How Does the Social Security Administration Decide if I Qualify for Disability Benefits for Congestive Heart Failure?
If you have congestive heart failure, Social Security disability benefits may be available. Congestive heart failure (CHF) is called chronic heart failure by the Social Security Administration. To determine whether you are disabled by CHF, the Social Security Administration first considers whether your heart failure is severe enough to meet or equal a listing at Step 3 of the Sequential Evaluation Process. See Winning Social Security Disability Benefits for Congestive Heart Failure by Meeting a Listing. If you meet or equal a listing because of CHF, you are considered disabled.
If your chronic heart failure is not severe enough to equal or meet a listing, the Social Security Administration must assess your residual functional capacity (RFC) (the work you can still do, despite your heart disease), to determine whether you qualify for disability benefits at Step 4 and Step 5 of the Sequential Evaluation Process. See Residual Functional Capacity Assessment for Congestive Heart Failure.
About Congestive Heart Failure and Disability
The Cardiovascular System
Before discussing heart failure, a brief description of the cardiovascular system is needed. The heart is normally a four-chambered muscle situated behind and to the left of the sternum (breast bone). The upper chambers are the left atrium and right atrium. The lower chambers are the left and right ventricles. The ventricles are much larger than the atria (see Figure 1 below).
Figure 1: An anterior view of the heart, featuring the atria, ventricles, and arteries.
Oxygen depleted blood from the veins returns to the heart from the body’s tissues. It enters the right atrium and flows through the tricuspid valve into the right ventricle. The right ventricle pumps blood through the pulmonary valve and into the pulmonary arteries for re-oxygenation by the lungs.
Oxygenated blood from the lungs returns to the left atrium of the heart by pulmonary veins and passes through the mitral valve into the left ventricle. From the left ventricle, newly oxygenated blood is ejected through the aortic valve into the aorta, which is the parent artery of all of the body’s other arteries (see Figure 2 below).
Figure 2: The heart during contraction.
The arterial system of the body that receives blood pumped out of the left ventricle is known as the systemic circulation. The blood moving from the right ventricle through the lungs is called the pulmonary circulation. The valves are important because they open only in one direction, so that blood flow always moves the right way when the heart contracts.
What Is Congestive (Chronic) Heart Failure?
Congestive heart failure, called chronic heart failure by the Social Security Administration, is the inability of the heart to pump enough oxygenated blood to the body tissues (see Figure 3 below). Congestive or chronic heart failure (CHF) affects about 5 million people in the U.S., and is increasing due to the aging of the population.
The heart’s ability to pump blood may be impaired by a variety of causes including myocardial infarction (heart attack), ischemic heart disease (decreased blood flow to heart muscle, usually as a result of coronary artery disease), and cardiomyopathy. The failure of the ventricles to pump blood efficiently results in blood accumulating in the heart, and enlargement of the ventricles.
Figure 3: The heart pumps blood through an immense network of veins and arteries.
Right Heart Failure
Failure of the right ventricle is known as right heart failure. In right-sided failure, there tends to be congestion (fluid accumulation) in organs such as the liver and peripheral edema (swelling) in the feet, because of pressure transmitted back through the venous system. Cor pulmonale—heart disease caused by lung disease—is the main cause of right-sided failure.
Left Heart Failure
Failure of the left ventricle is known as left heart failure. In left-sided failure, pulmonary edema is expected because of increased pressures transmitted back to the pulmonary vascular system.
Ischemic heart disease affecting the left ventricle is usually responsible for left-sided failure. However, the two sides of the heart do not operate in isolation: failure on one side will be associated with failure of the other side, so there are no abnormal findings that are characteristic of only right or left types of heart failure. See Can I Get Social Security Disability Benefits for Ischemic Heart Disease?
Predominant systolic dysfunction or systolic failure is the inability of the heart to contract normally and expel sufficient blood. It is characterized by an enlarged, poorly contracting left ventricle and reduced ejection fraction. Ejection fraction (EF) is the percentage of the blood in the ventricle pumped out with each contraction. Most of the claims for disability benefits seen by the Social Security Administration involve systolic heart failure.
Predominant diastolic dysfunction or diastolic failure is the inability of the heart to relax and fill normally. It is characterized by a thickened ventricular muscle, poor ability of the left ventricle to distend (stretch), increased ventricular filling pressure, and a normal or increased EF. Twenty to 40% of heart failure is due to diastolic dysfunction. Some people have both systolic and diastolic dysfunction.
Symptoms and Signs of Congestive Heart Failure
To establish that you have chronic heart failure for the purpose of receiving Social Security disability benefits, your medical history and physical examination should describe characteristic symptoms and signs of pulmonary or systemic congestion or of limited cardiac output. And these signs and symptoms should be associated with the abnormal findings on appropriate medically acceptable imaging. Factors that cause heart failure, but that can be improved or eliminated, such as heart failure induced by high altitude, arrhythmias, and dietary sodium overload, would not be expected to result in chronic failure.
Symptoms of congestion or of limited cardiac output include:
- Easy fatigue.
- Shortness of breath (dyspnea) on exertion.
- Chest discomfort at rest or with activity.
- Shortness of breath on lying flat (orthopnea).
- Sudden shortness of breath while sleeping (paroxysmal nocturnal dyspnea (PND)).
- Cardiac arrhythmias resulting in palpitations, lightheadedness, or fainting.
Signs of congestion may include:
- An enlarged liver (hepatomegaly).
- Fluid accumulation in the abdomen (ascites).
- Increased jugular vein distention or pressure.
- Rales (abnormal breath sounds heard with a stethoscope listening over the lungs, especially the bases of the lungs).
- Peripheral edema (fluid retention and swelling in the extremities).
- Rapid weight gain.
However, these signs need not be found on all examinations because fluid retention may be controlled by treatment.
Prognosis and Mortality in Heart Failure
Available statistics regarding mortality vary, but there is general agreement that, at the time of diagnosis, CHF has a 5-year mortality in the 35-50% range. This very general number shows what a serious diagnosis is involved, but there are great differences in individual mortalities that are determined by age, sex, race, cause of failure, as well as the nature and severity of other medical disorders. For example, mortality is higher for African-Americans than Caucasians, higher for males than females, higher for age than youth, higher in diabetics, and higher in those with hypertension.
Winning Social Security Disability Benefits for Congestive Heart Failure by Meeting a Listing
To determine whether you are disabled at Step 3 of the Sequential Evaluation Process, the Social Security Administration will consider whether your congestive heart failure is severe enough to meet or equal the chronic heart failure listing. The Social Security Administration has developed rules called Listing of Impairments for most common impairments. The listing for a particular impairment describes a degree of severity that the Social Security Administration presumes would prevent a person from performing substantial work. If your chronic heart failure is severe enough to meet or equal the listing, you will be considered disabled.
The listing for chronic heart failure is listing 4.02, which has two parts, A and B. To meet the listing you must satisfy both part A and part B despite receiving prescribed treatment.
Part A is mainly concerned with diagnosis, while Part B deals with clinical and functional severity. A legitimate diagnosis of heart failure from any cause must be established before consideration of part A or part B of the listing. The critical question to determine listing-level severity is whether some degree of chronic heart failure remains after treatment for an acute episode of failure.
Meeting SSA Listing 4.02A for Heart Failure
You will meet Part A of Listing 4.02 if you have chronic heart failure (with characteristic symptoms and signs) while on a regimen of prescribed treatment and–
A. Medically documented presence of one of the following:
1. Systolic heart failure, with left ventricular end diastolic dimensions greater than 6.0 cm or ejection fraction of 30 percent or less during a period of stability (not during an episode of acute heart failure); or
2. Diastolic heart failure, with left ventricular posterior wall plus septal thickness totaling 2.5 cm or greater on imaging, with an enlarged left atrium greater than or equal to 4.5 cm, with normal or elevated ejection fraction during a period of stability (not during an episode of acute heart failure);
Part A.1: Systolic Heart Failure
Part A.1 requires systolic heart failure. Assuming that chronic heart failure is otherwise reasonably documented as a general requirement of the listing, part A.1 requires an objective determination of either cardiomegaly (cardiac enlargement) or left ventricular dysfunction.
Cardiomegaly can be demonstrated with echocardiography showing a left ventricular end diastolic diameter of greater than 6.0 centimeters. This is actually the inside diameter of the left ventricular cavity during diastole—the left ventricular inside diastolic diameter (LVIDD). In diastole the heart is relaxed and filling with blood (see Figure 4 below).
Figure 4: The relaxed heart during diastole.
The LVIDD does not include the thickness of the heart muscle wall, because it is the dilation of the LV cavity that suggests a failing heart rather than the total diameter of the heart. Many hypertensive individuals have thickened heart muscle without heart failure (even though hypertension is associated with the risk of heart failure); in fact, even the thickness of a normal heart will be significantly greater than the LVIDD. Any other reliable cardiac imaging test, such as cardiac magnetic resonance imaging (cardiac MRI) or ventriculography performed during cardiac catheterization, can also satisfy the LVIDD measurement. However, echocardiography is the cheapest way to non-invasively get a good measurement of cardiac chamber size; contrast injection is not required for this type of measurement so no risk is involved.
It is also acceptable to document left ventricular dysfunction by showing left ventricular ejection fraction (LVEF) of 30% or less. The LVEF is the percent of blood in the left ventricle that the ventricle can pump out with each contraction. A normal LVEF is 55-65%. Most authorities would agree that an LVEF is not significantly abnormal until it falls below 50%. An LVEF of 30% or less provides the best quantified objective information and definitely shows serious heart disease. LVEF can be measured by any of the imaging studies mentioned.
LVEF alone does not always reveal chronic heart failure. A normal LVEF is usually not compatible with a diagnosis of systolic heart failure. In fact, an LVEF of more than 30% should make the diagnosis of chronic systolic heart failure suspect. But heart failure caused by diastolic dysfunction can be associated with a normal LVEF although there may be clinical signs of failure (in the present or past) in the form of venous congestion such as edema, hepatomegaly (enlarged liver), and jugular vein distention as well as shortness of breath with exertion and weakness. Fortunately, the Social Security Administration has added a provision for diastolic heart failure in Part A.2.
It is critical that the cardiac measurements be done during a period of stability after treatment for acute heart failure.
Part A.2: Diastolic Heart Failure
Part A.2 requires diastolic heart failure. The required abnormal cardiac measurements can most easily be obtained by echocardiography, but a cardiac MRI or any other reliable means of measuring cardiac dimensions are acceptable. The posterior muscular wall of the heart and interventricular partition separating the cardiac ventricles must be abnormally thickened to at least 2.5 centimeters (cm) and the left atrium must have a diameter of at least 4.5 cm. Since the LVEF in diastolic heart failure is normal or increased, that abnormality is also expected by part A.2. All of these measurements would be a routine part of any cardiac imaging study. In the medical literature, diastolic heart failure is also referred to as “heart failure with preserved ejection fraction.”
It is critical that the cardiac measurements be done during a period of stability after treatment for acute heart failure.
Meeting SSA Listing 4.02B for Heart Failure
You will meet Part B of Listing 4.02 if you have chronic heart failure (with characteristic symptoms and signs) while on a regimen of prescribed treatment–
B. Resulting in one of the following:
1. Persistent symptoms of heart failure which very seriously limit the ability to independently initiate, sustain, or complete activities of daily living in an individual for whom an MC, preferably one experienced in the care of patients with cardiovascular disease, has concluded that the performance of an exercise test would present a significant risk to the individual; or
2. Three or more separate episodes of acute congestive heart failure within a consecutive 12-month period, with evidence of fluid retention from clinical and imaging assessments at the time of the episodes, requiring acute extended physician intervention such as hospitalization or emergency room treatment for 12 hours or more, separated by periods of stabilization; or
3. Inability to perform on an exercise tolerance test at a workload equivalent to 5 METs or less due to:
a. Dyspnea, fatigue, palpitations, or chest discomfort; or
b. Three or more consecutive premature ventricular contractions (ventricular tachycardia), or increasing frequency of ventricular ectopy with at least 6 premature ventricular contractions per minute; or
c. Decrease of 10 mm Hg or more in systolic pressure below the baseline systolic blood pressure or the preceding systolic pressure measured during exercise due to left ventricular dysfunction, despite an increase in workload; or
d. Signs attributable to inadequate cerebral perfusion, such as ataxic gait or mental confusion.
If the Part A diagnostic considerations are satisfied, then any of B.1 through B.3 must also be fulfilled in regard to clinical/functional severity in order for you to meet the listing.
Part B.1 Persistent Symptoms
Part B.1 is satisfied by persistent symptoms consistent with chronic heart failure that are severe enough that a Social Security Administration medical consultant thinks cardiac exercise testing is contraindicated. Optimally, symptoms and limitations will be documented in your medical records and not mentioned simply in association with your application for disability benefits.
Part B. 2 Episodes of Acute Failure
Part B.2 requires at least 3 episodes of acute congestive heart failure (diastolic or systolic) in a consecutive 12-month period. By the requirement for “extended physician intervention such as hospitalization or emergency room treatment for 12 hours or more,” the Social Security Administration is assuring that most cases of repeated acute CHF will be easily identifiable.
The required evidence of fluid retention characteristic of acute congestive failure could be provided by hepatomegaly (liver enlargement), ascites (fluid in the abdomen), jugular vein distention or pressure, rales (abnormal lung sounds), peripheral edema (fluid retention and swelling in the extremities), or rapid weight gain.
The Social Security Administration correctly does not require that congestive signs be present on all examinations. In cases of prolonged ER treatment or hospitalization for acute CHF, it is usually easy to validate episodes of acute CHF based on history, physical examination, symptoms, and cardiac imaging. This kind of information is to be expected in the hospital record.
Part B.3 Inability to Perform on Exercise Tolerance Test
Part B.3 requires medical reasons related to chronic heart failure that caused you to be unable to achieve a workload equivalent to 5 METs or less (exertion approximately equal to brisk walking) during an exercise tolerance test.
Part B.3.a can be satisfied by inability to perform 5 METs exertion on an exercise test due to symptoms of heart failure, thus precluding the ability to do even sedentary work. Symptoms that indicate worsening heart failure developing during exercise are severe shortness of breath (SOB) and weakness, as well as chest discomfort such as angina pectoris and subjectively forceful heart beats (palpitations). Objective findings suggesting the onset of failure during exercise are the development of an S3 heart sound (an abnormal heart sound heard with a stethoscope that indicates ventricular dysfunction) or even frank pulmonary edema (fluid in the lungs). The pulmonary edema can be heard with a stethoscope as wet-sounding rales with inspiration, especially at the bottoms (bases) of the lungs.
In addition to symptoms of heart failure induced by exercise, part B.3.a can be satisfied by specific objective abnormalities that result in inability to do 5 METs of exertion. In most instances, these will be cases in which the treating physician has performed exercise testing.
Part B.3.b refers to abnormalities appearing on electrocardiogram (ECG, EKG) during exercise, in the form of abnormal beats. Part B.3.b describes an exercise-induced ventricular arrhythmia of a kind that can be life-threatening if it persists. Therefore, the exercise test must be stopped if these findings appear.
Part B.3.c refers to an abnormal blood pressure response to exercise, characterized as a fall of systolic pressure at least 10 mm Hg below the baseline, standing, pre-exercise level. A 10 mm Hg fall in systolic blood pressure at any time during exercise could also qualify. Such abnormality can be caused by a potentially life-threatening left ventricular dysfunction and requires immediate termination of exercise testing. However, in some situations a fall in blood pressure may be caused by more innocuous factors such as deconditioning, apprehension, and drugs. In these instances, as determined by informed medical judgment, part B.3.c would not be satisfied.
Part B.3.d recognizes the inability of a failing heart to supply the brain with blood during exertion (see Figure 5 below). This can result in the onset of an uncoordinated gait or mental confusion. The attending physician should immediately stop an exercise test in which these abnormalities appear, as they are life-threatening, or at least could cause a fall and serious injury.
Figure 5: Circulation of blood to the brain and other parts of the body.
Residual Functional Capacity Assessment for Congestive Heart Failure
What Is RFC?
If your congestive heart failure is not severe enough to meet or equal a listing at Step 3 of the Sequential Evaluation Process, the Social Security Administration will need to determine your residual functional capacity (RFC) to decide whether you are disabled at Step 4 and Step 5 of the Sequential Evaluation Process. RFC is a claimant’s ability to perform work-related activities. In other words, it is what you can still do despite your limitations. An RFC for physical impairments is expressed in terms of whether the Social Security Administration believes you can do heavy, medium, light, or sedentary work in spite of your impairments. The lower your RFC, the less the Social Security Administration believes you can do.
Categories of Limitations for Heart Disease
Whatever the nature of heart disease, limitations on your ability to work will always fall into certain broad categories:
- Limitation from anginal chest pain.
- Limitation from shortness of breath (dyspnea).
- Limitation from weakness.
- Limitation from easy fatigability.
- Limitation from life-threatening arrhythmia.
- Limitation from environmental factors.
The Social Security Administration should carefully consider each of these factors when determining your RFC.
It is important that the treating physician carefully document the nature and severity of your symptoms, something that is critical not only to treatment but also to disability determination.
There is no way an accurate RFC can be determined without close consideration of your symptoms as well as the objective data.
This point has to be emphasized, because some Social Security Administration adjudicators will try to use objective cardiac performance alone to determine RFC. Of course, the Social Security Administration still must judge your credibility. Alleged symptoms that deviate markedly from what would be expected based on the objective evidence could mean more development of the medical evidence is needed to uncover the cause of the symptoms. But other possibilities include malingering (the symptoms are consciously made up to get benefits), exaggeration, or a mental disorder.
Left Ejection Fraction
Both in clinical medicine and in disability determination, the most frequently used measure of cardiac performance is the left ventricular ejection fraction. LVEF is the percentage of blood in the left ventricle that is pumped out with each heart beat. As the LVEF falls, so does exertional capacity. That does not mean that the only basis for determining exertional capacity is the LVEF; it is one thread in the overall impairment severity.
- An LVEF of 40-49% implies a limitation to no more than medium work.
- An LVEF of 30-39% implies a limitation to no more than light work.
- An LVEF of 20-29% implies a limitation to no more than sedentary work.
- An LVEF of less than 20% implies a limitation to less than sedentary work and that would meet or equal a listing and result in a finding of disability.
These numbers are not Social Security Administration policy and should not be applied arbitrarily; they just provide a modifiable framework for a more refined determination. They are used as ceilings on exertional limitation which should not be exceeded without proof of higher exertional capacity, such as performance on an exercise test. (Rare individuals can perform levels of exertion on objective testing that substantially exceed what one would expect if anticipating performance based on LVEF alone.) Obviously, a claimant with a history of documented heart failure could meet listing 4.02B with an ejection fraction of 30% and other abnormalities and so should not be assigned an RFC for light work.
It is well-known that poor LVEF after treatment for chronic heart failure has a poor survival prognosis, with death occurring within 6 months in 21% of those with an LVEF of 40% or less. Recently, it has been determined that there is a considerable disability and mortality burden on CHF patients even if their LVEF is well-preserved (40% or higher), with a 6-month mortality of 13% and functional decline (symptoms and hospital readmissions) almost as great as those with lower ejection fractions (21% vs. 30%).
Diastolic Cardiac Dysfunction
Diastolic cardiac dysfunction can be associated with a normal left ventricle ejection fraction (LVEF). In these cases, the left ventricle is stiff and cannot relax properly. In such claims, the Social Security Administration should not cite a normal LVEF as an important factor in determining RFC.
Unfortunately, many treating physicians, even cardiologists, do not address whether a patient has diastolic dysfunction in the medical records. A cardiologist who is involved in evaluating your heart disease should be asked specifically about diastolic dysfunction when your symptoms of weakness and shortness of breath exceed what would be expected based on the usual systolic function of the left ventricle, i.e., the LVEF or similar systolic performance indicators.
Some cardiologists will not even have considered the possibility of diastolic dysfunction, but the acknowledgement of that as a possibility can add credibility to your alleged symptoms. It should not be assumed that the Social Security Administration adjudicator, even if a medical doctor, will think of diastolic dysfunction when reviewing a cardiac claim. The chances of a cardiologist considering this abnormality as a possibility is greater than for other doctors, but the Social Security Administration does not have cardiologists reviewing most heart impairment claims.
Since the left ventricular ejection fraction may be normal in diastolic failure, the LVEF (as discussed above) is of little value in assessing exertional capacity. In these cases, more weight must be given to symptoms such as fatigue and shortness of breath as exertionally limiting. For example, if you have well-compensated and uncomplicated systolic heart failure with a LVEF of 50% and normal heart size, you could arguably be considered capable of medium work. However, such an exertional RFC would be a disservice if you have diastolic heart failure and a LVEF of 50%, with symptoms compatible with no more than light work. In this case, your symptoms must be given increased weight.
Cardiopulmonary exercise testing has objectively demonstrated that there is no significant difference in systolic and diastolic heart failure patients in regard to exertional capacity, despite marked differences in LVEF.
When Medium RFC Is Appropriate
If you have had one documented episode of CHF in the past due to chronic heart disease and are compensating well with treatment, you might be given a medium RFC if all factors—including symptoms, information about exertional capacity, coronary artery disease status, and ventricular performance data—are compatible with that level of work. This situation indicates you are doing extremely well in the treatment of your heart failure. It is inconceivable that you should receive a “not severe” determination if you have had chronic heart disease severe enough to have ever produced heart failure.
When Light RFC Is Appropriate
If you had a documented episode of CHF in the past due to chronic heart disease and still have a significantly enlarged heart with a cardiothoracic ratio (CT ratio) of 55% or more, it would be difficult to justify an RFC higher than light work. Depending on your relevant symptoms on daily activities, as well as other abnormalities, the RFC could be lower.
When Sedentary RFC Is Appropriate
If you had a documented episode of CHF in the past due to chronic heart disease and can only complete 5 to 6 METs on an exercise test (a level of exertion roughly equivalent to brisk walking), a restriction to sedentary work would be appropriate. Although exercise tests are very helpful in obtaining objective information about exercise capacity, the Social Security Administration should never purchase such testing if you already satisfy the listing. However, your treating physician may have performed testing and those results become relevant to the disability determination.
Significant heart disease should be a reason to limit exposure to extreme heat or cold while working, because these temperature extremes add significant stress to the body’s physiology with a corresponding decrease in exertional ability. For example, it would not be reasonable to expect someone with significant heart disease to work in 90° plus heat or in freezing temperatures; symptoms will onset earlier under such circumstances. In some cases, environmental stressors can be tolerated if the exertional workload is lessened. The Social Security Administration ignores environmental stress in most heart cases and this is not proper.
Informed medical judgment is required to evaluate the possible effect of environmental temperatures on cardiac disease, but assurance of precision is not possible and great weight should be given to your individual medical condition.
Lung Disease in Claimants With Congestive Heart Failure
If you have significant lung disease and you have had an episode of CHF in the past due to chronic heart disease, your over-all impairment severity rating should be reduced by at least one level, i.e., from medium work to light work or light work to sedentary work, or sedentary work to a finding of equivalence to listing requirements.
The pulmonary and cardiovascular systems are interactive and co-dependent. For example, if a claimant has an RFC for medium work capacity based on emphysema and an RFC for medium work capacity for heart disease, then the overall RFC should never be higher than light work with restrictions from being exposed to extreme heat or cold, or excessive dust and fumes. The only exceptions to this rule would be rare instances in which a claimant demonstrates a higher exertional capacity on objective exercise testing.
Many claimants with lung disease also have heart disease. This is especially true of cigarette smokers, who often have both chronic obstructive pulmonary disease (chronic bronchitis and emphysema) and coronary artery disease. Failure to recognize increased severity as a result of the inter-dependence of cardiac and pulmonary impairments is a major source of error by Social Security Administration adjudicators, despite federal regulations requiring consideration of the combined effect of impairments. See Can I Get Social Security Disability Benefits for Lung Disease?
Your Symptoms and Activities of Daily Living
Your symptoms are important. In considering activities of daily living (ADLs), you should make every effort to provide the Social Security Administration with clear examples of activities that precipitate symptoms—whether those symptoms are chest pain, shortness of breath, weakness, dizziness or something else.
Can you walk half a mile? A block? Half a block? Up two flights of stairs? One flight? How are you affected by heat and cold, with specific examples? What objects can you lift? How far can you carry them? What activities could you perform before you had heart disease that you are no longer able to do?
Even if you can complete many activities, but at a slower than normal pace, you may not have functional capacity for an effective work-related ability. So, activity completion durations are important in all forms of heart disease. If you can walk half a mile but it takes an hour with frequent stops, because of shortness of breath or anginal chest pain, it would be ridiculous to consider this a meaningful walking distance for any real-life job function.
If you have CHF, particularly with a history of heart failure and continuing ventricular dysfunction, you may be able to perform at a certain activity level one day but not other days. You may be able to perform a number of activities such as shopping and cooking but be exhausted for several days afterward. Medical conditions are not static in their effects on people. Even the quality of sleep can make a big difference in function the next day. Medications and the development of transient pulmonary edema at night can easily ruin a night’s rest.
Most treating physicians do not know the level of detail about a claimant’s activities of daily living (ADL) that is needed for accurate adjudication. While their opinion is important, detailed information about ADLs almost always must come from you or people who have observed you in daily life.
Use of the arms is particularly demanding on the heart; that is why women with heart disease sometimes get exhausted trying to wash their hair and cannot push a vacuum cleaner around. Vague statements about ADLs, with answers such as “I don’t do anything” or “none” for questions from the Social Security Administration about activities are close to useless for evaluation and do not increase the likelihood of a favorable decision. Most claimants do not understand how to complete daily activity forms given to them by the SSA; the responses are too brief and vague. Unfortunately, this can get a deserving claimant denied, because critical functional details were not given to the Social Security Administration.
Other Issues Affecting Disability and Heart Failure
Right Ventricular Function
The listing for chronic heart failure says nothing about right ventricular function, and often medical evidence contains no information about the right side of the heart. Most claimants for disability benefits have left ventricular dysfunction caused by ischemic heart disease, specifically coronary artery disease. See Can I Get Social Security Disability Benefits for Ischemic Heart Disease?
When cardiac catheterization data is available, it usually involves only the left side of the heart, because the cardiologist performing the procedure is interested in evaluating the large epicardial coronary arteries supplying the heart muscle with blood (see Figure 6 below); these arteries have to be approached from the left heart. Catheterization of the right side of the heart would require a separate procedure.
Figure 6: Closed heart valves with views of the coronary arteries.
However, dysfunction of the right ventricle—as evidenced by a decreased right ventricular ejection fraction (RVEF)—significantly adds to the severity of the impairment. In fact, cor pulmonale specifically affects the right side of the heart. In other instances, heart attacks damage the right ventricle as well as the left ventricle. The treating physician should have information about right heart function, if you have cor pulmonale or other disorder that affects the right side of the heart. Non-invasive imaging studies of the heart, such as cardiac MRIs and radionuclide angiography, can provide specific information about right heart function.
The Social Security Administration adjudicator should not disregard right ventricular dysfunction. Yet this can happen when the adjudicator—such as a disability examiner or SSA hearing officer—is not a physician and therefore does not have the medical knowledge necessary to evaluate cardiac cases.
Anemia is common in heart failure. In some studies it affects more than half of patients. Exercise capacity is significantly dependent on hemoglobin concentration. Even heart failure patients who have no symptoms while on treatment may have decreased exercise tolerance due to anemia. If you have ever had heart failure, you should have your hemoglobin or hematocrit measured before the Social Security Administration decides you case. Anemia can provide a credible explanation to symptoms that might otherwise be hard to explain. This is a factor that a Social Security Administration is likely to overlook.
Even modest anemia can justify further lowering your RFC and sometimes even a finding that your impairment equals a listing.
Left Bundle Branch Block
Another consideration is left bundle branch block (LBBB), because it is present in about a fourth to a third of patients with heart failure. The presence of LBBB with heart failure results in increased risk of mortality, including sudden death, compared to those heart failure patients without LBBB (16.1% vs. 10.5%).
LBBB in heart failure impairs optimum synchronization of left ventricular contraction, causing a decreased ejection fraction and cardiac output. Biventricular pacemakers were introduced to address this problem, in an attempt to re-synchronize the contractility of the right and left sides of the heart (cardiac resynchronization therapy, CRT).
Twenty to 30% of patients don’t have functional improvement with CRT. Therefore, the Social Security Administration should not assume your condition will improve with CRT. Some biventricular pacemakers include a cardiover-defibrillator for arrhythmias. Many patients who receive CRT probably are severely enough impaired to meet the listing for chronic heart failure. It is extremely unlikely that the RFC for those who do not meet the listing would exceed light work. Those that don’t meet the listing are most likely candidates for sedentary work.
Getting Your Doctor’s Medical Opinion About What You Can Still Do
Your Doctor’s Medical Opinion Can Help You Qualify for Social Security Disability Benefits
The Social Security Administration’s job is to determine if you are disabled, a legal conclusion based on your age, education and work experience and medical evidence. Your doctor’s role is to provide the Social Security Administration with information concerning the degree of your medical impairment. Your doctor’s description of your capacity for work is called a medical source statement and the Social Security Administration’s conclusion about your work capacity is called a residual functional capacity assessment. Residual functional capacity is what you can still do despite your limitations. The Social Security Administration asks that medical source statements include a statement about what you can still do despite your impairments.
The Social Security Administration must consider your treating doctor’s opinion and, under appropriate circumstances, give it controlling weight.
The Social Security Administration evaluates the weight to be given your doctor’s opinion by considering:
- The nature and extent of the treatment relationship between you and your doctor.
- How well your doctor knows you.
- The number of times your doctor has seen you.
- Whether your doctor has obtained a detailed picture over time of your impairment.
- Your doctor’s specialization.
- The kinds and extent of examinations and testing performed by or ordered by your doctor.
- The quality of your doctor’s explanation of your impairment.
- The degree to which your doctor’s opinion is supported by relevant evidence, particularly medically acceptable clinical and laboratory diagnostic techniques.
- How consistent your doctor’s opinion is with other evidence.
When to Ask Your Doctor for an Opinion
If your application for Social Security disability benefits has been denied and you have appealed, you should get a medical source statement (your doctor’s opinion about what you can still do) from your doctor to use as evidence at the hearing.
When is the best time to request an opinion from your doctor? Many disability attorneys wait until they have reviewed the file and the hearing is scheduled before requesting an opinion from the treating doctor. This has two advantages.
- First, by waiting until your attorney has fully reviewed the file, he or she will be able to refine the theory of why you cannot work and will be better able to seek support for this theory from the treating doctor.
- Second, the report will be fresh at the time of the hearing.
But this approach also has some disadvantages.
- When there is a long time between the time your attorney first sees you and the time of the hearing, a lot of things can happen. You can improve and go back to work. Your lawyer can still seek evidence that you were disabled for a certain length of time. But then your lawyer will be asking the doctor to describe your ability to work at some time in the past, something that not all doctors are good at.
- You might change doctors, or worse yet, stop seeing doctors altogether because your medical insurance has run out. When your attorney writes to a doctor who has not seen you recently, your attorney runs the risk that the doctor will be reluctant to complete the form. Doctors seem much more willing to provide opinions about current patients than about patients whom they have not seen for a long time.
Here is an alternative. Suggest that your attorney request your doctor to complete a medical opinion form on the day you retain your attorney. This will provide a snapshot description of your residual functional capacity (RFC) early in the case. If you improve and return to work, the description of your RFC provides a basis for showing that you were disabled for a specific period. If you change doctors, your attorney can get an opinion from the new doctor, too. If you stop seeing doctors, at least your attorney has one treating doctor opinion and can present your testimony at the hearing to establish that you have not improved.
If you continue seeing the doctor but it has been a long time since the doctor’s opinion was obtained, just before the hearing your attorney can send the doctor a copy of the form completed earlier, along with a blank form and a cover letter asking the doctor to complete a new form if your condition has changed significantly. If not, your attorney can ask the doctor to send a one-line letter that says there have been no significant changes since the date the earlier form was completed.
There are times, though, that your attorney needs to consider not requesting a report early in the case.
- First, depending on the impairment, if you have not been disabled for twelve months, it is usually better that your attorney wait until the twelve-month duration requirement is met.
- Second, if you just began seeing a new doctor, it is usually best to wait until the doctor is more familiar with your condition before requesting an opinion.
- Third, if there are competing diagnoses or other diagnostic uncertainties, it is usually best that your attorney wait until the medical issues are resolved before requesting an opinion.
- Fourth, a really difficult judgment is involved if your medical history has many ups and downs, e.g., several acute phases, perhaps including hospitalizations, followed by significant improvement. Your attorney needs to request an opinion at a time when the treating doctor will have the best longitudinal perspective on your impairment.
Medical Opinion Forms
Medical opinion forms can be great time savers for both your attorney and your doctor, but they must be used with care. Forms may not be appropriate at all in complex cases; and they need to be supplemented in many cases so that all issues are addressed. The best forms are clear and complete but not too long.
When the time is right, here is a form for your disability attorney to use: