A medical examination is often required when applying for disability benefits through the Social Security Administration (SSA). This appointment, known as a Consultative Examination (CE), is scheduled when the agency needs more current or complete medical evidence than is available in your existing records. This article clarifies what a claimant should expect when the SSA schedules an appointment with an internist for this specific evaluation. This appointment is solely for evidence gathering and is not a clinical visit for treatment or diagnosis.
Understanding the Internist’s Role in Disability Claims
An internist is a medical doctor specializing in internal medicine, focusing on the diagnosis and treatment of diseases in adults. The SSA frequently selects internists to conduct physical CEs because their broad medical training covers the wide range of chronic conditions that often form the basis of disability claims, such as heart disease, diabetes, and rheumatological disorders. The internist conducting the CE is an independent physician contracted by the state agency, Disability Determination Services (DDS), and is not an employee of the SSA.
The doctor’s sole purpose during this appointment is to gather objective medical evidence on behalf of the DDS. They do not assume the role of your treating physician and will not offer medical advice, prescribe medication, or initiate a long-term care plan. Their task is strictly to provide an unbiased, clinical assessment of your current physical condition and functional limitations.
Preparing for Your Consultative Examination
Preparing effectively for the CE helps ensure the internist can gather all the necessary information. You should create a detailed list of all current medications, including the dosage and prescribing doctor, to bring with you to the appointment. It is also helpful to compile a list of all treating physicians, clinics, and hospitals where you have received care for your disabling condition.
Arranging reliable transportation and arriving on time is necessary, as failure to attend the CE without a strong reason can lead to a denial of your claim. You should dress in comfortable, loose-fitting clothing that allows the doctor to easily examine your joints and perform range-of-motion tests. Bring a government-issued photo identification and your appointment notice, as well as any assistive devices you regularly use, such as a cane, walker, or brace.
Before the appointment, you should consider how to concisely describe the impact of your condition on your daily life. Be prepared to discuss specific examples of how your symptoms limit your ability to perform basic tasks, such as bathing, dressing, or lifting objects. While you should be honest and detailed, it is important not to exaggerate or minimize your limitations, as the examining doctor is trained to observe inconsistencies.
The Examination Process and Scope
The consultative examination typically begins with a detailed history-taking component. The internist will ask about the onset of your symptoms, your treatment history, and the severity of your pain and limitations. This is your opportunity to clearly articulate how your condition restricts your ability to perform work-related activities, making sure your answers are consistent with information you provided earlier in your application.
Following the history, the internist will conduct a physical examination that is targeted toward your alleged impairments. This physical assessment is often shorter than a standard check-up and focuses on objective findings related to your ability to function. The doctor will typically evaluate your muscle strength, check your reflexes, and assess your range of motion in the affected joints. They may also observe your gait, how you get on and off the examination table, and your ability to sit, stand, and bend.
The scope of the CE is limited to gathering specific medical evidence requested by the DDS. If the existing medical records are insufficient, the internist may order specific diagnostic tests, such as X-rays or blood work, to complete the evaluation. These additional tests are paid for by the DDS, and you will not incur any out-of-pocket costs.
How the Report Influences Your Claim
After the examination, the internist prepares a detailed report that summarizes their clinical findings and observations. This report includes the medical history provided by the claimant, the results of the physical examination, and any objective test results obtained during the appointment. The completed documentation is sent directly to the DDS claims adjudicator for inclusion in your disability file.
The internist’s report serves as medical evidence for the DDS, but the doctor does not make the final determination on your disability status. The DDS claims examiner and a medical consultant review the CE report alongside all other existing medical records, treatment notes, and statements in your file. This collected evidence is then used to determine your Residual Functional Capacity (RFC).
The RFC is an administrative assessment that defines the maximum work-related activities you can still perform despite your medical limitations. For physical claims, the RFC details your exertional capacity, such as how long you can sit, stand, walk, and how much you can lift or carry. The DDS uses this RFC assessment to determine if you are capable of performing your past work or any other type of work that exists in the national economy, ultimately deciding your eligibility for benefits.