Social Security (“SSA”) defines fibromyalgia as a complex medical condition that is characterized by widespread pain in the joints, muscles, tendons, or soft tissues that has lasted for at least three months. In Social Security Ruling 12-2p, SSA explains what evidence is needed to establish a medically determinable impairment of fibromyalgia and how fibromyalgia will be evaluated. SSA will be looking for sufficient objective evidence to support a finding that your fibromyalgia, or your fibromyalgia in combination with any other impairments prevents you from performing substantial gainful activity. Substantial gainful activity is the ability to work full-time, generally 8 hours a day, five days a week.
How do I show fibromyalgia is a medically determinable impairment?
SSA will only find fibromyalgia is a medically determinable impairment if it has been diagnosed by a physician. However, they will not rely on a diagnosis alone. Your diagnosis must be accompanied by specific evidence. There are two different criteria that SSA will consider in determining if a fibromyalgia diagnosis is supported by the evidence. Your evidence should either meet the 1990 ACR Criteria for Classification of Fibromyalgia or the 2010 ACR Preliminary Diagnostic Criteria; you do not need to meet both.
1990 ACR Criteria for Classification of Fibromyalgia.
- A history of widespread pain that has persisted for at least three months.
- At least 11 positive tender points on physical examination. Your provider should do a tender point test or refer you to someone who can.
- Evidence that other impairments that could cause your symptoms were excluded. This may include imaging such as x-rays or MRI that are not consistent with your level of pain or laboratory testing ruling out issues such as thyroid function or rheumatoid factor.
2010 ACR Preliminary Diagnostic Criteria.
- A history of widespread pain.
- Repeated episodes of six or more fibromyalgia symptoms. The most common symptoms and signs are fatigue, waking unrefreshed, memory or other cognitive problems, depression, anxiety, or irritable bowel syndrome. However, other conditions recognized as often co-occurring with fibromyalgia include interstitial cystitis, irritable bladder disorder, TMJ, migraines, gastric reflux, and restless leg syndrome.
- Evidence that other disorders that could cause these symptoms were excluded. Any testing you have had done, is important, even if results were negative. Social Security wants to make sure that diseases like multiple sclerosis, lupus, and rheumatoid arthritis are not the cause of your symptoms.
SSA will look at whether your medical provider has performed a physical exam and reviewed your medical history. They will evaluate whether your medical provider’s treatment notes are consistent with the diagnosis of fibromyalgia and consistent with any work-related limitations.
What kind of documentation will SSA be looking for?
- Objective medical evidence will be most important. This will be your diagnosis of fibromyalgia, any testing and any observations from your medical provider supporting this diagnosis and its impact on your ability to function. These findings should cover the time period from the 12-months before your onset date or application date forward. SSA will be looking for consistent and supportable findings.
- Evidence from non-medical sources can be helpful. This may be evidence from friends, family members, former employers, or clergy. This kind of evidence cannot be used to establish a diagnosis of fibromyalgia, but can help SSA determine the severity of your fibromyalgia and how it impacts your ability to function.
- Your report of symptoms will also be evaluated. It is important that your report of symptoms is consistent with the objective medical evidence and supported by the other evidence in the record.
What can I do now?
- If fibromyalgia is part of your disability claim, we need to have a current diagnosis. Some people have had fibromyalgia for years before they file a claim. Many times, the diagnosis accompanied by the appropriate tender point testing or other observations and signs discussed above are not part of the current medical record. It is very important for you to have an updated diagnosis in the file accompanied by testing or other objective findings. This testing should include tests to exclude other conditions that could cause your fibromyalgia symptoms. It is not enough that your provider simply notes “fibromyalgia” in your record. This must be accompanied by appropriate testing, observations, and report of symptoms such as pain, fatigue, sleep issues, brain fog, or depression. Start talking to your provider now to create a consistent, supportable record.
2) In addition to having a supported diagnosis in the file, be sure you communicate with your provider how fibromyalgia affects you and limits your ability to perform work-related functions. The better you communicate to your provider the specific limitations you experience due to fibromyalgia, the more consistent the record will be. Common issues you should discuss with your medical provider include:
– Pain interfering with your ability to sit, stand, walk, or lift.
– Pain limiting your ability to kneel, crouch, crawl, stoop, climb, or use your upper extremities.
– Sleep issues that cause fatigue or the need to take breaks or naps during the day.
– Difficulty focusing, concentrating, or remembering due to brain fog or other mental issues such as depression.
– Any limitations you have in performing your activities of daily living due to your fibromyalgia.
– Let your provider know if you have good days and bad days. This is not uncommon with fibromyalgia. If you have bad days regularly make sure to discuss your activity level on these days with your doctor. Also discuss with your medical provider if there are activities that make your symptoms worse. Not everyone has the same symptoms and limitations due to fibromyalgia. It is important that your specific experience with fibromyalgia is discussed with your medical provider.
- Stay compliant with medication and treatment. If you are not willing to take medications or otherwise comply with your provider’s recommended treatment for your fibromyalgia, please let us know why. A failure to follow through with recommended treatment can be seen as an indication that your fibromyalgia is not as severe as you say. We want to make sure SSA understands your specific situation.
- If possible, undergo any testing recommended by your provider. As discussed above, SSA will be looking to see if your pain is actually due to other conditions. Always let us know if you are unable to undergo any recommended testing due to issues such as finances.
Remember, fibromyalgia is an impairment that affects each individual differently. Not everyone will have the same symptoms or limitations. It is important for us to help SSA understand the specific way you are affected by fibromyalgia.