SSR 96-2p: Giving Controlling Weight to Treating Source Medical Opinions

SSR 96-2p
EFFECTIVE/PUBLICATION DATE: 07/02/96
SSR 96-2p: POLICY INTERPRETATION RULING TITLES II AND XVI: GIVING CONTROLLING
WEIGHT TO TREATING SOURCE MEDICAL OPINIONS
PURPOSE: To explain terms used in our regulations on evaluating medical opinions concerning when treating
source medical opinions are entitled to controlling weight, and to clarify how the policy is applied. In particular, to
emphasize that:
1.A case cannot be decided in reliance on a medical opinion without some reasonable support for the opinion.
2.Controlling weight may be given only in appropriate circumstances to medical opinions, i.e., opinions on the
issue(s) of the nature and severity of an individual's impairment(s), from treating sources.
3.Controlling weight may not be given to a treating source's medical opinion unless the opinion is well- supported
by medically acceptable clinical and laboratory diagnostic techniques.
4.Even if a treating source's medical opinion is well- supported, controlling weight may not be given to the opinion
unless it also is "not inconsistent" with the other substantial evidence in the case record.
5.The judgment whether a treating source's medical opinion is well-supported and not inconsistent with the other
substantial evidence in the case record requires an understanding of the clinical signs and laboratory findings
and what they signify.
6.If a treating source's medical opinion is well- supported and not inconsistent with the other substantial evidence
in the case record, it must be given controlling weight; i.e., it must be adopted.
7.A finding that a treating source's medical opinion is not entitled to controlling weight does not mean that the
opinion is rejected. It may still be entitled to deference and be adopted by the adjudicator.
CITATIONS (AUTHORITY): Sections 205(a), 216(i), 223(d), 1614(a)(3), and 1631(d) of the Social Security Act, as
amended; Regulations No. 4, sections 404.1502 and 404.1527, and Regulations No. 16, sections 416.902 and
416.927.
PERTINENT HISTORY: Our regulations at 20 CFR 404.1502, 404.1527, 416.902, and 416.927 were revised on
August 1, 1991, to define who we consider to be a "treating source" and to set out detailed rules for evaluating treating
source medical opinions and other opinions. Among the provisions of these rules is a special provision in 20 CFR
404.1527(d)(2) and 416.927(d)(2) that requires adjudicators to adopt treating source medical opinions (i.e., opinions on
the issue(s) of the nature and severity of an individual's impairment(s)) in one narrowly defined circumstance. As we
stated in the preamble to the publication of the final rules:
The provision recognizes the deference to which a treating source's medical opinion should be entitled. It does
not permit us to substitute our own judgment for the opinion of a treating source on the issue(s) of the nature
and severity of an impairment when the treating source has offered a medical opinion that is well-supported by
medically acceptable clinical and laboratory diagnostic techniques and is not inconsistent with other substantial
evidence.
FR 36932, 36936 (1991).
POLICY INTERPRETATION:
Explanation of Terms
Controlling weight. This is the term used in 20 CFR 404.1527(d)(2) and 416.927(d)(2) to describe the weight we give
to a medical opinion from a treating source that must be adopted. The rule on controlling weight applies when all of the
following are present:
1.The opinion must come from a "treating source," as defined in 20 CFR 404.1502 and 416.902. Although
opinions from other acceptable medical sources may be entitled to great weight, and may even be entitled to
more weight than a treating source's opinion in appropriate circumstances, opinions from sources other than
treating sources can never be entitled to "controlling weight."
2.The opinion must be a "medical opinion." Under 20 CFR 404.1527(a) and 416.927(a), "medical opinions" are
opinions about the nature and severity of an individual's impairment(s) and are the only opinions that may be
entitled to controlling weight. (See SSR 96-5p, "Titles II and XVI: Medical Source Opinions on Issues Reserved to
the Commissioner.")
3.The adjudicator must find that the treating source's medical opinion is "well-supported" by "medically
acceptable" clinical and laboratory diagnostic techniques. The adjudicator cannot decide a case in reliance on a
medical opinion without some reasonable support for the opinion.
4.Even if well-supported by medically acceptable clinical and laboratory diagnostic techniques, the treating
source's medical opinion also must be "not inconsistent" with the other "substantial evidence" in the individual's
case record.
If any of the above factors is not satisfied, a treating source's opinion cannot be entitled to controlling weight. It is an
error to give an opinion controlling weight simply because it is the opinion of a treating source if it is not well-supported
by medically acceptable clinical and laboratory diagnostic techniques or if it is inconsistent with the other substantial
evidence in the case record. However, when all of the factors are satisfied, the adjudicator must adopt a treating
source's medical opinion irrespective of any finding he or she would have made in the absence of the medical opinion.
For a medical opinion to be well-supported by medically acceptable clinical and laboratory diagnostic techniques, it is
not necessary that the opinion be fully supported by such evidence. Whether a medical opinion is well-supported will
depend on the facts of each case. It is a judgment that adjudicators must make based on the extent to which the
opinion is supported by medically acceptable clinical and laboratory diagnostic techniques and requires an
understanding of the clinical signs and laboratory findings in the case record and what they signify.
It is not unusual for a single treating source to provide medical opinions about several issues; for example, at least one
diagnosis, a prognosis, and an opinion about what the individual can still do. Although it is not necessary in every case
to evaluate each treating source medical opinion separately, adjudicators must always be aware that one or more of
the opinions may be controlling while others may not. Adjudicators must use judgment based on the facts of each
case in determining whether, and the extent to which, it is necessary to address separately each medical opinion from
a single source.
Medically acceptable. This term means that the clinical and laboratory diagnostic techniques that the medical source
uses are in accordance with the medical standards that are generally accepted within the medical community as the
appropriate techniques to establish the existence and severity of an impairment. The requirement that controlling
weight can be given to a treating source medical opinion only if it is well-supported by medically acceptable clinical and
laboratory diagnostic techniques helps to ensure that there is a sound medical basis for the opinion.
Not inconsistent. This is a term used to indicate that a well-supported treating source medical opinion need not be
supported directly by all of the other evidence (i.e., it does not have to be consistent with all the other evidence) as long
as there is no other substantial evidence in the case record that contradicts or conflicts with the opinion.
Whether a medical opinion is "not inconsistent" with the other substantial evidence is a judgment that adjudicators
must make in each case. Sometimes, there will be an obvious inconsistency between the opinion and the other
substantial evidence; for example, when a treating source's report contains an opinion that the individual is significantly
limited in the ability to do work-related activities, but the opinion is inconsistent with the statements of the individual's
spouse about the individual's actual activities, or when two medical sources provide inconsistent medical opinions
about the same issue. At other times, the inconsistency will be less obvious and require knowledge about, or insight
into, what the evidence means. In this regard, it is especially important to have an understanding of the clinical signs
and laboratory findings and any treatment provided to determine whether there is an inconsistency between this
evidence and medical opinions about such issues as diagnosis, prognosis (for example, when deciding whether an
impairment is expected to last for 12 months), or functional effects. Because the evidence is in medical, not lay, terms
and information about these issues may be implied rather than stated, such an inconsistency may not be evident
without an understanding of what the clinical signs and laboratory findings signify.
Substantial evidence. This term describes a quality of evidence. Substantial evidence is "...more than a mere scintilla.
It means such relevant evidence as a reasonable mind might accept as adequate to support a conclusion."
(Richardson v. Perales, 402 U.S. 389 (1971), SSR 71-53c, C.E. 1971-1975, p. 418.) The term is intended to have this
same meaning in 20 CFR 404.1527(d)(2) and 416.927(d)(2). It is intended to indicate that the evidence that is
inconsistent with the opinion need not prove by a preponderance that the opinion is wrong. It need only be such
relevant evidence as a reasonable mind would accept as adequate to support a conclusion that is contrary to the
conclusion expressed in the medical opinion.
Depending upon the facts of a given case, any kind of medical or nonmedical evidence can potentially satisfy the
substantial evidence test. For example, a treating source's medical opinion on what an individual can still do despite
his or her impairment(s) will not be entitled to controlling weight if substantial, nonmedical evidence shows that the
individual's actual activities are greater than those provided in the treating source's opinion. The converse is also true:
Substantial evidence may demonstrate that an individual's ability to function may be less than what is indicated in a
treating source's opinion, in which case the opinion will also not be entitled to controlling weight.
When a Treating Source's Medical Opinion is not Entitled to Controlling Weight
Adjudicators must remember that a finding that a treating source medical opinion is not well-supported by medically
acceptable clinical and laboratory diagnostic techniques or is inconsistent with the other substantial evidence in the
case record means only that the opinion is not entitled to "controlling weight," not that the opinion should be rejected.
Treating source medical opinions are still entitled to deference and must be weighed using all of the factors provided in
CFR 404.1527 and 416.927. In many cases, a treating source's medical opinion will be entitled to the greatest
weight and should be adopted, even if it does not meet the test for controlling weight.
Also, in some instances, additional development required by a case--for example, to obtain more evidence or to clarify
reported clinical signs or laboratory findings--may provide the requisite support for a treating source's medical opinion
that at first appeared to be lacking or may reconcile what at first appeared to be an inconsistency between a treating
source's medical opinion and the other substantial evidence in the case record. In such instances, the treating
source's medical opinion will become controlling if, after such development, the opinion meets the test for controlling
weight. Conversely, the additional development may show that the treating source's medical opinion is not
well-supported by medically acceptable clinical and laboratory diagnostic techniques or may create an inconsistency
between the medical opinion and the other substantial evidence in the case record, even though the medical opinion at
first appeared to meet the test for controlling weight. Ordinarily, development should not be undertaken for the purpose
of determining whether a treating source's medical opinion should receive controlling weight if the case record is
otherwise adequately developed. However, in cases at the administrative law judge (ALJ) or Appeals Council (AC)
level, the ALJ or the AC may need to consult a medical expert to gain more insight into what the clinical signs and
laboratory findings signify in order to decide whether a medical opinion is well-supported or whether it is not
inconsistent with other substantial evidence in the case record.
Explanation of the Weight Given to a Treating Source's Medical Opinion
Paragraph (d)(2) of 20 CFR 404.1527 and 416.927 requires that the adjudicator will always give good reasons in the
notice of the determination or decision for the weight given to a treating source's medical opinion(s), i.e., an opinion(s)
on the nature and severity of an individual's impairment(s). Therefore:
When the determination or decision:
is not fully favorable, e.g., is a denial; or
is fully favorable based in part on a treating source's medical opinion, e.g., when the adjudicator adopts a
treating source's opinion about the individual's remaining ability to function;
the notice of the determination or decision must contain specific reasons for the weight given to the treating
source's medical opinion, supported by the evidence in the case record, and must be sufficiently specific to
make clear to any subsequent reviewers the weight the adjudicator gave to the treating source's medical opinion
and the reasons for that weight.
When the determination or decision is fully favorable and would be even without consideration of a treating
source's medical opinion, the notice of the determination or decision must contain an explanation of the weight
given to the treating source's medical opinion. This explanation may be brief.
EFFECTIVE DATE: This Ruling is effective on the date of its publication in the Federal Register.
CROSS-REFERENCES: SSR 96-5p, "Titles II and XVI: Medical Source Opinions on Issues Reserved to the
Commissioner;" Program Operations Manual System, sections DI 22505.001, and DI 24515.001-24515.003; Hearings,
Appeals, and Litigation Law manual, sections I-2-530, I-2-532, I-2-534, I-2-539, I- 2-540, I-2-825, I-3-111, I-3-712,
I-3-812, and Temporary Instruction 5-310.