What Process Does Social Security Use To Evaluate Disability Claims?
Social Security uses a 5-Step sequential evaluation process to determine if your SSDI or SSI claim will be approved
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 who works 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 $1,350 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 medical conditions may (even if well-supported by years of medical evidence), if you do not meet the non-medical eligibility requirements, your claim will not advance to Step 2 and your claim will be technically denied. 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 impairments are severe. To determine whether your impairments are severe, all medical evidence is assembled. At any phase in the process, the adjudicator can request that you complete Activities of Daily Living and Vocational Questionnaires, which provide an opportunity 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 impairment 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. The specific listing under which your claim will be evaluated is dependent upon which type of impairment you have. For example, if it is a breathing-related impairment, it would be evaluated under Listing 3.00 Respiratory System, but if it was an immunological impairment, it would be evaluated under Listing 14.00 Immune System Disorders. 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, and including severe and non-severe impairments. 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, inability to maintain concentration, persistence or pace, 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 impairments prevent 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 you 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 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.
All Adjudicators Use the Same 5-Step Sequential Evaluation
Whether your claim is at the Initial Application phase, the Reconsideration phase or the Hearing phase, the person who is making the determination regarding whether you are disabled will use the same 5-step sequential evaluation listed above. The key is presenting your claim in a manner that allows them to approve it at either step 3, 4, or 5 of the evaluation. If you would like assistance getting your claim approved, please contact us now to get started.
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