Featured image for “How Does the SSA Look at Fibromyalgia?”

How Does the SSA Look at Fibromyalgia?

September 5, 2017

If you have fibromyalgia, and your symptoms keep you from being able to work, you may want to apply for Social Security Disability benefits. We’re going to break down SSR 12-2p: Titles II and XVI: Evaluation of Fibromyalgia, a policy interpretation ruling the Social Security Administration (SSA) published in 2012, which finally laid out a decisionmaking process for SSA judges to determine whether someone’s fibromyalgia is a Medically Determinable Impairment (MDI) and make determinations about awarding disability benefits.

The first important thing to understand is that the SSA judge has to find that you have an MDI, which means they think your fibromyalgia is impairing your ability to work, but just having an MDI doesn’t get you disability benefits. The next step is for the judge to decide whether your impairment keeps you from working—either your old job, or the field you’ve been working in, or whether there is other work out there that they think you could still do. If the judge finds that there isn’t work out there that you could be doing, then they can award you disability benefits.

So you can have fibromyalgia, and the judge can even find that it’s an impairment for you in your life, but it’s important to be able to show that you’re so impaired that it keeps you from doing your work, or lots of other kinds of work.

Let’s back up to the beginning and go through all the steps where you’ll have to have evidence to show to the judge. [As a side note, at all of these stages, you can pursue this process on your own, or you can retain an attorney to help you. In either case, it’s important for you to understand what’s going on and how the process works.] First, you’ll have to prove that you have fibromyalgia. For this, the judge will need evidence from a licensed medical or osteopathic doctor—this can be your primary care doctor or a specialist, but the judge will need detailed notes of their treatment of you and recording your symptoms over time, so you will need your fibromyalgia-related medical records from the past few years, even if you haven’t been seeing your current doctor very long. Just having your doctor send a note saying you have fibromyalgia isn’t going to be enough.

Judges Use Criteria to Determine Impairment

There are two specific sets of criteria that SSA judges use to determine whether your fibromyalgia amounts to an MDI. Your judge will use whichever one fits your situation better. The first set of criteria is the 1990 American College of Rheumatology (ACR) Criteria for Classification of Fibromyalgia. You’ll need to show all three of the following:

  • A history of widespread pain, which means you’ve had pain for at least 3 months, and it has to be on both the right and left side of your body, above and below the waist, but if it varies in intensity or comes and goes, that’s okay. There also has to be pain in the spine—low back pain, neck pain, upper or middle back pain, or chest pain, in the front of the spine.
  • At least 11 tender point sites on your body. It lists where these are expected to be—there are 18 possibilities and your doctor needs to document that you have tenderness at 11 or more of them, again, on both sides of your body and above and below the waist.
  • And your doctor has to show that they’ve ruled out other health conditions it could be—that they’ve done blood work and imaging and ruled out other conditions you could have.

The other set of criteria the SSA judge can use is the 2010 ACR Preliminary Diagnostic Criteria. Your doctor will need to show all three of these:

  • A history of widespread pain (again, both sides of your body, above and below the waist, and lasting for at least 3 months);
  • You repeatedly experience six or more symptoms, signs, or co-occurring conditions, especially fatigue, cognitive issues–“fibro fog,” depression, anxiety, waking unrefreshed, or irritable bowel syndrome (this is just a partial listing of common symptoms and issues—you could bring up many others);
  • Again, your doctor will have to show that they ran tests and excluded other health conditions you could have.

So, through one of these two sets of criteria, your doctor’s evidence will have to show the judge that you do have fibromyalgia, and that it’s an impairment for you. In addition to evidence from your doctor, the SSA judge may want additional evidence from other professionals you see, like a psychologist, to understand better the issues you’re coping with. They may also want nonmedical evidence, like testimony from your friends, family, past employers, coworkers, or clergy, to get a sense of how your fibromyalgia affects your day-to-day life and your ability to work.

Does The Impairment Keep You From Working?

Assuming the SSA judge is persuaded at this point that you have fibromyalgia and it’s an impairment for you in your life, he or she will evaluate whether your fibromyalgia keeps you from working. Again, the interpretation ruling gives the judge a list of steps to go through to make this determination. The judge will need to ask if you’re working now—if you are doing “substantial gainful activity,” then they’ll have to decide you’re not disabled.

Then the judge will decide if your pain or other symptoms create more than a minimal restriction or limitation on your ability to do your work. If they do, then the judge will say you have a “severe” impairment.

The judge will compare your symptoms to a listing of other conditions that are often disabling, because fibromyalgia doesn’t have its own listing in their official manual, so they’ll look for another way to classify your impairment for their own purposes.

This brings the judge to the Residual Functional Capacity determination. This is when they use their understanding of your impairment, and any impairments in their manual they can categorize you under, to decide if they think you’re still able to do your past work in your own field, or if there is other work in the national economy they think you can do, even with your limitations.

Only then, if the judge finds that you can’t do your old job and there isn’t any other job you could do, will the judge award you disability benefits.