- How Does the Social Security Administration Decide if I Qualify for Disability Benefits for Lupus?
- About Lupus and Disability
- Winning Social Security Disability Benefits for Lupus by Meeting a Listing
- Residual Functional Capacity Assessment for Lupus
- Getting Your Doctor’s Medical Opinion About What You Can Still Do
To determine whether you are disabled at Step 3 of the Sequential Evaluation Process, the Social Security Administration will consider whether your lupus is severe enough to meet or equal the lupus 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 Social Security Administration presumes would prevent a person from performing substantial work. If your lupus is severe enough to meet or equal the listing, you will be considered disabled. The listing applicable to lupus is 14.02. It has two parts: A and B. You will meet the listing if you satisfy either part.
Meeting Social Security Administration Listing 14.02A for Lupus
You will meet listing 14.02A if you have systemic lupus erythematosus (see Diagnostic Criteria Required by the Social Security Administration) with:
A. Involvement of two or more organs/body systems, with:
1. One of the organs/body systems involved to at least a moderate level of severity; and
2. At least two of the constitutional symptoms or signs (severe fatigue, fever, malaise, or involuntary weight loss).
Part A requires involvement of at least two or more organs or body systems without consideration of severity. Parts A.1 and A.2 must both be satisfied.
Part A.1 requires that the involvement of at least one of the organs or body systems must be of moderate severity. So, what is “a moderate level of severity?” In many cases, the answer to this question is highly subjective. However, most doctors would probably agree on certain generalizations.
Moderate impairments are a more than slight or trivial compromise in the structure (anatomy) or function (physiology) of an organ or body system. Unavoidably, medical judgment is necessary to assess the level of impairment. Different organs or organ systems require different approaches to determining severity. For example, lung function tests provide a basis for deciding the level of impairment of the respiratory system, while imaging studies (e.g., x-rays, MRIs) along with physical examination and observation of gait permit an informed judgment regarding the severity of the dysfunction of a joint.
The treatment prescribed by your doctor is a clue to severity. Failure to prescribe treatment is a powerful argument that the doctor doesn’t think the abnormality is severe, unless there is a documented medical reason why treatment is indicated but cannot be given. Other factors include prognosis, as well as response to any treatment, and the expected natural history of the disorder with and without treatment.
In the mind of many doctors, symptoms also play a part in deciding whether a disorder has reached a threshold of “moderate” medical severity. However, the Social Security Administration has split off this aspect into part A.2, probably for the sake of clarity.
You must have at least two constitutional symptoms or signs that are medically severe. “Constitutional” means the entire body is affected. The Social Security Administration defines qualifying constitutional symptoms and signs as “severe fatigue, fever, malaise, or involuntary weight loss.” The Social Security Administration defines severe fatigue as a frequent sense of exhaustion that results in significantly reduced physical activity or mental function. Malaise means frequent feelings of illness, bodily discomfort, or lack of well-being that result in significantly reduced physical activity or mental function.
No specific requirement for the degree of fever is given, and it must be assumed that any abnormally high temperature would qualify. Fever should be documented in medical records as measured by medical personnel; home readings can have some weight but only if consistent with the treating doctor’s findings.
The Social Security Administration provides no criteria for the severity of “involuntary weight loss.” Since normal body weight may fluctuate a few pounds (from day to day fluid changes, if nothing else), this should be taken into account. Otherwise, no particular amount of weight loss is imposed by the listing. However, weight loss should be documented by medical personnel with reliable equipment.
Your credibility is always an issue. You must have a medically determinable impairment that could reasonably produce the symptoms you allege.
Meeting Social Security Administration Listing 14.02B for Lupus
You will meet listing 14.02B if you have systemic lupus erythematosus with:
B. Repeated manifestations of SLE, 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:
1. Limitation of activities of daily living.
2. Limitation in maintaining social functioning.
3. Limitation in completing tasks in a timely manner due to deficiencies in concentration, persistence, or pace.
Part B has a first requirement of the same constitutional signs or symptoms as discussed for part A.2. See Constitutional Symptoms.
Meaning of Repeated
“Repeated” means that the manifestations:
- Occur on an average of three times a year, or once every 4 months, each lasting 2 weeks or more; or
- Do not last for 2 weeks but occur substantially more frequently than three times in a year or once every 4 months; or
- Occur less frequently than an average of three times a year or once every 4 months but last substantially longer than 2 weeks.
Your impairment will satisfy this criterion regardless of whether you have the same kind of manifestation repeatedly, all different manifestations, or any other combination of manifestations. For example, two of the same kind of manifestation and a different one. You must have the required number of manifestations with the frequency and duration required in this section. Also, the manifestations must occur within the period covered by your claim.
Your immune system disorder must result in a “marked” level of limitation in one of three general areas of functioning: Activities of daily living, social functioning, or difficulties in completing tasks due to deficiencies in concentration, persistence, or pace. Functional limitation may result from the impact of the disease process itself on your mental functioning, physical functioning, or both your mental and physical functioning. This could result from persistent or intermittent symptoms, such as depression, severe fatigue, or pain, resulting in a limitation of your ability to do a task, to concentrate, to persevere at a task, or to perform the task at an acceptable rate of speed. You may also have limitations because of your treatment and its side effects.
“Marked” means more than moderate but less than extreme. “Marked” is not defined by a specific number of different activities of daily living in which your functioning is impaired, different behaviors in which your social functioning is impaired, or tasks that you are able to complete, but by the nature and overall degree of interference with your functioning. You may have a marked limitation when several activities or functions are impaired, or even when only one is impaired. Also, you need not be totally precluded from performing an activity to have a marked limitation, as long as the degree of limitation seriously interferes with your ability to function independently, appropriately, and effectively. The term “marked” does not imply that you must be confined to bed, hospitalized, or in a nursing home.
Activities of Daily Living
Activities of daily living include, but are not limited to, such activities as doing household chores, grooming and hygiene, using a post office, taking public transportation, or paying bills. The Social Security Administration will find that you have a “marked” limitation of activities of daily living if you have a serious limitation in your ability to maintain a household or take public transportation because of symptoms, such as pain, severe fatigue, anxiety, or difficulty concentrating, caused by your immune system disorder (including manifestations odf the disorder) or its treatment, even if you are able to perform some self-care activities.
You should describe in detail how symptoms limit your activities including the nature, location, duration, precipitating cause, and severity of any limiting symptom.
Social functioning includes the capacity to interact independently, appropriately, effectively, and on a sustained basis with others. It includes the ability to communicate effectively with others. The Social Security Administration will find that you have a “marked” limitation in maintaining social functioning if you have a serious limitation in social interaction on a sustained basis because of symptoms, such as pain, severe fatigue, anxiety, or difficulty concentrating, or a pattern of exacerbation and remission, caused by your immune system disorder (including manifestations of the disorder) or its treatment, even if you are able to communicate with close friends or relatives.
Behavior, including social interactions, that is closely supervised at the instigation of someone else is not independent. Appropriate behaviors are perhaps mostly easily defined in this context by what is not appropriate, such as withdrawal, frequent crying, anger, or emotional outbursts that make social interactions difficult or impossible. Effective sustained communication includes the ability to comprehend and respond to spoken or written language with sufficient clarity and focus that useful information can be exchanged in a reasonable amount of time.
Completing Tasks in Timely Manner
Completing tasks in a timely manner involves the ability to sustain concentration, persistence, or pace to permit timely completion of tasks commonly found in work settings. The Social Security Administration will find that you have a “marked” limitation in completing tasks if you have a serious limitation in your ability to sustain concentration or pace adequate to complete work-related tasks because of symptoms, such as pain, severe fatigue, anxiety, or difficulty concentrating, caused by your immune system disorder (including manifestations of the disorder) or its treatment, even if you are able to do some routine activities of daily living.
Specific information is needed. Examples of tasks you cannot complete in a timely manner don’t necessarily have to involve a workplace, but should allow the Social Security Administration adjudicator to make a deduction of your ability to perform work-related tasks. If you have difficulty completing tasks around the house or in other environments, you or other family members should be able to provide detailed information regarding failed tasks, including the nature of the task, length of time you can work at it until you have to stop, and the symptoms that caused you to stop. For example, inability to dust or vacuum for more than ten minutes because of fatigue is clear and to the point. The inability to finish grocery-shopping because of difficulty concentrating is another example. There are many possibilities.
Continue to Residual Functional Capacity Assessment for Lupus.