Gout is a type of arthritis caused by uric acid build up
Gout is a type of arthritis that causes burning pain, stiffness, and swelling in a specific joint. In more than 50% of cases, the gout is localized to the big toe, but it can also affect your foot, ankle, knees or other joints. Gout is a result of having too much uric acid in the bloodstream. The uric acid forms crystals that affect your joints, tendons and other areas of the body. If left untreated, gout can result in disabling symptoms, including severe joint damage and reduction in range of motion. Gout is more likely to affect men than women and people with kidney disease, diabetes, obesity and who consume significant quantities of alcohol are at the greatest risk of developing gout.
Will Social Security approve my disability claim based on gout?
Your claim must be well-presented and articulated to Social Security in order to get approved. To determine whether you meet their definition of being disabled, Social Security relies on a complex formula that assesses 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. To be approved, your gout symptoms must be well supported by medical evidence, ideally including synovial fluid analysis (which tests your uric acid levels around the joint) and imaging results, such as MRIs, X rays or CT scans. The more medical treatment you receive, the more credibility your claim will have, and the better chance of getting approved.
How Does SSA Determine If My Gout Is Disabling?
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 Disability Determination Service (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 rheumatoid arthritis may be, if you do not meet the non-medical eligibility requirements, your claim will not advance to Step 2; instead, you will receive a technical denial, which has very little chance of being successfully appealed.
Step 2: Severe Impairment. The question at Step 2 is simply, “Are your conditions severe?” To answer this question, 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 gout 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 non-severe, your claim will be denied at Step 3 and you would have the opportunity to appeal this denial. However, if the conditions are determined to be severe, your claim progresses to Step 3 for further analysis.
Step 3: Medical Listings. At Step 3, the question is whether your gout 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. Gout claims are evaluated under Listing 1.03 Major Dysfunction of a Joint. Disability under Listing 1.03 requires at least one of these conditions: a dislocation, shortening of a muscle or joint, stiffening or immobility of a joint, instability, chronic joint pain and stiffness with limitation of motion, other abnormal motion of the affected joint(s), joint space narrowing or bony destruction. Each of these conditions must also involve a problem with a hip, knee, or ankle that prevents you normal walking, or a shoulder, elbow, wrist or hand that prevents arm or hand movement, or picking up or holding an object.
Rheumatoid arthritis can also be evaluated under Listing 14.09 Inflammatory Arthritis, which is among the most complex Listings for Social Security to evaluate. Disability under this listing requires persistent inflammation or persistent deformity of: One or more major peripheral weight-bearing joints resulting in the inability to ambulate effectively; One or more major peripheral joints in each upper extremity resulting in the inability to perform fine and gross movements effectively; or inflammation or deformity in one or more major peripheral joints with: involvement of two or more organs/body systems with one of the organs/body systems involved to at least a moderate level of severity; and at least two of the constitutional symptoms or signs (severe fatigue, fever, malaise, or involuntary weight loss). The claim can also meet this listing with repeated manifestations of inflammatory arthritis, with at least two of the constitutional symptoms or signs (severe fatigue, fever, malaise, or involuntary weight loss) and one of the following at the marked level: limitation of activities of daily living; limitation in maintaining social functioning; limitation in completing tasks in a timely manner due to deficiencies in concentration, persistence, or pace.
Diagnosis and evaluation of these impairments must be supported by medical records from a treating physician, ideally including X-rays, CT scans, MRIs, as well as tests that measure uric level acid in the blood. If the adjudicator reviews your medical evidence 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 for further analysis.
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 what you are capable of doing, the adjudicator develops your Residual Functional Capacity (RFC). Your RFC identifies what your body and mind can still do after considering all of your medical 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 – and your medical records will need to prove you can no longer perform this job.
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. If the adjudicator determines you can still perform the functions required in you past work, you will be found Not Disabled and denied. You would then have the opportunity to appeal this denial. However, if you cannot perform your prior work, the analysis proceeds to Step 5. For example, if the Security Guard’s rheumatoid arthritis 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.
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 your Work Experience, specifically any skills and abilities you acquired from your past work. The fact that you are now at Step 5 means 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 gout might have acquired skills which would transfer to a Medical Assistant position, 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. It is difficult to get claims approved for gout if you are a Younger individual, because oftentimes the adjudicator will conclude you are able to perform a sit down or sedentary job, such as telemarketing or assembly work.
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 Based on Gout Be Approved?
Social Security disability claims based on gout require expert understanding of the above process and presentation of medical evidence in a manner that will enable Social Security to understand it and evaluate it properly. 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.