perform work-related activities for an adult, or to function independently in an age-appropriate manner for children. In considering the intensity, persistence and limiting effects of an individual’s symptoms, SSA examines the entire case record, including objective medical evidence, the individual’s statements, other information provided by medical sources and individuals and any other relevant evidence in the record.
SSA first examines objective medical evidence. However, an individual’s statements about intensity, persistence and limiting effects of symptoms cannot be disregarded because objective medical evidence does not substantiate the degree of impairment the individual alleges.
If objective medical evidence does not allow for a fully favorable decision, then SSA considers other evidence, including the individual’s statements, medical sources, and non-medical sources. Factors SSA considers are: daily activities; location, duration, frequency, and intensity of pain or other symptoms; factors that precipitate and aggravate symptoms; dosage, effectiveness and side effects of medication; treatment other than medication and other measures used to relieve symptoms such as lying on the back or sleeping on a board.
If the individual’s statements are consistent with objective medical evidence, SSA will determine that the symptoms are more likely to reduce capacity for work related activities. SSA also considers the consistency of the individual’s statements. However, inconsistent statements do not necessarily mean statements are inaccurate because symptoms may vary, worsen or improve over time.
SSA considers attempts to seek and follow medical treatment once it is prescribed in evaluating symptom intensity and persistence. However, SSA will not find an individual’s symptoms inconsistent with the evidence without considering possible reasons for not seeking or complying with treatment. Factors SSA may consider include: the individual may have structured activities to reduce symptoms to a tolerable level, the individual may receive periodic treatment or evaluation for medication refills because symptoms have plateaued, medication side effects are less tolerable than the symptoms, inability to afford treatment, a medical source advises that there is no further effective treatment, or a mental impairment limits the ability to understand the need for treatment.
Determinations or decisions must contain specific reasons for the weight given to symptoms consistent with and supported by the evidence, and be clearly articulated to allow the individual and any subsequent reviewer to assess how the adjudicator evaluated the symptoms. Adjudicators cannot assess overall character or truthfulness. Adjudicators can only focus on the evidence presented. SSR 16-3p (March 28, 2016).