Title 20
SECTION 220.53
220.53 When the Board will purchase a consultative examination and how it will be used.
§ 220.53 When the Board will purchase a consultative examination and how it will be used.(a)(1) General. The decision to purchase a consultative examination for a claimant will be made after full consideration is given to whether the additional information needed (e.g., clinical findings, laboratory tests, diagnosis, and prognosis, etc.) is readily available from the records of the claimant's medical sources. Upon filing an application for a disability annuity, a claimant will be required to obtain from his or her medical source(s) information regarding the claimed impairments. The Board will seek clarification from a medical source who has provided a report when that report contains a conflict or ambiguity, or does not contain all necessary information or when the information supplied is not based on objective evidence. The Board will not, however, seek clarification from a medical source when it is clear that the source either cannot or will not provide the necessary findings, or cannot reconcile a conflict or ambiguity in the findings provided from the source's records. Therefore, before purchasing a consultative examination, the Board will consider not only existing medical reports, but also the background report containing the claimant's allegations and information about the claimant's vocational background, as well as other pertinent evidence in his or her file.
(2) When the Board purchases a consultative examination, we will use the report from the consultative examination to try to resolve a conflict or ambiguity if one exists. The Board will do this by comparing the persuasiveness and value of the evidence. The Board will also use a consultative examination to secure needed medical evidence the file does not contain such as clinical findings, laboratory tests, a diagnosis or prognosis necessary for decision.
(b) Situations requiring a consultative examination. A consultative examination may be purchased when the evidence as a whole, both medical and non-medical, is not sufficient to support a decision on the claim. In addition, other situations, such as one or more of the following, will normally require a consultative examination (these situations are not all-inclusive):
(1) The specific additional evidence needed for adjudication has been pinpointed and high probability exists for obtaining it through purchase.
(2) The additional evidence needed is not contained in the records of the claimant's treating sources.
(3) Evidence that may be needed from the claimant's treating or other medical sources cannot be obtained for reasons beyond his or her control, such as death or noncooperation of the medical source.
(4) Highly technical or specialized medical evidence which is needed is not available from the claimant's treating sources.
(5) A conflict, inconsistency, ambiguity or insufficiency in the evidence must be resolved.
(6) There is an indication of a change in the claimant's condition that is likely to affect his or her ability to function, but current severity is not documented.
(7) Information provided by any source appears not to be supported by objective evidence.