How Does the Social Security Administration Decide if I Qualify for Disability Benefits for Fibromyalgia?
If you have fibromyalgia, Social Security disability benefits may be available to you. To determine whether you are disabled by fibromyalgia, the Social Security Administration will consider whether your fibromyalgia qualifies as a severe medically determinable impairment at Step 2 of the Sequential Evaluation Process. See Fibromyalgia as a Medically Determinable Severe Impairment. If your fibromyalgia qualifies at Step 2, the Social Security Administration then considers whether your condition is severe enough to equal a listing at Step 3 of the Sequential Evaluation Process. See Winning Social Security Disability Benefits for Fibromyalgia by Equaling a Listing.
If your fibromyalgia is not severe enough to equal a listing, the Social Security Administration must assess your residual functional capacity (RFC) (the work you can still do, despite your fibromyalgia), to determine whether you qualify for benefits at Step 4 and Step 5 of the Sequential Evaluation Process. See Residual Functional Capacity Assessment for Fibromyalgia.
About Fibromyalgia and Disability
Fibromyalgia, also known as fibrositis and fibromyositis, is an impairment characterized by a lack of objective findings. Its cause is unknown, there is no cure, and the symptoms are subjective.
Notwithstanding the lack of objective findings, fibromyalgia can have a devastating impact on your ability to work.
Fibromyalgia is defined by the American Collegeof Rheumatology (ACR) as “widespread pain in all four quadrants of the body for a minimum duration of 3 months and at least 11 of the 18 specified tender points which cluster around the neck and shoulder, chest, hip, knee, and elbow regions.”
Other typical symptoms are irritable bowel syndrome, chronic headaches, temporomandibular joint dysfunction, sleep disorder, severe fatigue, and cognitive dysfunction.
Fibromyalgia as a Medically Determinable Severe Impairment
At Step 2 of the Sequential Evaluation Process, you must have a medically determinable impairment that is severe. The Social Security Administration has accepted that fibromyalgia can constitute a medically determinable impairment. A medically determinable severe impairment must be established through medically acceptable clinical and laboratory diagnostic techniques.
Generally, to establish fibromyalgia as a medically determinable severe impairment, you must show:
- Widespread pain for at least three months.
- Pain on palpation in at least 11 of the 18 tender point sites (as identified by the American College of Rheumatology).
- Morning stiffness or stiffness after sitting for a short period of time.
Winning Social Security Disability Benefits for Fibromyalgia 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 impairment is severe enough to meet or equal a 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. A claimant who meets or equals a listing is considered disabled.
The Social Security Administration has no listing for fibromyalgia. Since fibromyalgia is not a listed impairment, you cannot be found to meet a listed impairment based on your fibromyalgia alone. However, the specific findings in your case should be compared to any pertinent listing to determine whether “medical equivalence” may exist. In other words, you may be entitled to Social Security disability benefits if the severity of your condition equals an existing listing for a different impairment.
If you have psychological problems related to fibromyalgia, they should be evaluated under the mental disorders listings. The Social Security Administration should consider whether your impairments meet or equal the severity of a mental listing. See Can I Get Social Security Disability Benefits for Depression, Bipolar Disorder, or Mania? and Can I Get Social Security Disability Benefits for Anxiety, Phobias, Panic Attacks, Obsessive Compulsive Disorder, or PTSD?
Residual Functional Capacity Assessment for Fibromyalgia
What Is RFC?
If your fibromyalgia is not severe enough to 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. An RFC for mental impairments is expressed in terms of whether Social Security Administration believes the claimant can do skilled, semi-skilled, or unskilled work in spite of impairments, or whether the claimant cannot even do unskilled work. The lower your RFC, the less the Social Security Administration believes you can do.
RFC and Fibromyalgia
If you have fibromyalgia, you may have significant residual limitations that could potentially result in allowance of your claim.
In determining your RFC, the Social Security Administration adjudicator should consider all of your symptoms in deciding how they may affect your ability to function. Symptoms of fibromyalgia that the adjudicator should consider include those mentioned in the American College of Rheumatology’s definition of fibromyalgia:
- Widespread pain in all four quadrants of the body
- As many as are present of the 18 specified tender points around the neck and shoulder, chest, hip, knee, and elbow regions.
Other typical symptoms that could limit you functional capacity include:
- Irritable bowel syndrome.
- Chronic headaches.
- Temporomandibular joint dysfunction.
- Sleep disorder.
- Severe fatigue.
- Cognitive dysfunction.
The Social Security Administration has issued a ruling that provides guidance to Social Security Administration adjudicators about what to consider in assessing a fibromyalgia claimant’s RFC. In evaluating the credibility of the symptoms you report, the adjudicator should ask your treating doctor or other medical sources to provide information about the extent and duration of your impairments, including observations and opinions about how well you are able to function, the effects of any treatment, including side effects, and how long the impairments are expected to limit your ability to function.
Opinions from your medical sources, especially treating doctors, concerning the effects of fibromyalgia on your ability to function in a sustained manner in performing work activities or in performing activities of daily living are important in enabling adjudicators to draw conclusions about the severity of your impairments. Any information a medical source is able to provide contrasting your impairments and functional capacities since the onset of your fibromyalgia with your status before its onset will be helpful in evaluating your impairments and their functional consequences. See Getting Your Doctor’s Opinion About What You Can Still Do.
Information from third-parties may be very useful in deciding your credibility. Information other than your allegations and reports from your treating doctors helps the adjudicators to assess your ability to function on a day-to-day basis and to depict your capacities over a period of time. Such evidence includes, but is not limited to:
- Information from neighbors, friends, relatives, or clergy.
- Statements from past employers, rehabilitation counselors, or teachers about your impairments and their effects on how your function in the work place, rehabilitation facility, or educational institution.
- Statements from health care professionals who have treated you, other than doctors, such as nurse-practitioners, physicians’ assistants, naturopaths, therapists, social workers, and chiropractors.
- Your own record (such as a diary, journal, or notes) of your impairments and their impact on function over time.
Getting Your Doctor’s 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: