The Social Security Administration (SSA) maintains a list of medical conditions that are so severe they automatically mean that you are disabled. If your condition is not on the list, the SSA must decide if it is of equal severity to a medical condition that is on the list. The rules state that an Administrative Law Judge must consider the opinion of a physician or psychologist designated by the Commissioner concerning medical equivalence whenever a claimant is not engaging in substantial gainful activity and has a severe impairment(s) that does not “meet” the requirements of a listing.
The equaling analysis is often performed by a non-examining State agency physician at the initial and reconsideration levels. However, in most cases there are additional medical records presented before a hearing that were not available at the time of the prior determinations by the SSA.
Social Security Ruling 96-6p requires an Administrative Law Judge to obtain an updated medical opinion from a medical expert in the following circumstances:
- When no additional medical evidence is received, but in the opinion of the Administrative Law Judge or the Appeals Council the symptoms, signs, and laboratory findings reported in the case record suggest that a judgment of equivalence may be reasonable; or
- When additional medical evidence is received that in the opinion of the Administrative Law Judge or the Appeals Council may change the State agency medical or psychological consultant’s finding that the impairment(s) is not equivalent in severity to any impairment in the Listing of Impairments.
Therefore, if an Administrative Law Judge believes that the evidence suggests a medical equivalence may be reasonable, or that additional evidence may change the State agency’s prior medical equivalence determination, an updated opinion about medical equivalence is required.
