Yes. In the experience of this Los Angeles social security lawyer, the Social Security Administration (SSA) routinely ignores the opinions and recommendations of treating doctors when they deem the opinion unsupported by medical evidence. Other times, the SSA may consider a recommendation inconsistent with the patient’s file or outside the area of expertise for the treating physician.
All such cases are reviewed by an Administrative Law Judge (ALJ), who assigns “controlling weight” to a doctor based on how much they feel that doctor’s opinion should count in a treatment or assessment decision.
To a patient, having their physician’s opinions disregarded can prove extremely frustrating, but they can fortunately appeal the decision. Read to learn about the SSA’s decision-making factors the applicant must consider when formulating an appeal.
Treating Physicians and Controlling Weight
Generally speaking, the SSA is expected to honor a treating physician’s opinions and recommendations under two specific criteria:
- The opinions have been well-supported by clinical and laboratory diagnostic techniques recognized by the professional medical community
- The opinions are deemed “not inconsistent” with the rest of the applicant’s file
When both criteria have been met, the SSA will almost always grant “controlling weight” to the physician’s opinion, meaning that they will not attempt to contradict the doctor’s findings or treatment recommendations.
When the SSA or an ALJ Will Give Partial Weight to a Physician
Any time controlling weight is not granted in full, the SSA and their ALJ team will have to evaluate how much weight to give to the physician’s opinion compared to another physician within their system.
To do so, they look to the following factors:
- Duration and frequency of patient interactions — Doctors who have a long, consistent history with patients are usually given more weight than those with limited interactions
- Specialization and area of expertise — Simply put, the SSA will give more weight to a physician if the opinion relates to their area of expertise and their professional role within your care. For example, an Ear Nose and Throat (ENT) doctor will be given less weight regarding an opinion of your heart condition than would a cardiologist.
- Consistency within the patient file — Medical claims that stand out as unusual or potentially exaggerated are often given less weight compared to claims that appear consistent with your medical examination and treatment history
Based on these factors, an ALJ will recommend assigning weight to the treating physician’s opinion. Common recommendations include qualifications like “substantial weight” or “no weight.”
ALJs that do not justify their recommendations properly using factors such as the ones above often enable applicants to have a denial of benefits reversed or remanded.
How Doctors Can Increase Their Opinion’s Weight
In order to increase the chances of having their opinion count as “controlling weight” in a case, doctors should look to medical and laboratory tests held within a high medical standard. They should also document their findings in detail as they relate to the condition.
For instance, a physician should never write “the patient is disabled” since “Disability” in this context refers to a legal designation as determined by the SSA. Instead, they should write to the nature of their patient’s impairment, such as saying “the patient experiences tremendous pain when trying to place weight upon their right hip joint, especially when lifting heavy objects or attempting to raise themselves from a seated position.”
Any observations that could be seen as inconsistent with other findings should be justified by even more documentation than usual, and possibly references to medical literature reinforcing the phenomenon.
One of the most helpful documents in this process is a Residual Functional Capacity form, which can allow the doctor to evaluate typical functions and recommended restrictions. This form should be filled in detail, instead of a physician merely “checking all the boxes.”
Call Colton Social Security Lawyer To Dispute Your Denial
We’ve been helping disabled individuals in the Greater Los Angeles area, the Inland Empire, and Orange County get the disability benefits they need for years. Call Dr. Bill LaTour and his team today at 800-803-5090 or fill out our online form to schedule a free consultation.