Endometriosis and Filing for Disability
Endometriosis can be a very painful debilitating disease that imposes functional limitations, therefore it is a valid medical condition to include on an application for Social Security or SSI disability. The condition falls under the classification of genitourinary impairments. If it were listed in SSA disability Blue Book listings, it would be evaluated using the requirements outlined in section 6.00, Genitourinary System - Adult.
However, the genitourinary listing makes no mention of any disorders other than those that are involve kidney problems. Although this is a common disorder for women to list on a disability application, the SSA Bluebook does not provide specific severity requirements for someone filing for disability on the basis of endometriosis. Perhaps this is due to the fact that most women who suffer from this condition are successfully treated with medications and surgical procedures. And, for most women, the symptoms of this condition are intermittent. Still, there are many women who suffer significant pain and other problems constantly.
Since there is no impairment listing for this condition, they must prove that their condition is so severe, in spite of treatment, that they are unable to work at a level considered to substantial gainful work activity by the Social Security Administration.
In cases that involve medical impairments such as endometriosis, medical documentation is paramount. If possible, medical records should provide a diagnosis, description of pain and symptoms, treatment and response to treatment, medications, objective testing, and a prognosis. It is helpful to have a statement from their doctor providing an opinion as to their ability to sustain employment considering their symptoms and limitations of their endometriosis.
Social Security disability determinations consider the ways and extent to which a person is functionally limited by their medical conditon because it impacts their ability to engage in work activity. Consequently, disability determinations are based on residual functional capacity rather than specific medical conditions. Therefore, a person may have a difficult time being approved for disability solely on the basis of endometriosis, but it is not impossible if it is so severe that it prevents the performance of substanital gainful activity.
These selected pages answer some of the most basic, but also some of the most important, questions for individuals who are considering filing a claim for disability benefits.
Facts about the condition
1) Endometriosis occurs when the endometrium (the cells that line the wall of the uterine cavity) are misplaced and end up growing in other areas of the body, usually within the pelvic area. The cells are usually found in the pelvic lining, ovaries, bladder, bowel, or the rectum, though they can appear in other places. Sometimes they can spread to the vagina and cervix.
2) Only females can develop endometriosis, usually found during the reproductive years, usually between the ages of 25 and 35. It is estimated that nearly 5 to 10 percent of the United States population of women have endometriosis.
3) Although the uterine cells have moved to other areas of the body with endometriosis, they still respond to hormonal changes, such as menstruation. These cells outside the uterus cause adhesions and scarring that cause pain.
4) Although some women have absolutely no symptoms at all, the most common symptoms are pelvic pain, painful sexual intercourse, pain with menstruation and bowel movements, back pain, and infertility. The pain associated with endometriosis can be mild or extremely severe.
5) Although there is no cure for endometriosis, many women use painkillers, birth control pills, progesterone injections or pills, gonadotropin agonist drugs (they halt the production of estrogen by the ovaries), and some women have surgery to remove the tissues.
6) When women are past their child-bearing age, they may opt for a hysterectomy to help with endometriosis.
7) Although the cause of endometriosis is unknown, many in the medical community believe that estrogens, retrograde menstruation, transplantation, genetics, environmental factors, and weakened immune systems may be potential factors in causing the condition.
8) Doctors can diagnose endometriosis by performing a pelvic laparoscopy, pelvic exam and transvaginal ultrasound.
9) If a woman is considered infertile due to endometriosis, surgery may help. Moderate cases of endometriosis may see a 60 percent increase of pregnancy rates after surgery, mild cases will see about a 75 percent increase, and those with severe cases may only see a 30 or 40 percent pregnancy rate after surgery.
Qualifying for disability benefits with Endometriosis
Whether or not you qualify for disability and, as a result, are approved for disability benefits will depend entirely on the information obtained from your medical records.
This includes whatever statements and treatment notes that may have been obtained from your treating physician (a doctor who has a history of treating your condition and is, therefore, qualified to comment as to your condition and prognosis). It also includes discharge summaries from hospital stays, reports of imaging studies (such as xrays, MRIs, and CT scans) and lab panels (i.e. bloodwork) as well as reports from physical therapy.
In many disability claims, it may also include the results of a report issued by an independent physician who examines you at the request of the Social Security Administration.
Qualifying for SSD or SSI benefits will also depend on the information obtained from your vocational, or work, history if you are an adult, or academic records if you are a minor-age child. In the case of adults, your work history information will allow a disability examiner (examiners make decisions at the initial claim and reconsideration appeal levels, but not at the hearing level where a judges decides the outcome of the case) to A) classify your past work, B) determine the physical and mental demands of your past work, C) decide if you can go back to a past job, and D) whether or not you have the ability to switch to some type of other work.
The important thing to keep in mind is that the social security administration does not award benefits based on simply having a condition, but, instead, will base an approval or denial on the extent to which a condition causes functional limitations. Functional limitations can be great enough to make work activity not possible (or, for a child, make it impossible to engage in age-appropriate activities).
Why are so many disability cases lost at the disability application and reconsideration appeal levels?
There are several reasons but here are just two:
1) Social Security makes no attempt to obtain a statement from a claimant's treating physician. By contrast, at the hearing level, a claimant's disability attorney or disability representative will generally obtain and present this type of statement to a judge.
Note: it is not enough for a doctor to simply state that their patient is disabled. To satisy Social Security's requirements, the physician must list in what ways and to what extent the individual is functionally limited. For this reason, many representatives and attorneys request that the physician fill out and sign a specialized medical source statement that captures the correct information. Solid Supporting statements from physicians easily make the difference between winning or losing a disability case at the hearing level.
2) Prior to the hearing level, a claimant will not have the opportunity to explain how their condition limits them, nor will their disability lawyer, attorney or representative have the opportunity to make a presentation based on the evidence of the case. This is because at the initial levels of the disability system, a disability examiner decides the case without meeting the claimant. The examiner may contact the claimant to gather information on activities of daily living and with regard to medical treatment or past jobs, but usually nothing more. At the hearing level, however, presenting an argument for approval based on medical evidence that has been obtained and submitted is exactly what happens.
About the Author: Tim Moore is a former Social Security Disability Examiner in North Carolina, has been interviewed by the NY Times and the LA Times on the disability system, and is an Accredited Disability Representative (ADR) in North Carolina. For assistance on a disability application or Appeal in NC, click here.
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