SSDI Medical Evaluation

SSDI Eligibility Explained

To qualify for Social Security Disability Insurance (SSDI), individuals must meet specific criteria set by the Social Security Administration (SSA).

SSDI applicants must have accumulated enough work credits through employment covered by Social Security.

Additionally, SSDI defines disability as a condition that prevents substantial gainful activity and is expected to last at least one year or result in death.

Work Credits Requirements for SSDI Benefits

Accumulating a sufficient amount of work credits within a specified time period is required to qualify for social security disability benefits.

Individuals earn work credits based on their annual income from employment or self-employment to earn up to 4 credits each year.

The number of work credits required to qualify for SSDI varies with age:

• Before age 24: 6 credits in the three years before disability.
• Ages 24 to 31: Credits for half the time between age 21 and the onset of disability.
• Ages 31 and older: Generally, 20 credits in the last ten years before disability.

If you have accumulated enough work credits, then you must consider whether your medical conditions meet the SSA’s definition of disabled.

First, you must have a medically determinable physical or mental impairment that:

• Has lasted or is expected to last for a continuous period of at least 12 months; or
• Is expected to result in death.

If your condition meets that criteria, it must also prevent you from performing substantially gainful activity (SGA).

What is the Social Security Administration Definition of Substantial Gainful Activity (SGA)?

The SSA defines substantial gainful activity (SGA) as work that:

• Involves significant physical or mental activities; and
• Is usually done for pay or profit (whether or not a profit is actually realized).

Other aspects considered when the SSA is determining if an applicant is prevented from performing substantial gainful activity include, but are not limited to:

• Earnings threshold: In 2024, the monthly SGA income limit is $1,550 for non-blind individuals and $2,590 for blind individuals. Earning above these amounts generally means a person is engaging in substantial gainful activity.
• Exceptions: Some activities are generally not considered SGA, such as self-care, household tasks, hobbies, therapy, school attendance, and social programs.
• Self-employment considerations:  For self-employed individuals, the SSA uses special formulas called the “Countable Income Test” or the “Three Tests” to determine SGA.
• Subsidized work:  If an employer provides special accommodations or extra support due to a disability, the SSA may only count the actual value of the work performed towards SGA, not the full wages paid.
• Unsuccessful work attempts: Work attempts lasting 6 months or less that end or are reduced below SGA level due to the impairment may not be considered SGA.

Other Aspects in the SSA’s Definition of Disabled

Other aspects in the SSA’s definition of a disability include, but are not limited to:

• The condition must be severe enough to prevent the person from doing their past work or adjusting to other work.
• The impairment must be medically determinable, meaning it results from anatomical, physiological, or psychological abnormalities that can be shown by medically acceptable clinical and laboratory diagnostic techniques.

The SSA uses a 5-step sequential evaluation process to determine if someone meets this definition of disability.

This includes assessing the person’s current work activity, severity of impairment, ability to do past work, and ability to adjust to other work.

It’s important to note that this is considered a strict definition of disability.

The SSA states that their disability beneficiaries are “among the most severely impaired in the country” and are more than three times as likely to die in a year compared to others their age.

If you or someone you love is struggling with a medical condition inhibiting your ability to perform SGA, you may be entitled to monthly social security benefits.

Contact TruLaw using the chat on this page for a free SSDI consultation and learn more about financial assistance options and support available to you today.

The SSDI Medical Evaluation Process

The Social Security Disability Insurance (SSDI) medical evaluation process involves assessing whether an applicant can engage in substantial gainful activity, the severity of their condition, and their ability to perform past or any other work.

This evaluation is conducted by Disability Determination Services (DDS), which reviews medical evidence and makes determinations on disability claims.

Five-Step Sequential Evaluation Process

The Social Security Administration (SSA) uses a five-step sequential evaluation process to determine an individual’s eligibility for SSDI benefits.

The five (5) steps of the SSDI evaluation include:

1. Substantial Gainful Activity (SGA): Determines if the applicant is working and earning above a certain income threshold, which would typically disqualify them from being considered disabled.
2. Severity of Impairment: Assesses whether the applicant’s condition significantly limits their ability to perform basic work activities.
3. Medical Listings: Evaluate if the impairment meets or equals a listed medical condition in the SSA’s Listing of Impairments.
4. Past Relevant Work: Considers if the applicant can perform any work they have done.
5. Other Work: This determines whether the applicant can adjust to other work based on their residual functional capacity, age, education, and work experience.

Role of Disability Determination Services (DDS)

The Disability Determination Services (DDS) consider various factors when evaluating medical evidence to ensure accuracy and consistency while determining the unique characteristics of your claim.

These evaluations may include, but are not limited to:

• Medical Evidence Review: DDS gathers and reviews medical records from the claimant’s healthcare providers. If necessary, they may arrange for consultative examinations to obtain additional information.
• Interaction with Applicants: DDS communicates with applicants to gather necessary documentation and clarify any issues related to their medical condition or work history.
• Timeline and Communication: The evaluation process can take several months, depending on the complexity of the case and the need for additional examinations. DDS ensures that applicants are informed about the status of their claims throughout the process

Medical Evidence Requirements

The medical evidence used to prove your disability can include various sources, such as detailed medical records, comprehensive lab results, and professional statements provided by physicians.

A disability medical exam is arranged and carried out when additional information is needed to facilitate a thorough and informed decision-making process.

Types of Medical Records & Evidence Needed

A wide array of medical evidence enhances your SSDI claim by providing robust support for your case.

The variety and completeness of your documentation can be used to demonstrate the severity of your condition to the SSA.

The following types of medical evidence that may be used include:

• Medical Records: These include documentation from doctors, hospitals, clinics, and other medical sources that detail the claimant’s medical history and treatment.
• Lab Results: Results from laboratory tests that support the diagnosis and severity of the condition.
• Physician Statements: Professional opinions from treating physicians regarding the claimant’s condition and its impact on their ability to work.
• Impairment Documentation: Complete and detailed medical records establishing the existence and severity of an impairment.
• Gathering and Organizing Evidence: Claimants should collect all relevant medical documentation and submit it promptly to avoid delays in processing their claims

Role of a Disability Examiner & Consultative Examinations

A consultative examination (CE) is an additional medical evaluation performed by a treating source or another qualified medical professional at the request and expense of the SSA.

The information obtained by a disability examiner during your consultative exam (CE) provides the SSA with current records to compare against your medical history to support your disability claim.

The doctor performing your consultative disability exam will typically conduct:

• A physical or mental assessment;
• A diagnostic test; and
• An evaluation of functional capabilities.

An SSDI lawyer can help you request and compile the medical evidence required for your application.

Contact TruLaw using the chat on this page for a free consultation today to see if we can help you in successfully applying or appealing for SSDI benefits.

Recent Changes in the SSDI Evaluation Process

In 2024, the Social Security Administration (SSA) introduced a significant change to the disability evaluation process by reducing the past work evaluation period from 15 years to 5 years.

This change aims to simplify the process for applicants by focusing on their most recent and relevant work experiences.

Reduction in Past Work Evaluation Period

The previous requirement of providing a detailed work history spanning 15 years often led to incomplete or inaccurate reporting, as it was challenging for individuals to recall such extensive details.

The SSA implemented this change to lessen the administrative burden on applicants and improve the quality of information received by decision-makers.

By concentrating on a shorter timeframe, the SSA can make more accurate determinations regarding an applicant’s current skills and capabilities, which better reflect today’s job market.

This update is part of a broader effort to modernize the vocational policy used in disability decisions.

Impact of Changes on SSDI Approval Rates

The reduction in the past work evaluation period is expected to positively impact approval rates for SSDI applicants.

By focusing on recent employment history, the SSA acknowledges that job skills and requirements evolve rapidly, making older work experiences less relevant.

This change allows for a more accurate assessment of an applicant’s ability to perform substantial gainful activity based on current skills.

Early data following the implementation of this rule suggests an increase in approval rates, as it reduces the number of denials based on outdated work history.

This process also decreases administrative costs and backlogs to provide applicants with timely decisions.

Tips for a Successful SSDI Application

A well-prepared Social Security Disability Insurance (SSDI) application is key to improving your chances of approval.

Thorough documentation and attention to detail can make a significant difference in the outcome of your claim.

Comprehensive Medical Documentation

Proper medical documentation forms the backbone of a strong SSDI application.

It provides concrete evidence of your condition and its impact on your ability to work.

Providing complete and accurate medical records is important for a strong SSDI application:

• Include all relevant medical tests, lab results, and imaging studies
• Obtain detailed statements from treating physicians about your limitations
• Keep a symptom journal to track how your condition impacts daily activities
• Ensure all records are current and cover the full duration of your disability

Working with an SSDI Attorney

An experienced SSDI attorney can be a valuable asset in navigating the application process.

They can help you avoid common mistakes and strengthen your case.

Seeking legal guidance can greatly enhance your application’s chances of success:

• Attorneys can help identify and obtain key evidence to support your claim
• They understand SSA requirements and can frame your case effectively
• Legal representation is valuable if you need to appeal a denied claim
• Choose an attorney with specific experience handling SSDI cases

Avoiding Common Pitfalls

Being aware of potential mistakes can help you steer clear of issues that could jeopardize your application.

Attention to detail and consistency are key factors in a successful SSDI claim.

Be mindful of these frequent mistakes that can harm your application:

• Failing to follow prescribed treatments or attend medical appointments
• Understating or exaggerating the impact of your disability
• Missing important filing deadlines or application requirements
• Continuing to work while claiming total disability

SSDI Appeals Process

The appeals process includes reconsideration, an ALJ hearing, Appeals Council review, and federal court review.

New evidence can strengthen an appeal if the initial application is denied.

Steps in the Appeals Process

The appeals process is vital for applicants whose initial claims have been denied.

Each step offers an opportunity to present your case and provide additional evidence to support your claim.

The Social Security disability appeals process consists of four (4) main stages:

1. Reconsideration: A complete review of your claim by someone who did not take part in the initial decision.
2. Hearing by an Administrative Law Judge (ALJ): An impartial review of your case by a judge who examines all evidence and may call on a medical consultant and/or vocational expert.
3. Appeals Council Review: The Appeals Council looks at all requests but may deny a request if it believes the hearing decision was correct.
4. Federal Court Review: The final stage where you can file a civil lawsuit in a U.S. District Court.

Key deadlines to remember:

• You have (60) days from receiving a denial notice to file for the next level of appeal.
• If you miss the 60-day deadline, you may need to submit a “Good Cause for Late Filing” request.

Resources available:

• Online appeal forms through the SSA website
• Local Social Security offices for in-person assistance
• Disability attorneys or advocates who can guide you through the process

Importance of Additional Evidence

Presenting new, relevant evidence can significantly improve your chances of a favorable decision on appeal.

More medical evidence can help address any gaps or weaknesses in your initial application that may have led to the denial.

Gathering new evidence is crucial for a successful appeal:

• Medical records: Recent test results, doctor’s notes, and treatment plans can provide updated information on your condition.
• Work history information: Detailed employment records help assess how your disability affects your ability to work.
• Personal statements: Your own account of how the disability impacts your daily life can be compelling evidence.

To strengthen your appeal:

• Obtain detailed statements from treating physicians about your limitations.
• Keep a symptom journal to track how your condition affects daily activities.
• Ensure all medical records are current and cover the full duration of your disability.

Working with medical professionals:

• Schedule follow-up appointments to document ongoing symptoms and treatments.
• Request that your doctors provide specific assessments of your functional limitations.
• Ask for written opinions on how your condition prevents you from working.

Remember, the key to a successful appeal is providing comprehensive, up-to-date evidence that clearly demonstrates how your condition meets the SSA’s definition of disability.