Helpful Hints / Guide Used By Social Security Disability Examiners in Assessing Common Disease Conditions and Impairments

Here’s a cheat sheet used by many disability claims examiners (Georgia) when reviewing Social Security disability and SSI claims.

It was given as a quick reference guide for new disability claims examiners and highlights the most common “allegations” [disease conditions] listed by claimants.

This insider information may assist you in deciding what things you might want to focus on as you prepare your application and / or talk with your medical provider about what specific information and testing s/he might provide or conduct in support of your claim.

The reader is cautioned that these basic guidelines were given in 2003, and because Social Security rules and regulations are in a constant state of change, they are not to be construed as gospel, nor valid for today.

Every claim is different, but what is presented below represents a general framework of how an examiner might begin to approach the task of getting medical records to support this range of specified common diseases/conditions.

Instructions to the Disability Claims Examiner:

The following are some helpful hints/guides on what to look for in the medical records according to body system/allegations. These are the most common allegations we deal with. Always focus on abnormalities when reading MER.

Social Security Disability Physical Allegations / Disease Conditions

Arthritis —Same as Back Allegations except add description of joints, h/o treatment and response to treatment. With 

Asthma—Shortness of breath (SOB), wheezing, rattling in the chest. Chest x-rays DO NOT show anything with asthmatics as a rule. Focus on the number of ER visits or hospitalization for asthma.

Test: Pulmonary Function Studies (PFS); Recency of MER should be within the year prior to adjudication [beginning date of current application for benefits] of claim. Can go back further to establish severity if you need to. What is the response to treatment?

Back Allegations--look for recency of the MER. With orthopedic allegations we like the MER to be within six months of the date you are developing the case if they are currently insured (i.e. Title 2 eligible) or in Title 16 cases. [In NC, the time period would be within three months of your date of application] 

Chronic Artery Disease (CAD)—(clogged/restricted arteries of the heart) Look for chest pain in these cases. Need a description of the CP as well as what brings it on and what relieves it.) Have they had heart surgeries in the past and what was the response to it? Again you need longitudinal history on heart cases.

Tests: focus on any results of the following: catheterization, PTCA, CABG, ECHO, EKG, Thallium Scan.

Chronic Heart Failure (CHF)—SOB, fluid retention in lower limbs and feet, exertional intolerance (hard to walk to the mailbox w/o SOB), easily fatigued. We need longitudinal records (history) in all heart allegations, which means you need to obtain & focus on MER years in the past if available, as well as current MER.

Test: Chest x-ray; Exercise Treadmill Test (ETT); ECHO

Chronic Obstructive Pulmonary Disease (COPD)—SOB, can’t get enough air in or out, has a “barrel” chest appearance. Try to get longitudinal history of treatment, recency of MER should be within the year.

Tests: Chest x-ray is very helpful because COPD will show up on a CXR; PFS or DLCO.

Diabetes—look for neuropathy of the lower extremities (loss of sensation, tingling) or retinopathy of the eyes as well as poor circulation leading to ulcers on the legs. This would be on serious diabetes cases. Most diabetes can be controlled with diet and meds and therefore not likely to be an allowance [claims approval]. The more serious the diabetes the more likely there will be End Organ Damage to the heart, kidneys and eyes. Look for frequency of incidences of acidosis on insulin dependent diabetics. (# of hospital visits)

Fractures—(limbs-upper/lower, pelvis etc.)-X-rays, ROM. Keep in mind most fractures resolve in 12 months to non severe. Of course there can be exceptions like non-union of the fracture.

High Blood Pressure—Look for “End Organ Damage” (EOD) which means damage to the heart, brain, eyes or kidneys. Look for a BP reading of over 140/90, anything below this is usually non-severe or controlled with medications. Most of the time you have no symptoms with HBP, occasionally a claimant will allege dizziness.

Test: CXR, EKG.

Kidney Disease—Determine if the claimant is on permanent dialysis treatment, if so the case can be moved with just a little medical information [i.e. given a favorable decision] or telephone call to the dialysis clinic to confirm. A longitudinal history is also good on these cases.

Tests: Creatinine, hematocrits (blood tests)

Seizures/Epilepsy —Focus on the frequency of the seizures with medications and a description of the seizure (grand mal/major vs. petit mal/minor) EEGs are somewhat helpful, however, they are not always reliable in diagnosing seizures. Look for recent lab testing to see if the medications they are taking are being taken at a therapeutic level. If they show a low level of medication in their blood stream it either means they are non compliant with taking the meds. Or the dosage needs to be adjusted. Always send Seizure questionnaires to the claimant and it is advisable to send a third party seizure Q to someone who has witnessed the seizures or knows some information about that claimant’s seizures.

Tests: laboratory blood testing

Vision Allegations—you will need to look for visual acuity testing, or in the case of glaucoma, visual fields testing. In visual acuity testing you need to know if it is with correction or without. Does the claimant watch TV and read, drive a car???

Mental Allegations

You will be looking for a history of treatment as far back as you can go as you are developing longitudinal history. Look for medications they may be on for the mental problems as well as if they are currently receiving counseling or have had recent hospitalizations. Always send/call for ADLs to the claimant when they allege a mental impairment and always send/call to a third party to obtain ADLs on the claimant. The big thing you need to focus on as you read the medical records is the treatment history and the severity of the allegations.

More on Reporting Mental Allegations >>>