Many applicants for Social Security disability benefits who apply based on fibromyalgia (FM) get denied. Part of the reason has been that Social Security doesn't have a disability "listing" for the condition. (Social Security's disability listings provide the criteria needed for many different impairments to be approved as disabilities.) To address the problem, the Social Security Administration (SSA) published a ruling in 2012 giving guidance to disability claims examiners and administrative law judges (ALJs) as to how to assess fibromyalgia cases. This ruling should help reduce the number of fibromyalgia claimants who are denied at the initial application stage and go on to file an appeal and eventually win disability benefits.
Even so, many fibromyalgia patients will continue to be denied benefits. If you're applying for disability based on fibromyalgia, it helps to know how the SSA views this particular impairment (also known as fibromyositis).
Traditionally, when a disability claims examiner received a case in which the only reason for disability was fibromyalgia, the outlook for an initial approval was poor. Disability examiners generally gave little weight to a claim of fibromyalgia unless another condition was involved, such as arthritis or degenerative disc disease, one that was more likely to come with objective evidence of the disease like x-rays. Why was this? Part of the problem has to do with the nature of fibromyalgia—its symptoms are largely subjective and its causes are not understood. Because its symptoms vary from one person to the next, and because the medical profession had not figured out FM's causes, disability examiners were never sure how to classify such cases. As the medical profession has begun to understand fibromyalgia better, Social Security has developed new standards for assessing fibromyalgia.
To be considered for disability benefits, you must have an impairment established by medical evidence such as lab tests and medical "signs" of the illness or disease. In other words, your impairment cannot be established only by your reports of your symptoms. This is called the requirement of having a "medically determinable impairment" (MDI)—the SSA must see medical signs of an impairment that could reasonably be expected to produce your symptoms. Proving this can be difficult with FM, since the illness is usually characterized by subjective reports of widespread pain, tenderness in the muscles, joints, and soft tissues, fatigue, dizziness, and "fibro fog."
Fortunately, in July 2012, Social Security issued a ruling explaining when fibromyalgia should be found as a medically determinable impairment. The ruling directs claims examiners and judges to rely on criteria issued by the American College of Rheumatology (ACR) to determine whether an applicant has fibromyalgia, and thus has an MDI.
First, to be considered an MDI, the patient should have evidence of chronic widespread pain, including pain in the back, neck, or chest, and a doctor must have ruled out other diseases (such lupus, hypothyroidism, and multiple sclerosis) through the use of lab tests or x-rays. In addition, the patient must have one of the following:
The claims examiner assigned to your claim will review your medical records to see if they include evidence of the above criteria. The examiner will read your doctor's notes on your complaints of pain, fatigue, and possible cognitive difficulties. To assess the credibility of your complaints, the claims examiner (or judge, if on appeal) may ask your doctor to provide information about the extent and duration of your impairments, his or her opinion of how well you are able to function, what treatments were tried and whether they were helpful and had side effects, and how long the doctor expects your ability to function to be limited. The longer your medical record includes evidence of fibromyalgia symptoms and treatment, the better.
If the SSA determines that you have the medically determinable impairment of fibromyalgia, Social Security's evaluation is not over; in fact, it has just begun. The SSA will probably will develop a "residual functional capacity" (RFC) assessment for you to determine if there is any work you can do, including your past work. An RFC assessment is an evaluation of your ability to perform various exertional levels of work; for example, if you can't lift more than 10 pounds, you will be given a sedentary RFC. The SSA bases your RFC on your medical records, opinions from doctors and specialists, and statements from you and possibly your family members. In assessing your RFC, the SSA will rely on your doctor's opinion as to your abilities, like how long you can stand, sit, and walk, how much you can lift, and how well you can focus and remember instructions. These functional limitations are the key to showing the SSA why you can't work.
After creating your RFC, the SSA will compare it to the types of jobs available for someone with your RFC level and limitations. If your RFC rules out all jobs, even sedentary work, you will be found disabled. For more information, see our articles on how Social Security uses your RFC and Tips on Winning Disability With Fibromyalgia.
More so than in other cases, hiring a lawyer to appeal a denial of benefits for fibromyalgia can really help, since disability lawyers are familiar with the Social Security ruling on fibromyalgia (SSR 12-2p) and the latest court decisions on when disability should be granted for fibromyalgia. This knowledge can help disability attorneys find errors made by the claims examiner or judge in the disability determination and use them to your advantage.
In addition, if only a primary care physician or internist has given you a fibromyalgia diagnosis, try to arrange a visit with a specialist; a diagnosis made by a rheumatologist will be more credible to a disability examiner or judge and will strengthen your Social Security disability claim or appeal.