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How Social Security Evaluates Fibromyalgia

Although many people manage symptoms of fibromyalgia, for others, it can be debilitating. Even under these circumstances, obtaining Social Security disability benefits for this condition is challenging. Understanding how the Social Security Administration (SSA) evaluates fibromyalgia can help claimants better prepare when filing a claim.

Establishing a Medically Determinable Impairment of Fibromyalgia

Fibromyalgia can affect people differently. The most common symptom, however, is widespread pain in the tendons, muscles and joints. It must be severe enough and meet the requirements of a medically determinable impairment (MDI).

There are two factors that must be present in order to qualify. The first is that the widespread pain has been a symptom for at least three months. The second is ruling out the possibility of another condition.

In addition to these factors, one of the following must be established:

  • tested positive in at least 11 of the 18 tender points; or
  • at least six other symptoms frequently occur (like fatigue, not feeling refreshed upon waking, anxiety, depression, irritable bowel syndrome and memory/cognitive problems).

How Fibromyalgia is Evaluated in a Disability Claim

SSA determines widespread pain when all quadrants of the body (above and below waist, along with both left and right side) and axial skeleton pain (lower back, cervical spine, thoracic spine or anterior chest) have been persistent for a minimum of three months. There may have been episodes where pain wasn’t present or it fluctuated.

The SSA also evaluates how other conditions have been ruled out. Because the symptoms of fibromyalgia mimic other mental and physical disorders, there must be evidence that shows it’s not something else. This might be demonstrated through a variety of lab tests and imaging.

When evaluating tender points, there are 18 that a doctor should test using digital palpation with a force of about nine pounds. These sites are located on both sides of the body.

The location of the 18 tender points a doctor will test includes:

  • base of skull (occiput);
  • back/side of neck (low cervical spine);
  • shoulder (trapezius muscle);
  • near shoulder blade (supraspinatus);
  • top of rib cage near breast bone/sternum (second rib);
  • outer aspect of elbow (lateral epicondyle);
  • top of buttock (gluteal);
  • below hip (greater trochanter); and
  • inner aspect of knee.

Documentation Necessary for a Fibromyalgia Disability Claim 

There must be enough medical evidence to support that fibromyalgia is an MDI. Although most of this evidence will come from a treating physician, it could be obtained by other medical sources — such as a psychologist.

Sometimes to evaluate the severity and functional effects of the condition, nonmedical sources will be called upon. This can further help SSA understand the impact the disability has had on an individual’s life, for instance, talking with an employer to learn how it interrupted the person’s ability to work.

If there isn’t enough evidence to help SSA determine eligibility, the SSA may request other records or information. Because these claims can get complex, legal representation may be necessary to help pursue a disability claim. Call Markhoff & Millman at 866-205-2415 to set up a consultation.

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