Part 2: How does the SSA evaluate fibromyalgia?
Published on May 22nd, 2019 by Eric Slepian
Today we continue our look at fibromyalgia, a potentially disabling illness that afflicts many of our clients. We work with them and their doctors to solidly establish their disability before the Social Security Administration (SSA) in their applications for Social Security Disability Insurance or Supplemental Security Income, known as SSDI and SSI, respectively.
As we explained in part 1, fibromyalgia can be one of the harder impairments to prove because of the subjectivity of most symptoms, including pain, fatigue and problems with concentration and clarity of thought.
Social Security Ruling on fibromyalgia
The SSA issues Social Security Rulings, called SSRs, to provide direction to all SSA employees involved in deciding SSDI and SSI claims. SSR 12-2p directs the evaluation of claims based wholly or partially on fibromyalgia.
The SSR outlines how to evaluate the evidence to determine if fibromyalgia is a “medically determinable impairment,” also referred to as an MDI, which prevents the claimant from performing “substantial gainful activity,” or SGA, meaning roughly whether the person’s symptoms prevent financially significant work.
Sufficient objective medical evidence
The 2012 ruling says that the only “acceptable medical source,” or AMS, to diagnose fibromyalgia is a licensed medical or osteopathic doctor. In 2017, the SSA also recognized licensed advanced practice registered nurses and licensed physician assistants as AMSs for fibromyalgia.
The SSA looks not only at the diagnosis, but also at:
- Whether the medical professional reviewed the claimant’s medical history
- Whether the medical provider performed a physical examination
- Whether the provider’s treatment notes are consistent with fibromyalgia
- Whether the treatment notes reflect the symptom history
- Whether the notes describe the doctor’s “assessment over time of the person’s physical strength and functional abilities”
Required criteria
The SSA will find that a claimant has an MDI of fibromyalgia if a doctor diagnosed it, other information in the file is not inconsistent with the diagnosis, and one of these two criteria groups from the American College of Rheumatology are met:
1. All three of these exist: widespread pain for at least three months (but can vary in intensity), at least 11 of 18 tender points positive for pain under pressure, and medical exclusion of other possible diagnoses
2. All three of these exist: the first and third criteria in the first group plus persistent manifestation of at least six fibromyalgia “symptoms, signs, or co-occurring conditions”
Other relevant evidence
The SSA will consider other helpful evidence, especially to learn about functional limits from fibromyalgia, including:
- Other medical sources
- Nonmedical sources like friends, family, clergy, employers, rehabilitation counselors, teachers and SSA interviewers
The SSA may also send the claimant for a “consultative examination” for more medical evidence.
Fibromyalgia can be a devastating disease with a crippling effect on a person’s daily functioning and ability to work. While the SSA’s approach to SSDI and SSI claims based on fibromyalgia may sound complicated, an experienced attorney can help develop the record and advocate before the SSA on behalf of a claimant with fibromyalgia.
