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Social Security Disability SSI and Fibromyalgia

Fibromyalgia is one of the most cited allegations on applications for disability that are filed with the Social Security Administration (under SSD or SSI). To qualify for disability with fibromyalgia, a person applying for disability must show that their condition is:

1) medically determinable,

2) is severe versus non-severe,

3) has been disabling for at least one full year (note: if the individual has not been disabled for a year at the time they file, Social Security will use the medical evidence to project whether or not the condition will ultimately last the required length of time), and

4) prevents the ability to engage in work activity at a certain level.

What is that "certain" level? SSA does allow individuals who file for disability to engage in paid work (and this includes individuals who are currently receiving disability benefits) as long as their gross monthly earnings are below the dollar amount threshold for SGA. SGA stands for substantial gainful work activity. And it is essentially an earnings limit that disability applicants and recipients must stay under in order to maintain eligibility to receive disability benefits. Here is the current earnings limt.

Though, increasingly, medical research shows that fibromyalgia is a stand-alone illness for which the primary medications seem to involve pain relief, Fibromyalgia, as of yet, is not included in the Social Security Administration's disability impairment listings.

As that is the case, winning disability benefits based on fibromyalgia will involve the medical vocational allowance process in which a person's medical history and work history will be examined to determine whether or not the individual is capable of returning to their past work or performing some type of other work based on their age, education, skills, and current physical and mental functional limitations.

Because the approval process for fibromyalgia cases is medical-vocational, individuals applying for disability with fibromyalgia should be sure to provide all available information concerning their history of treatment. A detailed history of work employment (including job titles and descriptions of the duties for each job) will also assist the process and can help to ensure that a disability claims examiner does not misidentify the claimant's past work or level of skills (which could set the stage for the incorrect assumption that the claimant is still capable of working).

Additionally, a qualified supporting statement from a treating physician (a treating physician is a physician who has a history of providing medical treatment to a patient and is, therefore, qualified to render an opinion as to their functional outlook) can serve to establish that the claimant does meet the SSA definition of disability as a result of their residual functional capacity (what a person can still do despite their condition).

These following 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 based on fibromyalgia.

Fibromyalgia diagnosis, Pain medications, and SSA Medical exams

Fibromyalgia affects two to four percent of the general population. It affects women far more that men and is often associated with other conditions such as post-traumatic stress disorder, stress, anxiety, chronic fatigue, irritable bowel syndrome, and depression. In addition to other co-morbid mental conditions, some people have a cognitive dysfunction commonly known as brain fog, or fibrofog. Fibro fog may include problems with concentration and/or short and long term memory.

Note: concentration and attention problems, and memory impairment are both valid considerations on applications for disability. The Social Security Administration will sometimes send claimants with allegations of impaired memory to a consultative examination (often referred to as a CE) known as a memory scale, or Wechsler Memory Scale, a neuropsychological test designed to measure different memory functions in a person.

Considering the co-morbid conditions associated with fibromyalgia it is not hard to understand why Social Security and many medical professionals have considered fibromyalgia a mental rather than a physical condition. However, this tendency has often lead physicians to take the errant position that fibromyalgia is "all in a person's head". Given the history of medicine, this is a typical response. But the failure to understand the cause and source of an illness does not prove the non-existence of the illness.

Despite the fact that medical studies conducted over the past thirty years indicate fibromyalgia is a disorder of the central nervous system of an unknown etiology that is associated with mental conditions rather than being a stand-alone mental disease or disorder, fibromyalgia is now recognized as a disease in its own right by the ICD, or International Classification of diseases.

Additionally, fibromyalgia is now being treated with pharmaceutical medications whose purpose is to fight pain. One is lyrica, although it should be mentioned that lyrica is also used to control seizures. Another fibromyalgia medication that is used for combatting pain is savella, though this is also used as an antidepressant.

Fibromyalgia symptoms are very much like other arthritic conditions such as rheumatoid arthritis or osteoarthritis. It causes widespread pain that can affect the entire body, although most suffers have tender points or trigger points of pain. Doctors have located eighteen trigger points on the body; if a person has eleven or more of those trigger points they receive a diagnosis of fibromyalgia.

Ideally, a fibromyalgia diagnosis should be made by a pain specialist, or at the very least a physician who has knowledge of fibromyalgia tender points and trigger points. A general diagnosis of fibromyalgia by a physician who does not know how to properly diagnose the condition may, in the end, only be as valuable as a diagnosis of depression by a person's family doctor who is not a psychologist or psychiatrist.

In either case, the person making the diagnosis may not have a substantial knowledge of the condition and their ability to properly diagnose may be in question. Making matters worse for the disability claimant filing on the basis of fibromyalgia is the fact that the doctor who perform SSA medical exams may not A) have direct experience with fibromyalgia or B) not know much about trigger or tender points.

How the social security administration evaluates fibromyalgia cases

Social Security requires objective medical evidence to support a diagnosis of fibromyalgia. Unfortunately, lab tests (i.e. blood work) and imaging tests are useless for establishing fibromyalgia or its potential severity.

So what can you do to provide Social Security with objective medical evidence? Make sure that your medical file contains a diagnosis of fibromyalgia, trigger point testing results, and documentation of your medications, treatment, response to treatment, and limitations.

Social Security disability is about function more than specific conditions. It is especially important to have a well-documented history of the limitations associated with your condition. Social Security disability examiners must make a determination as to how restrictive your residual functional capacity (what you are able to do in spite of the limitations imposed upon you by your fibromyalgia) is--and if your RFC prevents you from being able to perform any your past jobs or any other kind of job.

If the disability examiner finds that you are not able to do any of your past jobs or any other jobs due to the restrictions of your fibromyalgia you may be approved for disability benefits.

Note: this method of approval, in which a disability examiner or judge at a hearing will conclude that you cannot return to substantial and gainful work activity either at a past job or at some other type of work is known as a medical vocational allowance. Some claims get approved on the basis of listing criteria

As of yet, however, there's no listing for fibromyalgia in the bluebook. That being the case, disability examiners evaluate SSD and SSI cases for which the primary allegation is fibromyalgia the same way they'd evaluate any claim for which there might exist the potential for a medical vocational allowance (which, essentially, is each and every claim that's filed).

In other words, they:

A) consider the medical evidence,

B) look for evidence substantiating physical and mental limitations,

C) work with their unit medical consultant/unit physician and unit psychological consultant (in their processing unit) to arrive at a physical residual functional capacity rating and/or a mental residual functional capacity rating,

D) measure these ratings against the demands of the claimant's past work,

E) if the claimant is incapable of returning to their past relevant work, measure them (the RFC ratings) against the demands of suitable other work for which the claimant might possibly be expected to transition to, based on medical and vocational factors, including age, work skills, functional limitations, and education.

As an aside, I can guarantee you that it is not typically the practice of disability examiners in the various disability processing agencies across the country (usually known as DDS, or disability determination services) to ever refer to the regs.

I.E. if an impairment is not in the bluebook, it all comes down to the sequential evaluation decision process (in which SSA find that a person can has or does not have the ability to go back to a job.

Qualifying for SSDI or SSI disability benefits

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 (this is the CE, or consultative examination previously mentioned).

There are two ways of being approved for disability benefits. The first is by satisfying the requirements of a listing in the SSA impairment listing manual. The second, the way the majority of claims are approved, is through a medical vocational allowance, a decision process that uses the SSA five step system of evaluation.

Currently, the Social Security Administration does not have a listing for fibromyalgia. Therefore, the medical vocational route that utilizes the sequential system of evaluation is the only method of being approved for fibromyalgia.

In this process, in order to be approved, a person must be found to be 1) not working and earning a substantial and gainful income at the time of their application for disability, 2) must have a severe medical impairment as validated by medical record documentation, 3) must not be able to return to their past work because of their current limitations that may be physical, mental, or both, and 4) must not have the ability to do some type of other work because a combination of certain factors rule that capability out (including their current functional limitations, age, job related skills, and their education level).

Because SSA disability claims (Social Security Disability and SSI) use both medical records and vocational work information to decide claims, it is essential at the time a person is filing for disability on the basis of fibromyalgia to supply the most accurate information regarding medical sources and treatment and regarding one's past jobs.

Accurately listing medical treatment information will allow an adjudicator (a disability examiner or a judge at a hearing) to view the necessary medical records from all the relevant treatment sources.

Accurately listing all past jobs, their dates of employment, accurate job titles, and full descriptions of the work involved for each job will allow an adjudicator to make a more accurate classification of one's jobs and skills and can make a difference in the decision that is made on a case.

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 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.

Return to:  Social Security Disability Resource Center, or read answers to Questions

Related Body System Impairments:

Social Security Disability SSI and Fibromyalgia
Facts about Chronic fatigue and Filing for Disability
The Frustration of Fibromyalgia
Should Fibromyalgia Sufferers exercise?
Acupuncture for Fibromyalgia
Reduce Sugar for Fibromyalgia
Diagnosed with cfs and fm, would i be eligible for SSD?
Fibromyalgia, Social Security Disability, and Applying for Benefits
Chronic Fatigue, Social Security Disability, and Applying for Benefits

Information on the following topics can be found here: Social Security Disability Questions and in these subsections:

Frequently asked questions about getting Denied for Disability Benefits | FAQ on Disability Claim Representation | Info about Social Security Disability Approvals and Being Approved | FAQ on Social Security Disability SSI decisions | The SSD SSI Decision Process and what gets taken into consideration | Disability hearings before Judges | Medical exams for disability claims | Applying for Disability in various states | Selecting and hiring Disability Lawyers | Applying for Disability in North Carolina | Recent articles and answers to questions about SSD and SSI

These pages answer some of the most basic questions for individuals who are considering filing a claim.

How to Apply for Disability - What medical conditions can you apply and qualify for?
How long does it take to be approved for SSI or Social Security disability?
What happens if I file a disability application and it is denied by a disability examiner or Judge?
How do you prove your disability case if you have a mental condition or impairment?
Social Security Disability Back pay and How Long it Takes to Qualify for it and receive it