New Social Security ruling should help PWcs win benefits
By Vicki Walker

On April 30, the Social Security Administration (SSA) issued a Ruling stating its disability benefits apply to CFS patients, just as they do to other disabled Americas. While the new ruling will hardly "open the floodgates" for CFS patients to garner disability wages, it should make it easier for disabled CFS patients to acquire their benefits at an earlier stage in the SSA appeals process.

The five steps
SSA uses a "five-step sequential evaluation process" to determine whether each individual is disabled within SSA's strict guidelines. One of the requirements is that the claimant has medical signs or laboratory findings which reflect their condition.

At the outset, the "Policy Interpretation Ruling" informs the reader that "CFS, when accompanied by appropriate medical signs or laboratory findings, is a medically determinable impairment that can be the basis for a finding of 'disability.'" It then gives examples of signs and lab findings which can show that the patient has a medically determinable impairment (MDI)-the first step a claimant must pass in order to be found disabled within SSA policy.

Some examples are: swollen or tender lymph nodes, nonexudative pharyngitis, muscle tenderness, tender points, abnormal MRI brain scan, neurally mediated hypotension and persistent neurocognitive impairment. SSA repeatedly clarifies that there may be other signs or lab findings which, when consistent with the patient's medical record, can be used as evidence for an MDI.

In the second step of SSA's sequential evaluation process, it must be shown that the MDI is "severe." In this ruling, SSA states that, once a finding of an MDI has been made, the patient's symptoms can be used to measure the severity of the disability. For example, "if fatigue, pain, neurocognitive problems or other symptoms are found to cause a limitation or restriction having more than a minimal effect on an individual's ability to perform basic work activities, the adjudicator must find that the individual has a 'severe' impairment."

In the third step, SSA must consider whether the claimant's disability meets or equals a "listed" impairment. CFS is not a listed impairment, but many CFS patients meet the criteria for other impairments. For example, a judge in New Jersey recently found a CFS claimant met the criteria for multiple sclerosis and awarded disability on that basis. Many judges have found that CFS patients who have overlapping depression meet that listing. Overall SSA policy states that when a patient meets a particular listing (along with the severity criteria), disability must be awarded.

If the claimant's disability is found to be severe, but does not meet or equal a listed impairment, the evaluation process continues.

The fourth step of the SSA sequential evaluation process requires the adjudicator to determine whether the claimant can do his/her past relevant work, and the fifth step requires proof that the claimant cannot do any other type work that is available in the economy. While these steps have a more subjective standard of proof, the CFS Ruling does state that "younger individuals" (age 18-49) may be disabled if they are unable to work. SSA policy typically presumes that younger people can find other types of work and disability benefits are often denied on that basis.

Resolving conflicts
Many CFS patients have experienced SSA adjudicators who have ordered "consultative examinations" (CEs) with outside medical sources who are uninformed about CFS or who seem like hired guns to discredit their disability claims. The new Ruling states, if the adjudicator finds the claimant's record to be incomplete or inconsistent, the treating health care provider should be contacted first to provide the needed information. Only if the treating source is unable to satisfy the request should a CE be ordered. The Ruling also explains that a CFS claimant's medical record may contain conflicting evidence due to the "complicated diagnostic process involved in these cases" and any conflicts should first be resolved through the patient's own doctor (rather than an outside CE).

And, finally, SSA offers the opportunity for claimants to submit supporting statements from other medical sources, as well as "third parties" such as neighbors, friends, relatives, clergy, former employers, school teachers, and others who are familiar with their functional limitations.

Overall the new Social Security Ruling should improve disabled CFS patients' outcomes. The Program Operations Manual System (POMS), the basic guidebook for handling disability claims, will be revised shortly to reflect the Ruling. Training of SSA personnel about the ruling, which is binding on adjudicators at all levels, including administrative law judges, won't begin until July. Even so, the Ruling should immediately become a critical part of any CFS patient's claim for disability benefits.

Ruling to guide reviews, too
If you are in the process of applying for SSDI payments, reference Ruling 99-2p to ensure that the new rules are used to review your case. The ruling will also guide decisions made in Continuing Disability Reviews (CDRs) conducted by SSA.

While the Ruling will have no direct impact on cases involving private long-term disability insurance, it eventually is expected to influence decisions in those cases. An SSA determination of disability on a non-psychiatric basis should make it more difficult for private insurers to terminate benefits by lumping CFS in with psychiatric illnesses. 
 

Vicki Walker is Public Policy Coordinator for The CFIDS Association of America. She is in her seventh year of service to the Association.