Disability for Back Pain: What Qualifies for SSDI Benefits?
By Wally Mountz / October 24, 2016 / Applying for Social Security Disability & SSI Benefits / 6 Comments
Back pain and spinal problems are the most frequent Social Security Disability claim. We explain how you can successfully collect SSDI benefits if you qualify.
If you have chronic back pain, the last thing you want to worry about is money. Add in doctor’s appointments, physical therapy, laboratory tests, and never-ending travels to specialists and your life quickly becomes very complicated. On top of that you mayneed to file a claim for disability benefits, which can be a daunting process.
Chronic back pain is the most common disability application the Social Security Administration (SSA) deals with each day. In fact, statistics reveal that back pain is a leading cause for someone to miss work, and bone degeneration is the primary disability for people under forty-five years old. Back pain can vary from a dull, nagging ache to severe pain preventing you from even getting out of bed.
The Essentials When Applying for Disability Due to Back Pain
Documentation is Key
For a successful Social Security or Supplemental Security Income disability application for back pain, your diagnosis and limitations must be well documented. Your condition must also fall into Social Security’s “severe” classification. To receive disability from the SSA, your back pain should be diagnosed as a specific medical problem, such as a herniated disk, nerve root compression, or sciatica, for example. Even if you have a herniated disk, medical personnel should determine that the condition is not subject to rectifying treatment, and that it also meets their “chronic” definition. This is in contrast to other types of back pain.
For example, misuse or overuse of back muscles is a frequent complaint as people age, but such back pain resulting from normal aging will not be approved for a disability claim. SSA understands that most back pain will resolve itself within a few weeks or a few months, and back pain is a very common complaint as people age. Accordingly, they essentially expect you to deal with it as you move toward retirement age.
What is Chronic Back Pain?
Chronic pain is pain that is not resolved within the usual recovery time frame for an injury—perhaps three to six months or pain that arises from a degenerative condition of the spine and persists. As unlikely as it may seem, back conditions are sometimes difficult to diagnose. Much of the time, diagnosis has to be based on your personal report of pain, which is very one-sided at best and does not always lend itself to rigorous scientific examination with medical findings. Lack of a firm diagnosis can make it very hard, nearly impossible, to get a determination that you are disabled. This is due to Social Security’s definition of disability, which says disability is “the inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted, or can be expected to last, for a continuous period of not less than twelve months.”
For this reason, initial claims and even reconsideration appeals are often denied. The result is that back pain claims often end up in a second appeal, which is a hearing before an administrative law judge.
Judges will look at a doctor’s reports and any test results, of course; but they must go further and act more like a court jury deciding a case, meaning that they will also examine your work history, your previous and current statements concerning your condition, any witness statements, and photographs, or video tape if available.
They will also want to see a detailed record of your attempts for treatment and any results. Such treatment might include physical therapy, yoga, exercises, medications, supplements, surgery, chiropractic or acupuncture treatments, bioelectric therapy, or ultrasound treatments. For instance, the hearing official might be interested in knowing if you have received any cortisone shots, how effective they were, how long relief lasted, and if any side effects occurred.
Specifically, what SSA is looking for is a “medically determinable” condition, which would distinguish your condition from a chronic back pain normally associated with aging or an short-term injury. Examples of possible precipitating events could include heavy lifting, improper lifting, an accident, a fall, or back strain caused by a sports activity. Such cases would usually heal within a matter of weeks, which would be less than the required one-year time frame and would therefore not be allowed.
Documentation You Need to Receive Disability for Back Pain
Doctors and Tests
Medical proof is best—verifiable proof from a doctor and test results from MRIs and X-rays showing that your pain results from something abnormal in the spinal column or spinal canal. For instance, an X-ray showing that a vertebrae was fractured, an MRI indicating degeneration of bone in the spine, especially with nerve impingement, or a CT scan identifying a severely herniated disc, this could be the proof they want.
Your doctor’s records are very important in the claim process, and such notes must be very detailed. They should show your level of pain, rate of recurrence, triggering events, relief strategies, and a well-formed time line of the entire process. It is vital that you show continuing attempts to relieve this chronic pain. The physician should also list how this disability is affecting your normal daily activities. Because of these requirements, you should make certain that you have a doctor who is experienced in dealing with patients suffering from back pain.
Activities of Daily Living
You may also be required to fill out an Activities of Daily Living (ADL) form, which describes your limitations throughout your normal day. Remember not to exaggerate your problems because you do not want to damage your credibility with the SSA. Answer carefully and truthfully.
You need to fairly assess your daily chores and determine if you can no longer perform some of these or if they take longer to complete than normal. Is your social schedule the same or has the pain kept you housebound and away from friends and relatives? Has your pain changed your psychological state? Do you now have troubling moods or depression that has alienated friends, neighbors, and relatives? Does the pain stop you from thinking clearly or remembering details? Any of these problems could have a direct effect on your ability to maintain any full-time job you might qualify for.
SSA may also contact your friends and relatives and ask them specific questions about your normal activities and if your pain is noticeable to them. The examiner may turn to one of their medical consultants for another opinion of the case. Unfortunately, these consultants will only examine available records to reach their conclusions. Many facts may escape them because you would not be interviewed.
Spinal Problems Recognized for Benefits by SSA
Social Security’s Blue Book has a listing of conditions that qualify for automatic approval for disability benefits based on medical condition alone without evaluation of transferable work skills or education, but chronic pain is not included. Nonetheless, a number of diseases and medical problems associated with chronic pain could pave the road to disability benefits: chronic renal disease, inflammatory arthritis, inflammatory bowel disease, somatoform disorders, and diseases of the neurological system all produce pain and could be the basis for receiving disability benefits. And, certain spinal conditions producing pain are listed.
Three of the categories of spinal problems that could lead to being approved for disability benefits based on a listing in the Blue Book are:
- Nerve Root Compression
SSA provides examples of spinal cord compression or nerve root compression that could cause moderate or chronic pain all the way up to paralysis:
- Herniated, slipped, prolapsed disc (herniated nucleus pulposis [HNP])
- Facet arthritis
- Vertebra fracture
- Degenerative disc disease (DDD)
All of these, however, must be accompanied by certain findings to meet the listings.
Residual Functional Capacity
If you do not qualify for benefits under the listings, your claim will be evaluated to determine your limitations and capacities. This is done by determining your medical limitations and considering them as related to the demands of your former occupations and potential new occupations. One tool for determining functional limitations is a Residual Functional Capacity (RFC) assessment, which may be completed by Social Security doctors based on your medical records or an RFC might be completed by your physician or a consulting physician. The RFC form is used to record your ability to work full-time and will also assess your current physical abilities, such as the following:
- Amount of weight you could carry and lift
- Your ability to walk and how far
- How long you could sit
- Your ability to push and pull
- How long you could maintain a standing position
- Your ability to bend over and lift
- Your ability to reach over your head
To bolster your case, have your own doctor, preferably a specialist in back pain and injury, complete an RFC. The more functional limitations noted on the form, the better your case for winning a disability claim.
Examples of Functional Limitations
- Unable to remain seated for 6 hours in a normal workday
- Unable to stand for 2 hours a day
- Unable to walk one block without stopping
- Need to lie down during the day
- Unable to carry 10 pounds intermittently during a workday
- Has to keep one or both legs elevated during the day
Maintain Your Credibility
When you have to appeal up to a hearing, the administrative law judge may also consider your personal statements to determine if they are believable or if you seem to be exaggerating your claims. A psychiatric consultation could also be ordered for a better picture of your mental health and to assess whether your claims are inconsistent with what is expected with your particular condition.
To gauge your credibility, a hearing officer or judge may consider the following:
- Your statements
- The intensity of your pain, the location, and how long the pain and effects last
- Triggering incidents
- Effectiveness of medications, dosage, and any side effects
- Self-treatment strategies and their effectiveness, such as sleeping on a board or icing or applying a heat pack to the painful area
- Employer statements
- Employment history and how the pain affected it
- Witness statements
- Medical records, including your doctor’s records and prognosis
- The history and results of any therapy
- Any indications of untruthfulness, such as stating in the records that you cannot sit more than a few minutes, but you remain seated during a long interview with an examiner or at the hearing
- How compatible all your statements are with existing records
- An examination of the history of your condition and how it has changed over time
These findings could well be critical for approving or denying your claim. In fact, if you have a long history of emergency room visits, examinations by different doctors, and any therapeutic procedures, such as acupuncture, physical therapy, medications trials and different dosages, your creditability may be boosted, which can only help your case.
Claims and Appeals
If you are prepared to gather the documentation discussed and any other particular to your situation, you can file a back pain claim on your own; but if you are denied and have to appeal, it would be a good idea to arm yourself with a qualified attorney who handles Social Security disability claims. This attorney should have experience with the Social Security and Supplemental Security Income disability application and appeals processes. Also check to be sure the attorney has successfully handled chronic back pain claims as well.
Your lawyer will review your claim file and help you prepare your appeal. If you have to appeal a second time, the attorney will prepare you for the hearing. He or she will know when and how to cross-examine experts used by SSA to show why their conclusions are incorrect or too stringent. Such testimony could be particularly helpful for approving your benefits.