Inflammatory Arthritis, Lupus, HIV
SSA Bluebook definition: Auto-Immune System Disorders
Like lyme disease, lupus (or systemic lupus erythmatosus) is a chronic disorder that 1. involves exacerbations and remissions (i.e. lupus flare-ups) and 2. involves multiple body systems.
However, unlike lyme disease, the social security administration does actually devote some space in the "blue book" to lupus claims. For those who are unaware, the blue book is the impairment listing manual that is used by both social security disability examiners and administrative law judges alike to render decisions on ssd and ssi disability claims that involve certain medical issues (i.e. "listed" impairments such as lupus).
At this point, it may be a good idea to stop and explain, in condensed form, how the disability process works, what disability examiners and disability ALJs are, and how the blue book comes into play in the disability process.
Individuals who pursue disability benefits generally get their claims started by contacting a local social security office and requesting that an application for disability benefits be taken. However, the social security office is only where the process begins.
After an application has been taken, it is not processed at the social security office, but, instead, is sent to a state-level agency whose primary function is to make decisions on disability cases. In some states, this agency will be known as the bureau of disability determination, but in most states it bears the title DDS, which stands for disability determination services. It is at DDS that disability examiners are based and it is at DDS where most of the medical development on a disability claim will actually be performed.
Exactly what is a disability examiner? In a nutshell, disability examiners make decisions on disability claims at the initial application and reconsideration levels. After a claimant has filed an ssi or ssd application at the social security office, their file is transferred to DDS where it is assigned to an examiner. Typically, as soon as an examiner receives a new file, letters are sent out to a claimant's medical providers for the purpose of gathering records. Once these records have been received, an examiner will be in a position to make a decision and close a case.
Unfortunately, more often than not, the decision rendered on a claim will be a denial and, in all too many cases, a social security disability or ssi disability claimant will have to request a hearing before a federal administrative law judge.
How does an ALJ, or administrative law judge play into the disability evaluation process? Basically, though administrative law judges operate at a higher level, they perform the same function as disability examiners. They read a claimant's records and, if they see the need, will occasionally require that a claimant be seen at a CE, orconsultative medical examination, in order to obtain more recent medical information.
Plainly put, disability examiners and ALJs (administrative law judges) are the adjudicators in the social security administration's disability system. And they both use the blue book, or SSA impairment listing manual, in instances where a claimant has a disability that is listed in the book.
As was stated earlier, lupus is differentiated from lyme disease in that lupus has a listing (the listing in the blue book is 14.02, systemic lupus erythmatosus, under the category of immune system impairments). However, the lupus listing is also differentiated from most other listings by the fact that the lupus listing refers mainly to other listings.
Here's how the listing actually reads:
14.02 Systemic lupus erythematosus. Documented as described in 14.00B1, with:
(A) One of the following:
- Joint involvement, as described under the criteria in 1.00; or
- Muscle involvement, as described under the criteria in 14.05; or
- Ocular involvement, as described under the criteria in 2.00ff; or
- Respiratory involvement, as described under the criteria in 3.00ff; or
- Cardiovascular involvement, as described under the criteria in 4.00ff or 14.04D; or
- Digestive involvement, as described under the criteria in 5.00ff; or
- Renal involvement, as described under the criteria in 6.00ff; or
- Hematologic involvement, as described under the criteria in 7.00ff; or
- Skin involvement, as described under the criteria in 8.00ff; or
- Neurological involvement, as described under the criteria in I 1.00ff, or
- Mental involvement, as described under the criteria in 12.00ff.
(B) lesser involvement of two or more organs/body systems listed in paragraph A, with significant, documented, constitutional symptoms and signs of severe fatigue, fever, malaise, and weight loss. At least one of the organs/body systems must be involved to at least a moderate level of severity.
As one can see, the lupus listing for social security disability or ssi disability allows for a wide range of discretion on the part of disability examiners and judges. As paragraph A states, a claimant with a properly documented lupus diagnosis can be awarded benefits on the basis of satisfying certain body system-specific criteria. However, a disability claimant can also be awarded benefits via the criteria specified in paragraph B.
Paragraph B of the lupus listing allows a bit of "wiggle room" for claimants who are unable to meet the exact criteria for any one body system. However, paragraph B also "ups the ante" by requiring that medical documentation be shown for 2 body systems (as opposed to just one body system in paragraph A).
Paragraph B of the lupus listing also requires significant documentation of the following: severe fatigue, fever, malaise, and weight loss. And, lastly, paragraph B of the listing requires that at least one of the two body systems affected by lupus must involve a moderate level of serverity. Arguably, it is this last requirement that may pose the largest hurdle for anyone attempting to meet the paragraph B criteria since "moderate" is, to some extent, a subjective evaluation.
Of course, many individuals with lupus who are approved for disability will not be approved as the result of meeting the requirements of the lupus listing. Instead, they will be awarded ssd or ssi benefits on the basis of a medical vocational allowance.
A "med-voc allowance" occurs whenever a disability claimant does not meet the requirements of a listing but is nonetheless approved via consideration of the following factors: 1. age, 2. education, 3. work skills, and 4. level of functional limitation.
Essentially, medical vocational allowances work like this: if a claimant has an impairment that has lasted (or can be expected to last) twelve full months, and the impairment is severe enough to prevent the claimant from engaging in one of their past jobs and also prevents them from engaging in certain "other" types of work (as determined by age, education, transferrable work skills, and functional restrictions), then the claimant will be approved for disability--even if they do not meet the requirements of a listing, such as the listing for lupus.
Disability benefit approvals based on a medical-vocational allowance occur far more frequently than approvals made on the basis of meeting a listing. But in either case, it all comes down to the information that is contained in a claimant's medical records. And this fact makes it especially important that a lupus patient's doctors and other treating sources should make good references in their treatment notes as to the limitations a patient has as a result of having lupus. For more information on the type of information that should be found in a doctor's treatment notes, read the following page.
- By means of a medical vocational allowance;
- By meeting or equaling the requirements of the multiple sclerosis listing (listing 11.09) in the social security administration's impairment listing manual (commonly referred to as the "blue book").
To be approved via a medical vocational allowance, an MS claimant's medical records must show that their condition is severe and has lasted, or can be projected to last, for a period not less than twelve months. During this actual or projected twelve month period, the claimant's condition must also prevent them from working at a job they have done in the past, and prevent them from engaging in suitable forms of other work.
Medical vocational allowances are how most disability claims are approved. However, an MS patient can be approved for social security disability or SSI disability benefits on the basis of meeting or equaling the requirements of the multiple sclerosis listing.
The multiple sclerosis listing (listing 11.09) provides specific criteria for disability approvals made on the basis of MS. Essentially, the listing provides for three separate and distinct types of criteria that, when individually met, may result in an awarding of benefits (in other words, a claimant is not required to satisfy all three types of MS criteria, but, rather, only one). These three categories can be labeled as follows:
- Motor function impairment
- Visual impairment
- Mental impairment.
Regarding the first category, motor function impairment, an individual with MS can meet the requirements of the multiple sclerosis listing IF their medical records document a diagnosis of multiple sclerosis and one of the following:
- Significant, persistent motor function disorganization in two extremities (two arms, two legs, or one arm and one leg) to the extent that this disorganization causes a sustained disturbance of either gait and station or gross and dexterous movements.
- OR - Significant motor function fatigue with substantial muscle weakness (on repetitive activity). This fatigue and weakness must be able to be demonstrated upon physical examination. Additionally, it must be considered to result from multiple sclerosis - related neurological dysfunction.
Regarding the second category, visual impairment, a multiple sclerosis patient can be approved for social security disability or SSI disability benefits if their medical records indicate a diagnosis of multiple sclerosis and also demonstrate a loss of visual acuity, peripheral vision, or visual efficiency. For most disability claimants, of course, the visual criteria that will apply will relate to lost visual acuity and it is in this area that SSA is fairly strict. To satisfy the visual acuity criteria, a claimant's eyesight must be so deficient that, even in the better eye and even after best correction has been made, their residual eyesight is 20/200 or worse.
Finally, a social security disability or SSI disability claimant can be approved for benefits on the basis of the multiple sclerosis listing if
- they have been diagnosed with MS and
- they meet or equal the requirements of the blue book listing for organic mental disorders (listing 12.02).
The social security administration defines organic mental disorders as behavioral or psychological abnormalities that are associated with brain dysfunction. To meet the requirements for an organic mental disorder (i.e. for an MS patient to be approved for disability on the basis of an OMD), the presence of a specific organic factor must be demonstrated to be related to the psychological or behavioral abnormalities in question. Proof of this organic factor and its etiological link may be provided by
- A. the claimant's medical history,
- B. the findings of physical examinations, and
- C. the results of laboratory tests.
Additionally, beyond documenting the presence of an organic factor for which behavioral or psychological abnormalities are the result, the severity of an organic mental disorder must also be demonstrated.
In general terms, this means more than a minimal limitation of the ability to perform basic work activities, or marked restrictions in the ability to engage in activities of daily living, maintain social functioning, and maintain concentration, persistence, or pace. Another indicator of severity in the area of organic mental disorders would berepeated episodes of decompensation, each of extended duration.
If you have further questions, or would like to discuss your disability or claim with us, please call (865) 637-0515 for your free consultation.