Which medical conditions are most likely to win disability on appeal?

Question: Do certain disabilities have a better chance of being approved for benefits after an appeal hearing? If so, why?

Answer: The Social Security Administration just released an interesting report that grouped disability applicants by diagnosis. It provided the rates of approval at the initial application stage and rates of approval after the appeal hearing, for many different types of disabilities (based on the primary medical condition listed in the disability application).

As it should be, those conditions with the highest approval rates at the initial application stage also had the highest rate of approval on appeal. These were the diseases widely considered to be the most severe; for instance, pancreatic, esophageal, and stomach cancer; chronic renal failure; and severe mental retardation. In fact, 81% of all applications based on cancer were approved initially, with 89% getting approved on appeal. (Note that many of the conditions in this group are also on the compassionate allowance list, which contains conditions that are so serious that they “obviously meet disability standards,” according to Social Security.)

I looked at which disabilities had the highest reversal rate on appeal; that is, which disabilities were often denied on initial approval but approved on appeal. A couple that stood out to me were chronic fatigue syndrome and carpal tunnel syndrome. For instance, out of a random sample from the disability research file, there were a total of 472 chronic fatigue syndrome claims. Out of these, 102 were approved at the initial application stage and 370 were denied (a 22% approval rate). After appealing, out of the 278 denials that were appealed, 76% of them were approved.

Similarly, of 117 carpal tunnel syndrome applications, only 19% were initially approved, and then 67% of the appealed claims were approved. Other diagnoses that fall into this group include sleep apnea, back problems, chronic migraines, somatoform disorders, skin problems, asymptomatic HIV, Crohn’s disease, and immune system disorders like lupus and rheumatoid arthritis. Most are illnesses that your average (and, in some cases, uninformed) folks consider to be less serious.

Why are so many of these cases being denied at the initial application stage? Are DDS claims examiners denying valid claims due to some type of pressure, or cynicism, forcing ALJs to have to overturn their decisions? Or is the question: Why are administrative law judges eager to reverse so many denials? Are these ALJs substituting their medical judgment for those of doctors? (Medical experts are not present at most hearings to help the ALJ decide whether an applicant is medically disabled.)

I think several issues are at play here. First, those who appeal often wait a year for a hearing. During that time, some medical conditions progress, leading to more complications, more inability to work, and higher approval rates. For instance, 93% of those who applied with asymptomatic HIV were initially denied. For those who appealed, the denial rate on appeal was only 38%. It’s likely that, by the time of the hearing, many of the HIV+ applicants had evidence that their impairments had become severe.

Another reason could be that only those with more serious issues appeal when they are denied. While the majority of applicants who are denied do appeal, interestingly, most applicants who are applying for learning disorders or attention deficit disorder (or more likely, their parents) decide not to appeal. (There are, however, other reasons for not appealing,  some of them socioeconomic.) On a side note, these two conditions have some of the highest rates of denial, at both the initial application and appeal stages.

Another issue that may affect the high rates of denials for some types of illnesses is that there may be a culture at DDS of denying diseases that are thought to be less severe, like fibromyalgia, chronic fatigue syndrome (CFS), carpal tunnel syndrome (CTS), migraines, reflex sympathetic dystrophy syndrome (RSD), and complex regional pain syndrome (CRPS). And no doubt some claims examiners are dubious as to whether there is any physiological basis for these illnesses. But courts have now forced the SSA to recognize that fibromyalgia and CFS, and even RSD and CPRS and similar diseases, can be valid, payable disabilities. (As a result, Social Security recently released a ruling for fibromyalgia with guidance on when it is should be considered a medically determinable condition.) In short, claims examiners may now have to start taking these conditions more seriously at the initial application stage.

Back problems such as degenerative disc disease, which Social Security sees a lot of claims for, run into trouble as well. In this sample, out of almost 90,000 applicants with back pain and limitations, only 23% were approved initially, but 61% were approved on appeal. Seeing this number of applications for back problems, claims examiners may become immune to complaints of back pain without proof of stenosis, nerve root compression or the like. (After all, after age 45 or 50, almost everyone has some sort of back problem.) Of course, back pain, pain syndromes, and other syndromes are harder to prove; the impairments and limitations these applicants claim are largely based on self-reported and subjective symptoms. When applicants initially apply for disability based on these conditions, they and their doctors may not have submitted enough solid medical evidence of disability.

The appeal rate of approval could very well be higher for many conditions because, once these applicants hire legal representation for their hearings, their disability lawyers work with the applicants’ doctors to order lab tests, clinical exams, x-rays, etc. to provide the evidence the lawyers know is needed to win the claims. Lawyers also know the legal rules Social Security must obey before deciding an applicant is not disabled, and they aren’t afraid to exploit them. All this legal maneuvering no doubt helps win appeal hearings, especially since the government does not have an attorney to represent its interests at the hearings.