Even if your patient’s specific disability does not appear under the “Listings, ” he or she may still be legally disabled and entitled to Social Security benefits of his or her impairment is “equal to” the severity of those on the Listings.
Most physicians are aware that the Social Security Administration regulations list detailed medical descriptions of conditions, which are considered disabling as a matter of law.
To “meet” the Listings, a person seeking disability benefits must provide evidence from a medical source (preferably, the treating doctor) verifying the condition. If the medical diagnosis matches one of the medical descriptions listed, the person is legally disabled for the purpose of qualifying for Social Security Disability benefits. Very straightforward.
However, a patient also qualifies for disability benefits if the claimed disabling condition is “equal to” one of the conditions on the Listings. That is, if the claimed condition results in an impairment or “functional limitations” equal in severity to those resulting from one of the conditions described in the Listings. This is called “medical equivalence.”
For example, you have a patient with chronic low back pain which he says makes it impossible to sit or persist in any task for longer than 30 minutes, much less make it through a day of work. It requires him to lie down frequently on good days; and on “bad days” it renders him incapable of getting up at all.
Pain medications, anti-inflammatories, physical therapy and home exercises have not helped. The MRI shows a couple of bulging, but not herniated, discs. You have diagnosed “lumbosacral strain.” You check the Social Security Listings, under 1.00 “Musculoskeletal System,” subsection 1.05 “Disorders of the Spine.” Your patient does not have any of the specified conditions. He does not “meet” any of the Listings.
At this point, your patient’s right to Social Security Disability benefits will depend on the answer to this question:
“DOES THE FUNCTIONAL LIMITATION IMPOSED ON MY PATIENT BY THIS CONDITION EQUAL THE FUNCTIONAL LIMITATION MY PATIENT WOULD HAVE IF HE HAD A CONDITION WHICH APPEARS IN THE LISTINGS?”
In this case, your patient’s pain is causing the functional limitation. Your answer, however, must be based not only on your patient’s complaints of pain, but on your objective observations and results of testing made during examination and the results of any laboratory or diagnostic tests.
Your objective findings must give a reasonable basis for your patient’s complaints of pain, but objective findings are NOT needed “to verify” the extent of the pain and disability your patient claims. All that is needed is that the objective medical condition could reasonable be expected to produce the symptoms.
In other words, if your examination, observations and testing have resulted in a diagnosis of a condition which may reasonably be expected to produce the type of symptoms your patient has, then there is an objective basis for those symptoms. It would be helpful to your patient if your chart notes reflected this connection. That is, after stating your findings, if these findings can reasonably be expected to produce your patient’s symptoms, say so.
If your patient seems sincere in his desire to return to work and appears to be genuinely in pain, say so.
The law recognizes that different people experience pain in different ways. That is why it does not require doctors to objectively verify the extent of the pain.
However, you should gain enough insight into your client’s pain to be able to state the extent to which it limits your patient’s functioning. If your patient’s pain impairs him, that is, limits his functioning as severely as it would if he were suffering with, say, a herniated nucleus pulposus or spinal stenosis (with pain, muscle spasm, significant limitation of motion in the spine, appropriate radicular distribution of significant motor loss with muscle weakness and sensory and reflex loss), then his condition is “equal to” one of the listings under “Disorders of the Spine” and he is entitled to Social Security Disability benefits as if he “met” the Listings.
The judge must also consider whether the cumulative severity of multiple conditions or a “combined condition” (for example, when a pain syndrome involves both a physical and a psychological component, such as depression) equals that of the Listings. Therefore, if your patient is afflicted by multiple conditions or a combined condition, reflect in your records their total impact on his/her ability to function.
As indicated in Volume I of this journal, your role is not to state whether your patient is “disabled,” or to compare his functional limitations with those in the Listings. But your medical opinion may and should address what your patient can and cannot do. Those reviewing the claim will translate these into the patient’s degree of impairment or functional limitations.
If you are addressing questions such as how long your patient is capable of sitting, standing, walking, driving, etc. in an eight-hour clay, be sure to be clear as to whether all your answers apply to the same eight-hour day. For example, if in response to questions you indicate that your patient can sit for 4 hours, stand for 4 hours and drive for 4 hours, please state whether the sitting must be included in, rather than added to, the driving; and whether the 4 hours of standing may occur in the same day. Also, be sure to state how long your patient may be able to work at one stretch, and how much and how frequently rest may be required. Also, take into account that the work setting will call for not just sitting but sustained productive activity while sitting.
You need not be familiar with the Listings. Recall that the treating physician’s role is to provide medical evidence of what the patient can and cannot do on a sustained basis – and if this amounts to an inability to perform substantial gainful activity which has lasted or is expected to last at least 12 consecutive months (or end in death).
In summary, your records and diagnosis should be based on findings from examinations and tests which show whether there is an objective medical condition which may reasonably result in your patient’s symptoms. Your findings need not objectively support the extent of your patient’s symptoms. This task is, of course, impossible. Your records should address the impact of the patient’s condition on his ability to function by stating what he can and cannot do and for how long, etc. in a work setting. This should take into account the total impact of multiple or combined conditions. If you believe your patient is sincerely experiencing pain which significantly impairs his ability to function and/or he/she sincerely desires to recover and return to work (or you know him/her to be a hard worker, now frustrated by a medical condition), say so.
Your patient may be wrongfully denied benefits -benefits which he/she needs due to an inability to work – based on a misinterpretation or misapplication of your records, if you do not address these matters explicitly.
This article was prepared by Arthur W. Stevens, III