POMS Reference

DI 22505: Development of Medical Evidence of Record (MER)

TN 3 (02-01)

A. Policy

1. Evidence From All Sources

  1. Develop evidence, including diagnostic tests, from all sources identified by the individual or discovered during development who have treated or evaluated the individual for the alleged or documented impairment(s) during the applicable 12-month period. Refer to DI 22505.001B.2.

  2. Do not develop evidence from sources about something clearly unrelated to the impairment(s), e.g., cold, flu, toothache.

2. Developing Medical Evidence of Record (MER) Outside of the 12-Month Period

When developing MER outside of the 12-month period:

  1. Use judgment and selectivity based on the facts of the particular case.

  2. Consider technical factors as indicated in DI 22505.001A.3.

3. When Not To Make Routine Requests

Do not make routine requests for medical information to a source who is:

  • Consistently uncooperative, i.e., will not submit information on any patient. Document this on the case development summary (see DI 20503.001E),

  • Deceased, or

  • Retired. (However, most doctors will transfer their records to a successor upon retirement. If the disability determination services (DDS) determines this has occurred, contact the successor.)

B. Procedure

1. Before Initiating Development Requests

Before initiating development requests:

  1. Examine folder to determine specific development needed;

  2. Consider development already undertaken (see DI 22505.001B.2); and

  3. Determine if additional evidence is needed.

2. Initial Request for MER

  1. Consider steps to expedite development:

    • Telecommunications contact - Refer to DI 22505.030 if evidence is obtained via telephone or telerecording.

    • FAX services (see DI 81020.060F).

    • Contact by mail - Phrase mail requests for evidence as directly and concisely as possible to elicit the precise information needed.

    • Claimant participation - Furnish the claimant with a medical evidence request report form, an SSA-827, and a preaddressed return envelope. Annotate the DDS name and address on the medical report form. The DDS may also want to include a telephone number.

  2. Request the particular kinds of evidence needed in support of the claim.

  3. Develop a minimum of 12 months' evidence in every case except when the alleged onset date is less than 12 months before the application filing date.

  4. If more than one development action is needed, conduct the actions concurrently.

C. References

  • For the definition of complete 12-month medical history, DI 22505.001A.3.

  • For discussion of follow-up to obtain MER, DI 22505.035.

  • For policies and procedures on when and how to develop the claimant's capability to manage benefit payments, DI 23001.000 ff.

  • For developing evidence on non-citizens from foreign medical sources, DI 23515.005C and DI 23515.005E.

  • For developing evidence from Foreign medical sources on US citizens, see DI 43510.005 and GN 00301.190,