article Medical Information and SSA Disability Criteria

SSA Disability Criteria

This article reviews SSA's definition of disability, which differs from a medical definition. It is focused on a person's ability to work so that s/he can earn SGA despite limitations.

It is very important for you to keep SSA's definition of disability in mind as you work with an applicant. Understanding SSA disability criteria helps the SOAR case manager assess the documentation necessary to support the claim of disability. 

• SSA’s definition of disability differs from a solely medical definition in that it encompasses the person’s ability to work at SGA despite limitations
• Under SSA rules, “an adult is disabled if he or she is:
  • unable to do any substantial gainful activity by reason of...
  • any medically determinable physical or mental impairment...
  • which can be expected to last or has lasted for a continuous period of not less than 12 months or is expected to result in death" 

Substantial Gainful Activity (SGA)

• The inability to earn SGA (set annually by SSA).

Significant Functional Impairment

For a person to qualify for SSA disability benefits due to a mental illness, the application must provide information illustrating significant functional impairment clearly tied to the person’s diagnosis.

• DDS assesses limitations in four areas of mental functioning:
  • Understand, remember, or apply information
  • Interact with others
  • Concentrate, persist, or maintain pace
  • Adapt or manage oneself

For a person to qualify due to a physical impairment, the application must demonstrate significant limitations in meeting the physical, mental, sensory and other requirements of work. A limited ability to perform certain physical demands of work activity (e.g. sitting, standing, walking, lifting, carrying, etc.) may reduce your ability to do past work and other work.

Medically Determinable Physical and/or Mental Impairment

What is a "Medically Determinable Impairment"?

A medically determinable physical or mental impairment is an impairment that results from anatomical, physiological, or psychological abnormalities which can be shown by medically acceptable clinical and laboratory diagnostic techniques. A physical or mental impairment must be established by medical evidence consisting of signs, symptoms, and laboratory findings-not only by the individual's statement of symptoms.

The Listing of Impairments

The severity of the illness(es)/condition(s) must meet or be equivalent to the criteria, or requirements, of a medical condition(s)

• This is generally referred to as “The Listings” or “The Blue Book,” and can be accessed on the Social Security Administration's Medical/Professional Relations page.
• The Listings are categorized by body system (i.e., cardiovascular, musculoskeletal, mental)
• The Listings are separate for adults and children
• They are updated to reflect advancements in treatment, prognosis, and recovery

Diagnoses

Disability can be based on impairments from one or a combination of illnesses. If a person has a serious mental illness and physical health issues, the combination may meet the disability criteria.

• Note that the mental disorders in The Listings are presented differently from the disorders listed in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), published by the American Psychiatric Association (APA) and the International Statistical Classification of Diseases and Related Health Problems (ICD-10).
• The Listings include severity criteria for each disorder
• These criteria describe impairment-related functional limitations that are incompatible with the ability to work at SGA
• For more information about working with someone with HIV/AIDS see this additional guidance

Documentation

The diagnosis must be documented in medical records, laboratory reports, or other clinical findings of an Acceptable Medical Source (AMS).

• An AMS may be a:
  • Doctor (MD/DO/PhD/EdD/PsyD)
  • Advanced Practice Registered Nurse (APRN), which includes: Certified Nurse Midwife, Nurse Practitioner, Certified Registered Nurse Anesthetist, and Clinical Nurse Specialist
  • Physician Assistant
  • Audiologist
• DDS prefers that medical evidence come from an ongoing treatment provider
• DDS reviews the documentation for the severity of the illness

Duration

SSA’s Definition of Duration

The impairment tied to the illness(es) must have “lasted or be expected to last 12 months or more or result in death." SSA does not cover “short-term” disability.