A denial letter from the Social Security Administration (SSA) can be hard to decipher. While the agency must let you know why they denied your claim for disability benefits, their explanations aren't always easy to understand. If the SSA didn't think there was enough in your medical record to show that you can't work (a "medical denial"), you'll want to know why.
Reading the SSA's explanation of why it denied your claim will give you important information about the parts of your medical record that you'll need to work on in order to get an approval on appeal. Below are some of the most common reasons for medical denials and what you can do to increase your chances of being approved after filing an appeal.
Social Security doesn't provide temporary disability benefits for conditions that last a few months. Before they'll award benefits, you'll have to show that your impairment has lasted, or is expected to last, for at least one year. The SSA refers to this minimum disability period as the durational requirement.
For example, somebody who has been diagnosed with cancer and has completed chemotherapy might not be found disabled if the medical record shows that the cancer has gone into remission (meaning the cancer is under control) nine months after diagnosis. But if treatment for cancer signs and symptoms is still going on after 16 months, the condition will meet the duration requirement.
If you've been denied because Social Security thinks your impairments won't last for an entire year, make sure to document any ongoing treatment. Obtaining a note from your doctor stating that you'll be receiving treatment for a year or more can also let the SSA know how long your impairment is expected to last.
Even if you've received at least a year of treatment for your condition, Social Security might find that your impairment is "non-severe." This type of denial means that, while the disability examiner reviewing your claim acknowledges your diagnosis and treatment, the examiner didn't find that your condition impacts your life in a significant way.
For example, consider two claimants, Alice and Oscar, who are both claiming disability due to depression. Alice is on a low-dose antidepressant and receives occasional counseling. In her treatment notes, her doctor mentions that Alice sometimes struggles with irritability, but otherwise is capable of managing her finances and is an active volunteer with her church. Social Security might consider Alice's depression to be a non-severe impairment, because it appears to affect her life only minimally.
Oscar also receives treatment for depression, but he's on a higher dosage of multiple antidepressants and receives frequent counseling. In his treatment notes, his doctor notes that Oscar spends several days of the week in bed due to his depression. Oscar's relatives do his grocery shopping for him and make sure his bills are paid, because one of the side effects of Oscar's medications is forgetfulness. Social Security will consider Oscar's depression to be a severe impairment, because it significantly interrupts his life.
It's very common to have both severe and non-severe impairments in your medical record. If you've been denied because Social Security doesn't think your impairments are severe enough, make sure that you're letting them know about all the ways that your impairments limit you. Just having a diagnosis isn't enough— Social Security needs to see how your life has changed as a result.
One of the most common reasons for a medical denial is when Social Security thinks that you don't have enough medical records. Social Security places a lot of importance on medical records because they provide insight into the nature of your impairments.
When you apply for disability benefits, the SSA asks you to list the names of the doctors you've seen and the dates that you've seen them. For any impairment, the SSA wants to see that you've been consistently seeking and obtaining medical treatment. Because people usually go to the doctor or hospital when something's wrong with them, if your record is missing doctor's notes or hospital visits, the SSA can assume that there's nothing wrong with you.
Of course, people don't seek medical treatment for many reasons, even when they need it. Lack of health insurance is a common reason why people don't go to the doctor as often as they should. Even when covered partially by insurance, diagnostic tests such as MRIs and CT scans can be very expensive, which discourages people from using these important tools. Medications can be cost-prohibitive as well. Simply getting to the doctor's office can be difficult if you don't have access to a car, funds for a rideshare, or public transportation.
When your medical record shows only a few visits to the doctor, Social Security can mistake not being able to afford or access treatment with not needing treatment. If you haven't been able to obtain medical treatment and Social Security denied your application due to insufficient evidence, it's important to let them know why you couldn't get treatment. The SSA can send you to an examination on their own dime—called a consultative examination—if they need more information about your medical conditions.
Social Security wants to see that you've tried most, if not all, available medical remedies for your impairments before you file for disability benefits. Having a condition that's stubborn enough that you can't fix it medically, despite following your doctor's recommendations, strengthens your claim that the condition is preventing you from working.
If your doctors have recommended a course of treatment that could help you feel better, and you don't follow their advice, Social Security will deny your claim based on failure to follow prescribed treatment. If you haven't tried a treatment, Social Security doesn't know whether it would have worked well enough for you to return to work.
Disability applicants can have many reasons why they didn't follow prescribed treatment. One reason is when the doctor prescribed medication or treatment that you're unable to afford. Another is when the recommended treatment is particularly risky, such as a complicated surgery. In these cases, Social Security won't hold it against you for not following "doctor's orders."
Social Security doesn't award disability benefits based solely on drug or alcohol abuse (DAA) disorders. But if your medical record contains evidence of a struggle with DAA, Social Security won't go straight to a denial. Instead, the agency will look at your history to determine whether your DAA is "material" to the question of whether you're disabled. Essentially, Social Security needs proof that you have an impairment that would prevent you from working even if drugs or alcohol weren't in the picture.
It's easier to show that your medical condition wouldn't improve even without your use of drugs or alcohol for some impairments than for others. For example, if you have difficulty lifting a gallon of milk after neck surgery, your limitation is unlikely to depend on whether you're using drugs or alcohol. But the signs and symptoms of many mental disorders can mimic or overlap those of drug or alcohol use. That's why it's important to establish a period of sobriety or abstinence while you're receiving medical treatment. This gives Social Security an idea of your health "baseline" without interference from the effects of DAA.
Another way to establish that your medical condition exists independently of your substance use, especially if you're recently in recovery and don't yet have a period of sobriety, is to get statements from your healthcare providers. Their opinions can shed light on the limitations you have that are separate from drug and alcohol use. These professional opinions can help Social Security decide whether your drug or alcohol use is material to your claim.
Social Security can't award you benefits if they can't find you! When you file your application for disability, you'll need to provide a mailing address, a phone number, and an email address (if you have one). This way, Social Security knows how to reach you if they need additional information or want to send you important forms. Disability claims examiners will make several attempts to reach you, but if they don't hear from you after a while, they can consider you a "lost claimant" and deny your claim.
Social Security also needs your permission to release medical records that are vital to your application (SSA will send the signed forms to your medical providers). The agency will send you a medical release form, and if you don't return it, they won't be able to obtain your records and will deny your claim. Social Security will also deny you if it schedules you for a consultative examination and you don't attend.
Fortunately, there's a lot you can do to help overcome a medical denial. It's important to regularly attend doctor's visits and to let the SSA know when you do. If your medical visits have been pretty sparse, it's best to start consistent treatment as soon as possible. If you're uninsured, try looking for sliding scale providers or free clinics in your area. Respond promptly to any communication from Social Security, and notify them if you've moved.
Collecting and reviewing your medical record is a time-consuming process, and can be intimidating if you're doing it without any help. Consider getting an experienced disability lawyer or advocate on your side. They'll be able to sort through your records, request any that are missing, and deal with any evidence that can hurt your claim.
Updated May 4, 2022