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January 21, 2018

Social Security Disability, Fibromyalgia

Fibromyalgia and Disability

by Jim Abernathy

Fibromyalgia is a legitimate medical condition that the Social Security Administration recognizes may be disabling.  According to Social Security's  rules, fibromyalgia is "a complex medical condition characterized primarily by widespread pain in the joints, muscles, tendons, or nearby soft tissues that has persisted for at least 3 months."  Further, the rule states that fibromyalgia "can be the basis for a finding of disability," but that to do so, it must be "established by appropriate medical evidence."

In years past, however, neither the medical community nor the Social Security Administration uniformly recognized the legitimacy of the condition.

Prior to 1990, and even for some time afterward, "fibromyalgia," "fibrositis" and "myofascial pain syndrome" were labels that doctors might use interchangeably when a patient reported  pain in multiple locations across their body that had no obvious physical explanation.  There was no general agreement in the medical community as to what the term "fibromyalgia"  meant, and some doctors  attributed the reported symptoms to various mental illnesses.   However, in February 1990, the American College of Rheumatology published diagnostic criteria that provided a more concrete method of diagnosing fibromyalgia.  Those criteria focused on "tender points" or specific places on the body that were extremely painful upon being pressed or touched.   Those criteria were revised in 2010 to describe the additional symptoms and other conditions that tend to go along with fibromyalgia.  Because of these criteria from the American Rheumatology Association, fibromyalgia does not carry the same uncertainty among medical professionals as it once did.

Likewise, prior to 1998, some Social Security Administrative Law Judges did not view fibromyalgia as a "medically determinable impairment" that could support a disability finding.  Those judges believed that a diagnosis of fibromyalgia was based upon reported symptoms, alone, without any means of verification.  However, on May 11. 1998, the Deputy Commissioner for Disability and Income Security Programs issued an official memorandum that stated "SSA has taken a definitive position that fibromyalgia and CFS [chronic fatigue syndrome] can constitute medically determinable impairments within the meaning of the statute."  In 2012, SSA published an official ruling that adopted both the 1990 American College of Rheumatology diagnostic criteria and the 2010 revised criteria.  Today, satisfying either set of criteria is enough to establish that a person has a "medically determinable impairment" of fibromyalgia. 

However, it is important to note that just because a doctor has made a diagnosis of fibromyalgia and that diagnosis appears in the doctor's medical records, that is not enough, by itself,  to satisfy SSA's requirements.  SSA must have documentation that shows that either the 1990 or the 2010 criteria have been satisfied.  Therefore, if a person has "tender points," then the doctor will need to document that those tender points are present, along with the locations where those tender points were found.  Additionally, if a person has "a history of widespread pain," then the doctor will need to document the details of where that pain has been located and how long the pain has lasted.  As the Social Security Ruling states, "a history of widespread pain" means:

pain in all quadrants of the body (the right and left sides of the body, both above and below the waist) and axial skeletal pain (the cervical spine, anterior chest, thoracic spine, or low back)—that has persisted (or that persisted) for at least 3 months.

Additionally, if the person has signs and symptoms or co-occuring conditions commonly associated with fibromyalgia, then the doctor will need to document them.  Those signs and symptoms include: 

fatigue, cognitive or memory problems (‘‘fibro fog’’), waking unrefreshed, depression, anxiety disorder,  irritable bowel syndrome, chronic fatigue syndrome, irritable bladder syndrome, interstitial cystitis, temporomandibular joint disorder, gastroesophageal reflux disorder,migraine, restless leg syndrome, muscle weakness, headache, pain or cramps in the abdomen, numbness or tingling, dizziness, insomnia, constipation, pain in the upper abdomen, nausea, nervousness, chest pain, blurred vision, fever, diarrhea, dry mouth, itching, wheezing, Raynaud’s phenomenon, hives or welts, ringing in the ears, vomiting, heartburn, oral ulcers, loss of taste, change in taste, seizures, dry eyes, shortness of breath, loss of appetite, rash, sun sensitivity, hearing difficulties, easy bruising, hair loss, frequent urination, or bladder spasms.

Finally, if other causes that would explain the symptoms have been ruled out, then the doctor needs to document that fact.   Ideally, the doctor would document the tests and methodologies that were used to exclude the other potential causes.