Claims based on back pain need to be credible and supported with strong medical evidence
Back pain is a generalized term for any pain that emanates from or to the spinal region. Back pain can be caused by natural deterioration in the spine typically due to aging, or from an accident or injury. There are three primary regions of the spine, the cervical region (around the neck area), the thoracic region (the middle of the back) and the lumbar region (the lower back). Medical problems associated with the back typically are identified by the region of the back in which the pain is most significant. Cervical symptoms often include neck pain, arm pain, shoulder pain, headaches, numbness or tingling in hands and arms, poor balance and other symptoms. Thoracic symptoms typically include rib and mid-back pain. Lumbar symptoms typically include low back pain, numbness or tingling in legs and feet, leg weakness, drop foot, and other symptoms. The causes of back pain are typically associated with conditions such as spinal disorders, disc herniation, spinal stenosis, degenerative disc disease, slipped discs, bone spurs, spondylosis, scoliosis, nerve root compression, osteoarthritis, and other conditions. As anyone who has lived with back pain knows, these conditions and symptoms can make day-to-day activities virtually impossible.
Does Social Security consider back pain to be disabling?
The short answer is, “It depends.” And it depends on many factors, most notably the severity of your symptoms, the effectiveness of treatment options, the strength of your medical evidence, your age, your education level and the type of work you have done. A tricky issue with disability claims based on back pain is that the underlying cause of the back pain is oftentimes not medically determinable. This means that the back pain cannot be attributed to a specific underlying medical condition, such as those listed above – it just hurts, but nobody knows why! Unfortunately, that is generally not enough to be found disabled as medical specificity and proof are required. So, back pain cases often come down to the strength of medical evidence found in radiological imaging, such as X-rays and MRIs that reasonably support the alleged limitations.
How exactly does Social Security evaluate a disability claim based on back pain?
Social Security employs a 5-step sequential evaluation process to determine if you qualify for disability benefits under the SSDI and/or SSI programs. At each phase of a disability claim, there is an adjudicator, or decision-maker. At the Initial Application and Reconsideration phases, the decision-maker is a DDS Examiner in consultation with a DDS Physician. At the Hearing phase, the decision-maker is the Administrative Law Judge who often consults with a Medical Expert (ME). The following evaluation is employed by the adjudicator at each phase.
Step 1: Non-Medical Criteria. First and foremost, you cannot be working above what Social Security calls a Substantial, Gainful Activity (SGA) level. Basically, you cannot be earning more than $1,090 on a gross (pre-tax) monthly basis. The SGA rule is the most important non-medical criteria, but there are other non-medical criteria that also must be satisfied in order for the claim to progress to a complete medical review at Step 2. No matter how severe and debilitating your back pain might be (even if it is well-supported by years of medical evidence), if you do not meet the non-medical eligibility requirements, your claim will be technically denied and will not advance to Step 2. You can appeal a technical denial, but generally speaking if the facts are correct, the appeal will be unsuccessful.
Step 2: Severe Impairment. The question at Step 2 is whether or not your symptoms are severe. To determine whether your impairments are severe, all medical evidence is assembled. If you have an Attorney or Non-Attorney Representative, they should be heavily involved in this process. The adjudicator can also request that you complete Activities of Daily Living and Vocational Questionnaires, which provide an opportunity for you to communicate how your symptoms have impacted your ability to function normally. The adjudicator may also schedule a Consultative Examination (CE) with a doctor who is contracted by DDS to perform medical evaluations on their behalf. Once all evidence has been assembled, the adjudicator reviews the information and decides whether or not your symptoms are severe. To be considered severe, the symptoms must limit your ability to perform basic work-like activities. Severity can take many forms, including physical limitations, such as limited ability to walk, stand, lift, push, carry things, etc. Severity can also encompass the inability to speak, hear, see, concentrate, follow basic instructions, get along with co-workers, etc. If your symptoms are determined to be severe, your claim progresses to Step 3, otherwise it is denied at Step 2 and you have the opportunity to appeal.
Step 3: Medical Listings. At Step 3, the question is whether your back pain meets or equals a medical “Listing.” Social Security has broken down the human body and mind into 14 different Impairment categories, called the Listing of Impairments. Back pain claims are typically evaluated under Listing 1.04 Disorders of the Spine, which is a subset of Listing 1.00 Musculoskeletal System impairments. Disability under Listing 1.04 requires at least one of the following: a herniated disc, spinal pain radiating throughout the body, nerve compression, osteoarthritis, degenerative disc disease, arthritis in the spinal joints or a fractured vertebra, resulting in compression of either a nerve root or the spinal cord. Each of these conditions must also cause nerve root compression and pain, limitation of motion of the spine, motor loss associated with muscle weakness, sensory or reflex loss, and a positive straight-leg raising test; or lumbar spinal stenosis, spinal pain causing a change in position or posture more than once every two hours, or compression of the lower (lumbar) spine causing chronic pain and preventing effective walking. Diagnosis and evaluation of these impairments must be supported by medical records from a treating physician, including X-rays, CAT scans, MRIs, myelograms and bone scans. If the adjudicator reviews your medical records and determines you meet a medical listing, you are found to be Disabled at Step 3 and you are eligible to receive disability benefits. If, however, you do not meet a medical listing, the claim proceeds to Step 4.
Step 4: Past Work. The objective of Step 4 is to determine whether you have the ability to perform work you have performed previously. To determine this, the adjudicator determines your Residual Functional Capacity (RFC). Your RFC identifies what your body and mind can still do after considering your medical symptoms. In developing your RFC, the adjudicator will consider all impairments and symptoms, including mental and physical. The adjudicator will estimate your ability to perform such functions as sitting, standing, walking, lifting, carrying, pushing, pulling, reaching, handling, stooping, crouching, remembering, understanding, etc. Your RFC might contain some of the following limitations: inability to stand and walk for greater than 4 hours total out of an 8 hour workday, inability to sit for longer than 2 hours, inability to lift and carry more than 10 pounds, inability to climb ropes or ladders, etc.
Once the adjudicator has developed your RFC, they will then list your Past Relevant Work (PRW), which is any job you performed during the 15 year period immediately preceding the Alleged Onset Date (AOD) of your disability. In general, if there is a job that you performed within 15 years of your AOD in which you worked close to full-time for a period of at least a few months, that job will likely be considered Past Relevant Work.
After finalizing your list of Past Relevant Work, the adjudicator must now classify it. The type of work you have done in the past will be classified by both exertional level and by skill level. For example, a Nurse works at the Medium exertional level and the position is considered Skilled, while a Security Guard works at the Light exertional level and the position is considered Semi-Skilled. Once all of your PRW has been classified, the adjudicator must then determine whether you have the functional ability to perform any of your past work. For example, if the Security Guard’s back pain prevents him or her from being able to stand and walk as is required for jobs at the Light exertional level, he or she would be unable to perform Security Guard work due to the limitations found in the RFC and the claim would advance to Step 5. If, on the other hand, the adjudicator determines you can still perform the functions required in your past work, you will be found Not Disabled and denied. You would then have the opportunity to appeal this denial.
Step 5: Other Work. Step 5 considers whether you can perform any other type of work, even if you have not performed it in the past. The adjudicator utilizes the same Residual Functional Capacity (RFC) developed in Step 4, and also considers your Age, Education, and Work Experience.
To start, Social Security classifies your Education level as follows:
• Illiterate (or unable to communicate in English)
• Marginal (generally 6th grade or less)
• Limited (generally 7th through 11th grades)
• High school (and above)
The Education level is important as it affects the skill level of different jobs that you might be able to perform. For example, if you have a Marginal education, then you would be limited to performing Unskilled jobs, but if you have a High school education then you would be expected to be able to perform both Semi-Skilled and Skilled jobs.
The adjudicator will then consider the next factor, Work Experience. Work Experience means any skills and abilities that you acquired from your past work. The fact that you are now at Step 5 means that the adjudicator determined at Step 4 that you can no longer perform your past work. However, the adjudicator will consider whether any of the skills and abilities you learned from your past work would transfer to a different job. For example, a Nurse who performed her job at the Medium exertional level and who can no longer perform her past work due to back pain might have acquired skills which would transfer to a position as a Medical Assistant, a job which she could perform at the Light exertional level.
Finally, the adjudicator will consider the last factor, Age. Social Security evaluates adults in several Age categories:
• Younger (ages 18-49)
• Closely approaching advanced age (ages 50-54)
• Advanced age (ages 55-59)
• Closely approaching retirement age (ages 60+)
While Younger individuals have the burden of proving they are unable to perform any type of work, the burden is lessened in the more advanced age categories. Social Security refers to this premise as the Medical-Vocational Guidelines, or the “Grid Rules” because the key factors are laid out in a grid with the final column being a determination of either Disabled or Not Disabled. Basically, the older, less educated and the fewer transferable skills you acquired in your past work, the more likely you are to be found Disabled.
If the adjudicator determines you can perform some other type of work, based on your age, education, and prior work experience, you would be found Not Disabled and denied. You would have the opportunity to appeal this denial. If, however, the adjudicator determines you cannot perform any other type of work, you would be found Disabled and approved for disability benefits at Step 5.
Conclusion: Will my disability claim be approved?
Social Security disability claims based on back pain are never easy to get approved. They require expert understanding of the above evaluation process, as well as compelling medical evidence. If the medical evidence does not support the alleged severity, the claimant is often found to be less than credible and denied. If you would like to discuss the specifics of your case with a disability expert now, please contact us. We will do everything possible to get your claim approved.