Fibromyalgia was Officially Recognized by the Social Security Administration

Fibromyalgia was officially recognized by the Social Security Administration as a qualifying condition for Social Security Disability Benefits.

Social Security Ruling, SSR 12-2p; Titles II and XVI: Evaluation of Fibromyalgia

Introduction

Fibromyalgia (FM) is a complex medical condition considered primarily by widespread pain in the muscles, joints, tendons, or nearby soft tissues that have persisted for at least 3 months. Fibromyalgia is a common syndrome. When a person seeks disability benefits due in whole or in part to Fibromyalgia, it is properly considered the person’s symptoms when it has been decided whether the person has a medically determinable impairment (MDI) of fibromyalgia. To address these matters, the Social Security Administration (SSA) published a new ruling that helps administrative law judges (ALJs) and examiners evaluate Fibromyalgia, even if the symptoms cannot be validated or confirmed by definitive testing, as with conditions like rheumatoid arthritis or degenerative disc disease.

Policy Interpretation

• What specific criteria can establish that a person has an MDI of FM?
• What general criteria can establish that a person has an MDI of FM?

So We try to answer these questions here. Many applicants for Social Security disability benefits who apply based on FM get denied. Part of the reason has been that Social Security does not have a disability “listing” for this illness. To address the issue, the SSA published a ruling in 2012 giving guidance to disability claims ALJs and examiners as to how to assess FM cases. The ruling should help those who are initially denied benefits to win during the appeals process.
To be considered for disability benefits, you must have an impairment established by medical evidence like lab tests and medical signs of the disease or illness. In other words, your impairment cannot be established only by your reports of your symptoms.
This is called the requirement of having an MDI. The Ruling does note that symptoms like fatigue and pain may preclude the ability to do even unskilled work. Still, the challenge remains that there are no medical tests that can prove the existence of extensive pain, tenderness in the joints, muscles, and soft tissues, dizziness, fatigue, and “fibro fog” and, more important, no test that measures the severity of these symptoms. These symptoms must be clearly and consistently noted in the treatment records to be considered credible by an ALJ.

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The 1990 ACR Criteria for the Classification of Fibromyalgia. Based on these criteria, we may find that a person has an MDI of FM if he or she has all three of the following:

1. A history of widespread pain that lasts for at least three months.  The pain may fluctuate in intensity and may not always be present.
2. Evidence that other disorders that could cause the symptoms or signs were excluded; and
3. One of the following: At least 11 tender points on physical examination OR Repeated manifestations of six or more fibromyalgia symptoms including: (Click on them to read in details)

• fatigue
• cognitive or memory problems (often called “fibro fog”)
• waking unrefreshed
• depression
• muscle pain
• pain or cramps in the abdomen
• muscle weakness
• headache
• Raynaud’s phenomenon
• hives or welts
• anxiety disorder
• Irritable bowel syndrome
• change in taste
• blurred vision
• fever
• heartburn
• oral ulcers
• loss of taste
• shortness of breath
• loss of appetite
• rash
• Heat sensitivity
• hearing difficulties
• easy bruising
• seizures
• dry eyes
• hair loss
• frequent urination or bladder spasms

The 18 tender point sites are located on each side of the body at the:

• Occiput (base of the skull);
• Low cervical spine (back and side of the neck);
• Trapezius muscle (shoulder);
• Supraspinatus muscle (near the shoulder blade);
• Second rib (top of the rib cage near the sternum or breast bone);
• Lateral epicondyle (outer aspect of the elbow);
• Gluteal (top of the buttock);
• Greater trochanter (below the hip); and
• Inner aspect of the knee.

Related Article: How to Prove You Have a Fibromyalgia as “Medically Determinable Impairment” for SSDI?

General Documentation and Other Sources of Evidences

If the Social Security Administration (SSA) determines that you have the MDI of FM, Social Security’s evaluation is not over, in fact, it has just begun. The SSA will probably develop a “residual functional capacity” (RFC) assessment for you to determine if there is any work you can do, including your past work.  An RFC assessment is an evaluation of your ability to perform various exertional levels of work and depends on your medical records.

In assessing your RFC, the examiner will read your doctor’s notes on your complaints of fatigue, pain, and possible cognitive difficulties. To assess the credibility of your complaints, the claims examiner can ask your doctor to provide information about the duration and extent of your impairments, her or his opinion of how well you are able to work, what treatments were tried and whether they were helpful and had side effects, and how long the doctor expects your ability to function to be limited. The longer your medical record contains evidence of FM symptoms and treatment, the better.  These functional limitations are the key to showing the SSA why you cannot work.

After creating your residual functional capacity, the Social Security Administration will compare it to the types of jobs available for someone with your residual functional capacity level and limitations.

What General documentation do They need?

1. As in all claims for disability benefits, we need objective medical evidence to establish the presence of an MDI. When a person alleges FM, longitudinal records reflecting ongoing medical evaluation and treatment from acceptable medical sources are especially helpful in establishing both the existence and severity of the impairment. In cases involving FM, as in any case, we will make every reasonable effort to obtain all available, relevant evidence to ensure appropriate and thorough evaluation.

2. We will generally request evidence for the 12 months before the date of application unless we have reason to believe that we need evidence from an earlier period, or unless the alleged onset of the disability is less than 12 months before the date of application.[12] In the latter case, we may still request evidence from before the alleged onset date if we have reason to believe that it could be relevant to a finding of the existence, severity, or duration of the disorder, or to establish the onset of disability. – Office of the Federal Register[US]

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Conclusion:

In accordance with 20 CFR 402.35(b)(1), the Commissioner of Social Security gives notice of Social Security Ruling, SSR 12-2p. This ruling provides guidance on how we develop evidence to establish that a person has a medically determinable impairment of fibromyalgia, and how we evaluate fibromyalgia in disability claims and continuing disability reviews under titles II and XVI of the Social Security Act. -FederalRegister.Gov

SSR 12-2p eliminates any last indication of doubt about the existence of FM as a severe medical problem, which can cause a patient to be completely disabled under the Social Security Act. The Ruling does not change what you will have to prove to obtain disability benefits, but it does provide a clear guidance that will prove useful in meeting your burden.

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Also Read: Tips to Apply and Win Disability (SSD) for CFS and Fibromyalgia

For Further Information Contact:
Cheryl Williams, Office of Disability Programs, Social Security Administration, 6401 Security Boulevard, Baltimore, Maryland 21235-6401, (410) 965-1020.

A complete copy of the ruling that provides guidance to SSD examiners is here: : https://www.federalregister.gov/documents/2012/07/25/2012-17936/social-security-ruling-ssr-12-2p-titles-ii-and-xvi-evaluation-of-fibromyalgia

Reference: Office of the Federal Register