Knee Replacement and Social Security Disability

In knee replacements, metal and plastic parts are used to replace a damaged knee with extreme pain, usually from arthritis or injury. There are three types of surgery: partial only takes out part of one knee, total (TKR) takes out one whole knee, and bilateral is when both knees are replaced at once.

Each year, over 700,000 Americans get theirs knees replaced, according to the Centers for Disease Control (CDC), and millions are currently living with a replaced knee. If you or a loved one needs this surgery, but can’t afford it, the Social Security Administration (SSA) may be able to help. The SSA awards financial benefits for those struggling to work due to a disabling condition.

If you had a knee replacement and cannot work, you may qualify for Social Security disability benefits.

The Financial Costs of a Knee Replacement

The cost varies depending on many factors, such as your insurance, the type of surgery you’ll need, the surgical approach, the hospital the surgery is done at, and your geographic location. Healthline reported that the average cost of knee replacement surgery is $49,500, though a partial knee replacement can cost 20 percent less than a TKR.

Not included in the $49,500 are the other hospital inpatient charges and outpatient costs, which can easily raise the bill over $60,000. According to Healthline, the average inpatient costs can add about $7,500 to your bill, while pre- and post-surgical can add another $5,000. If you have any preexisting conditions, like anemia, this may require special equipment and/or attention and cost

The other big expense of knee replacement is the recovery time. It can take a year or longer for you to regain full use of your knee(s), which can add thousands of dollars in lost income. Heathline explained that you’ll be out of work for at least six weeks, though this period can last much longer if there were complications during or after the surgery.

With or without insurance, the total expenses for knee replacement surgery may seem daunting, especially because of the lost income from the weeks you won’t be able to work. If you’re worried, talk to your doctor before the surgery to find out if they have any discounts or payment plans available.

After recovery, replacement dramatically reduces pain and increases the quality of life in 95 percent of patients. While only 10 percent of replaced knees last less than 10 years, most last 20 years. This means, if you get your knee replaced young, you may have to repeat the surgery when you get older.

Medically Qualifying for Benefits with the Blue Book

The SSA keeps an official list of impairments, called the Blue Book, to use in disability applications. They first evaluate every application against a Blue Book listing to determine if the application meets a medical requirement for disability benefits.

Knee Replacements can be found under section 1.00—Musculoskeletal System.

In order to qualify for benefits via the Blue Book, you need medical proof that either of these apply to you:

  • You have a major joint dysfunction that includes anatomical deformity and chronic joint pain, stiffness, and limitation of motion that affects your knee and severely interferes with your ability to walk.
  • You have had reconstructive surgery or surgical on your knee because of your severe inability to walk and you are not expected to return to normal movement for at least 12 months after surgery

The SSA further describes their requirements as being capable of sustaining a reasonable walking pace over a sufficient distance to regularly perform daily living activities. The inability to walk without help from hand-held assistive devices, like canes or walkers, to walk at a reasonable pace on a rough or uneven ground, to use standard public transportation, to carry out routine ambulatory activities, like shopping and banking, and to climb a few steps at a reasonable pace with the use of a single hand rail. Though, if you can walk independently in your own home, that doesn’t necessarily mean the SSA will consider you able to walk normally.

Additionally, pain and other symptoms can an important factor contributing to functional loss, but medical results are necessary to show the existence of an eligible impairment(s) that could reasonably cause your pain or other symptoms. The SSA will evaluate the intensity and persistence of your pain.

Talk to your doctor to see if you’re knee replacement recovery is expected to last 12 months or longer, because you may qualify for disability benefits.

Qualifying Without Meeting a Medical Listing

If you’re knee replacement surgery doesn’t meet the Blue Book listing, but your condition is debilitating enough that you’re unable to work, there is another way to get approved for benefits. The SSA will also examine the workplace and daily living limitations that your disability causes you to determine your Residual Functioning Capacity (RFC).

In order to be approved under an RFC, you need to be unable to work what the SSA considers Substantial Gainful Activity (SGA). The SGA income minimum is $1,130 per month in 2016. For all disability applications, including RFC approvals, it’s required that the complications from the procedure are expected to keep you out of work for at least 12 months.

In an RFC measurement, the SSA will evaluate your condition and the limitations you suffer from to classify the level of work they think you can do: sedentary, light, medium, heavy, and very heavy. Those who are found to be able to do heavy and very heavy work will rarely be approved for benefits. For the sedentary, light, and medium categories, the SSA has created a rule system, called grid rules that examine your work history, age, education level, and skills to evaluate the jobs that are available in your RFC level.

The SSA has three levels of expectant medical improvement. If you’re approved and expected to improve, your case will be reviewed between six and 18 months after your benefits start (which is at least 5 months after your reported onset date). If it’s possible that you’ll improve, the SSA will review your case before three years, and if improvement isn’t likely, your case won’t be reviewed until about seven years after your benefits start.

Since knee surgeries have a high success rate, usually applicants must wait until a year after surgery to discover the long-term affects, if any, from the procedure, so you’ll most likely be approved with the expectation you’re your condition will improve and the SSA will revisit your case sooner than other conditions.

To approve an RFC, you need to prove to the SSA that you don’t have the skills for a job in your work level or you can argue that you can’t even do sedentary work. Knee replacement complications can include pain, stiffness, loss of motion, difficulty bending over, lifting things, walking up and down stairs, and walking for certain distances or on rough or uneven grounds.

Those who didn’t attend college or have only had physically demanding jobs, jobs with a lot of standing or movement, such as manual labor, construction, automotive, would have a higher chance of approval than a person who worked jobs that required less physical activity.

How to Apply for Social Security Disability Benefits

If your movement is still limited after your knee surgery, talk to your doctor first to see what he or she recommends. The application process isn’t short—if you’re approved, you won’t receive benefits for five months, but many applications can take up to two years for approval and the starting of benefits. If your doctor doesn’t think your chances are high, it may not be worth the time and effort of applying.

Your application will require a number of personal documents, including your birth certificate and tax information, as well as medical evidence of your condition and your limitations. You need to make sure your initial claim application contains all of the necessary all of the medical information the SSA needs to evaluate it. Even if you meet the SSA listing, you may be delayed or denied if you didn’t submit everything the SSA needs.

Important medical evidence will include:

  • Results from any labs or tests done before your surgery
  • A summary of your ability to walk with and without a hand-held assistive device
  • An operative report of the surgery
  • Records of your hospitalization(s) during and after the surgery
  • History, length, and outcomes of all prescribed treatment
  • Detailed reports from your physical therapist and primary care doctor describing your disabilities

The SSA offers a convenient online application on their website, but if you aren’t comfortable applying online, you can make an appointment at your local SSA office. Make sure you have everything you need to apply, answer all questions, and don’t make any mistakes. If you leave information out, the SSA will have to take the time to retrieve that information or they may deny you. Most initial claim denials are due to missing documentation.

If there are any changes in your condition or you were admitted to the hospital after you’ve submitted your application, you must inform the SSA immediately. The more evidence you have of your condition, the more likely you’ll be approved for disability benefits.

If you’re approved for benefits, your spouse and children may also be eligible for benefits. To learn more about the different forms about disability benefits, visit our pages on Social Security Disability Insurance and Supplemental Security Income. You can also read our page on tips for applying for Social Security disability with a knee replacement.

Additional Resources