The most common ailment presented by applicants for Social Security Disability and SSI is back pain. It is also one of the most common reasons people go the doctor and miss work. According to the Mayo Clinic, more than 3 million cases per year are treated.
With so many new cases being diagnosed and treated every year, it is important for claimants for back pain disability benefits to have some understanding of what a strong back pain claim looks like in the eyes of the Social Security Administration. It is my belief that most Americans who apply for benefits would rather work and that most people are willing to endure a heavy amount of suffering to hold on to their jobs and provide for their families. But there comes a point when the pain becomes unbearable and a return to work is impractical if not impossible.
You may have reached a pain level where continuing to work is not an option. Even your doctor agrees that your documented limitations show you cannot maintain employment, and yet your claim was denied. How does that happen? Part of it can be attributed to an arbitrary, over-worked system, but another substantial reason is the Listings of Medical Impairments and what is called the Grids. If a claimant’s condition meets the Listings, then the claim is approved.
The Listing for disorders of the spine starts with examples – herniated nucleus pulposus, spinal stenosis, osteoarthritis, degenerative disc disease and facet arthritis among others. However, a diagnosis of one of those conditions does not necessarily mean a claimant has met the Listings and will be awarded benefits. After the condition has been diagnosed, there must be certain earmarks or attributes connected to the condition. Most claimants will be aware of their general diagnoses but not familiar with the underlying pathologies and tests necessary to show point-for-point correlation with the language of the Listings.
Let’s use degenerative disc disease as our example because it is the most commonly diagnosed back or spinal condition for which disability benefits are sought. With the diagnosis of degenerative disc disease or any other spinal condition, there must also be evidence of nerve root compression, limitation of motion of the spine, motor loss and if there is involvement of the lower back, a positive straight-leg raising test. If there is no nerve root compression or other evidence listed above, the degenerative disc disease can still meet the Listings if there is spinal arachnoiditis resulting in the need for changes in position or posture more than once every two hours. If both spinal arachnoiditis and nerve root compression are absent, the back condition can still meet the Listing if there exits lumbar spinal stenosis resulting in pseudoclaudication manifested by chronic pain and weakness, resulting in an inability to move effectively.
After having examined the Listing itself, how does the claimant apply it to his situation? The only effective way is to have the claimant’s doctor review the Listings and perform the required tests if those tests were not already completed. It is possible for the Social Security Administration to order what is called a Consultative Examination or CE. A Consultative Examination is an examination by a doctor hired by the Social Security Administration.
It is not uncommon for the Social Security Administration to send a claimant to a Consultative. However, it is uncommon for the Consultative Examiner to conclude that a claimant’s impairments actually meet the medical requirements of the Listings. There are several reasons why few Consultative Examiners find that claimants meet the Listings. In some cases, it is because the Consultative Examiner lacks the equipment to perform the tests. In other instances, according to more cynical minds, a CE rarely finds the claimant meets the Listings because Consultative Examiners are paid by the Social Security Administration itself. And according to that line of reasoning, Consultative Examiners who frequently find that claimants meet the Listings or that claimants lack the capacity to do their past relevant work are Consultative Examiners who are not likely to be retained by the Social Security Administration for much longer.
Have your advocate submit a Range of Motion form used by the American Medical Association Guide to the Evaluation of Permanent Impairments. It is a short but an amazingly useful form that can make it difficult for the Administrative Law Judge to find the claimant can return to her Past Relevant Work.
Another form you may want to ask your advocate if he or she is familiar with is the Physical Capacities Evaluation Form (PCE). This form is more detailed than the Range of Motion and is sometimes used by various state disability determination offices. If a claimant is able to get his or her treating doctor to complete the PCE, it can be an extremely valuable tool in the arsenal of the advocate. The Physical Evaluation Form is a medical opinion of how much standing, sitting, bending and lifting a claimant can do over various time periods.
If the Consultative Examiner finds that the claimant meets the Listings, then the inquiry is over and the claimant should be awarded benefits. However, if the claimant’s treating doctor contends she meets the Listings but the Consultative Examiner does not think the claimant’s spinal condition meets the Listings, the claim is very likely to be denied and the case continues to the hearing stage. It is possible the Disability Examiner could find the claimant’s spinal disorder does not meet the Listings but the combination of impairments such as headaches, side effects of medications, shoulder pain could equal the impact of the listed conditions and the claimant would then be entitled to benefits.
In the event it is determined the claimant’s condition is found not to meet or equal a listing, then the next step is to decide if the claimant’s impairments prevent the claimant from doing his or her former work. At the point where it is determined the claimant cannot do her past relevant work, the Medical-Vocational Guidelines come into play. An in-depth discussion of the Medical-Vocational Guidelines or Grids is beyond the scope of the blog. But at the juncture where the Grids come into consideration, the Range of Motion form and the Physical Capacities form mentioned above could tip the scales in favor of the claimant getting a favorable decision. The intent of those forms is to show how long and how well the claimant can handle the physical requirements of certain activities associated with maintaining employment such as sitting, lifting, standing, walking, climbing, finger/hand manipulations and others. If the weight of those forms, completed by doctors familiar with the claimant’s history, show the applicant is prevented from not only doing her past relevant work but also every other kind of work, it is much more likely the claimant will get a favorable decision even if it determined that the primary impairment does not meet or equal a Listing. Those forms should be completed by your doctor early in the application process.