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Winter 2000

Disability Evaluation in a Nutshell

By Douglas Smith
Attorney at Law

Patients claiming disability benefits depend on their doctors to provide the evidence that the Social Security Administration (SSA) requires to declare them legally "disabled." SSA can be hard to convince; it denies two-thirds of claims in the initial decision. Many chronic fatigue syndrome (CFS) patients are able to obtain benefits, but there is usually a long time lapse involved.

A ruling issued by the SSA in April 1999 (SSR 99-2p) that acknowledges CFS as a legitimate disability will not necessarily "open the floodgates" but may make it easier for disabled CFS patients to acquire benefits at an earlier stage in the appeals process. 

The process
Claimants must meet at least one of two criteria to be considered disabled. First, the medical findings for patients with CFS must "equal in severity" the findings specified for any of the 100 or more impairments in the SSA's Listing of Impairments (there is no specific listing for CFS).

If they do not, then SSA evaluates whether the claimant has sufficient "residual functional capacity" to do sustained work in an ordinary work setting on a regular and continuing basis.

Medical reports
Keep in mind that the medical records of the primary treating physician carry the most weight in disability determination. SSA usually sends "fill in the blank" forms to doctors whose patients have filed claims, but the best vehicle for answering is a letter of report.

Reports should indicate that the claimant has a medically determinable impairment (or combination of impairments), that those impairments significantly limit physical and/or mental ability to perform substantial gainful work, and that the impairment is expected to last for a continuous period of at least 12 months. Following is the format preferred by the SSA for medical reports:

• Medical history---if you're dealing with a patient with a chronic disability, keep records that reflect how impairments develop over time, making writing this part of the report easier.
  
  
• Clinical findings---the results of physical or mental status examinations, plus notation of any findings deemed significant by the SSA Listing of Impairments.
  
  
• Laboratory findings---copies of test reports should be attached.
  
  
• Diagnoses---statement of diseases or injuries based on symptoms. When depression is present, indicate whether it is the cause of the patient's symptoms or the result of CFS, and whether the depression alone is sufficiently severe to be disabling.
  
  
• Treatment prescribed---should include response and prognosis.
  
  
• Medical assessment of functional capacity---if the patient's chart lacks details, the information often can be obtained by asking the patient, family, friends and others, or by having the patient complete a daily activities worksheet.

Additional tips*
Medical reports can refer to information from the patient and other sources, including counselors and therapists, to illustrate the nature and severity of CFS. When information is quoted from a lay person, the treating doctor must explain why it should be considered credible. For example, you may explain that the limitations reported by a patient are credible because they are consistent with characteristics of CFS and the clinical findings.

You may also provide supplemental information. Encourage patients to keep a daily log of symptoms, activities and general health status. A copy can be attached to the medical report along with basic information about chronic fatigue syndrome.

There are other ways to assist in the claims process. SSA and private insurers may refer patients for Independent Medical Examinations-you can intervene with a request that the examiner be familiar with CFS, since many are not and attribute the condition solely to psychological causes.

*Source: Katrina Berne, PhD

This article has been adapted from a booklet available from The CFIDS Association of America. To order, call 704-365-2343.

Writing a convincing medical report
Physicians’ reports are key to con-vincing SSA claims processors that CFS is more than just "being tired." Taking time to document a patient’s impairment in language familiar to the SSA can reduce the amount of time it takes to reach a decision. The following excerpts from a "model" letter to the SSA may provide some suggestions for compelling points to make in your own reports.

"Mary Brown is a 47-year old female diagnosed with chronic fatigue syndrome (CFS, also referred to as CFIDS--chronic fatigue and immune dysfunction syndrome). CFS is a disorder of unknown etiology that results in profound disabling fatigue, inability to exert oneself physically and is often associated with substantial decline in cognitive functioning as well as various musculoskeletal and neurologic symptoms. Like many chronic illnesses, CFS is characterized by often unpredictable fluctuations in severity. Its treatment is largely symptomatic, and there is currently no universal cure.

"I spoke to Ms. Brown’s previous supervisor, who commented they had lost a wonderful worker--she was being considered for a promotion when she became ill.

"It is my firm medical judgment that Ms. Brown lacks the capacity to work at any job on a regular sustained basis primarily because of the debilitating fatigue she experiences and her inability to stand for more than a few minutes at a time. Her ability to maintain concentration and her poor short-term memory severely impair her ability to communicate and would drastically reduce her productivity. These types of deficits are well documented.

"I consider Ms. Brown’s fatigue as debilitating as the extreme fatigue often seen in systemic lupus erythematosus (listing 14.02), many malignancies and multiple sclerosis (listing 11.09). Her fatigue and problems concentrating are as severe, if not more severe, than the sequelae of a minor brain injury under listing 11.18."