12. What medical information must DES gather and consider?

Once DES receives a completed medical report, Disability Supplement and any other medical information sent by the local DTA office, DES must:

  • Follow up on any missing information before making a decision to deny your disability. DES must contact your doctor and other health care providers if this missing information is needed to make a decision on your disability. 106 C.M.R. § 703.191(H), § 702.315(B)(2)(a) and DES Procedural Standard 99-3 (September 7, 2009).
  • Schedule an evaluation for you by an independent doctor (a "consultative exam" or “CE”) if they decide that there is not enough information in your EAEDC disability file to make a determination. 106 C.M.R. § 702.315(B)(2)(b).
    • You must cooperate with this evaluation unless you have a very good reason not to. Otherwise your benefits can be denied.
    • DES is required to make an effort to contact your treating source(s) before scheduling a consultative exam. See DES Procedural Standard 00-3 (December 5, 2011) regarding consultative exams.

Example: John, who is 55 years old, suffers from chronic obstructive pulmonary disease. His doctor said that John meets the EAEDC medical standards, listed the tests she had ordered, and detailed the limitations on John's ability to walk and stand. However, because the doctor didn't include the laboratory tests, DES must contact the doctor or the laboratory to get these test results. If the medical information sent to DES is not sufficient for DES to decide John is disabled, DES should follow up on any other missing information and schedule a further evaluation (CE) if necessary.

After DES completes its review, DES communicates their findings to DTA through the DES Disability Tracking Form, see sample in Appendix C.

Advocacy Reminders:

  • DES has to give controlling weight to treating source (your doctor’s) medical opinions over opinions of non-treating sources, such as consultative examiners. Your doctor’s opinions have to be supported by medically acceptable clinical and laboratory diagnostic techniques and need to be consistent with other substantial medical and non-medical evidence in your disability file. See DES Procedural Standard 08-2 (May 8, 2009).
  • DES cannot deny your disability without a complete medical file.  If any medical evidence within the prior 12 months is missing, DES has to try to collect this evidence. This may include contacting your doctor to see if the evidence is available, asking that doctor to complete missing tests or send in missing information, or scheduling a consultative exam to be done by another doctor. See DES Procedural Standard 11-1 (November 20, 2012).
  • If you are unable to attend a consultative exam (CE), call DES in advance or within 72 hours of a missed appointment to reschedule. The first time you call, DES has to accept any reasonable excuse why you are not able to go. If you call another time to reschedule the same exam, you will have to show more specific reasons. For example, a court date, school or work conflict, illness, or breakdown in transportation, etc. DES may ask you to show proof of the reason. See DES Procedural Standard 98-5 (May 27, 2014).
  • If you do not attend your CE and do not call DES, DES will make a decision based on the incomplete medical information in your file. See DES Procedural Standard 98-5 (May 27, 2014).
  • Consult with an advocate if you missed your CE and are unable to reschedule.
  • If you are deaf or speak a foreign language, DES must provide an interpreter for the consultative exam if you need one.
  • DES does not provide transportation to CEs for EAEDC applicants but has to try to schedule your CE with a provider whose office is within 10 miles or less from your home. DES also can arrange for your psychological CE to take place at the local DTA office. See DES Procedural Standard 11-1 (November 20, 2012).
  • If DES reviewed your case in the past for EAEDC, TAFDC or MassHealth disability purposes, the prior case record should be reviewed to determine whether any of the medical evidence is relevant to the current assessment. See DES Procedural Standard 08-1 (September 7, 2009).
  • DES is obligated under the Americans with Disabilities Act to provide assistance or other accommodations to people with disabilities. Ask your DTA worker for help. See Question 79 and DES Procedural Standard 11-1 (November 20, 2012).
11. What is the Disability Evaluation Service (DES)?
13. How does DES evaluate my disability?