Disability Determinations - Medical and Other Evidence
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Disability Determinations - Medical and Other Evidence


Revised December 12, 2011



WAC 388-449-0010What evidence do we consider to determine disability?
WAC 388-449-0015What medical evidence do I need to provide?

WAC 388-449-0010

WAC 388-449-0010

Effective June 1, 2012

WAC 388-449-0010 What evidence do we consider to determine disability?

To determine whether a medically determinable impairment exists, we consider medical evidence from "acceptable medical sources."    "Acceptable medical sources" include:

  1. For a physical impairment, a health professional licensed in Washington State or where the examination was performed:
    1. A physician, which includes:
      1. Medical doctor (M.D.);
      2. Doctor of osteopathy (D.O.);
      3. Doctor of optometry (O.D.) for visual disorders;
      4. Doctor of podiatry (D.P.) for foot disorders; and
      5. Qualified speech-language pathologists, for purposes of establishing speech or language impairments only.
  2. For a mental impairment, professionals licensed in Washington State or where the examination was performed:
    1. A psychiatrist; or
    2. A psychologist;
  3. We accept medical evidence of how your impairment(s) affect your ability to function from treating medical sources once a diagnosis of a medically determinable impairment has been established by an "acceptable medical source” listed in (1) and (2) above, "treating medical sources" include:
    1. All medical professionals listed in (1) and (2) above;
    2. A physician treating you for a mental impairment;
    3. A physician’s assistant for a physical impairments; and
    4. An advanced nurse practitioner for conditions within their certification.
  4. "Other evidence" information from other sources not listed in subsection (1), (2), or (3) of this section who can provide supporting documentation of functioning for impairments established by acceptable medical sources in subsections (1) or (2) of this section. Sources of "other evidence" include public and private agencies, schools, parents, caregivers, employers, and practitioners such as social workers, mental health professionals, naturopaths, chiropractors, physical therapists, and audiologists.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

Clarifying Information

1.    A diagnosis of a disabling impairment must be established by an acceptable medical source. This means report or chart notes from a physician, psychiatrist, or psychologist within the last 5 years.

2.    After a diagnosis of a potentially disabling impairment has been established, we can use medical evidence from treating providers (PAC’s and ARNP) for current medical evidence.

3.    Once we have an impairment established by a doctor, and current medical evidence, then we may, at our discretion, use documentation of how an impairment limits functioning from other sources. Other sources include, but are not limited to:

a.    Chiropractors

b.    Physical therapists

c.    Naturopaths

d.    Therapists

e.    Social workers

f.     Care givers

g.    Employers

h.    Family members


WAC 388-449-0015

WAC 388-449-0015

Effective June 1, 2012

WAC 388-449-0015 What medical evidence do I need to provide?

You must give us medical evidence of your impairment(s) and how they affect your ability to perform regular and continuous work activity. Medical evidence must be in writing and be clear, objective and complete.

  1. Objective evidence for physical impairments means:
    1. Laboratory test results;
    2. Pathology reports;
    3. Radiology findings including results of X rays and computer imaging scans;
    4. Clinical finding, including but not limited to ranges of joint motion, blood pressure, temperature or pulse; and documentation of a physical examination; and
    5. Hospital history and physical reports and admission and discharge summaries; or
    6. Other medical history and physical reports related to your current impairments.
  2. Objective evidence for mental impairments means:
    1. Clinical interview observations, including objective mental status exam results and interpretation.
    2. Explanation of how examination findings meet the clinical and diagnostic criteria of the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM).
    3. Hospital, outpatient and other treatment records related to your current impairments.
    4. Testing results, if any, including:
      1. Description and interpretation of tests of memory, concentration, cognition or intelligence; or
      2. Interpretation of medical tests to identify or exclude a connection between the mental impairment and physical illness.
  3. Medical evidence sufficient for a disability determination must be from a medical professional described in WAC 388-449-0010 and must include:
    1. A diagnosis for the impairment, or impairments, based on an examination performed by an acceptable medical source defined in WAC 388-449-0010 within five years of application;
    2. A clear description of how the impairment relates to your ability to perform the work-related activities listed in WAC 388-449-0005;
    3. Documentation of how long a condition has impaired your ability to perform work related activities;
    4. A prognosis, or written statement of how long an impairment will impair you ability to perform work related activities; and
    5. A written statement  from a medical  professional (defined in WAC 388-449-0010) describing what you are capable of doing despite your impairment (medical source statement) based on an examination performed within ninety days of the date of application or the forty-five days before the month of disability  review.
  4. We consider documentation in addition to objective evidence to support the acceptable medical source or treating provider’s opinion that you are unable to perform substantial gainful employment, such as proof of hospitalization.     
  5. When making a disability decision, we don’t use your report of symptoms as evidence unless objective evidence shows there is an impairment that could reasonably be expected to produce those symptoms.
  6. We don't use symptoms related to substance abuse or a diagnosis of addiction or chemical dependency when determining disability if we have evidence substance use is material to your impairment(s).
  7. We consider substance use to be material to your impairment(s) if you are disabled primarly because of drug or alcohol abuse or addition.
  8. If you impairment will persist at least sixty days after you stop using drugs or alcohol, we do not consider substance use to be material to your impairment.
  9. If you can't obtain medical evidence sufficient for us to determine if you are likely to be disabled without cost to you, and you meet meet the other eligibility conditions in WAC 388-400-0060, we pay the costs to obtain objective evidence based on published payment limits and fee schedules.
  10. We determine the likelihood of disability based solely on the objective information we receive. We are not obligated to accept another agency's or person's decision that you are disabled or unemployable.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

Clarifying Information

1.    Statements regarding how impairments limit a person’s functioning must be consistent with objective medical evidence.

2.    When determining if a medically determinable condition exists, we only use diagnosis of conditions that will produce potentially disabling symptoms or impairments. These symptoms can either be the direct result of the disease or injury, or as a result of treatment for the condition.

      Examples of diagnosis that don’t qualify as a diagnosis of a potentially disabling condition:

a.    ADHD, and other learning disorders,  are not considered  disabling conditions for adults by SSA and cannot be used as a disabling condition for ABD.

b.    Hypertension is typically asymptomatic and therefore is expected produce potentially disabling symptoms.

c.    Hepatitis is also typically asymptomatic or produces mild symptoms. if the disease has progressed, interferon treatment could result in significant fatigue, but way not meet the duration requirement for disability.

d.  Bereavement or grief is not acceptable diagnosis. While the severity may be temporarily disabling, it is not reasonable to expect the condition for 12 months or more.

3.   Pain cannot be used as a diagnosis. There must be a medically determinable condition (diagnosis of an injury or disease). Once the diagnosis has been established by an acceptable medical source, then written evidence from other treating professionals or non-medical sources can be used to determine how the impairment affects the person’s ability to function.


EXAMPLE

Milly has a diagnosis of degenerative disc disease from a physician. Her MRI indicates moderate stenosis. Milly provides a letter from her daughter describing how her mother complains of tingling sensation in her hands and that she has recently seen her mother drop objects that weigh more than 10 lbs.

Since Milly has a medically determinable condition that could result in the symptoms described, her daughters statement can be used to help determine the severity of her impairments and her exertional level.


EXAMPLE

Bart states that pain in his knee keeps him from working. The physician who examined him found mild edema, but no crepitus, or other abnormal findings, and Bart’s gait and station were noted as WNL. Bart also provided a statement from a physician’s assistant (PAC) that he had seen previously that stated Bart was limited to sedentary work due to knee pain.

Since Bart does not have a medically determinable condition, the statement from the PAC can’t be used to when making a determination of disability.

Modification Date: December 12, 2011