Today continues the five questions used in making a Social Security or Supplemental Security Income (SSI) disability medical decision.   Earlier posts covered the first question, Are you working?, and the second, Is your condition “severe”?  

To be severe, the medical condition must significantly limit your ability to do basic work-related activities for at least one year.   The state Disability Determination Services (DDS) goes to the third question only if your condition is severe. 

Question three:   Is your condition found in the list of disabling conditions? 

Previously I mentioned that the medical requirements for Social Security disability and Supplemental Security Income (SSI) disability are essentially the same.  This is for adults.  SSI has a disabled child category that does not exist for Social Security because SSA benefits are payable to eligible young children under age 18 based on age, not health.   

Separate for adults and children, there is a listing of medical conditions for each major body system.   These listings describe impairments considered severe enough to prevent an adult from doing any gainful work activity.  In the case of children under age 18 applying for SSI, impairments listed are severe enough to cause marked and severe functional limitations. 

Most of the listed impairments are permanent or expected to result in death, or the listing includes a specific statement about duration.  For all other listings, evidence must show that the impairment has lasted, or is expected to last, a continuous period of at least 12 months.   

If the severity of your medical condition is on the Listing of Impairments, the usual result is to determine that you are disabled.  Once medically approved, the Disability Determination Services (DDS) returns the application to the local Social Security office for completion of any non-medical development and payment. 

For medical decisions, Social Security has initiatives designed to expedite processing of new disability claim.  Through the Compassionate Allowance initiative, certain cases that usually qualify under the Listing of Impairments can be medically approved as soon as the diagnosis is confirmed.  Examples include acute leukemia, Lou Gehrig’s disease (ALS) and pancreatic cancer.  The agency also uses computer screening to help identify cases with a high probability of medical allowance.   More about these some other time.  

If your medical condition is not on the list, the DDS examiner must decide if it is of equal severity to a medical condition that is on the list.  If equal severity is met, disability is usually established.   When discussing development of the second question, Is your disability severe?, I suggested including all your physical or mental medical conditions on the medical Disability Report even if one is the most important.  Doing so could be important here.  

If your condition is not on the list of disabling conditions and not of equal severity to a medical condition that is on the list, the Disability Determination Services (DDS) examiner goes to question four.

As will I in the future.

Today continues the five questions used in making a Social Security or Supplemental Security Income (SSI) disability medical decision. 

Are you working? is the first question.  If yes, the local Social Security office evaluates the work activity.  In 2012, earnings that average more than $1,010 per month will probably result in denial without further medical development.  (Reminder:  very different rules apply when a person receiving SSA or SSI returns to work.)

 If less, the state Disability Determination Services (DDS) continues to the second question:  Is your condition “severe”? 

To the person applying the answer is obvious – of course, it is.  In practice, it is not so simple.  To be “severe” the medical condition must significantly limit your ability to do basic work-related activities for at least one year.  If the condition is not that severe, the state DDS will not consider you disabled.  If your condition is that severe, the DDS goes to the third question. 

Before going to the third question, I think now is a good time to mention a few things.  

First, the Social Security disability application and medical questionnaire (SSA Adult Disability Report – Form SSA-3368) can be completed online.  SSI applications are not online but use the same online SSA-3368.  Whether completing an application online or with an SSA office, first read Information You’ll Need When You Apply for Disability Benefits. 

Second, the DDS examiners do not see applicants and usually do not speak to them.  Application development involves obtaining and analyzing evidence from your medical providers.  Information from you is very important to present a clear picture.  Provide personal details when completing the medical questionnaire (SSA Adult Disability Report – Form SSA-3368).  For example, list all your physical or mental medical conditions even if one is the most important.  Doing so gives the DDS examiner more to consider when requesting and reviewing medical evidence.  One item might not be severe by itself, but a combination of illness or injuries might be.  This can also be important for other parts of the DDS decision. 

Third, the question of severity goes directly to your ability to work.  Part of the Adult Disability Report asks how your injury or illness affects your ability to work including health related changes or reasons for stopping.  Be specific.  After all, who knows better than you do? Unfortunately, often this gets a vague answer like “I cannot work anymore because I’m sick”.  Compare that to an answer such as “Before my accident / illness I worked at least an 8 hour day, partially inside desk work doing xxx but about a third of it outside doing xxx.  When working outside I lifted tools and equipment weighing xxx pounds.  Since my accident / illness I could not work outside because xxx. The boss moved me to inside work but now just walking wears me out to the point that after an hour I’m done in so I had to stop working.“  If you were the DDS examiner, which answer would be more useful to you?  Be specific. 

Fourth, you are not expected to provide medical records.  You do need to tell where you receive medical treatment including names, addresses and approximate dates of treatment.  You give information about medical tests you had and treatment provided.  You also provide medical releases so that your doctors, hospitals and other sources can be contacted. 

Fifth, your doctor does not make the Social Security medical decision.  State DDS disability examiners and doctors do using medical evidence from your doctors and hospitals, clinics or institutions along with all other case information.  Your medical providers are asked about your medical condition such as what it is, when it began, treatment and your ability to do work related activities.

 More in the future.

Today I am returning to the topic of how a Social Security disability decision is made.   

The Social Security disability application and medical questionnaire (SSA Adult Disability Report – Form SSA-3368) can be completed online.  SSI applications are not online but use the same online SSA-3368.  Whether completing an application online or with an SSA office, first read Information You’ll Need When You Apply for Disability Benefits

For both Social Security and Supplemental Security Income (SSI), local Social Security office representatives make non-medical decisions.  For Social Security, a non-medical decision is if the applicant has enough work at the right time to be insured for disability.  For SSI, a non-medical decision could be if income and resource requirements are met.  

When all non-medical requirements are met, local offices send the application to a state agency called the Disability Determination Services (DDS).  Following very specific SSA requirements, DDS’s make the medical decisions. The process is essentially the same for Social Security and SSI so, for simplicity, I will just refer to Social Security disability. 

Five basic questions are developed when making the medical decision.  These questions always follow the same order.  Development needed to answer any of the five can be significant.  

By legislative design, the Social Security Administration definition of disability is strict, different from other programs, and related to the applicant’s ability to work.  Benefits are paid only for total disability.  No provisions exist for partial or short-term disability. 

In general, a medically determinable physical or mental impairment(s) must have lasted, or be expected to last, at least one year or be expected to result in death.   During this time, you cannot do the work you have done and would not be able to adjust to other work because of your health.  In addition to your health, SSA disability decisions consider your age, past work experience and education.  The five questions refer back to this Social Security definition of disability.  

The first question:   Are you working?   

Most applicants are not working when they apply for disability but some are.  Given that being unable to work is the major component of the disability definition, you can readily see that ongoing employment raises questions that must be addressed.  Local SSA offices evaluate work activity, usually before the claim goes to the state Disability Determination Services (DDS).  

You generally cannot be considered disabled if you are working and your earnings average more than a certain dollar amount per month.  This amount usually changes annually.  In 2012, it is about $1,010 per month.   If ongoing employment earnings exceed this amount, the application is usually denied.  If less, development continues. (Note: very different rules apply when a person already receiving benefits returns to work.)  

Sometimes an applicant returns to work while the claim is at the DDS.  If so, the claim returns to the local SSA office for evaluation of the work.   

Next time:  the second question