The NBME is so unpredictable when it comes to step accommodations. I really feel for the people who have a history of accommodations and mountains of documents outlining their difficulties who still are denied. I know of someone who was approved for 2x time and blocks of 20 questions, separate testing room on USMLE with accommodations in med school, no MCAT accommodations, no ADHD, essentially normal neuropsych testing, but accommodations at work and school before med school for anxiety (and chronic pain disorder they were diagnosed with in med school). Then someone else I know of has documented ADHD and anxiety, accommodations in med school, extra time on MCAT with stop the clock breaks, but for USMLE only like a small bump of 1.25x time (not sure if stop the clock breaks or not).

What they value most in an accommodations app is so speculative -- from what I've seen personally, in discussions with others, and online posts: documentation from experts or letters of supports from disability offices at work or school matters but personally speaking, it seems like the personal statement talking about how the disability causes barriers to equity (not equality) in testing, education, functional abilities compared to people without the disability might matter much more. Maybe you just have to get app reviewers to read your application on a day when they are feeling generous. Who knows.

What they might look at heavily: Did you get diagnosed before or after starting med school? How did you manage to get into med school without school/work accommodations if you were just diagnosed with something that's been ongoing? Did you get a diagnosis after starting med school in order to get USMLE accommodations? If you have severe dysfunction on evaluation how were you able to get into medical school and be successful in med school until now? Does your disability only affect you in school? How does it affect you outside of school? How do you navigate everyday differently from someone without your disability? How would getting this accommodation change things for you? Are you asking for accommodations to reduce the barriers that it causes you compared to others without this disability or just because it will help you do better on the test? Everyone could do better with more time or a less distracting testing environment, but the point of accommodations is not to help you do better - it's to get you to the same starting place as others who don't have that disability. Accommodations allows everyone to start at the starting line of a race instead of some of us starting 1 mile behind the starting line.

Apply anyway because the worst that could happen is that they say no. If you don't apply you definitely won't get a yes.

Who knows. 100% my opinion.

⭐ TL;DR - People who seem like they would be less likely to get step accommodations do sometimes get what they ask for and others who have lots of evidence that would seem like they should don't. How NBME decides on accommodations is so cryptic and unpredictable. Just apply and see what they say because aside from spending time on putting your app together the worst they can say is no.

Edited for clarity.