IV. How does Social Security evaluate various treating physicians’ medical documentation of the patient’s impairments?

The Ruling reads: “We consider the nature of the treatment relationship between the medical source and the claimant…If we find that a treating source’s medical opinion regarding the nature and severity of a person’s impairment(s) is well-supported by medically acceptable clinical and laboratory diagnostic techniques, and the opinion is not inconsistent with other substantial evidence in the case record, we will give it controlling weight.”

If there is conflicting medical evidence in the claimant’s record, Social Security “may seek clarification of any such conflicts in the medical evidence first from the person’s treating or other medical sources…”

If there is insufficient medical evidence to determine disability, Social Security may seek further evidence from treating or other sources; additional existing records may be asked for; more information may be requested from the claimant or others; Social Security may request the claimant undergo a consultative examination by an independent examiner of their own choosing.

(Note: The claimant must accept and attend such an examination or Social Security may deny benefits. Hence it is important to provide sufficient evidence from physicians, when possible, to avoid a consultative examination.)