Top 6 Medical Reasons for a Disability Denial

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.

Knowing why the agency denied your claim gives 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 you can learn about 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.

What's a Medical Denial?

Medical denials are issued when claimants meet the preliminary financial qualifications for either Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI), but they don't have enough evidence to show that they can't work. Medical denials are different from technical denials, which means that a claimant isn't legally allowed to receive either SSDI or SSI—usually because they don't have enough work credits for SSDI and are "overresourced" for SSI, a needs-based benefit.

How Does Social Security Determine Whether I'm Medically Disabled?

After you submit your claim for disability benefits, Social Security will gather records from the medical sources you listed on your application form. Disability examiners will review your doctors' notes, lab tests, objective imaging (like X-rays and MRIs), medications, and other documents relevant to your health to see what functional limitations you have and how much they restrict your activities of daily living. The agency will then determine whether your limitations are significant enough to meet the requirements of a listed impairment or rule out all full-time work.

Why Was My SSDI or SSI Claim Denied?

Social Security awards disability benefits to people who have a medically determinable impairment that keeps them from earning at or above the level of substantial gainful activity for one year or more. If the SSA doesn't think you fit this definition, your claim will be denied. Specifically, there are several main medical reasons why the agency denies claims.

1) Your Impairments Aren't Expected to Last 12 Months

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.

2) Your Impairments Have a Minimal Impact on Your Abilities

Even if you've received at least a year of treatment for your condition, the SSA 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. Here's an example of how that might play out with two disability claimants who are both applying for benefits due to depression:

It's very common to have both severe and non-severe impairments in your medical record. If you've been denied because the SSA 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.

3) You Don't Have Enough Medical Evidence

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 agency 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 your application was denied due to insufficient evidence, it's important to let the SSA know why you couldn't get treatment. The agency can send you to a consultative examination if more information is needed about your medical conditions.

4) You Didn't Follow Prescribed Treatment

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, the SSA will deny your claim based on failure to follow prescribed treatment. If you haven't tried a treatment, the agency 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 complicated surgery. In these cases, Social Security won't hold it against you for not following "doctor's orders."

5) Drug or Alcohol Abuse Is Material to Your Claim

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, the agency won't go straight to a denial. Instead, claims examiners 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 substance 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 health care providers. Their opinions can shed light on the limitations you have that are separate from drug and alcohol use and help Social Security decide whether DAA is material to your claim.

6) You Didn't Keep in Contact or Cooperate With the SSA

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, the agency knows how to reach you if they need additional information or want to send you important forms. 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.

The SSA also needs your permission to release medical records that are vital to your application. 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. You can also be denied if you're scheduled for a consultative examination and you don't attend.

Appealing a Medical Denial

Most people aren't approved for disability benefits on their first try. Fortunately, you have 60 days from when you receive your denial letter to appeal the decision. When preparing your appeal, you can (and often should) request a copy of your case file from the SSA for review. Knowing the specifics about why you were denied can help you write a persuasive appeal letter that can increase your likelihood of success.

Keep in mind that the appeals process is a lengthy one. Chances are that you'll receive another denial letter before you get the opportunity to speak with an administrative law judge about your claim. Most people who are ultimately approved for SSDI or SSI are only awarded after they've had a disability hearing, which in some cases can take several years.

How a Disability Attorney Can Help

There's a lot you can do on your own to help overcome a medical denial. 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 records is a time-consuming process, however, and can be intimidating if you're doing it by yourself. Consider getting an experienced disability lawyer or nonattorney advocate on your side. Your representative will be able to sort through your records, request any that are missing, and deal with any evidence that can hurt your claim. Disability lawyers don't get paid unless (and until) you win your case, and many offer free consultations, so there's little risk in finding one near you who's a good fit for your needs.