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Disability Benefits for Fibromyalgia

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Social Security Disability Lawyers: Riverside, San Bernardino & Orange County

Disability Benefits for Fibromyalgia

On the one hand, it may be more difficult to get long-term Social Security Disability benefits for a diagnosis of fibromyalgia, because in fibromyalgia, there are often no objective diagnostic tests, including lab tests, x-rays, or imaging studies (e.g. MRI), that confirm the diagnosis of fibromyalgia. [But, see: p. 2, paragraph 6, below.] Social Security may therefore take the position that because there are no “objective' abnormal findings, the medical records don't “prove” you have fibromyalgia or that your fibromyalgia pain is “real.”
 
How then can you can “prove” to Social Security that you have fibromyalgia and that your fibromyalgia pain is “real?” Before we talk about that, it may be helpful to first review the “causes” of fibromyalgia and how it is diagnosed.
 
What Causes Fibromyalgia?


The actual cause of fibromyalgia is not known. Several theories have been proposed, but they are only theories. Since there is no known cause, it stands to reason that there is also no known cure for fibromyalgia. (If you think about it, it's difficult to cure something without first knowing its cause.)
 
The most commonly proposed theories as to how people develop fibromyalgia include the following:

  • Fibromyalgia may be a disorder in the brain and spinal cord (“central nervous system”) that affects how nerves carry pain impulses.
  • Repetitive injuries to muscles and nerves may lead to fibromyalgia.
  • Discrete trauma, which may be physical or emotional, may trigger fibromyalgia.
  • Rheumatoid arthritis and other autoimmune disorders, such as lupus may lead to the development of fibromyalgia.
  • Genetic factors, that control the way we process painful stimuli, may be associated with fibromyalgia.
  • Fibromyalgia may be caused by an imbalance in levels of neurotransmitters, such as serotonin, Substance-P, and others.

 
What Are the Symptoms of Fibromyalgia


The most frequent symptom of fibromyalgia is persistent, recurrent, and widespread soft-tissue musculoskeletal pain and aching, involving sometimes the whole body. The pain is internally felt, and typically there is little to see externally in a fibromyalgia patient.
 
Other symptoms of fibromyalgia may include insomnia, lack of restorative or “restful” sleep, headaches (including migraines), chronic and excessive fatigue, depression, difficulty concentrating, maintaining focus, or having memory lapses (“fibro fog”), irritable bowel symptoms, and bladder irritation.
 
How Fibromyalgia Is Diagnosed
 
There are new diagnostic criteria for fibromyalgia, that were initially formulated in 2010 (and revised in 2016), that are now being used to diagnose fibromyalgia. The traditional way of diagnosing fibromyalgia has been to use criteria set forth by the American College of Rheumatology (ACR) in 1990, which were based on the presence of at least 11 out of 18 “trigger points” or “tender points.” Previously, tender “trigger” points were the most important finding that Social Security looked for and doctors used to diagnose fibromyalgia. However, trigger points are no longer recommended by the ACR in the diagnosis of fibromyalgia, because they tend to come and go, and the ACR has determined that they are not reliable.
 
The ACR has revised its Diagnostic Criteria for fibromyalgia, by removing “trigger points” from the new criteria, which now include:

  • Widespread pain index (WPI) ≥7
  • Symptom severity (SS) scale score ≥5 or WPI 3 - 6
  • SS scale score ≥9
  • Absence of another disorder that would otherwise explain the pain

 
Even though trigger points are no longer used by the ACR and by many doctors in diagnosing fibromyalgia, Social Security has not “caught up” with the new medical criteria for fibromyalgia, and in its evaluation process, including a hearing before the Administrative Law Judge, Social Security continues to use the presence or absence of trigger points as an “important” diagnostic feature.
 
If you can get your doctor to diagnose your fibromyalgia by applying both the old and the new diagnostic criteria, that may be helpful to get you through the Social Security process and will show the ALJ that your doctor really understands fibromyalgia.
 
There Is a New Blood Test to Diagnose Fibromyalgia
 
Some doctors believe that fibromyalgia can now be diagnosed with the help of a new, objective blood test, called the FM/a test. The FM/a test analyzes a patient's blood for abnormalities in “cytokines,” which are produced by the immune system. Patients with fibromyalgia have a significantly different pattern of cytokine production, which helps to differentiate fibromyalgia from other autoimmune disorders, such as rheumatoid arthritis, lupus erythematosus, and others.
 
The FM/a test is approved by Medicare and other insurance carriers. It's an objective test that may help confirm the diagnosis of fibromyalgia, which in the past has not had an objective diagnostic test to rely on.
 
Ten Tips to Help You Get Disability Benefits
 
If you suffer from fibromyalgia and are unable to work, the following ten “tips” or guidelines will help you get Social Security disability benefits.
 
1.)        Get a Diagnosis


Your doctor must diagnose, and document, in your medical records, that you suffer from fibromyalgia. This can be a little tricky, because there are ‘old' and ‘new' diagnostic criteria. Your doctor should document that you fulfill at least the ‘old' criteria (that rely on trigger points) for the diagnosis of fibromyalgia. If you can, get the doctor to confirm your diagnosis by the ‘new' criteria as well, and ask him to do the new FM/a blood test for fibromyalgia.
 
Get as much objective documentation of fibromyalgia as you can, which will help convince Social Security that your diagnosis and your symptoms are “real.”
 
2.)        Document Your Pain


In the medical records, your doctor must consistently document that you are suffering from disabling musculoskeletal pain and how it impairs your ability to sit, stand, walk, lift and carry. [See: paragraph 6, below.] Your doctor will do that only if, every time you see him, you tell him that you are having pain and describe to him how it affects your ability to function.
 
3.)        Document Impaired Function
           

In the medical records, your doctor must document more than the fact that you have fibromyalgia pain, because Social Security needs to know how your fibromyalgia pain affects your ability to work and function. To do that, Social Security requires answers to specific questions. [See: paragraph 5, below.] From the answers to these questions, Social Security decides how much work you can do, if any. This is called your “Residual Functional Capacity,” or “RFC.”
 
How your doctor answers these questions, may determine whether you get disability benefits.
 
In addition to pain, if you suffer from some of the other manifestations of fibromyalgia, such as an inability to focus and concentrate (“fibro fog”), chronic fatigue, abdominal pain, or bladder problems, have your doctor document those symptoms as well, and how they impair your ability to function.
 
4.)        Questions That Prove Impaired Function
             

Social Security decides how disabled you are by asking your doctor to answer how your fibromyalgia pain (and other symptoms) impairs your ability to sit, stand, walk, lift, and carry. The answers to these questions will be used by Social Security to determine whether you can do sedentary, light, moderate, or heavy work.
 
5.)        Less Than Sedentary
           

Although the Social Security disability rules are very complicated, the bottom line is that the odds of getting a disability award from Social Security will be much better if your doctor can document your ability to work is “less than sedentary.”

Social Security's definition of “less than sedentary” is that the most you can:

  • Lift or carry, is less than 10 pounds
  • Walk or stand, is less than 2 hours 
  • Sit, is less than 6 hours

In other words, out of an 8-hour workday, this means that your fibromyalgia requires you to rest, by lying down, more than 2 hours every day.

If your doctor documents these specific functional limitations, this means to Social Security that your fibromyalgia pain (and other symptoms) makes you unable to do even a desk job (“less than sedentary”), and your chances of getting a disability award will be greatly increased. 

6.)        Tell Your Doctor

You must tell your doctor at each office visit how much fibromyalgia pain, fatigue, or “fibro fog” you have, how many hours you must lie down during the day to rest, and how your pain and other symptoms impairs your ability to sit, stand, walk, lift, or carry.

7.)        Your Doctor's Opinion Needs Support


With fibromyalgia, there may not be much “objective” support for your doctor's diagnosis of fibromyalgia and for his opinions as to how disabled you are. Remember, laboratory tests, x-rays, and imaging studies are typically not significantly abnormal in fibromyalgia.

That is why it is especially important for your doctor to document in the medical records that you meet at least the “old” diagnostic criteria (with trigger points) for fibromyalgia, as well as the “new” criteria, and for your doctor to consider performing the new FM/a blood test, as objective evidence of fibromyalgia.

8.)        Be Consistent in Reporting Your Pain and Other Symptoms to Your Doctor


In getting disability benefits, you must do your part. Be consistent in describing your symptoms to the doctor, each time you are there in the office. Explain to the doctor not only what your symptoms are (e.g., musculoskeletal pain, chronic fatigue, inability to concentrate [“fibro fog”]), but how your symptoms impair your ability to do even a desk job, and how many hours a day you must lie down to rest.

Your doctor is not going to know this unless you tell him.

9.)        Find a Good Doctor
           

Your doctor should be a doctor that believes in and understands fibromyalgia. (Not all doctors do.) He should be knowledgeable and willing to work with you to help you get the Social Security disability benefits that you deserve.

SSA utilizes the term "Impairments" (and resulting "limitations" - why you cannot work) are the essential bits of information that must be clearly and consistently documented throughout your medical history by the treating sources (medical doctors, psychologists, psychiatrists).

SSA additionally utilizes the term "Residual Functional Capacity" (RFC); this is a key concept related to the resulting physical and/or mental impairments from conditions for which the disability claim is based upon and the impact upon ability to work. 

SSA has its own forms that are used for Physical RFC here and for Mental RFC here. These forms can be filled out by the treating source who has the opportunity to examine the patient and understand the limitations which result from his/her condition and thereby document with specificity in the language of SSA disability.


Conclusion

Getting disability benefits for fibromyalgia is not a simple matter. It requires careful and consistent documentation by your doctor of not only your symptoms, but how they impair your ability to function.

Whether you qualify for disability may depend on your age, educational level, prior work history, transferrable skills, and other factors. However, if your fibromyalgia prevents you from doing even a desk job (“less than sedentary”), and your doctor has consistently documented your diagnosis of fibromyalgia and your functional impairments, then your chances of getting a Social Security disability award will be much better.

Fibromyalgia Informational Resources

Mayo Clinic
https://www.mayoclinic.org/diseases-conditions/fibromyalgia/symptoms-causes/syc-20354780

FM/a Test for Fibromyalgia
https://www.fmcpaware.org/fm-a-real-medical-disease

American College of Rheumatology (ACR)
https://www.rheumatology.org/I-Am-A/Patient-Caregiver/Diseases-Conditions/Fibromyalgia

SSA utilizes the term "Impairments" (and resulting "limitations" - why you cannot work) are the essential bits of information that must be clearly and consistently documented throughout your medical history by the treating sources (medical doctors, psychologists, psychiatrists).

SSA additionally utilizes the term "Residual Functional Capacity" (RFC); this is a key concept related to the resulting physical and/or mental impairments from conditions for which the disability claim is based upon and the impact upon ability to work. 

SSA has its own forms that are used for Physical RFC here. These forms can be filled out by the treating source who has the opportunity to examine the patient and understand the limitations which result from his/her condition and thereby document with specificity in the language of SSA disability.

Your disablity lawyer must work closely with your treating physician to get the proper documentation of your specific findings and impairments into the medical records. At Law Med that's what we do.

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