Social Security Administration Issues New Fibromyalgia Disability Ruling

Fibromyalgia is a chronic illness that is characterized by diffuse pain in the muscles, tendons and other soft tissues. Joint pain can also occur with the condition. Other common symptoms include fatigue, headaches, sleep issues, depression, and difficulty concentrating. There are many other symptoms that can accompany fibromyalgia. Symptoms experienced by each patient can vary widely.

Fibromyalgia symptoms can also vary greatly over time, with the signs and symptoms of the illness being much more pronounced at some times than others. Individuals with fibromyalgia may be almost entirely without symptoms on some days, while other days they may be unable to function due to pain, fatigue and other complications.

Social Security Disability (SSD) benefits are intended to provide financial support for individuals who are completely disabled and unable to work because of a serious medical condition. Because fibromyalgia symptoms can be different from one case to the next and the severity of daily symptoms can vary as well, it has traditionally been very difficult for fibromyalgia sufferers to qualify for SSD benefits.

In an effort to clarify the qualification criteria for SSD applicants with fibromyalgia, the Social Security Administration (SSA) has published revised disability ruling details for the condition. The new criteria are now included in the SSA’s “Blue Book”, which is the manual of disabling conditions utilized by Disability Determination Services staff when reviewing applications for eligibility under SSD guidelines.

The medical evidence contained within any SSD application is crucial in proving a disability claim. The SSA uses this documentation in two primary ways:

  1. To determine if the medical condition from which the applicant suffers seriously limits their ability to work and perform other daily tasks.
  2. To evaluate whether the applicant has a “medically determinable impairment”.

A medically determinable impairment is one that can be proven through accepted medical evaluation and diagnostic testing. The SSA’s new disability ruling for fibromyalgia issued in July 2012 lays out two instances in which fibromyalgia may be considered a medically determinable impairment.

Under the first set of criteria, the application must prove:

  1. A history of diffuse (widespread) pain, lasting a minimum of three months, and occurring in all four quadrants of the body.
  2. 11 of the 18 primary tender points associated with the condition, and these tender points must also be spread throughout all four body quadrants.
  3. Medical evidence documenting that other disorders that can cause the same or similar symptoms have been ruled out by a qualified medical professional.

Because the symptoms of fibromyalgia are extensive and are quite similar to those seen with a number of other disorders, ruling out other medical conditions through diagnostic tests and evaluations can be very time consuming and costly, not to mention stressful and frustrating. But, doing so is crucial to qualifying for SSD benefits, and for most applicants denied SSD, it’s the third point in the list above that is not proven in their applications.

Under the second set of criteria for proving a medically determinable impairment with a diagnosis of fibromyalgia, the first and third points are the same. The second point may be omitted, but in its place the application must prove the repeated presence of six or more of the central or most common symptoms associated with fibromyalgia. These symptoms include:

  1. Fatigue
  2. Sleep disturbances
  3. Unrestorative sleep
  4. Memory and cognitive thinking problems
  5. Irritable bowel syndrome
  6. Headaches
  7. TMJ syndrome
  8. Depression
  9. Anxiety
  10. Painful menstrual periods
  11. Tingling or numbness in the limbs or extremities
  12. Restless leg syndrome
  13. Hypersensitivity to light, sound, and heat and/or cold

The opinion of a treating physician regarding the applicant’s limitations is not enough to substantiate a claim. The application must meet one of the two evidentiary thresholds as outlined above. Additionally, the medical documentation included in the file must not conflict with other details in the application. In other words, the medical records and all other information in the application must present a consistent picture of the applicant’s limitations and overall condition.

Proving eligibility for SSD benefits is complicated and working closely with your physician is crucial to seeing a favorable outcome. Hiring a Social Security lawyer is also recommended as he or she can assist you in building a strong case file, can potentially shorten the wait for disability benefits, and may even increase your chances of being found eligible under the SSA’s guidelines for disability.