Social Security disability benefits are often the final safety net for individuals suffering from medical impairments, such as ankylosing spondylitis, that make it impossible for them to work. For most, struggling through the Social Security Administration’s (SSA) bureaucracy is frustrating, confusing and slow. This article will explain and simplify the Social Security disability program and how it generally applies to claims related to spondyloarthritis (referred to as spondyloarthropathy by the U.S. Social Security Administration).
Spondylitis Association of America (SAA): What are Social Security Disability Benefits?
Richard I. Feingold (RF): Social Security Disability Insurance Benefits and Supplemental Security Income disability benefits are the two disability benefit programs administered by the U.S. Social Security Administration. These benefit programs provide monthly benefits and health insurance to those who qualify. There are both medical and non-medical requirements of these programs.
SAA: How does a claimant prove they are disabled?
RF: The Social Security Act defines disability as the inability to engage in any substantial gainful activity (SGA) by reason of any medically determinable physical or mental impairment(s) which has lasted or can be expected to last for a continuous period of not less than 12 months, or can be expected to result in death.
SAA: What is SSA’s five-step evaluation process for determining disability?
RF: Social Security first asks whether a claimant is engaging in SGA, that is working at a substantial level. If work earnings are more than $1,130 per month in 2016, or $1,170 per month in 2017, Social Security can consider those amounts to be substantial and the application for benefits can be denied. There are additional rules for self-employed individuals.
If a claimant is not engaging in SGA (Step 1,) then Social Security determines if there is a medically determinable impairment that significantly limits the individual’s physical or mental abilities to do basic work activities (Step 2). If a claimant has at least one severe impairment, then Social Security considers whether the criteria of any of its listed impairments have been satisfied. If so, the claimant can be found disabled (Step 3). If not, then Social Security must establish the claimant’s “residual functional capacity (RFC).” Once that is done, Social Security takes into account the RFC in finding whether the claimant can perform his or her “past relevant work” (Step 4) or any other work (Step 5). At Step 5 SSA considers the claimant’s age, education and transferable skills in ascertaining whether or not the claimant is disabled under the law.
SAA: What are the Listings of Impairments (Step 3 of the process)?
RF: The Listing of Impairments describes, for each major body system, impairments considered severe enough to prevent an individual from doing any gainful activity. They do not encompass all possible impairments. Listing 14.00 is titled, “Immune System Disorders – Adult.” It contains a number of illnesses within it, each separately enumerated.
The introductory comments in Listing 14.00 state, “The spectrum of inflammatory arthritis includes a vast array of disorders that differ in cause, course, and outcome. Clinically, inflammation of major peripheral joints may be the dominant manifestation causing difficulties with ambulation (walking) or fine and gross movements; there may be joint pain, swelling, and tenderness. The arthritis may affect other joints, or cause less limitation in ambulation or the performance of fine and gross movements. However, in combination with extra-articular features, including constitutional symptoms or signs (severe fatigue, fever, malaise, involuntary weight loss), inflammatory arthritis may result in an extreme limitation…
Inflammatory arthritis involving the axial spine (spondyloarthropathy) may be associated with disorders such as: (i) Reiter’s syndrome; (ii) ankylosing spondylitis; (iii) psoriatic arthritis; (iv) Whipple’s disease; (v) Behçet’s disease; and (vi) Inflammatory bowel disease. Inflammatory arthritis involving peripheral joints may be associated with disorders such as: (i) rheumatoid arthritis; (ii) Sjögren’s syndrome; (iii) psoriatic arthritis; (iv) crystal deposition disorders (gout and pseudogout); (v) Lyme disease; and (vi) inflammatory bowel disease.”
Listing 14.00 further states that: “Extra-articular features of inflammatory arthritis may involve any body system; for example: Musculoskeletal (heel enthesopathy), ophthalmologic (iridocyclitis, keratoconjunctivitis sicca, uveitis), pulmonary (pleuritis, pulmonary fibrosis or nodules, restrictive lung disease), cardiovascular (aortic valve insufficiency, arrhythmias, coronary arteritis, myocarditis, pericarditis, Raynaud’s phenomenon, systemic vasculitis), renal (amyloidosis of the kidney), hematologic (chronic anemia, thrombocytopenia), neurologic (peripheral neuropathy, radiculopathy, spinal cord or cauda equina compression with sensory and motor loss), mental (cognitive dysfunction, poor memory), and immune system (Felty’s syndrome (hypersplenism with compromised immune competence).”
Within Listing 14.00 is Listing 14.09 – Inflammatory arthritis. There are four sections contained in this Listing:
1. Persistent inflammation or persistent deformity of:
1.1. One or more major peripheral weight-bearing joints resulting in the inability to ambulate effectively…or
1.2. One or more major peripheral joints in each upper extremity resulting in the inability to perform fine and gross movements effectively.
2. Inflammation or deformity in one or more major peripheral joints with:
2. 1. Involvement of two or more organs/body systems with one of the organs/body systems involved to at least a moderate level of severity; and
2.2. At least two of the constitutional symptoms or signs (severe fatigue, fever, malaise, or involuntary weight loss.)
3. Ankylosing spondylitis or other spondyloarthropathies, with:
3.1. Ankylosis (fixation) of the dorsolumbar or cervical spine as shown by appropriate medically acceptable imaging and measured on physical examination at 45° or more of flexion from the vertical position (zero degrees); or
3.2. Ankylosis (fixation) of the dorsolumbar or cervical spine as shown by appropriate medically acceptable imaging and measured on physical examination at 30° or more of flexion (but less than 45°) measured from the vertical position (zero degrees), and involvement of two or more organs/body systems with one of the organs/body systems involved to at least a moderate level of severity.
4. Repeated manifestations of inflammatory arthritis, with at least two of the constitutional symptoms or signs (severe fatigue, fever, malaise, or involuntary weight loss) and one of the following at the marked level:
4.1. Limitation of activities of daily living,
4.2. Limitation in maintaining social functioning,
4.3. Limitation in completing tasks in a timely manner due to deficiencies in concentration, persistence, or pace.
As used in the above listing, the inability to ambulate effectively means “…an extreme limitation of the ability to walk; i.e., an impairment that interferes very seriously with the individual’s ability to independently initiate, sustain, or complete activities. Ineffective ambulation is defined generally as having insufficient lower extremity functioning (see 1.00J) to permit independent ambulation without the use of a hand-held assistive device(s) that limits the functioning of both upper extremities…To ambulate effectively, individuals must be capable of sustaining a reasonable walking pace over a sufficient distance to be able to carry out activities of daily living. They must have the ability to travel without companion assistance to and from a place of employment or school. Therefore, examples of ineffective ambulation include, but are not limited to, the inability to walk without the use of a walker, two crutches or two canes, the inability to walk a block at a reasonable pace on rough or uneven surfaces, the inability to use standard public transportation, the inability to carry out routine ambulatory activities, such as shopping and banking, and the inability to climb a few steps at a reasonable pace with the use of a single hand rail. The ability to walk independently about one’s home without the use of assistive devices does not, in and of itself, constitute effective ambulation.
This listing also considers functional impairments in the arms, hands, and fingers. SSA’s regulations state that, “inability to perform fine and gross movements effectively means an extreme loss of function of both upper extremities; i.e., an impairment that interferes very seriously with the individual’s ability to independently initiate, sustain, or complete activities. To use their upper extremities effectively individuals must be capable of sustaining such functions as reaching, pushing, pulling, grasping, and fingering to be able to carry out activities of daily living. Therefore, examples of inability to perform fine and gross movements effectively include, but are not limited to, the inability to prepare a simple meal and feed oneself, the inability to take care of personal hygiene, the inability to sort and handle papers or files, and the inability to place files in a file cabinet at or above waist level.”
SAA: What if a claimant has a form of spondyloarthritis, but it is not as severe as the listing?
RF: A claimant can still be found disabled even if the condition does not qualify under the Listings of Impairments (Step 3.) As part of Step 4 of their analysis SSA evaluates a claimant’s Residual Functional Capacity (RFC) – what a claimant can still do despite the limitations caused by their impairments. If the claimant’s RFC does not prevent them from performing the duties of their past relevant work, then Social Security will deny the claim. However if a claimant’s RFC prevents the ability to perform their past relevant work, then Social Security will move on to Step 5 and determine whether or not the claimant can perform any other work.
SAA: What does SSA consider in determining whether a claimant can perform past relevant work?
RF: As mentioned above, at Step 4 of the 5 step sequential evaluation process, the claimant must prove that he or she cannot perform his or her past relevant work. Generally, past relevant work is work that the claimant has performed in the past 15 years at the SGA (substantial gainful activity) level for a sufficient amount of time for the claimant to have learned the techniques, acquired information, and developed the facility needed for average performance in the job situation. SSA considers the claimant’s RFC (residual functional capacity) and compares it to the physical and mental demands of this past relevant work. If the claimant’s RFC prevents him or her from performing the physical and mental demands of this past work, the SSA should find that the claimant cannot perform his or her past relevant work and the inquiry moves to Step 5: whether the claimant can perform any other work in the regional or national economy. If the claimant cannot perform other work available in significant numbers in the regional and national economy, the claim will be approved. If the claimant can perform other work, the claim will be denied.
SAA: How important is objective proof of medical symptoms?
RF: SSA’s regulations require that any impairment must result from anatomical, physiological, or psychological abnormalities which can be shown by medically acceptable clinical and laboratory diagnostic findings. While a claimant’s description of symptoms to the claimant’s doctor and the explanation of a condition’s impact on daily activities must be considered by the SSA, a physical or mental impairment must be established by medical evidence consisting of signs, symptoms, and laboratory findings.
SAA: How important is it that a claimant obtains medical treatment for the conditions?
RF: Given the above, this is critical. The focus in all disability claims is upon the medical evidence – that is the physician’s clinical findings, office notes, reports, and medical test results. That evidence is primary and is often more important than what the claimant says on SSA forms or in testimony at a hearing. While a claimant’s description of a condition’s impact on their day-to-day activities is important and must be considered by the SSA, the content of the medical documentation is the primary source of evidence in deciding the claim. SSA generally gives more weight to the findings and opinions of treating specialists, such as orthopedic doctors, rheumatologists, neurologists, and pain specialists, than to family practitioners.
SAA: What can a claimant expect throughout the application process?
RF: Unfortunately claims are taking longer to be decided, in large part because fewer claims are being approved prior to a hearing with an Administrative Law Judge. Also, fewer claims are being approved therefore more appeals may be necessary, sometimes to federal court. It is important to get proper guidance through an experienced representative to help maximize one’s chances of approval.
SAA: What resources are available to help navigate the application process and improve one’s chances of approval?
RF: As stated above, your representative can be a big help. The Spondylitis Association of America is a tremendous resource. Family and friends certainly should be included because this can be a trying process. Additionally, Social Security’s website has a ton of helpful, readable information. Please also consult my website, Usadisabilitylaw and sign up for my newsletter.
This article originally appeared in the Winter 2016 issue of Spondylitis Plus, the quarterly news magazine of Spondylitis Association of America. Members receive every copy of Spondylitis Plus in the mail for free. Get a Membership!