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Understanding Arthritis

and Social Security Disability Benefits

Eligibility

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Arthritis can greatly affect your ability to carry out daily activities, especially when the condition is severe. To increase your chances of securing Social Security Disability Insurance (SSDI) for arthritis, it’s crucial to understand the eligibility requirements, including the medical documentation and symptom severity needed to support your claim.

Successfully applying for SSDI or Supplemental Security Income (SSI) requires demonstrating that your arthritis qualifies as a “severe impairment” that prevents you from working. This guide offers a simplified overview for those considering an SSDI claim due to arthritis. However, it should not replace the SSA’s Blue Book, which provides detailed and up-to-date information. For the most comprehensive guidelines and the latest updates, please consult the SSA’s Blue Book.

Table of Contents

What is arthritis?

Arthritis involves the inflammation and sensitivity of one or more joints, leading to discomfort and stiffness, which generally become more severe with age. The two most prevalent forms of this condition are osteoarthritis and rheumatoid arthritis (RA). As the leading cause of disability in the country, arthritis impacts almost 60 million adults and numerous children. With over 100 variations and related conditions, arthritis affects joints and can harm other organs.

RA patients often face significant financial burdens, with medication costs reaching up to $30,000 annually. Despite health insurance covering part of the costs, patients might still pay out of pocket for up to 30% of their drugs. For example, Disease-Modifying Antirheumatic Drugs (DMARDs) cost between $1,500 and $2,000 per year, while biologics, a newer RA treatment administered by healthcare professionals, can cost $1,300 to $3,000 per month.

If medications aren’t sufficient, surgery may be required, such as joint replacements or arthroscopic surgeries, which can cost tens of thousands of dollars. The average cost for an inpatient knee replacement is approximately $30,249. Post-surgery expenses, including physical therapy, assistive devices, and additional medications, further add to the financial strain. Moreover, therapy to cope with the emotional impact of chronic disease and complementary therapies like acupuncture can also increase costs. Beyond medical expenses, RA can lead to lost productivity and wages, with the Rheumatoid Arthritis Support Network estimating annual costs from $1,500 to $22,000 per patient due to low productivity, absenteeism, and lost wages.

Does Your Arthritis Qualify You For Social Security Disability Benefits (SSDI)?

The Social Security Administration (SSA) recognizes certain forms of arthritis as disabling under its Blue Book. Specifically, rheumatoid arthritis is listed under Section 14.09, Inflammatory Arthritis. To qualify, your condition must be advanced, demonstrating that you cannot consistently perform any type of work. The severity of your condition must significantly limit your ability to perform basic work activities such as walking, standing, sitting, lifting, pushing, pulling, reaching, carrying, or handling. It also includes limitations in seeing, hearing, and speaking, as well as understanding, carrying out, and remembering simple instructions. Furthermore, you must show difficulty in responding appropriately to supervision, co-workers, and work situations, and dealing with changes in a routine work setting.

When evaluating disorders of the skeletal spine that compromise nerve roots, such as herniated nucleus pulposus, spinal osteoarthritis (spondylosis), vertebral slippage (spondylolisthesis), degenerative disc disease, facet arthritis, and vertebral fracture or dislocation, the SSA considers how these conditions affect the cervical or lumbar spine. You may be eligible for SSDI Disability benefits if these abnormalities compromise the nerve roots, leading to cervical or lumbar spine dysfunction, or both. Spinal nerve disorders originating in the nervous system, like spinal arachnoiditis, are evaluated under the neurological disorders body system, Section 11.00.

To qualify for SSDI benefits for arthritis, you must provide evidence that you are unable to engage in Substantial Gainful Activity (SGA). Additionally, you need a substantial work history, proving that you have paid into the Social Security system over time.

How the Social Security Administration (SSA) classifies arthritis

The Social Security Administration (SSA) categorizes many types of inflammatory arthritis as immune system disorders. They assess whether you experience difficulties walking or moving your joints, or if you suffer from joint pain, swelling, and tenderness.

If your inflammatory arthritis affects your axial spine (such as psoriatic arthritis) or your peripheral joints (like rheumatoid arthritis and psoriatic arthritis), you may qualify for disability. To do so, you must demonstrate to the SSA that your condition prevents you from working.

Disability for osteoarthritis, spine osteoarthritis, and facet arthritis

The SSA classifies various types of arthritis under its listings for musculoskeletal disorders. Conditions where the skeletal spine exerts pressure on a nerve root, such as facet arthritis, or causes abnormalities in a major joint in the upper or lower body, like osteoarthritis, can qualify as musculoskeletal conditions eligible for disability benefits.

Osteoarthritis

Osteoarthritis, the most common form of arthritis, affects millions globally. It occurs when the protective cartilage at the ends of bones wears down over time. This condition commonly affects joints in the hands, knees, hips, and spine.

Musculoskeletal Disorders

The SSA evaluates musculoskeletal disorders, including:

  • Herniated Nucleus Pulposus

  • Spinal Osteoarthritis (Spondylosis)

  • Vertebral Slippage (Spondylolisthesis)

  • Degenerative Disc Disease

  • Facet Arthritis

  • Vertebral Fracture or Dislocation

These spinal disorders can lead to cervical or lumbar spine dysfunction when abnormalities compromise the nerve roots in these areas. Spinal cord disorders originating in the nervous system, such as spinal arachnoiditis, are evaluated under the neurological disorders body system, Section 11.00.

Systemic Lupus Erythematosus (SLE)

SLE is another condition listed under Immune System Disorders in the SSA’s Blue Book.

Major Dysfunction of a Joint(s)

For arthritis to qualify for disability under the SSA guidelines, it must result in significant joint dysfunction characterized by:

  • Gross anatomical deformity (e.g., subluxation, contracture, bony or fibrous ankylosis, instability)

  • Chronic joint pain and stiffness with limited or abnormal motion

  • Medically acceptable imaging showing joint space narrowing, bony destruction, or ankylosis

Additional criteria include:

  • Involvement of a major peripheral weight-bearing joint (hip, knee, ankle) resulting in an inability to walk effectively

  • Involvement of a major peripheral joint in each upper extremity (shoulder, elbow, wrist-hand) leading to an inability to perform fine and gross movements effectively

  • Reconstructive surgery or surgical arthrodesis of a major weight-bearing joint, where effective ambulation did not resume within 12 months of onset

Disorders of the Spine

Spinal conditions such as herniated nucleus pulposus, spinal arachnoiditis, spinal stenosis, osteoarthritis, degenerative disc disease, facet arthritis, and vertebral fractures can qualify if they compromise a nerve root or the spinal cord. Criteria include:

  • Evidence of nerve root compression with neuro-anatomic pain distribution, spinal motion limitation, motor loss (muscle atrophy or weakness), sensory or reflex loss, and a positive straight-leg raising test (if involving the lower back)

  • Spinal arachnoiditis confirmed by operative notes, pathology reports, or medically acceptable imaging, resulting in severe burning or painful dysesthesia requiring frequent changes in position

  • Lumbar spinal stenosis resulting in pseudoclaudication, confirmed by imaging, with chronic non-radicular pain and weakness, leading to an inability to walk effectively

Disability for inflammatory arthritis, rheumatoid arthritis, psoriatic arthritis, gout, pseudogout, and psoriatic arthritis

The SSA recognizes various types of inflammatory arthritis, including rheumatoid arthritis, psoriatic arthritis, gout, and pseudogout, as immune system disorders. They assess whether you have difficulty walking or moving your joints, or suffer from joint pain, swelling, and tenderness.

According to the SSA’s Blue Book, Section 14.09 on Inflammatory Arthritis, you may qualify for disability benefits if your condition meets specific criteria:

A. Persistent Inflammation or Deformity

  1. Lower Extremities:
    • One or more major peripheral joints in a lower extremity with medical documentation of at least one of the following:
      • Documented need for a walker, bilateral canes, crutches, or a wheeled mobility device requiring the use of both hands.
      • Inability to use one upper extremity to perform fine and gross movements, with a documented need for a one-handed assistive device or a wheeled mobility device requiring one hand.
  2. Upper Extremities:
    • One or more major peripheral joints in each upper extremity with medical documentation of the inability to use both upper extremities to perform fine and gross movements independently.

B. Inflammation or Deformity in Major Joints

Involvement of one or more major joints in an upper or lower extremity with:

    1. Two or more organs/body systems are involved, with at least one at a moderate level of severity.
    2. At least two constitutional symptoms or signs, such as severe fatigue, fever, malaise, or involuntary weight loss.

C. Ankylosing Spondylitis or Other Spondyloarthropathies

Spinal Ankylosis:

    • Fixation of the dorsolumbar or cervical spine, shown by medically acceptable imaging and measured at 45° or more of flexion from the vertical position.
    • Fixation of the dorsolumbar or cervical spine, shown by medically acceptable imaging and measured at 30° to 45° of flexion, with two or more organs/body systems involved at a moderate level of severity.

D. Repeated Manifestations of Inflammatory Arthritis

At least two constitutional symptoms or signs, such as severe fatigue, fever, malaise, or involuntary weight loss, with one of the following at a marked level:

    1. Limitation of daily living activities.
    2. Limitation in maintaining social functioning.
    3. Limitation in completing tasks due to deficiencies in concentration, persistence, or pace.

For detailed criteria and further information, you can refer to the SSA’s Blue Book.

Keeping thorough records of your symptoms, medical treatments, and how arthritis impacts your daily life and ability to work is crucial for your disability claim.

Social Security 5-Step Process for Determining SSDI Benefits Eligibility

The SSA uses a 5-step process to determine eligibility for disability benefits. Here’s how it applies to arthritis:

  1. Whether You’ve Worked Since Developing a Disability:

    • The SSA first checks if you are working and earning above a certain amount. If you are, you may not qualify as disabled under their rules.

  2. Severe Medical Impairments:

    • The SSA evaluates if your arthritis is a severe medical impairment that significantly limits your ability to perform basic work activities. Joint pain alone may not be sufficient; they need additional information.

  3. Meeting a Medical Listing:

    • Arthritis must meet the criteria specified in the SSA’s Blue Book listings for musculoskeletal disorders. This includes:

      • How arthritis was diagnosed, including doctor’s notes, physical exam findings, and test results.

      • How arthritis limits your ability to work and perform certain activities.

      • The severity and duration of arthritis.

      • The use of assistive devices, such as a cane or walker.

      • Any surgeries you’ve undergone, with operative reports from surgeons.

      • Your response to various treatments, such as medications and physical therapy.

  4. Ability to Perform Past Work:

    • The SSA assesses whether you can still perform your past work despite your arthritis. If you can, you may not be considered disabled.

  5. Ability to Perform Other Work:

    • If you cannot perform your past work, the SSA evaluates if you can adjust to other types of work considering your age, education, work experience, and the limitations imposed by your arthritis.

How to prove arthritis for SSDI disability benefits

To qualify for Social Security Disability Insurance (SSDI) due to arthritis, you must provide compelling evidence showing how your condition limits your work capabilities. Here’s a detailed guide on what you need to prove and the required medical evidence:

Demonstrating Loss of Work Capabilities

You need to illustrate how arthritis has severely impacted your ability to work. Many individuals with rheumatoid arthritis (RA) can continue working for years post-diagnosis, so it’s crucial to demonstrate that your condition has progressed to a point where working is no longer possible.

What’s Severe Enough in Cases of Arthritis

The SSA requires proof that your arthritis is severe enough to hinder your ability to perform substantial gainful activity. This involves:

  • Severe and Persistent Symptoms: Show consistent symptoms like intense joint pain, swelling, and stiffness.
  • Functional Limitations: Demonstrate significant limitations in your ability to walk, lift, carry, or perform fine and gross motor tasks.

Required Medical Evidence to Qualify for Benefits

You must provide comprehensive medical records that document the progression and severity of your arthritis. Your evidence should include:

  • Confirmed Diagnosis: A formal diagnosis of rheumatoid arthritis or other types of arthritis.
  • Blood Test Results: Laboratory tests indicating the presence of RA, such as rheumatoid factor (RF) and anti-CCP antibodies.
  • Imaging Studies: X-rays, MRIs, and other imaging tests that show joint damage and measure the range of motion.
  • Doctor’s Notes: Detailed notes from your healthcare providers describing the severity and frequency of your symptoms.
  • Treatment Records: Documentation of all treatments received, their outcomes, and any side effects experienced from medications.
  • Medications: A list of all medications you are taking for arthritis and their effects.
  • Medical Provider Contacts: Contact information for all your medical providers for verification purposes

Proving Arthritis for SSDI Disability Benefits

Musculoskeletal Disorders

If your arthritis falls under the “musculoskeletal disorders” category, the SSA will evaluate your difficulty using your upper and/or lower body due to your condition. These physical limitations must have lasted or are expected to last for at least 12 continuous months. Consider the following questions and include the answers in your disability application:

  • What kind of pain do you experience (e.g., burning, aching, pins and needles)?
  • What triggers your pain and what aggravates it?
  • Do you need to lie down because of your pain, and for how long during the day?
  • How long can you stand or walk at one time?
  • Do you need assistance with daily activities like putting on shoes or brushing your hair?
  • Have you modified your home to help with your condition, such as installing bars in the shower?

The SSA requires evidence showing how your condition limits your ability to perform activities in a work environment versus at home. For instance, being able to walk for several hours at home without an assistive device does not necessarily mean you can do the same in a work setting. This distinction should be clarified with medical evidence.

The SSA will also assess whether you need assistive devices to complete work or if your condition is so severe that you cannot use both your upper and lower body for work-related activities.

Immune System Disorders

If your arthritis is classified as an immune system disorder, such as psoriatic arthritis, rheumatoid arthritis, gout, or pseudogout, you need to provide proof of your condition and its severity. Your condition must meet one of the following criteria to qualify for disability benefits under immune system disorders, your condition must meet one of these criteria:

  1. Persistent Inflammation or Deformity:
    • One or more major peripheral joints in either your upper or lower limbs are persistently inflamed or deformed, preventing you from performing your work.
  2. Inflammation or Deformity with Constitutional Symptoms:
    • One or more major peripheral joints in either your upper or lower limb are inflamed or deformed, along with some constitutional symptoms such as severe fatigue, fever, malaise, or involuntary weight loss. Additionally, you must have complications in two or more organs/body systems.
  3. Ankylosing Spondylitis or Other Spondyloarthropathies:
    • Conditions like ankylosing spondylitis (which causes the bones in the spine to fuse and reduces flexibility) or other chronic joint diseases such as psoriatic arthritis or reactive arthritis.
  4. Repeated Manifestations of Inflammatory Arthritis:
    • At least two of the constitutional symptoms (severe fatigue, fever, malaise, or involuntary weight loss) must be present, along with:
      • Limitations in activities of daily living
      • Limitations in maintaining social functioning
      • Limitations in completing tasks on time due to deficiencies in concentration, persistence, or pace

Additional Questions for Your SSDI Application

For Rheumatoid Arthritis:

  • Have you completed a blood test, in addition to X-rays and MRIs?
  • Do you experience pain in specific joints?
  • Do you have documentation showing the progression of your condition over time?

For Psoriatic Arthritis:

  • Do you suffer from chronic pain, stiffness, or limited range of motion?
  • Have you had labs performed by a rheumatologist?

For Gout or Pseudogout:

  • Do you have two or more organs or body systems affected by gout?

How much is a SSDI disability amount for arthritis?

Social Security Disability Insurance (SSDI) is a federal program that provides financial assistance to individuals who have worked and paid taxes over the years but are now unable to work due to a disability. Here’s a detailed breakdown of what you need to know:

Potential Earnings with SSDI

  • Higher Earning Potential: The maximum SSDI check is $3,822 per month.

  • Average Monthly Check: For conditions like rheumatoid arthritis and similar immune system disorders, the average monthly check is approximately $1,557.95.

  • Factors Influencing Your Benefit: Your actual monthly benefit depends on both your arthritis and your work and income history. 

Qualifying for SSDI

  • Historical Earnings: Qualifying for SSDI doesn’t guarantee a fixed monthly check. Instead, the amount you receive is based on your historical earnings and the amount you’ve paid into Social Security over the years.

Work and Income History: Your benefit amount is determined by your earnings record, which reflects how much you have contributed to the Social Security system through payroll taxes.

Tips for Strengthening Your Disability Claim When Applying for Disability With Arthritis

  • Collect Comprehensive Medical Documentation:
    • Gather all relevant medical records, including doctor’s notes, physical exams, test results, and operative reports.
  • Track Symptoms and Functional Limitations:
    • Maintain a detailed record of how arthritis affects your daily activities and work-related tasks.
    • Document any difficulties in performing routine tasks and the use of assistive devices like canes or walkers.
  • Monitor Treatment Responses:
    • Keep a log of your responses to treatments, including medications and physical therapy, noting any side effects.
  • Organize Your Records:
    • Compile and organize all medical documentation and records systematically to facilitate the evaluation process by the SSA.

By providing thorough and well-documented medical evidence, you can significantly improve your chances of qualifying for SSDI benefits due to arthritis.

Conclusion

This guide offers a simplified overview for those who believe they may qualify for SSDI due to arthritis. Remember, this guide is not a substitute for the SSA’s Blue Book, which provides detailed and current information. For comprehensive guidelines and the latest updates, please consult the SSA’s Blue Book.

Understanding the complexities of arthritis and its impact on your ability to work is vital for your disability claim. Arthritis can severely limit basic work activities such as walking, standing, lifting, and other movements, often requiring extensive medical evidence to qualify for SSDI benefits. The financial burdens associated with rheumatoid arthritis, including high medication and surgical costs, further complicate the situation.

Even if you’re unsure whether your rheumatoid arthritis meets the criteria, you can still apply. Demonstrating to the SSA that your arthritis and its symptoms prevent you from working is key. The process can be challenging, as most applicants aren’t approved on their first try; only about 20% of first-time applications are successful. However, persistence pays off. If you appeal to the hearing phase and present your case before a judge, your chances of approval increase to over 50%.

At SSDI Benefits Group, we are here to support you through each step of your application or SSDI appeal process. Our experienced team will help you gather the necessary documentation and build a compelling case. We understand the SSA’s evaluation process and are committed to improving your chances of receiving the benefits you need. For more guidance, check out our step-by-step guide to applying for disability. Additionally, explore our resources for people with disabilities if you need financial assistance before or during your application. Contact us for a free assessment and let us assist you in securing your SSDI benefits.

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