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Which types of medical evidence are now sufficient or insufficient for supporting residual functional capacity in CDRs?
Executive summary
Social Security rules say RFC in Continuing Disability Reviews (CDRs) must be based on “all of the relevant medical and other evidence,” and claimants generally must supply that evidence—meaning objective tests, treating-source records, and medical source statements remain central to a CDR RFC determination [1]. Administrative guidance and practitioner resources emphasize that clear, specific medical opinions (doctor-completed RFC forms or functional capacity evaluations) are the most persuasive evidence; vague or non‑specific notes, unsupported therapist opinions, and forms lacking objective support are treated as weak or insufficient [2] [3] [4].
1. What the rules require: “all of the relevant medical and other evidence”
The Code of Federal Regulations explicitly instructs adjudicators to assess RFC using the full case record—medical and other evidence—and places the responsibility on claimants to provide that evidence for CDRs [1]. That language sets the floor: objective findings, treatment records, and any medical-source opinions in the file are the authorized basis for RFC determinations [1].
2. Most persuasive — detailed treating-source RFCs and objective functional testing
Practitioner guides and disability advocates repeatedly point to physician‑completed RFC forms and formal Functional Capacity Evaluations (FCEs) as the evidence types that carry the most weight because they provide specific, task‑based limits and tie limitations to objective findings [2] [5]. Attorneys and forms sites advise that RFC statements must identify diagnoses, describe how they limit work activities, and explain the medical basis for each restriction; when present and consistent with records, these documents strongly support RFC findings [2] [3].
3. Objective clinical data: imaging, labs, range-of-motion, and standardized measures
Although the CFR does not list particular tests, the sources used by practitioners and claimants show that imaging, pulmonary/cardiac tests, neurologic exams, range-of-motion measurements, and standardized assessments are the kind of objective clinical data adjudicators expect to see alongside opinions [4] [6]. Sources encourage up-to-date, comprehensive records showing treatment response and measurable impairments because subjective symptom reports alone are seldom decisive without corroborating objective evidence [4].
4. When evidence is insufficient: vague opinions, unsupported limitations, and undocumented therapist forms
Multiple practitioner resources warn that medical opinions lacking specificity—e.g., blanket assertions of disability without task‑based limits, or forms that do not cite supporting tests or exam findings—are unlikely to be persuasive in a CDR [2] [3]. Legal blogs and guides caution that range-of-motion entries or clinician statements can be viewed as unreliable if they conflict with imaging or other objective findings, or if they’re not explained in the record [7] [3].
5. Mental RFCs and the need for documented functional remarks
For mental impairments, specialized mental-RFC assessments that link symptoms to work‑related capacities and include Section II remarks explaining the evidentiary basis are treated as the stronger evidence; speculative or conclusory mental opinions without rationale are insufficient [8]. Keefe Disability Law materials emphasize that clinicians must not speculate where evidence is thin and should document the clinical basis for all ratings [8].
6. What CDR examiners look at in practice: consistency, currency, and context
Guidance for adjudicators and plain‑language explainers both stress consistency across the record—treatment notes, objective testing, and medical‑source statements should align—and currency, meaning recent records and documentation of ongoing limitations are important in a CDR [1] [4]. Practice‑oriented pieces recommend maintaining continuous, contemporaneous documentation so a claimant can meet the SSA’s burden to provide relevant evidence [1] [5].
7. Competing perspectives and practical takeaways for claimants
Legal and clinical sources converge on the practical point that a specific, well‑supported RFC (doctor‑filled forms, FCEs, objective testing) is sufficient when it ties limitations to documented findings; conversely, generic statements, unsupported therapist notes, or outdated records are insufficient [2] [3] [5]. Where sources diverge is in emphasis: some advocate aggressively obtaining FCEs or independent RFCs [5] [9], while others emphasize relying on longtime treating‑physician documentation [3] [2]. Claimants should therefore prioritize obtaining clear, contemporaneous, and test‑backed medical-source opinions for CDRs and ensure records directly connect diagnoses to specific, work‑related limitations [1] [2].
Limitations: available sources are practitioner guides, law‑firm blogs, and SSA CFR text; the SSA program instruction excerpt (POMS) referenced in search metadata [10] is listed but its content was not excerpted in our results, so specific POMS wording about “age and time on the rolls” is not cited in the body because the text itself was not available in the provided snippets (p1_s1 not quoted).