Many applicants for Social Security disability benefits who apply based on fibromyalgia (FM) get denied. Part of the reason is that the Social Security Administration doesn't have a disability "listing" for fibromyalgia. (Social Security's disability listings provide the criteria needed for many different impairments to be approved as disabilities.)
Fortunately, the Social Security Administration (SSA) has published a ruling giving guidance to disability claims examiners and administrative law judges (ALJs) on how to assess fibromyalgia cases. This ruling has helped reduce the number of fibromyalgia applicants who are denied at the initial application stage and increase the number of fibromyalgia sufferers who file an appeal and eventually win disability benefits.
Traditionally, when a disability claims examiner received a case in which the only reason for disability was fibromyalgia (also known as fibromyositis), the outlook for an initial approval was poor unless another condition was involved. Applicants often had better luck applying for related conditions, such as rheumatoid arthritis, spinal stenosis, or another condition that's more likely to come with objective evidence of the disease, like x-rays. Part of the reason for this has to do with the nature of fibromyalgia—its symptoms are largely subjective and its causes are not yet understood. Because its symptoms vary from one person to the next, disability examiners aren't sure how to classify fibromyalgia cases.
The outlook for fibromyalgia cases is starting to improve because more information is coming to light about the nature and causes of this illness, and because of the ruling Social Security published on fibromyalgia that explains how Social Security is required to assess the condition.
The SSA first screens all disability applications to see if the applicant has a "medically determinable impairment" that is severe. This means you must have a medical condition that has been diagnosed with objective evidence, such as lab tests and medical "signs" of the illness or disease.
In addition, the impairment must "interfere" with basic work-related activities. At later steps, the SSA will consider whether your limitations actually prevent you from doing any type of work.
But the first step is to get a diagnosis of fibromyalgia from your doctor, and preferably from a rheumatologist.
Before accepting symptoms as valid, the SSA must see signs of an impairment that could reasonably be expected to produce the symptoms. Proving this can be difficult with FM, since the symptoms, including widespread pain, tenderness in the muscles, joints, and soft tissues, fatigue, dizziness, and "fibro fog," are mostly self-reported.
Fortunately, Social Security's published ruling explains when fibromyalgia should be found as a medically determinable impairment (MDI). 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 the required signs of fibromyalgia, and thus has a medically determinable impairment.
According to the ruling, for fibromyalgia to be considered an MDI:
In addition, the patient must have one of the following:
Other possible symptoms include headache, muscle weakness, abdominal pain, seizures, dizziness, and Raynaud's phenomenon.
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 focus on your doctor's notes on your complaints of pain, fatigue, and possible cognitive difficulties, as well as the results of trigger-point testing and lab testing.
To assess the credibility of your complaints, the claims examiner (or judge, if on appeal) may ask your doctor to provide information about:
The further back your medical record includes evidence of fibromyalgia symptoms and treatment, the better.
If the SSA determines that you do have a medically determinable impairment, Social Security's evaluation is not over; in fact, it has just begun. You still have to show the SSA your medical limitations prevent you from doing any type of work on a full-time basis.
The SSA 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 preparing your RFC, the SSA will rely on your doctor's opinion (either your rheumatologist or your primary care doctor) of what activities you can do, such as:
Documenting functional limitations in these areas is the key to showing the SSA why you can't work.
After creating your RFC, the SSA will compare it to your previous job and the types of jobs available for someone with your RFC level and limitations. If your RFC rules out all jobs, even sedentary work, the SSA will find you disabled.
You can strengthen your case by understanding how Social Security disability examiners consider medical evidence. Here are some tips to help:
If you claim fibromyalgia when you apply for disability benefits, make sure you have an actual diagnosis with a date in your medical records. Sometimes a doctor has mentioned to a patient that they "might have fibromyalgia" without actually diagnosing this condition in their medical chart.
Also, on your application, make sure you include any other diagnoses of serious physical or mental medical conditions. As discussed above, Social Security disability cases based on fibromyalgia alone are generally difficult to win. But they're always easier to win if other impairments are involved, as long as the other impairments are serious as well.
If your family doctor or internist diagnoses you with fibromyalgia, try to be referred to a specialist, such as an orthopedist or a rheumatologist (or a chronic pain or fatigue specialist), who can give you the same diagnosis. You can try seeing a neurologist, since fibromyalgia is now thought to be caused by abnormalities in central pain processing.
Because family doctors sometimes hand out the fibromyalgia label when they can't otherwise diagnose a patient's complaints, the value of this diagnosis has become somewhat diluted. The diagnosis can be significantly strengthened, however, and taken more seriously, if the same conclusion is reached by a physician who specializes in bone or tissue disorders, or disorders that involve complaints of pain and fatigue.
If cognitive or mental issues add to your inability to work, a neurologist's opinion may be helpful as well. Your primary care doctor's opinion can also be helpful, not so much on the diagnosis of fibromyalgia, but to supplement the rheumatologist's opinion on the details of your claim and your limitations.
Try to avoid being diagnosed with fibromyalgia by a mental health professional. In the same way that family doctors might overuse the fibromyalgia diagnosis, so can psychiatrists, especially when they're treating patients for depression.
It's natural that someone who experiences continuous pain and fatigue might also have to deal with depression, but the SSA could interpret a fibromyalgia diagnosis by a mental health practitioner to mean that the disability applicant's symptoms and complaints are "psychosomatic" in nature (possibly brought on by stress) or "all in their head."
All Social Security disability cases are decided on the basis of medical records, at the initial application level, reconsideration level, and at the hearing level. You shouldn't apply for disability without knowing what your records state about your condition. Many applicants have been surprised to find that the doctor who claimed to support their case did not indicate the same level of support in his or her treatment notes that he or she submitted to the SSA.
By getting copies of your medical records before you apply, you can get a rough idea of how your case looks and decide if you need to switch to a different physician—perhaps one who is more capable concerning your treatment and more willing to support your disability case.
Keeping a calendar or journal with your physical and medical symptoms can help when your doctor asks about your symptoms. You'll be able to say how often you have pain or fatigue or memory problems, and how many days you're unable to do certain activities. Having a written record can also help convince the SSA that your symptoms are real and reflect a pattern of fibromyalgia. Include symptoms like cognitive issues, sleep issues, and digestive issues. Also record any side effects you have from taking your prescribed medication.
An easy way to apply for Social Security disability benefits is to file your claim online at www.ssa.gov/applyfordisability. You can also file a claim over the phone by contacting Social Security at 800-772-1213, but be prepared for long wait times. For more information, please see our article about applying for Social Security disability benefits.
If you have questions or you'd like help with your application, click for a free case evaluation with a legal professional to determine if your fibromyalgia qualifies for benefits.
Most people who apply for disability based on fibromyalgia get denied at the initial application stage. But you will get a chance to go to an appeal hearing in front of a judge to present your evidence. More so than in other cases, hiring a lawyer to represent you at a hearing for fibromyalgia can be critical, since disability lawyers are familiar with the Social Security ruling on fibromyalgia (SSR 12-2p) and the latest court decisions on when disability must be granted for fibromyalgia. This knowledge can help disability attorneys find errors made by the claims examiner and use them to your advantage.
Updated December 20, 2021