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

Congestive heart failure—also called chronic heart failure—is a potentially fatal condition where the heart doesn't pump blood as well as it should. Blood can then build up in the vessels that lead to the heart, causing problems in various parts of the body (commonly the lungs, legs, and liver) and an enlarged heart (cardiomegaly).

Heart failure doesn't mean that your heart has stopped, but it can cause symptoms that limit your ability to complete your daily routine and work full-time. If your congestive or chronic heart failure has kept you from working for at least one year, you may be eligible for Social Security disability benefits.

Is Congestive Heart Failure a Disability?

Social Security recognizes that congestive heart failure can interfere with your ability to work. Because symptoms vary and can range from mild to severe, the agency will need to see medical documentation that your heart failure is serious enough to either meet a listed impairment or rule out all full-time employment.

You'll also need to meet the non-medical requirements for the type of disability program you're applying for—Social Security Disability Insurance (SSDI) or Supplemental Security Insurance (SSI). Eligibility for SSDI is based on your work history, while SSI is needs-based and subject to certain income and asset limits.

Symptoms and Treatment of Congestive Heart Failure

Congestive heart failure symptoms typically include the following:

• shortness of breath
• fatigue during physical activity
• chest pain
• weakness, and
• swelling (edema) in your lower body.

Symptoms can vary in intensity from mild to severe. According to the American Heart Association, the New York Heart Association Functional Classification system is the most common method doctors use to classify symptoms of heart failure.

• Class I patients can perform ordinary physical activities without symptoms.
• Class II patients are comfortable at rest, but experience symptoms with ordinary physical activity.
• Class III patients experience symptoms with less than ordinary physical activity.
• Class IV patients show symptoms even at rest, and any physical activity causes further discomfort.

Treatment of congestive heart failure depends on how severe the symptoms are. For example, somebody with Class I symptoms could be able to manage the condition with regular exercise and a heart-healthy diet, while somebody with Class II-III symptoms might be prescribed medication (such as ACE inhibitors, beta blockers, or vasodilators). Class IV patients may undergo surgery to implant pacemakers or for a heart transplant.

Causes of Congestive Heart Failure

Most forms of chronic heart disease—including cardiomyopathy, pericardial disease, and valvular disease—eventually lead to cardiomegaly and congestive heart failure. Congestive heart failure is typically progressive, developing over a period of months or years.

Other causes of congestive heart failure include:

• a previous heart attack, which can cause scar tissue that interferes with heart functioning
• poorly controlled hypertension (high blood pressure)
• coronary artery disease (a narrowing of the vessels that supply blood to the heart)
• inflammation of heart muscle, valves, or tissue (endocarditis or myocarditis), and
• congenital heart defects.

Qualifying for Disability Under Listing 4.02 for Chronic Heart Failure

Disability applicants ("claimants") with very severe congestive heart failure—most likely those with Class III or IV symptoms—may qualify for benefits under Social Security's medical listing 4.02 for chronic heart failure. In order to get benefits by meeting the listing, you'll need to provide specific test results demonstrating that your heart failure persists despite being on medication.

Listing 4.02 doesn't require that you have fluid retention in your heart at the time of evaluation, but your medical records should show that you've had fluid retention at some point. You'll also need to provide Social Security with evidence of the objective signs and functional limitations below.

Objective Signs of Congestive Heart Failure

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

Systolic failure occurs when the left chamber (ventricle) of your heart is weak and can't contract normally. You can show that you have systolic heart failure with evidence of either one of the following:

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

Diastolic failure occurs when the left ventricle becomes stiff and your heart is unable to fill properly. You can show diastolic heart failure if you have documentation of all of the following:

• thickness of left ventricular wall and interventricular septum 2.5 cm or larger on imaging
• an enlarged left atrium (a smaller heart chamber) 4.5 cm or larger, and
• normal or elevated ejection fraction during a period of stability.

Functional Limitations of Congestive Heart Failure

You won't be able to meet listing 4.02 based on objective signs alone—that's just one part of the listing requirements. You'll also need to establish that you have significant functional limitations as a result of your congestive heart failure. There are three ways that you can demonstrate "listing-level limitations" under 4.02.

Multiple episodes of heart failure. You'll need to show that you've been hospitalized for acute (sudden and severe) heart failure three times or more within a one year period. Each episode must require "extended medical intervention" of 12 hours or more, separated by periods of stabilization.

Poor performance on an exercise tolerance test (ETT). An ETT or stress test usually requires you to walk on a treadmill while doctors perform an electrocardiogram. The goal of an ETT is to see how your blood circulates during physical activity, typically measured in units called metabolic equivalents (METs). You'll need to show that you can't perform the test at 5 METs or less due to shortness of breath, rapid heartbeat, low blood pressure, or reduced oxygen flow to the brain.

Limited independence in daily activities. Claimants for whom the exertion of an ETT poses a health risk must show that their persistent symptoms very seriously limit their activities of daily living.

Getting Disability Because of Your Functional Limitations

Qualifying for disability by meeting listing 4.02 can be challenging. Most claimants who receive benefits aren't awarded them because they meet a listing, but because they have a residual functional capacity (RFC) that limits the types of jobs they can perform.

Your RFC is a set of restrictions that reflect what you can and can't do, physically and mentally, in a work environment. Social Security reviews your medical records, self-reported daily activities, and doctors' opinions to determine your RFC.

What Does an RFC Look Like?

Claimants with congestive heart failure will likely have an RFC that contains exertional and non-exertional limitations. Exertional limitations are strength-related restrictions on how much weight you can lift and how long you can be on your feet. Non-exertional limitations can be physical (such as restrictions on bending, climbing, or reaching) or mental (restrictions on working with others or concentrating on tasks).

For example, if your doctor says you can't lift more than 10 pounds, your RFC will contain a limitation to sedentary work. Or, if your exercise tolerance test shows you can do some, but not much, physical exertion before you develop chest pain, your RFC will probably be for light work. Any medically documented difficulties you have with other work-related activities—like not being able to climb ladders without feeling weak—should be included in your RFC.

What Does Social Security Use My RFC For?

Social Security will look at the physical and mental demands of your past work to see whether you can do those jobs now, despite the limitations in your current RFC. If you can't, the agency will consider your age, education, and work experience (in addition to your RFC) to determine if there's any other work you can safely be expected to perform.

Qualifying for disability benefits by ruling out all work is sometimes referred to as a medical-vocational allowance. Claimants 50 years of age or older have an easier time getting a medical-vocational allowance due to the "grid rules," while most claimants younger than 50 will need to show that they can't do even the easiest sit-down jobs before they can receive benefits.

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. Social Security will want to see blood work, medical imaging (such as cardiac ECHO or MRI), and the results of an exercise stress test to evaluate your condition.

Once you've established treatment with a cardiologist, you can apply for benefits in several ways:

• File online at Social Security's website.
• Call 888-772-1213 between the hours of 8 a.m. and 7 p.m., Monday through Friday, to speak with a representative who can help you fill out the forms. (People who are deaf or hard of hearing can call the TTY number at 800-325-0778.)
• Go to your local Social Security field office to complete the application in person.

You can file the application yourself or you can get help from a friend or family member. Because few claimants are awarded on their first try, however, you may want to consider hiring a disability attorney at some point. Your lawyer can make sure you don't miss any important appeal deadlines, update your medical records, and represent you at a hearing in front of an administrative law judge.