This information may help lupus claimants with representation, as well as claimants who are not represented by an attorney or non attorney representative. Understanding how the Social Security Disability system works can make the difference between winning or not winning the continuing disability benefits and backpay to which a person is entitled. To win a claim for ongoing and past due benefits, claimants should learn about the disability process to improve their chances of winning. |
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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, or consultative 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:
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. Disability Advocates Help with Claims Free Case Evaluation Social Security Disability and noting functional limitations in records Winning Social Security Disability or SSI benefits |
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