This is one of the most difficult issues in a Social Security disability case.  You might look “normal,” but you know that there is no way that you can work. 

If you tell someone that you are applying for Social Security, they may raise their eyebrows in surprise, or even tell you, “you don’t look disabled.”

When you applied for Social Security, the technician may even have given you a hard time because you seemed fine.  

What most people do not understand is that not all disabilities are visible.  You cannot tell who might be disabled just by looking at them.

People with bi-polar disorder or fibromyalgia may look fine, when you see them. However, unless you are a close friend, or a family member, you may not see this person on a bad day.  And you have no idea that they have many more bad days than good days. 

So, how do you prove that you are disabled when you don’t look it?

I won’t say that looks have no impact in a disability case, but Social Security decides cases based on medical evidence. If you have documentation of your medical or mental problems AND evidence that your condition prevents you from being able to work, you have a good chance of winning, even if you look fine.

Check out my articles on working with doctors to develop your case.

San Francisco disability attorney Geri Kahn wrote about her experiences with providing records to Social Security:

Before filing a new initial claim I always order the records and then submit them directly to the Social Security field office immediately after I have filed the claim electronically.  I recently was at an interview in one of the field offices in San Francisco and the claims representative told me that he could not accept the records I was submitting because he was only permitted to fax 15 pages to the state agency disability  examiner.

Since you need to prove that you are unable to work to win a Social Security disability claim, Social Security often uses disability examiners to get a medical opinion of what a person can and cannot do.  Disability examiners use the medical records Social Security provides to make this decision.  

Then, Social Security uses the disability examiner’s opinion to decide if your condition(s) make you disabled.  

Limiting the number of pages sent to a disability examiner, and to 15 pages no less, is ridiculous. 

That is barely a sliver of the amount of information in most cases.  It’s like deciding whether an individual is disabled by seeing if they can walk down a hallway. 

Fortunately, most cases get a much better review with judges at the hearing level. If you are denied on your initial application, do not give up. Appeal!

via California Social Security Lawyer Blog.

The American College of Rheumatology has a great overview of what a rheumatologist is and when you should consider seeing one.

A rheumatologist is an internist or pediatrician who is qualified by additional training and experience in the diagnosis and treatment of arthritis and other diseases of the joints, muscles and bones. Many rheumatologists conduct research to determine the cause and better treatments for these disabling and sometimes fatal diseases.

What Do Rheumatologists Treat?

Rheumatologists treat arthritis, certain autoimmune diseases, musculoskeletal pain disorders and osteoporosis. There are more than 100 types of these diseases, including rheumatoid arthritis, osteoarthritis, gout, lupus, back pain, osteoporosis, fibromyalgia and tendonitis. Some of these are very serious diseases that can be difficult to diagnose and treat.

When Should You See a Rheumatologist?

If musculoskeletal pains are not severe or disabling and last just a few days, it makes sense to give the problem a reasonable chance to be resolved. But sometimes, pain in the joints, muscles or bones is severe or persists for more than a few days. At that point, you should see your physician.

Seeing a Rheumatologist in a Social Security case:

Seeing a specialist can often be critical in the Social Security case.

A rheumatologist can be especially helpful if you’re filing for disability because of arthritis or fibromyalgia. I have often seen Social Security reject a fibromyalgia diagnosis because the primary care provider’s records did not discuss specific findings or tender points. 

A rheumatologist can do the following:

• Confirm the diagnosis
• Evaluate severity of your symptoms
• Provide an opinion of the limitations caused by the condition

Via “What is a Rheumatologist?”.

It can be very difficult to win Social Security disability benefits based on fibromyalgia. However,  it can be done!

While Social Security no longer considers fibromyalgia as a “imaginary” condition, or a “junk” diagnosis, you still need to make sure the diagnosis of fibromyalgia is backed up by medical findings.

I have reviewed many medical records which mention fibromyalgia, but don’t say how the doctor made the diagnosis. There is no mention of physical examinations or findings.  Social Security may throw out the diagnosis because of a lack of medical support.  

Without a diagnosis, all you have are symptoms and Social Security cannot approve disability benefits on symptoms alone. 

This can stop a case dead in its tracks!

So, what do you need to properly diagnosis fibromyalgia?

The National Fibromyalgia Association provides an answer:

Currently there are no laboratory tests available for diagnosing fibromyalgia. Doctors must rely on patient histories, self-reported symptoms, a physical examination and an accurate manual tender point examination. This exam is based on the standardized American College of Rheumatology (ACR) criteria. Proper implementation of the exam determines the presence of multiple tender points at characteristic locations.

To receive a diagnosis of FM, the patient must meet the following diagnostic criteria:

• Widespread pain in all four quadrants of the body for a minimum duration of three months
• Tenderness or pain in at least 11 of the 18 specified tender points when pressure is applied

If you have fibromyalgia, and you are fighting for your Social Security disability benefits / SSI, ask your doctor if the basis for the diagnosis is documented in your file?

Do your medical records show “widespread pain in all four quadrants of the body for a minimum duration of three months?”

Do your medical records show, “tenderness or pain in at least 11 of the 18 tender points?”

Proper documentation is critical in a Social Security case. Make sure your records are complete.

I am often asked whether seeing a specialist will help in a Social Security disability case.

Do I need to see a specialist? I have my own doctor. What else can a specialist tell me about my case? How can they help?

I have seen numerous cases where Social Security has downplayed the opinion of a treating physician because the doctor is not a specialist!

I have even seen some cases where the Judge rejected the primary care provider’s opinion at hearing because he thought the doctor was just “saying what the patient wanted the doctor to say.”

A lot of these problems can be eliminated with a specialist’s evaluation and medical opinion.

Specialists’ opinions are often given extra weight and treated with deference by Social Security.

Social Security often views specialists as better trained, more experienced, and more objective. Specifically, Social Security is less likely  think that a specialist  is being supportive of a case only because they want to be “nice” to the patient.

A specialist’s records can do the following to help your case:

• A specialist can onfirm a diagnosis.
• A specialist can evaluate severity of your symptoms.
• A specialist can provide an opinion of the limitations caused by the condition.

Who wouldn’t want that?

The answer to this is “yes,” and “no.”

When Social Security requests medical records from a treatment provider (doctor, hospital, walk-in clinic, physical therapist, chiropractor, etc.), and they put a cap on how much they are going to pay for those records.

Unfortunately, they do not put any cap on how much the medical records provider can charge you if you request the same records.  I have previously written about how much  treatment providers can charge for medical records in the state of Colorado. Other states have similar laws in place setting the maximum for medical record charges. However, Social Security gets the best deal when it comes to requesting medical records.

You can use this to your advantage. During the initial evaluation of the case, Social Security will request your medical records from your treatment providers at no cost to you. This is why it is very important to provide Social Security with the most complete information about the doctors you are treating with, their names, addresses, and telephone numbers.

Also, it is a good idea to stayed in touch with the Disability Determination Services office in your state to make sure they are requesting, and receiving, these records.

If you are already past the initial evaluation step in your case, that is if you have already received your initial denial, it may be a good idea to work with an attorney to help limit what records you are requesting.   There are a couple of reasons for this:

In my experience handling Social Security disability cases in Colorado, Social Security rarely requests medical records  after the initial determination.   Occasionally, I see some judges requesting medical records.   But this is pretty rare, and only in cases where the claimant is not represented by counsel.

Doesn’t this mean that I can get Social Security to get my medical records at no cost to me if I simply don’t hire an attorney?

Well, no.  There is no guarantee that Social Security will get updated medical records. Additionally, you have no control over what records Social Security will try to get, or how far back they will go.

By working with an attorney, you can determine which doctors records are essential in your case, and which ones are not. The lawyer can also help you determine how far back the records should go, and most importantly, what records to specifically leave out of the request to keep costs to a minimum.

If you request all available medical records within a certain period of time, maybe a third of the records will actually be useful and relevant. The remaining records may be unnecessary lab results, physical therapy notes, nurses notes, or medication logs.   This is not to say, these types of records are always unnecessary, but frequently they do not add very much to building up a case. 

Remember: when you request medical records, you pay by the page. So, the more pages you receive (relevant or not) the more you pay.

Your lawyer can help craft a medical records request that will weed out the unnecessary pages, give you the most relevant records, and save you money.

ALISON (Automated Licensure Information System Online), is the online licensing database for the state of Colorado. I previously wrote about how this site is a great resource for finding an address for your doctor.

This site also has another use. If your doctor has been suspended, this will show up Alison.

When you apply for Social Security benefits, you will need to provide the name and address of each doctor you have seen for the last several years.

You may have this information for your current doctors, but finding the addresses for your older doctors may be trickier.

How do I find your doctor’s address if she has moved her office?

You can check old business cards, appointment cards, medical records or invoices for this information. You can also check the yellow pages, or check Google.

If all this fails, there is still one more way to track down a doctor.

If you are in Colorado and you have internet access, try ALISON (The Automated Licensure Information System Online). This is the online licensing database for the state of Colorado. If the doctor is licensed in Colorado, you should be able to find the doctor and the his/her current business address.

Just follow these simple steps:

1. In “Search Type,” select “Individuals.”
2. Click “Go to Search Form.”
3. When the next page loads, you can enter the doctor’s first and last name and the city where the doctor practices. If you do not know one or more of these, you can leave that field blank.
4. Click “Begin Search” to see the results.

If the doctor does not come up, check the spelling of the doctor’s name. Also try leaving the “city” field blank. I was trying to find a doctor whom I knew was practicing in Colorado Springs, but nothing came up under the doctors name in “Colorado Springs.” I left the “city” field blank and found the doctor right away. What happened? The license listed the city as “Colo. Springs” instead of “Colorado Springs.”

Keep Alison in mind if you cannot find the current address for one of your prior doctors.

You already know how important it is to get a Medical Source Statement in your Social Security disability case.

The best source for this is your own doctor.

However, I typically see Social Security have one of their technicians or a Social Security doctor, who has never seen or examined you, determine your limitations.

When I discuss this with my clients, I am often asked why? Why does it seem like Social Security purposefully avoids getting this information from the best source, your own doctor?

My opinion is that Social Security wants to ensure an objective opinion and believes that your own doctor won’t be objective. Social Security may be worried that because your doctor has been treating you for some time, he or she may write what you want rather than what the doctor really thinks.

I personally feel this is just bologna!

If Social Security won’t do it, you and your lawyer have to get this evidence from your doctor:

• This means getting your doctor to fill out a form;  
• Or, write a letter. 
• Sometimes, a doctor feels so strongly about a case, he or she will come in to testify.

It may seem like a small thing, but just getting your doctor’s perspective on your condition can make all the difference in your case.

As a general rule, if you are applying for Social Security disability benefits or appealing a Social Security denial, Social Security will penalize you for noncompliance with your doctor’s instructions. That means Social Security may deny your disability claim if you do not do what your doctors tell you.

But there are exceptions!!! Social Security cannot just use the non-compliance rule whenever it wants to.

1. First, the doctor actually has to prescribe the treatment. Not just merely discuss the option of treatment.
2. The treatment must also be clearly expected to restore functioning to the point that you are no longer disabled. That means, that the treatment is expected to allow you to go back to full time work. If you would still be disabled in spite of the treatment, then non-compliance is not an issue.
3. The evidence shows that you have refused to follow the treatment.

Even if Social Security can meet these three burdens, there are reasonable excuses which will prevent Social Security from penalizing you for not following doctor’s instructions.

What if I cannot afford the prescribed treatment or medications?

Inability to afford prescribed treatment is the most common “justifiable cause” in failing to follow prescribed treatment. If you cannot afford the medication or procedure, Social Security cannot penalize for it.

Here are some other reasonable excuses:

• Intense and unrelenting fear of surgery.
• The treatment carries a high degree of risk because of the enormity or unusual nature of the procedure (e.g., organ transplant, open heart surgery).
• You are presently unable to work because of a condition for which major surgery was performed with unsuccessful results, and additional major surgery is prescribed for the same impairment.
• Even personal or third party knowledge of persons who did not improve, or perhaps worsened, following surgery similar to that recommended. However, this by itself may not be enough.
• The treatment recommended involves amputation of an extremity (e.g., amputation at or above the tarsal region).
• Any duly licensed treating medical source who has treated you advises against the treatment prescribed.
• Even the inability to self medicate because of a mental or physical impairment may constitute good cause.

Social Security has the burden on the issue of noncompliance. You must receive a full opportunity to provide specific reasons for noncompliance before benefits can be denied on that basis.

photo credit: preciouskhyatt

Your doctor’s opinion of your disability is critical evidence in your Social Security disability case. If your doctor does not believe in you, you and your lawyer are facing an uphill battle.

Chances are, Social Security either sent you to one of their doctors for a consultative examination, or had your medical records reviewed by a Social Security doctor. If Social Security denied your claim, their doctors probably did not think you were disabled.

So, here is the problem: if the Social Security doctor says you are not disabled and your doctor does not believe in your disability, you may not have the evidence you need to prove your case.

What can I do if my doctor does not support me?

Unless you can get your doctor to change his or her mind, you may need to get a new doctor as soon as possible. You may not be able to undo the damage done by your current doctor, but you can at least provide fresh evidence that supports your disability from the new doctor.

I do not advocate shopping for a more favorable medical opinion. However, if you and your lawyer think that your doctor is biased against you, or against anyone applying for disability benefits, don’t let them ruin your claim!

In Colorado the cost of medical records are based on the number of pages you get. This means getting your records can quickly get expensive. But, you do not have to request every single scrap of paper, phone message, or referral that was ever generated by your doctor’s office. If you want to, you certainly can. But, chances are you will be paying for records you do not really need.

One way to keep the costs of your case down is to limit the scope of the medical records you are requesting. You can do this in two ways: Limit the dates of service (how far back you want the records to go), or, limit the type of records requested.

So, what records do I need to get?

While I can give you some very general guidelines, there is a very good chance your case may fall into an exception. This is an area where good judgement becomes crucial!!!

Generally speaking, you want to get records about a year before the disability began, or a year before you filed for benefits. More recent records are usually more valuable than older records.

Some exceptions: if there was a significant accident, treatment or diagnosis before this one year period, you may want to get those records.

As far as types of records, records from specialists are generally more valuable than records from a primary care provider. But, you usually want to get records from both.

When my office requests records from a hospital, I usually tell the hospital not to provide medication logs or nurses notes as they can double or triple the number of pages, and thereby greatly increase the cost of the records.

Please note: you could reverse the information here and it still may be correct. Sometimes older records are more valuable than newer records and a family doctor’s records that go back for ten years may be more important than the records of a one time evaluation with a specialist. There are no hard and fast rules. In this area, it is all a matter of judgment.

It is vital to get regular medical treatment when you are appling for Social Security disability benefits. I have even seen Judges roll their eyes when a claimant says there are no doctors they can see.

But, I don’t have insurance and I can’t afford to see a doctor on a regular basis. What am I supposed to do?

I’ve gone through my savings.

I’ve asked my spouse, parents and other family members to help me get medical care.

I’ve already even applied for Medicaid.

What does the Judge want from me?

I know you feel exhausted and that you have run out of options. But, have you tried the following:

• You may have community health centers, public health units, and low or no-cost clinics in your area. 
• Your local Department of Human Services can often provide you with which clinic may be able to treat you at either a no-cost or reduced cost basis. Click on the link, enter your city and state into the search query for local information.
• Colorado offers the Colorado Indigent Care Program (CICP) which provides low cost medical care at many clinics and hospitals.

The Judges are aware of these programs.  If you tell the Judge that you can’t get medical care, but you have not looked in to these options, you may get an eye roll during your hearing.  

Unfortunately, navigating these programs is not simple, but your local Human Services office can help walk you through the steps to get you medical assistance.

I hear a number of reasons for not seeing a doctor on a regular basis: 

I don’t like going to the doctor.

I prefer herbal medicine.

I have a high threshold for pain.

When I hurt I just stay in bed.

This is unfortunate because regular and ongoing treatment is one of the foundations of building a Social Security case.

Why? Treatment generates medical records which do several things to build your disability case:

1. Medical records can establish a medically determinable impairment. Social Security regulations prevent approving a disability claim based on symptoms alone. Social Security requires a medically determinable impairment, basically, a diagnosis that is medically sound and which accounts for your symptoms. Medical records can help develop this medically determinable impairment requirement.
2. Medical records also provide a history of your complaints, diagnoses, treatment, and how you are responding to treatment. Beyond the evidentiary value, this also shows that you did not just make up your symptoms around the time you filed for benefits. Yes, this is a possibility Social Security considers. Medical records shows you have taken steps to treat your conditions.