This information may help 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, of course, can make the difference between winning or not winning the continuing disability benefits and backpay to which a person is entitled. |
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Traumatic Brain Injury does not have a specific listing, as such, in the social security administration's blue book (the blue book is the impairment listing manual and impairments that are listed in this manual have specific medical criteria for disability claim approvals). However, TBI is given consideration under section 11.00 of the manual (neurological impairments) and, more specifically, is evaluated under the heading of cerebral trauma, or listing 11.18. The actual listing for 11.18, cerebral trauma, is very short, and reads as follows: Evaluate under the provisions of 11.02, 11.03, 11.04, and 12.02, as applicable. What does this single sentence say? Basically, that traumatic brain injury cases are evaluated primarily according to neurological criteria, and, partially, if applicable, according to the criteria set aside for organic mental disorders (section 12.00 of the manual is devoted to impairments of a mental nature). 
Here are the various impairment listings referred to in the cerebral trauma listing (11.18): 11.02 Convulsive epilepsy, grand mal or psychomotor. 11.03 Nonconvulsive epilepsy, petit mal, psychomotor, or focal. 11.04 Cerebrovascular accident, or CVA, otherwise known as stroke. 12.02 Organic mental disorders (defined as psychological or behavioral abnormalities associated with a dysfunction of the brain, the etiology of which is tied to a specific organic factor). To anyone unfamiliar with the manner in which social security disability and SSI disability claims are evaluated, it might seem strange to evaluate traumatic brain injury cases according to the criteria set aside for other impairments. However, SSA disability determinations are based on the concept of residual functional capacity, which can be paraphrased as "what a claimant is still able to do even after, or despite, the effects of their illness". Guided by this concept, disability claim processing tends to focus heavily on objective and measurable indications of functional restriction. Therefore, for this reason, cases involving TBI, or traumatic brain injury, are examined to determine whether or not a patient is suffering seizures of a convulsive or nonconvulsive nature. If seizures, or epilepsy, is present, the next step, of course, is to rate the severity of the seizure disorder according to the nature and frequency of seizure episodes.
What level of seizure activity warrants the determination that one is disabled? For convulsive epilepsy, documented seizures must occur more frequently than once a month, in spite of 3 months of prescribed treatment with either A. daytime episodes involving loss of consciousness and convulsions or B. nocturnal seizure episodes that have residuals that significantly interfere with daytime activities. For nonconvulsive epilepsy, there must be documentation of petit mal, psychomotor, or focal seizures occurring more than once weekly, in spite of at least 3 months of prescribed treatment (with altered or lost consciousness and manifestations of unconventional behavior or difficulty with daytime activities). In a similar manner, the deficits that apply to CVA, or stroke, are also used to evaluate traumatic brain injury patients, since they may suffer from deficits similar to those inflicted on stroke victims. The stroke listing (listing 11.04 in the blue book) details the following criteria: A. Sensory or motor aphasia that results in ineffective speech or communication; or B. Significant and persistent disorganization of motor function in two extremities, resulting in sustained disturbance of gross and dexterous movements, or gait and station. Lastly, TBI claimants are also evaluated according the criteria set forth in listing 12.02, organic mental disorders. The criteria for this listing is in three parts, designated A, B, and C, and to meet the listing, a claimant must satisfy either the part C criteria or the criteria indicated in parts A and B. To read the listing information for listing 12.02, organic mental disorders, for which traumatic brain injury claims may potentially be approved, you may wish to continue to this page -- Social Security, SSI, and Organic Mental Disorders. Before doing so, however, please take note of this fact: even in the most obvious cases, an applicant's disability status will need to be proven before benefits can be awarded. And proving a case simply boils down to providing adequate and sufficient medical record documentation. Therefore, for this reason, claimants should provide (on their disability application or disability appeal paperwork) a full and detailed disclosure of their sources of treatment, as well as the approximate dates for which treatment was received. Additionally, claimants may find it helpful to obtain and submit supportive statements from physicians who have provided treatment. Physician statements, of course, should be detailed and should explain why a patient is disabled---in other words, the doctor should indicate the patient's specific functional limitations and the degree to which these limitations exist. The importance of medical record documentation cannot be overemphasized. This is particularly true in the case of traumatic brain injury since it is the social security administration's position that deficits related to TBI are: 1. variable; 2. difficult to predict; 3. may be subject to alternating periods of remission and exacerbation; 4. and may require several months, post-injury, in order to rate the severity of a claimant's condition. Disability Advocates Help with Claims Free Case Evaluation |
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