Understanding how the system works can make a world of difference when it comes to getting a Social Security Disability Insurance (SSDI) claim approved.  It is a multi-step process that can take several months, and the more armed you are with knowledge, the greater the chances are that your application process will go smoothly and that you will be approved in the shortest amount of time possible.

One of the keys in this process is proving that you have a qualifying disability.  If you’re able to do this, you stand a good chance of receiving benefits.  Social Security Administration (SSA) processes hundreds of thousands of claims each year, and to help streamline the process, they have created a standardized list of qualifying disabilities that are all listed in the Blue Book of Impairments.  When you have a disability that is listed in the Blue Book, you have cleared a major hurdle in gaining approval.

A little background…how SSDI claims are processed

Social Security offers two programs for those seeking benefits in conjunction with their mental and physical disabilities.

Social Security Disability Insurance is for people who have worked and paid into the system through payroll deductions, and who have developed a disability expected to last one year or more or until they die.  Supplemental Security Income helps those who are disabled but do not qualify for Social Security Disability.  SSI benefits are based upon need and not whether a person qualifies with an insured status, unlike SSDI.

SSA’s regulations provide a procedure known as the “sequential evaluation process” for disability evaluation.  For adults, this is a five-step process that requires sequential review of:

1. the claimant’s current work activity
2. the severity of his or her impairment,
3. a determination of whether his or her impairments meets or medically equals a listing in the Blue Book
4. the claimant’s ability to perform past relevant work
5. the ability to do other work based on age, education, and work experience.

After a person submits an application for the SSDI benefit, their application is reviewed by a claims rep and a medical examiner.  Some applications are denied because a person has too much qualifying income, others are disqualified for a number of other reasons, such as not meeting qualifying medical disability standards.  The initial rejection rate is high.  About 70% of first time applications are denied for a variety of things.

As part of the review process, SSA officials will look at what kind of disability or multiple disabilities are being claimed.  An applicant will need to provide support proof through medical records, doctor’s statements, tests and any other pertinent types of documentation.

Once all of this has been received, a medical examiner will consult the Blue Book of Impairments to see if the applicant’s condition meets one of the qualifying listings.  If so, then a large piece of the approval process has been successfully navigated.  If your condition is not listed, you can still be approved, but your task will be much more complicated.

What is the Blue Book of Impairments

To determine what qualifies as a disability, Social Security bases many of their decisions on information contained in the Blue Book of Impairments.  Most commonly referred to as just the Blue Book, it lists in great detail all the qualifying medical conditions that meet SSA’s test for whether or not a condition is considered a qualifying disability.

While SSA relies heavily on the Blue Book for Social Security disability benefits, there are also other medical conditions that may meet the test for disability that are not included in the Blue Book.  An applicant does still have a chance of collecting disability benefits, but they will need to provide additional detailed information about their condition, including medical records, doctor’s statements and any other materials that can be used to make the case to Social Security in getting approved for benefits.

Many of the disabilities listed in the Blue Book are either chronic, permanent and/or fatal.  If a person has a disability and it is a listed condition in the Blue Book, it simplifies their application process when they provide the medical documentation needed for approval.  However, it does not guarantee that someone will be approved.  In fact, despite being listed in the Blue Book, many people with ailments may still be rejected for one reason or another.  The absence of a listing-level impairment does not mean a person is not disabled. In these instances, a claims rep will move on to the next step of the process and apply other rules to determine if a disability exists.

The Blue Book is broken into two main parts.  Part A is a listing of all conditions that qualify as a disability for Adults.  Part B is a listing for all conditions that qualify as a disability for Children.  Each part is broken into major categories, such as musculoskeletal system conditions or respiratory system conditions.  Within each of these categories, specific ailments are listed in detail to help give a clearly defined set of criteria as to what meets a qualifying condition.  When you can prove that you have the symptoms or the condition, this is known as “meeting the listing.”  Each listing will often include specific clinical and laboratory tests required to make an evaluation as well.

The medical criteria in Part A may also be applied in evaluating conditions for applicants under 18 if a condition has a similar effect on both adults and children.  In some instances, diseases are only found in children or the effects of a disease differs in how it affects children and adults.  When evaluating a child under 18, the criteria in Part B will be used first.  However, when the medical criteria in Part B do not apply, then criteria in Part A will be used instead.

An impairment may “equal” a Blue Book listing

If an impairment doesn’t match the requirements of a Blue Book listing, the disability claims examiner will determine if a claimant’s impairments can be considered equivalent to a similar listing in terms of severity.

The SSA allows what is known as an “equal” a listing because it can’t include every form or variant of a severe disability in the Blue Book listings. The SSA also recognizes that there are various ways to diagnose and document the same illness. In some cases, a listing may require that a claimant provide results of a very specific test to document their condition.  However, if a person did not take that test, but did take another test that shows the same results, it may be considered as equal documentation.

Equal listings may also be allowed in cases where a person has several impairments that by themselves are not severe enough to meet the requirements of a specific listing.  However, when these impairments are combined, their severity will equal the requirements of a listed impairment.

If the SSA says your impairments are equally as severe as those in the Blue Book listings, assuming you meet all other requirements, you will be granted SSDI benefits.

Blue Book Part A – Adult Listings

The Blue Book of Impairments undergoes reviews on a regular basis, and impairments are added or deleted as a result.  As of early 2018, here is a detailed list of Part A and Part B listings.

Musculoskeletal System 

• Disorders of the musculoskeletal system
• Major dysfunction of a joint(s) (due to any cause)
• Reconstructive surgery or surgical arthrodesis of a major weight-bearing joint
• Disorders of the spine
• Amputation (due to any cause)
• Fracture of the femur, tibia, pelvis, or one or more of the tarsal bones
• Fracture of an upper extremity
• Soft tissue injury

Special Senses and Speech

• Loss of central visual acuity
• Contraction of the visual field in the better eye
• Loss of visual efficiency, or visual impairment, in the better eye
• Disturbance of labyrinthine-vestibular function
• Loss of speech
• Hearing loss treated/not treated with cochlear implantation

Respiratory System 

• Chronic pulmonary insufficiency
• Asthma
• Cystic fibrosis
• Pneumoconiosis
• Bronchiectasis
• Mycobacterial, mycotic, and other chronic persistent infections of the lung
• Cor pulmonale secondary to chronic pulmonary vascular hypertension
• sleep-related breathing disorders
• lung transplant

Cardiovascular System

• Chronic heart failure
• Ischemic heart disease
• Recurrent arrhythmias
• Symptomatic congenital heart disease
• Heart transplant
• Aneurysm of aorta or major branches
• Chronic venous insufficiency
• Peripheral arterial disease

Digestive System

• Gastrointestinal hemorrhaging from any cause, requiring blood transfusion
• Chronic liver disease
• Inflammatory bowel disease (IBD)
• Short bowel syndrome (SBS)
• Weight loss due to any digestive disorder
• Liver transplantation

Genitourinary Disorders

• Chronic kidney disease
• Nephrotic syndrome
• Complications of chronic kidney disease

Hematological Disorders

• Hemolytic anemias
• Disorders of thrombosis and hemostasis
• Disorders of bone marrow failure
• Hematological disorders treated by bone marrow or stem cell transplantation
• Repeated complications of hematological disorders

Skin Disorders

• Ichthyosis
• Bullous disease
• Chronic infections of the skin or mucous membranes
• Dermatitis
• Hidradenitis suppurativa
• Genetic photosensitivity disorders
• Burns

Endocrine Disorders (including but not limited to)

• Pituitary gland disorders
• Thyroid gland disorders
• Parathyroid gland disorders
• Adrenal gland disorders
• Diabetes mellitus and other pancreatic gland disorders
• Hypoglycemia

Congenital Disorders that Affect Multiple Body Systems

• Non-mosaic Down syndrome

Neurological Disorders

• Epilepsy (convulsive and nonconvulsive)
• Central nervous system vascular accident
• Benign brain tumors
• Parkinsonian syndrome
• Cerebral palsy
• Spinal cord or nerve root lesions, due to any cause
• Multiple sclerosis
• Amyotrophic lateral sclerosis
• Anterior poliomyelitis
• Myasthenia gravis
• Muscular dystrophy
• Peripheral neuropathies
• Subacute combined cord degeneration (pernicious anemia)
• Other degenerative disease
• Cerebral trauma
• Syringomyelia

Mental Disorder

• Organic mental order
• Schizophrenic, paranoid and other psychotic disorders
• Affective disorders
• Intellectual disability
• Anxiety-related disorders
• Somatoform disorders
• Personality disorders
• Substance addiction disorders
• Autistic disorder and other pervasive developmental disorders

Cancer 

• Soft tissue cancer of the head and neck
• Skin
• Soft tissue sarcoma
• Lymphoma
• Leukemia
• Multiple myeloma
• Salivary glands
• Thyroid gland
• Breast
• Skeletal system
• Maxilla, orbit, or temporal fossa
• Nervous system
• Lungs
• Pleura or mediastinum
• Esophagus or stomach
• Small intestine
• Large intestine
• Liver or gallbladder
• Pancreas
• Kidneys, adrenal glands, or ureters
• Urinary bladder
• Cancers of the female genital tract
• Prostate gland
• Testicles
• Penis
• Primary site unknown after appropriate search for primary
• Cancer treated by bone marrow or stem cell transplantation
• Malignant melanoma

Immune System Disorders

• Systemic lupus erythematosus
• Systemic vasculitis
• Systemic sclerosis
• Polymyositis and dermatomyositis
• Undifferentiated and mixed connective tissue disease
• Immune deficiency disorders, excluding HIV infection
• Human immunodeficiency virus infection
• Inflammatory arthritis
• Sjögren’s syndrome

Blue Book Part B – Childhood Listings

Low Birth Weight and Failure to Thrive

• Low birth weight in infants from birth to attainment of age 1
• Failure to thrive in children from birth to attainment of age 3

Musculoskeletal System

• Major dysfunction of a joint (due to any cause)
• Reconstructive surgery or surgical arthrodesis of a major weight-bearing joint
• Disorders of the spine
• Amputation (due to any cause)
• Fracture of the femur, tibia, pelvis, or one or more of the tarsal bones
• Fracture of an upper extremity
• Soft tissue injury

Special Senses and Speech

• Loss of central visual acuity
• Contraction of the visual field in the better eye
• Loss of visual efficiency, or visual impairment, in the better eye
• Hearing loss treated/not treated with cochlear implantation

Respiratory System

• Chronic pulmonary insufficiency
• Asthma (in specific cases)
• Cystic fibrosis
• Lung transplant
• Growth failure due to any respiratory disorder

Cardiovascular System

• Chronic heart failure
• Recurrent arrhythmias
• Congenital heart disease
• Heart transplant
• Rheumatic heart disease

Digestive System

• Gastrointestinal hemorrhaging from any cause, requiring blood transfusion
• Chronic liver disease
• Inflammatory bowel disease (IBD)
• Short bowel syndrome (SBS)
• Growth failure due to any digestive disorder
• Liver transplantation
• Need for supplemental daily enteral feeding via a gastrostomy

Genitourinary Disorders

• Chronic kidney disease
• Nephrotic syndrome
• Congenital genitourinary disorder
• Growth failure due to any chronic renal disease
• Complications of chronic kidney disease

Hematological Disorders

• Hemolytic anemias
• Disorders of thrombosis and hemostasis
• Disorders of bone marrow failure
• Hematological disorders treated by bone marrow or stem cell transplantation

Skin Disorders

• Ichthyosis
• Bullous disease
• Chronic infections of the skin or mucous membranes
• Dermatitis
• Hidradenitis suppurativa
• Genetic photosensitivity disorders
• Burns

Endocrine Disorders

• Any type of diabetes mellitus in a child who requires insulin and has not attained age 6

Congenital Disorders that Affect Multiple Body Systems

• Non-mosaic Down Syndrome
• A catastrophic congenital disorder

Neurological

• Major motor seizure disorder
• Nonconvulsive epilepsy
• Benign brain tumors
• Motor dysfunction (due to any neurological disorder)
• Cerebral palsy
• Meningomyelocele
• Communication impairment associated with documented neurological disorder

Mental Disorders

• Organic mental orders
• Schizophrenic, paranoid and other psychotic disorders
• Affective disorders
• Intellectual disability
• Anxiety-related disorders
• Somatoform disorders
• Personality disorders
• Substance addiction disorders
• Autistic disorder and other pervasive developmental disorders

• Cancer
• Malignant solid tumors
• Lymphoma (excluding lymphoblastic lymphoma)
• Leukemia
• Thyroid gland
• Retinoblastoma
• Nervous system
• Neuroblastoma
• Malignant melanoma

Immune System Disorders

• Systemic lupus erythematosus
• Systemic vasculitis
• Systemic sclerosis (scleroderma)
• Polymyositis and dermatomyositis
• Undifferentiated and mixed connective tissue disease
• Immune deficiency disorders, excluding HIV infection
• Human immunodeficiency virus (HIV) infection
• Inflammatory arthritis
• Sjögren’s syndrome

Working with your doctor to get your SSDI claim approved

It is critical to be able to document your medical impairment with as much medical evidence to support your claim as possible.  Not only will SSA want to see copious medical records, lab reports, x-rays, medical statements and other related evidence, they will also want to make sure that some of the records are current, meaning that you have been seen by medical professionals within the past 6 months or sooner.

One of the most important documents you can have from your primary treating doctor is a medical source statement.  The SSA’s Disability Determination Services will outline what the impairment is and whether or not a claimant can perform tasks such as lifting, sitting, standing and walking, helping to either bolster your support that you cannot work, or providing evidence that you may be able to perform some form of limited work.

As a rule, a treating doctor’s opinions are given the most weight when a disability claim is evaluated.  However, in cases where a claimant obtains a medical source statement from a specialist that will be given even more weight when considering a claim.

The key is to not be reluctant when it comes to seeking support from the doctors who are treating you.  In some cases, you may also run into a doctor who may not support your claim.  When this happens and they are not sympathetic, it might be best to seek out other doctors who agree that your impairment is legitimate, and work with them to develop supporting medical evidence.  Also, you must make sure that physical health doctors providing documentation are licensed as MDs, and that all mental health doctors providing documentation are licensed as psychologists or psychiatrists.

If you want more details on how to work closely with your doctor as part of your approval process, check out our article “How Your Doctor Can Help You Get Approved for Social Security Disability.”

What you should know about Compassionate Allowances

One way to shorten the approval time and lessen the burden of documenting medical evidence is by submitting a claim with evidence that a medical condition is so obvious that it easily meets disability standards.

By law, SSA is required to make sure people can receive benefits quickly under this set of circumstances in what are known as Compassionate Allowances.  Compassionate Allowances quickly identify diseases and medical conditions that fall under the Blue Book of Impairments with minimal medical information.  Allowances include disabilities such as Alzheimer’s disease, some forms of cardiovascular disease, organ transplants, schizophrenia, and others.

The list of Compassionate Allowances has been developed based on public hearing held by Social Security, along with input from medical and scientific experts and the National Institutes of Health.

A full list of Compassionate Allowances can be found here.

What if my condition is not listed in the Blue Book?

The Blue Book is comprehensive and detailed, but there is simply no way that it can contain every possible disease or condition that would qualify as a disability.  If a condition is not listed in the Blue Book, do not be discouraged.  You have a little more work in front of you, but it is still possible to receive SSDI benefits if you can provide substantial proof that your condition has made it not possible for your to work.

It is common for people who are facing this issue to hire an attorney who specializes in SSDI applications and cases to assist them in preparing documentation and arguments.  This is because the amount of additional documentation can be formidable and can include hundreds of pages of complete medical records documenting the disability, testimony and sworn statements from doctors, a detailed and documented work history, and other related documents to help make the strongest case possible.

A disability attorney with several years of experience will have greater insights into what SSA needs and wants to help get an application approved and will be thoroughly familiar with all processes and deadlines along the way.  If you are suffering from any kind of advanced and debilitating condition, retaining an attorney can save valuable energy and reduce the amount of stress you may be under when it comes to securing benefits.

A disability attorney will also be able to assist with providing documentation for several possible conditions that when taken separately will not qualify for a disability, but when combined will allow a person to meet the standards set for by the SSA and in the Blue Book.

If your initial claim is rejected, a Social Security disability attorney can also prove to be a valuable asset in an appeal process, correcting any shortcomings from the initial application, bringing in expert witnesses to bolster your case, and working closely with additional medical professionals to document your case on your behalf.

Some conditions that could be construed as a disability are not listed in the Blue Book.  These include things such as Lyme disease, thyroid problems, narcolepsy, Fibromyalgia, interstitial cystitis, and others.  In situations such as these, rulings are sometimes made that draw in Blue Book listings to help support a claim for one of these unlisted conditions.  There are rulings for Chronic Fatigue Syndrome, Fibromyalgia, Interstitial Cystitis and Complex Regional Pain Syndrome.

In situations such as these, developing support and making a case can be highly complex, and is often best served by retaining a Social Security disability attorney to assist in this important process.

Can I appeal a claim?

If you are initially denied on your SSDI claim, then you have the right to appeal the determination.  There are actually several levels of appeals that you can pursue.

In most states, the first step is to file a request for reconsideration.  Instructions for filing a reconsideration will vary from state to state, but the steps you need to take will be included in your specific initial denial letter.  Some states skip the request for reconsideration completely and go directing to the hearing stage.  Those states include Alabama, Alaska, parts of California, Colorado, Louisiana, Michigan, Missouri, New Hampshire, New York and Pennsylvania.

Reconsiderations are reviewed by Disability Determination Services and involve a complete review of the initial application.  The difference is that the review is conducted by a medical consultant who were not a part of the initial decision.  DDS approves benefits in about 10% of all reconsideration appeals.  If you are denied again, you may pursue the next level of appeal which is a request for a hearing in front of an administrative law judge (ALJ).

You must request a hearing in front of an ALJ within 60 days of receipt of your reconsideration denial.  Appeals must be filed in writing and may be submitted by mail, in person to any Social Security office, or online where available.

ALJs are attorneys who work for the Office of hearings Operations.  Most of their work is focused on upholding or overturning decisions to deny or terminate disability benefits.  ALJs  may request medical expert testimony on complex medical issues.  Each hearing office maintains a roster of medical experts who are called to testify as expert witnesses at hearings or to respond to written interrogatories.  Hearing offices may also contact medical sources directly. An ALJ may issue a subpoena requiring production of evidence or testimony at a hearing.  Your chances for approval are much better at this level, as ALJs approve about 50% of the disability appeal claims that they oversee.

If you lose your appeal in front of an ALJ, you have the right to request that an Appeals Council review your claim.  The Appeals Council randomly selects cases to review, and has the power to grant, deny or dismiss a claimant’s request for review.  The Appeals Council will look for flaws in the ALJ’s decision before granting a review.  Approvals at this level are much less likely.  It’s estimated that only about 3% of Appeals Council reviews are granted.

The final step in the appeals process is to file a lawsuit in U.S. district court. A federal judge will hear your case without a jury, and is supposed to review a case only for legal errors.  District court judges reverse lower level appeals in a very small number of cases.  The good news is that judges remand about half of the disability cases they see for things such as the SSA not considering a doctor’s opinion sufficiently, or that other symptoms or medical proof should have been handled differently.

A few final thoughts…

The Blue Book of Impairments plays a critical role in determining whether or not a person will receive SSDI benefits. Those who have a listed and qualifying disability, and who can provide the necessary medical proof stand a good chance of having their application approved the first time they apply.

However, for those who do not have a qualifying condition, there are other avenues to pursue that can ultimately lead to approval as well.  In all cases, the best course of action is to be thorough, take the time to fill out forms as completely as possible, work with your doctors to meet the standards stated in the Blue Book if possible, and understand that the process will take time to produce desired results.

Also, do not rule out the possibility of appealing your initial decision.  Appeals are common and with the required additional work that you do to correct any application deficiencies, you could be approved for SSDI benefits.

For more information…

A good place to start with general questions regarding Social Security Disability Insurance is by calling the Social Security Administration at (800) 772-1213.  They will be able to answer basic questions and direct you to more targeted resources depending on your needs.  If you prefer, you can also visit the SSA website at www.ssa.gov.

If you’re deaf or hard of hearing, you can call the SSA toll- free TTY number at 1-800-325-0778, between 7 a.m. and 7 p.m. on business days

To get a Disability Starter Kit, you can go online here and download a copy that will help you start your claim process.

Social Security offers a series of YouTube videos that will walk applicants through disability claims, including an introduction to the process, filing a disability claim, medical evidence, quality review, appeals, the Appeals Council and the end of a claim.

SSA also has a Disability Planner that can assist and instruct you on how to qualify for benefits, give you tips on getting approved, and more.