Congestive Heart Failure: Can You Get Social Security Disability Benefits (SSDI or SSI)?

Social Security has a complicated method of evaluating chronic heart failure for disability.

By , Attorney

Congestive heart failure (CHF), or chronic heart failure, is a potentially lethal condition where the heart cannot pump a sufficient amount of blood, which can cause blood to accumulate in the vessels leading to the heart and can cause congestion or accumulation of fluid in various parts of the body. (If the left chambers of the heart fail, blood backs up into the lungs, causing lung congestion. If the right chambers of the heart fail, blood backs up into the legs and the liver, causing congestion and swelling, called edema.) CHF is usually accompanied by an enlargement in the size of the heart.

Symptoms and Treatment of Congestive Heart Failure

Symptoms of heart failure can be mild or moderate, including shortness of breath, fatigue, and weakness, especially with exercise. CHF can also cause heart palpitations and dizziness. There are four classifications for CHF under the New York Heart Association (NYHA) Functional Classification system: Class I, II, III, or IV. Class I patients have few symptoms and no limitation in ordinary physical activity while Class IV patients have severe limitations and experience symptoms even while resting. Social Security is more likely to find Class III and IV patients unable to work due to the severity of their symptoms.

Treatment of congestive heart failure (CHF) usually requires a program of rest, proper diet, modified daily activities, and medication (such as ACE inhibitors, beta blockers, digitalis, diuretics, or vasodilators).

Causes of Congestive Heart Failure

Most forms of heart disease, including cardiomyopathy and valvular and pericardial disease, eventually lead to an enlarged heart and congestive heart failure. Congestive heart failure is generally progressive and typically develops over a period of months or years.

Other causes of congestive heart failure include:

  • past heart attack, which can lead to the development of scar tissue that interferes with heart muscle function
  • poorly controlled hypertension (high blood pressure)
  • coronary artery disease, in which arteries that supply blood to the heart muscle are narrowed
  • endocarditis or myocarditis, where the heart muscle, valves, or surface tissue become inflamed, and
  • congenital heart defects.

Qualifying for Disability Under the Chronic Heart Failure Listing

The Social Security Administration (SSA) will evaluate whether a patient with CHF qualifies for disability under its listing for "chronic heart failure." To qualify for disability benefits under the SSA's listing for chronic heart failure, you must have been diagnosed with severe continuing heart failure despite being on heart medication. The SSA's listing doesn't require that you have fluid retention at the time of evaluation to get disability benefits, but your medical records should show that you had fluid retention at some point in time. You must have the required objective symptoms and functional limitations below.

Objective Symptoms of Congestive Heart Failure

Your medical record must show the following evidence of either systolic or diastolic heart failure.

Systolic failure. This occurs when the heart has weakened pumping strength and can be shown by one of the following:

  • the heart's ejection fraction (the percentage of blood pumped out of the heart with each heartbeat) is 30% or less during a period of stability (not during an episode of acute heart failure), or
  • the heart's left ventricular end diastolic dimensions are larger than 6.0 cm.

Diastolic failure. This occurs when the heart is unable to fill properly, and must be shown by all of the following:

  • thickness of left ventricular wall and interventricular septum 2.5 cm or larger on imaging
  • an enlarged left atrium 4.5 cm or larger, and
  • normal or elevated ejection fraction during a period of stability (not during an episode of acute heart failure).

Functional Limitations of Congestive Heart Failure

You must also have one of the following symptoms to qualify under the listing for chronic heart failure.

  • Inability to perform an exercise tolerance test (ETT) at a workload equivalent to 5 METs or less due to certain difficulties.
  • If an exercise tolerance test would be too risky, persistent symptoms of heart failure that very seriously limit activities of daily living (ADLs) are required, or
  • At least three episodes of heart failure and fluid retention within the past 12 months, requiring emergency room treatment or hospitalization for at least 12 hours.

Getting Disability Because of Your Functional Limitations

Assuming you don't qualify under the listing above (most people under 65 don't), the SSA is required to consider the effect of your heart condition on your capacity to work or perform routine daily activities. The SSA will give you a rating of the type of work it thinks you can do, called your residual functional capacity (RFC). Your RFC will rate your ability to do sedentary work, light work, or medium work.

For instance, if your doctor has limited you to no lifting more than 10 pounds, your RFC will be for sedentary work. Or, if your exercise tolerance test shows you can do little physical exertion before you develop symptoms (such as shortness of breath, chest discomfort, heart palpitations, or confusion), you will probably get a light RFC. Next, the SSA will determine if whether you can do your prior job given the limitations of your RFC. If you can't, it will look at your education level, age, and experience to determine if there's any other kind of work you can safely be expected to do (or whether you should get a medical-vocational allowance).

Ask your cardiologist to fill out a functional capacity form saying what you are not able or allowed to do (such as not being able to walk for more than one hour per day or not being able to lift more than 25 pounds) as well as what you are capable of doing (such as being able to sit upright for six hours to eight hours per day). If your doctor's form (or medical records) show that you have severe limitations or restrictions, this limits the number of jobs Social Security can say you are able to do, making it harder for Social Security to find you not disabled.

Applying for SSDI or SSI for Congestive Heart Failure

Before you apply for disability, you should visit a doctor several times about your heart condition. The SSA will need blood work, medical imaging (such as cardiac ECHO or MRI), and the results of an exercise stress test to evaluate your condition. Then, call 800-772-1213 to set up an appointment to submit an application for SSI or SSDI through your local SSA office.

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