Medical evidence is the foundation of every Social Security Disability Insurance (SSDI) claim. The Social Security Administration (SSA) decides whether you're disabled based primarily on your medical records. Without strong medical evidence documenting your condition and its limitations, your claim will likely be denied.
What Medical Evidence SSA Needs
SSA requires evidence of a medically determinable impairment—a condition established through clinical findings, not just your reported symptoms. Your diagnosis must come from acceptable medical sources and be supported by objective medical evidence like imaging, lab tests, clinical examinations, or pathology reports.
Beyond diagnosis, SSA needs evidence of how your condition limits your ability to work. This includes functional limitations such as how long you can sit, stand, or walk; how much you can lift; whether you can concentrate and complete tasks; and how your symptoms affect your daily activities.
Acceptable medical sources include licensed physicians (MD or DO), licensed psychologists, licensed optometrists, licensed podiatrists, and qualified speech-language pathologists. Chiropractors, nurse practitioners, and therapists are "other sources" whose evidence SSA considers but gives less weight.
Longitudinal Medical Records
SSA wants to see consistent medical treatment over time, not just a single evaluation. Longitudinal evidence showing ongoing treatment builds credibility for your claimed limitations. Gaps in treatment can be interpreted as evidence your condition isn't as severe as claimed.
If you can't afford treatment, document this explicitly. SSA should consider your inability to pay for care, but only if you clearly establish financial barriers. Free clinics, community health centers, and hospital charity care programs can help maintain treatment records even without insurance.
Treatment Notes vs. Medical Opinions
Treatment notes are records from your regular appointments documenting symptoms, clinical findings, treatment provided, and response to treatment. Detailed treatment notes showing consistent symptoms and limitations are powerful evidence.
Medical source statements or RFC assessments are opinions from your doctors about your specific functional limitations. These go beyond diagnosis to explain precisely what you can and cannot do. A supportive medical opinion from a treating physician can significantly strengthen your claim.
Ask your treating doctors to complete SSA's physical or mental RFC forms, or to write detailed opinion letters addressing your specific limitations. General statements like "patient is disabled" are less helpful than specific findings like "patient cannot lift more than 10 pounds due to documented lumbar radiculopathy."
SSA's Consultative Examinations
If your medical records are incomplete, SSA will send you to a consultative examination (CE) with a doctor hired by SSA. These exams are typically brief and may not capture the full extent of your limitations. They're designed to fill gaps, not replace ongoing treatment evidence.
CE doctors often minimize findings because they only see you once and have no treatment relationship. Having your own robust treatment records from doctors who know your condition is far more valuable than relying on consultative examinations.
Mental Health Evidence
Mental health claims require evidence from qualified mental health professionals. Regular therapy records and psychiatric treatment notes are essential. One-time psychological evaluations are insufficient to establish ongoing mental illness severity.
Document specific mental health limitations: difficulty concentrating, inability to handle workplace stress, problems interacting with others, inability to maintain regular attendance. Mental health records should note specific functional deficits, not just diagnoses.
Strengthening Your Medical Evidence
See your doctors regularly—gaps in treatment undermine claims. Describe all your symptoms at every visit; don't minimize or only mention the worst problems. Request that doctors document your functional limitations specifically. Bring a written list of concerns to appointments to ensure nothing is missed.
Keep copies of all medical records. SSA is supposed to obtain records, but they sometimes miss providers or get incomplete files. Submitting complete records yourself ensures nothing falls through the cracks.
If your doctors don't support your claim—perhaps they think you can work—you need to understand why and either address their concerns or find providers who better understand your limitations.
Medical Evidence and Appeals
If your initial claim is denied, you'll need additional evidence for your appeal. New medical evidence that better documents your limitations can change the outcome. Consider obtaining specialist evaluations, updated RFC opinions, or detailed letters from treating physicians explaining how your condition meets SSA's disability criteria.
Getting Legal Help
Disability attorneys and advocates understand what medical evidence SSA needs. They can identify gaps in your medical records and help you build a stronger case. Many disability attorneys work on contingency, collecting fees only if you win your claim.