Question: Is it often that a claim is accepted by DDS, returned by SSA for medical evaluations, then denied based on the DDS contracted evaluator, instead of the claimants’ doctors records and notes? I am asking because this is what happened to me. The evaluator at the DDS field office had granted me disability based on my doctors’ medical records and notes for my fibromyalgia and degenerative disk disease. My doctors had also listed depression and anxiety disorder since my physician has been treating me for those for years, so SSA’s quality assurance returned my claim, stating I needed a psych eval. Then I received the denial based on the recent examination, so they let a five minute exam over rule years of my doctors’ records. I am wondering if this kind of thing is common.
Answer: I’m sorry to hear about what happened. It’s not common that quality control gets involved, and it’s even less common that quality control overturns an approval. Quality control is done by Social Security’s Disability Quality Branches (DQBs). The DQBs look at a random sample of decided disability claims from each Disability Determination Services (DDS) office (about 1% of cases). Your case was unlucky enough to get chosen. Social Security practices this quality control because the DDS offices are run by each state, with state employees’ making decisions. Because Social Security is a federal program, quality control checks the DDS decisions to make sure they conform to federal law. You can read more about it in our article on the disability program’s Quality Assurance Review Board.
Quality control may have sent you for a mental consultative exam to get a psychiatrist’s opinion on the severity of your depression or anxiety, though this shouldn’t have affected DDS’s opinion that your fibromyalgia and DDD were disabling. If it did, you should be able to win on appeal. Or, quality control may have sent you to a mental evaluation to get an opinion on whether you were exaggerating your symptoms or even malingering (faking). If the mental exam came back saying you were exaggerating or malingering, that could explain why quality control overturned DDS.
Either way, you need to find out what the written report from the consultative exam says. You can do this by requesting your disability file from Social Security. Because DDS found you disabled, you probably have a good chance of winning your claim if you appeal. I recommend you talk to a lawyer about your situation.