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FM, CFS/ME and Disability

If you have Fibromyalgia (FM) and/or Chronic Fatigue Syndrome / Myalgic Encephalomyelitis (CFS/ME) and are unable to work, you may need to investigate what your options are for taking time off from your job or even for going on disability.

In cases involving FM and CFS/ME there are some very distinct obstacles to overcome in establishing a claim for Social Security Disability Insurance. (SSDI). In part, this is because the extent of severe fatigue and constant pain cannot necessarily be viewed through the lenses of a microscope, or on an x-ray.

Therefore it is imperative that all of your medical records demonstrate a consistency of complaints common to your disease, such as the severe pain associated with your illness. This will help establish a specific pattern regarding your debilitating illness that will be apparent when the SSA reviews your case.

To make it successfully through the disability process, however, you will need to work closely with your doctor and your attorney. You will also need to educate yourself thoroughly about the process, which can be lengthy and complicated, so you don't inadvertently do something now that will limit your options in the future. Here are some ideas on where to start:


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Medical Documentation

Fibromyalgia (FM)

In order to establish a claim for Social Security Disability it is necessary to establish proof of your medical disability. Remember, the Social Security Administration is focused on function, not on diagnosis. In all disability claims involving FM, it is important to document how this debilitating disease impacts your daily life by making you unable to function or to perform ordinary tasks.

The clinical notes and a report by the treating rheumatologist are the most important. A 1996 decision by the Seventh Circuit Court of Appeals established that a rheumatologist should consistently document the positive findings for the tender points, which are diagnostic for this disease. Additionally, the patient should be complaining at each office visit of the severe fatigue and constant pain that are consistent with this condition. A report that establishes that all other causes for the symptoms have been ruled out helps establish the existence of the disease.

To further establish your claim, you will need to show that due to the constant physical fatigue, you are unable to perform basic tasks such as housework, travel to and from appointments, shopping, and other social functions. Often depression becomes an issue because of the severe changes in lifestyle and ability. Treatment notes and reports from a psychiatrist or psychologist will help document the severity of this problem for your Social Security Disability claim. It is essential that the medical professionals associated with your case are supportive during the process, and that they provide the documentation that is necessary to assist you in proving your claim.


Chronic Fatigue Syndrome (CFS/ME)

In cases involving Chronic Fatigue Syndrome (CFS), the Social Security Administration (SSA) tends to make its determination based on a comprehensive overview of the medical evidence specific to your case. This medical evidence will include the extent and nature of the treatment provided by the various physicians who treat you and the clinical chart created for you at every visit.

Consequently, it is imperative that all of your medical records demonstrate a consistency of complaints common to your disease, such as the overwhelming fatigue, weakness and muscle aches, low grade fevers, and chronic headaches associated with your illness. This will help establish a specific pattern regarding your debilitating illness that will be apparent when the SSA reviews your case.

The clinical notes and a report by the treating physician are the most important. Additionally, the patient should be complaining at each office visit of the severe fatigue and constant pain that are consistent with this condition. A report that establishes that all other causes for the symptoms have been ruled out helps establish the existence of the disease.

To further establish your claim, you will need to show that due to the constant physical fatigue, you are unable to perform basic tasks such as housework, travel to and from appointments, shopping, and other social functions. Often depression becomes an issue because of the severe changes in lifestyle and ability. Treatment notes and reports from a psychiatrist or psychologist will help document the severity of this problem for your Social Security Disability claim. It is essential that the medical professionals associated with your case are supportive during the process, and that they provide the documentation that is necessary to assist you in proving your claim.

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Working with Your Doctor, Record Keeping, and Testing

During this period it is important that you coordinate with your doctor to make sure that all your symptoms are being meticulously documented. For FM, there should be detailed notes about all your office visits that chart how many tender points are sensitized and where they are located. You will need 11 of 18 tender points documented to be eligible for disability. All your symptoms should be noted as well, including the level of your pain and any activities you are unable to do. These records are critical if after a few months' rest you are still unable to return to work.

In cases involving CFS/ME, the Social Security Administration (SSA) tends to make its determination based on a comprehensive overview of the medical evidence specific to your case. This medical evidence will include the extent and nature of the treatment provided by the various physicians who treat you and the clinical chart created for you at every visit.

Consequently, it is imperative that all of your medical records demonstrate a consistency of complaints common to your disease, such as the overwhelming fatigue, weakness and muscle aches, low grade fevers, and chronic headaches associated with your illness. This will help establish a specific pattern regarding your debilitating illness that will be apparent when the SSA reviews your case.

It's also good idea to keep detailed notes yourself. A pain diary, for instance, can help you track activities you can and can't do, times of day that are better or worse for you, and how often pain or other symptoms interfere with your capability to do your job.

To further establish your claim, you will need to show that due to the constant physical fatigue, you are unable to perform basic tasks such as housework, travel to and from appointments, shopping, and other social functions. Often depression becomes an issue because of the severe changes in lifestyle and ability. Treatment notes and reports from a psychiatrist or psychologist will help document the severity of this problem for your disability claim. It is essential that the medical professionals associated with your case are supportive during the process, and that they provide the documentation that is necessary to assist you in proving your claim.

Before you apply for the next level of assistance, it's often a good idea (and may be a requirement) to have an independent analysis of what you are able to do physically and mentally. Functional capacity testing is usually done by a physical therapist or other healthcare professional who evaluates your ability to do such things as sit, stand, walk, lift and carry, push and pull, drive and understand directions, and concentrate on tasks you're given to do.

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Social Security Administration Memorandum on Fibromyalgia

Date: May 11, 1998


To: Verrell L. Dethloff
Administrative Law Judge, OHA
From: Deputy Commissioner for Disability and Income Security Programs

Subject: Fibromyalgia, Chronic Fatigue Syndrome Objective Medical Evidence Requirements for Disability Adjudication

(Your Memo 01/30/98) - REPLY

Commissioner Apfel has asked me to respond to the issues raised in your memorandum dated January 30, 1998. I also have copies of your memoranda addressed to Administrative Appeals Judge Andrew E. Wakshul and General Counsel Arthur Fried, which raise essentially the same issue. This memorandum is also a response to your letters to the General Counsel and Judge Wakshul.

Your letter indicates that the Social Security Administration (SSA) needs to take a definitive position with respect to whether fibromyalgia and chronic fatigue syndrome (CFS) constitute medically determinable impairments. You requested an opinion from OGC on this issue and suggested that the Appeals Council meet en banc or schedule oral argument to resolve the issue.

Although the regulations authorize the Appeals Council to hear oral argument in a case raising an important question of law or policy, the Appeals Council does not establish agency policy with respect to issues related to the evaluation of specific medical conditions. Rather, the office of Disability establishes agency policy is such cases.

Your letter states that fibromyalgia and CFS do not constitute medically determinable impairments within the meaning of section 223(d) (3) of the Social Security Act because there are no acceptable medical criteria by which these impairments can be diagnosed. Your letter further states that " 'symptoms' only become 'signs' when a medically determinable impairment has been established, and subjective 'signs' on examination are therefore not 'objective' evidence in the absence of other objective evidence for providing a predicate for a diagnosis."

However, SSA has taken a definitive position that fibromyalgia and CFS can constitute medically determinable impairments within the meaning of the statute. As you noted in your letter, CFS was discussed in the process unification training in 1996-1997.

Although we regret that you found this discussion inadequate, the training did state clearly and unequivocally that individuals alleging CFS can be found to have a medically determinable impairment under the disability program given the presence of certain specified signs and findings. This position is consistent with the instructions in Program Operations Manual System (POMS) DI 24515.075, Disability Digest No. 93-5, and Social Security Rulings (SSR's) 98-3p, 96-4p. and 96-7p, issued on July 2, 1996, which detail our policies as to how symptoms effect determinations of the presence of a medically determinable impairment, impairment severity, and the ability to engage in sustainable work activity.

Establishing the existence of a medically determinable impairment does not necessarily require that the claimant or the medical evidence establish a specific diagnosis. This is especially true when the medical community has not reached agreement on a single set of diagnostic criteria. All the Act and regulations require is that some physical or mental impairment be established through medically acceptable clinical and laboratory diagnostic techniques. In some cases, the record may not establish the diagnosis, but there will be medical signs established by medically acceptable clinical techniques that show that there is an impairment, and that there is a relationship between the findings and the symptoms alleged; i.e., that the existence of a medically determinable impairment that could reasonably be expected to produce the symptoms has been established.

As you indicated in your letter, with the publication of SSR's 96-4p and 96-7p in July 1996, we intended to emphasize the statutory standard requiring the establishment of a medically determinable impairment as a predicate to the evaluation of symptoms. However, we did not mean to imply that it is first necessary to establish a fixed diagnosis in order to find the presence of a medically determinable impairment. Rather, the medically determinable impairment is established in the presence of anatomical, physiological, or psychological abnormalities that can be objectively observed and reported apart from the individual's perceptions even in the absence of a definitive diagnosis.

Your argument based on the Rulings seems to misinterpret the explanation in Footnote 2 to SSR 96-4p, which explains our longstanding policy consistent with 20 CFR §§. 404.1528(b) and 416.928(b), that some symptoms, when appropriately reported by a physician or psychologist in a clinical setting, can also be considered "signs" because sometimes these observations constitute "medically acceptable clinical diagnostic techniques." This is true for mental impairments in general and for such widely accepted and recognizable disorders as migraine headaches.

CFS is a systemic disorder consisting of a complex of symptoms and signs that may vary in incidence, duration, and severity. The hallmark of CFS is the presence of clinically evaluated, persistent or relapsing chronic fatigue that is of slow or definite onset which cannot be explained by another diagnosed physical or mental disorder, or the result of ongoing exertion. It is not substantially alleviated by rest and results in substantial reduction in previous levels of occupational, educational, social, or personal activities. Within these parameters, CFS can exhibit a variety of symptoms and signs.

As with all claims for disability, documentation of objective physical and/or mental findings in cases involving CFS is critical to establish the presence of a medically determinable impairment. In cases in which CFS is alleged, longitudinal clinical records reflecting ongoing medical assessment and treatment from the individual's medical sources, especially treating sources, are imperative to document objective physical and/or mental findings. Every reasonable effort should be made to secure all relevant evidence in cases involving CFS to ensure appropriate and thorough disability evaluation

For purposes of Social Security disability evaluation, one or the more of the following medical signs clinically documented over a period of at least 6 consecutive months establishes the existence of a medically determinable impairment for individuals alleging disability on the basis of CFS:

  • episodes of clinically documented low-grade fever
  • palpably swollen and tender lymph nodes on physical examination
  • nonexudative pharyngitis
  • muscle wasting with no other direct cause identified

At this time, there are no specific laboratory findings that definitively document the presence of CFS. The results of tilt- table testing to evaluate neurally mediated hypotension may be abnormal in individuals with CFS. Nonspecific laboratory findings indicative of chronic immune system activation (e.g., slight elevations in immune complexes, depressed natural killer cell activity, or atypical lymphocytes) may he included in the evidentiary record of individuals alleging CFS, but such findings are not definitive of CFS nor are they necessarily evidence of a medically determinable impairment.

Some individuals with CFS report problems with neurocognitive functioning, including problems with short-term memory, comprehension, concentration, speech, and/or calculation. Other individuals with CFS may exhibit signs of a mental or emotional disorder, such as anxiety or depression. When deficits in these areas have been documented by mental status examination and/or

psychological testing, such findings constitute medical signs that establish the presence of a medically determinable impairment

If an adjudicator concludes that an individual has a medically determinable impairment, and the individual alleges severe fatigue on a recurring basis consistent with CFS, such fatigue must be considered in deciding whether the individual's impairment is severe. If chronic fatigue is found to significantly limit an individual's ability to perform basic work activities, a "severe" impairment must be found to exist at step 2 of the sequential evaluation process. Although symptoms alone cannot be the basis for finding a medically determinable impairment, an individual's symptoms and the effects of those symptoms on the individual's functional abilities must be considered both in determining impairment severity and in assessing the individual's residual functional capacity.

Fibromyalgia is a disorder defined by the American College of Rheumatology (ACR) and we recognize it as medically determinable if there are signs that are clinically established by the medical record. The signs are primarily the tender points. The ACR defines the disorder in patients as "widespread pain in all four quadrants of the body for a minimum duration of 3 months and at least 11 of the 18 specified tender points which cluster around the neck and shoulder, chest, hip, knee, and elbow regions." Other typical symptoms, some of which can be signs if they have been clinically documented over time, are irritable bowel syndrome, chronic headaches, temporomandibular joint dysfunction, sleep disorder, severe fatigue, and cognitive dysfunction.

I agree with your observation that we need to do a better job of explaining our policy with respect to the adjudication of claims involving impairments like fibromyalgia and CFS. Toward that end, we have been drafting policy guidance to help adjudicators evaluate these impairments.

I trust that this explanation and clarification will assist you in applying the regulations and rulings to cases involving fibromyalgia and CFS.

(Signed)

Susan M. Daniels, Ph.D.

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Social Security Administration Ruling on CFS

The Social Security Administration (SSA) issued a ruling on April 30, 1999 which paves the way for severely afflicted persons with Chronic Fatigue Syndrome (CFS) to be classified as having a medically determinable impairment. This ruling provides guidance to disability claims processors for applying SSA policy to applications for Social Security Disability Income (SSDI) benefits that result from disability due to CFS.

This does not imply that persons with CFS are automatically entitled to SSDI, but it should make it easier for severely afflicted CFS patients to granted benefits.

Social Security Ruling, SSR 99-2p.; Titles II and XVI:
Evaluating Cases Involving Chronic Fatigue Syndrome (CFS)
AGENCY: Social Security Administration.
ACTION: Notice of Social Security Ruling.

SUMMARY:
In accordance with 20 CFR 402.35(b), the Commissioner of Social Security gives notice of Social Security Ruling, SSR 99-2p. This Ruling clarifies disability policy for the evaluation and adjudication of disability claims invo1ving Chronic Fatigue Syndrome (CFS). This Ruling explains that, when it is accompanied by appropriate medical signs or laboratory findings, CFS is a medically determinable impairment that can be the basis for a finding of "disability." This Ruling ensures that all adjudicators will use the same policies and procedures in evaluating disability claims involving CFS, and provides a consolidated statement of these policies and procedures.

EFFECTIVE DATE:
April 30, 1999.

FOR FURTHER INFORMATION CONTACT:
Carolyn Kiefer
Office of Disability
Division of Medical and Vocational Policy
Social Security Administration
6401 Security Boulevard
Baltimore, MD 21235-6401
(410) 965-9104

SUPPLEMENTARY INFORMATION:
Although we are not required to do so pursuant to 5 U.S.C. 552(a) and (a), we are publishing this Social Security Ruling in accordance with 20 CFR 402.35(b). Social Security Rulings make available to the public precedential decisions relating to the Federal old-age, survivors, disability, supplemental security income, and black lung benefits programs. Social Security Rulings may be based on case decisions made at all administrative levels of adjudication, Federal court decisions, Commissioner's decisions, opinions of the Office of the General Counsel, and policy interpretations of the law and regulations.

Although Social Security Rulings do not have the same force and effect as the statute or regulations, they are binding on all components of the Social Security Administration, in accordance with 20 CFR 402.35(b), and are to be relied upon as precedents in judicating cases.

If this Social Security Ruling is later superseded, modified, or rescinded, we will publish a notice in the Federal Register to that effect.

(Catalog of Federal Domestic Assistance, Programs 96.001 Social Security Disability Insurance; 96.006 Supplemental Security Income)

Dated: April 23, 1999.

Kenneth S. Apfel,
Commissioner of Social Security.


Policy Interpretation Ruling Titles II and XVI: Evaluating Cases Involving Chronic Fatigue Syndrome (CFS)

Purpose

To restate and clarify the policies of the Social Security Administration for developing and evaluating title II and title XVI claims for disability on the basis of Chronic Fatigue Syndrome (CFS), also frequently known as Chronic Fatigue and Immune Dysfunction Syndrome.

Citations (Authority)

Sections 216(i), 223(d), 223(f), 1614(a)(3) and 1614(a)(4) of the Social Security Act, as amended; Regulations No. 4, subpart P, sections 404.1505, 40404.1508-404.1513, 404.1520, 404.1520a, 404.1521, 404.1523, 404.1526-404.1529, 404.1560-404.1569a and 404.1593-404.1594; and Regulations No. 16, subpart I, sections 416.905, 416.906, 416.908- 416.913, 416.920, 416.920a, 416.921, 416.923, 416.924, 416.924b, 416.924c, 416.926, 416.926a, 416.927-416.929, 416.960-416.969a, 416.987, 416.993, 416.994, and 416.994a.

Introduction

CFS is a systemic disorder consisting of a complex of symptoms that may vary in incidence, duration, and severity. The current case criteria for CFS, developed by an international group convened by the Centers for Disease Control and Prevention (CDC) as an identification tool and research definition, include a requirement for four or more of a specified list of symptoms. These constitute a patient's complaints as reported to a provider of treatment.

However, the Social Security Act (the Act) and our implementing regulations require that an individual establish disability based on the existence of a medically determinable impairment; i.e., one that can be shown by medical evidence, consisting of medical signs, symptoms and laboratory findings. Disability may not be established on the basis of an individual's statement of symptoms alone.

This Ruling explains that CFS, when accompanied by appropriate medical signs or laboratory findings, is a medically determinable impairment that can be the basis for a finding of "disability." It also provides guidance for the evaluation of claims involving CFS.

Policy Interpretation

CFS constitutes a medically determinable impairment when it is accompanied by medical signs or laboratory findings, as discussed below. CFS may be a disabling impairment.

Definition of CFS

CFS is a systemic disorder consisting of a complex of symptoms that may vary in incidence, duration, and severity. It is characterized in part by prolonged fatigue that lasts 6 months or more and that results in substantial reduction in previous levels of occupational, educational, social, or personal activities. In accordance with criteria established by the CDC, a physician should make a diagnosis of CFS "only after alternative medical and psychiatric causes of chronic fatiguing illness have been excluded" (Annals of Internal Medicine, 121:953-9, 1994). CFS has been diagnosed in children, particularly adolescents, as well as in adults.

Under the CDC definition, the hallmark of CFS is the presence of clinically evaluated, persistent or relapsing chronic fatigue that is of new or definite onset (i.e., has not been lifelong), cannot be explained by another physical or mental disorder, is not the result of ongoing exertion, is not substantially alleviated by rest, and results in substantial reduction in previous levels of occupational, educational, social, or personal activities. Additionally, the current CDC definition of CFS requires the concurrence of 4 or more of the following symptoms, all of which must have persisted or recurred during 6 or more consecutive months of illness and must not have pre-dated the fatigue:

  • Self-reported impairment in short-term memory or concentration severe enough to cause substantial reduction in previous levels of occupational, educational, social, or personal activities

  • Sore throat

  • Tender cervical or axillary lymph nodes

  • Muscle pain

  • Multi-joint pain without joint swelling or redness

  • Headaches of a new type, pattern, or severity

  • Unrefreshing sleep

  • Postexertional malaise lasting more than 24 hours

Within these parameters, an individual with CFS can also exhibit a wide range of other manifestations such as:

  • muscle weakness
  • swollen underarm (axillary) glands
  • sleep disturbances
  • visual difficulties (trouble focusing or severe photosensitivity)
  • orthostatic intolerance:
    • lightheadedness
    • increased fatigue with prolonged standing)
  • other neurocognitive problems:
    • difficulty comprehending and processing information)
    • fainting
    • dizziness
    • mental problems (e.g., depression, irritability, anxiety)

Requirement for a Medically Determinable Impairment

Sections 216(i) and 1614(a) of the Act define "disability" as the inability to engage in any substantial gainful activity (SGA) by reason of any medically determinable physical or mental impairment (or combination of impairments) which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months. Sections 223(d) and 1614(a) of the Act, and 20 CFR 404.1508 and 416.908 require that an impairment result from anatomical, physiological, or psychological abnormalities that can be shown by medically acceptable clinical and laboratory diagnostic techniques. The Act and regulations further require that an impairment be established by medical evidence that consists of signs, symptoms, and laboratory findings, and not only by an individual's statement of symptoms.

Under the CDC definition, the diagnosis of CFS can be made based on an individual's reported symptoms alone once other possible causes for the symptoms have been ruled out. However, the foregoing statutory and regulatory provisions require that, for evaluation of claims of disability under the Act, there must also be medical signs or laboratory findings before the existence of a medically determinable impairment may be established.

Establishing the Existence of a Medically Determinable Impairment

The following medical signs and laboratory findings establish the existence of a medically determinable impairment in individuals who have CFS. Although no specific etiology or pathology has yet been established for CFS, many research initiatives continue, and some progress has been made in ameliorating symptoms in selected individuals. With continuing scientific research, new medical evidence may emerge that will further clarify the nature of CFS and provide greater specificity regarding the clinical and laboratory diagnostic techniques that should be used to document this disorder.

Because of this, the medical criteria discussed below are only examples of signs and laboratory findings that will establish the existence of a medically determinable impairment; they are not all inclusive. As progress is made in medical research into CFS, additional signs and laboratory findings may also be found that can be used to establish that individuals with CFS have a medically determinable impairment. The existence of CFS may be documented with medical signs or laboratory findings other than those listed below, provided that such documentation is consistent with medically accepted clinical practice and is consistent with the other evidence in the case record.

Examples of Medical Signs That Establish the Existence of a Medically Determinable Impairment

For purposes of Social Security disability evaluation, one or more of the following medical signs clinically documented over a period of at least 6 consecutive months establishes the existence of a medically determinable impairment for individuals with CFS:

  • Palpably swollen or tender lymph nodes on physical examination

  • Nonexudative pharyngitis

  • Persistent, reproducible muscle tenderness on repeated examinations, including the presence of positive tender points or, any other medical signs that are consistent with medically accepted clinical practice and are consistent with the other evidence in the case record

Examples of Laboratory Findings That Establish the Existence of a Medically Determinable Impairment

At this time, there are no specific laboratory findings that are widely accepted as being associated with CFS. However, the absence of a definitive test does not preclude reliance upon certain laboratory findings to establish the existence of a medically determinable impairment in persons with CFS. Therefore, the following laboratory findings establish the existence of a medically determinable impairment in individuals with CFS:

  • An elevated antibody titer to Epstein-Barr virus (EBV) capsid antigen equal to or greater than 1:5120, or early antigen equal to or greater than 1:640

  • An abnormal magnetic resonance imaging (MRI) brain scan

  • Neurally mediated hypotension as shown by tilt table testing or another clinically accepted form of testing

  • Any other laboratory findings that are consistent with medically accepted clinical practice and are consistent with the other evidence in the case record; for example, an abnormal exercise stress test or abnormal sleep studies, appropriately evaluated and consistent with the other evidence in the case record

Mental Findings That Establish the Existence of a Medically Determinable Impairment

Some individuals with CFS report ongoing problems with the following:

  • short-term memory
  • information processing
  • visual-spatial difficulties
  • comprehension
  • concentration
  • speech
  • word-finding
  • calculation
  • other symptoms suggesting persistent neurocognitive impairment

When ongoing deficits in these areas have been documented by mental status examination or psychological testing, such findings constitute medical signs or (in the case of psychological testing) laboratory findings that establish the presence of a medically determinable impairment.

Individuals with CFS may also exhibit medical signs, such as anxiety or depression, indicative of the existence of a mental disorder. When such medical signs are present and appropriately documented, the existence of a medically determinable impairment is established.

Evaluation

1. General

Claims involving CFS are adjudicated using the sequential evaluation process, just as for any other impairment. Once a medically determinable impairment has been found to exist (see discussion above), the severity of the impairment(s) must be established. The severity of an individual's impairment(s) is determined based on the totality of medical signs, symptoms, and laboratory findings, and the effects of the impairment(s), including any related symptoms, on the individual's ability to function.

Also, several other disorders (including, but not limited to, FMS, multiple chemical sensitivity, and Gulf War Syndrome, as well as various forms of depression, and some neurological and psychological disorders) may share characteristics similar to those of CFS. When there is evidence of the potential presence of another disorder that may adequately explain the individual's symptoms, it may be necessary to pursue additional medical or other development.

2. Step

When an adjudicator finds that an individual with CFS has a medically determinable impairment, he or she must consider that the individual has an impairment that could reasonably be expected to produce the individual's symptoms associated with CFS, as required in 20 CFR 404.1529(b) and 416.929(b), and proceed to evaluate the intensity and persistence of the symptoms. Thus, if an adjudicator concludes that an individual has a medically determinable impairment, and the individual alleges fatigue, pain, symptoms of neurocognitive problems, or other symptoms consistent with CFS, these symptoms must be considered in deciding whether the individual's impairment is "severe" at step 2 of the sequential evaluation process and at any later steps reached in the sequential evaluation process. If fatigue, pain, neurocognitive symptoms, or other symptoms are found to cause a limitation or restriction having more than a minimal effect on an individual's ability to perform basic work activities, the adjudicator must find that the individual has a "severe" impairment. See SSR 96-3p, "Titles II and XVI: Considering Allegations of Pain and Other Symptoms in Determining Whether a Medically Determinable Impairment is Severe."

3. Step

When an individual is found to have a severe impairment, the adjudicator must proceed with the sequential evaluation process and must next consider whether the individual's impairment is of the severity contemplated by the Listing of Impairments contained in appendix 1, subpart P of 20 CFR 404. Inasmuch as CFS is not a listed impairment, an individual with CFS alone cannot be found to have an impairment that meets the requirements of a listed impairment; however, the specific findings in each case should be compared to any pertinent listing to determine whether medical equivalence may exist.

Further, in cases in which individuals with CFS have psychological manifestations related to CFS, consideration should always be given to whether the individual's impairment meets or equals the severity of any impairment in the mental disorders listings in 20 CFR, part 404, subpart P, appendix 1, sections 12.00 ff. or 112.00 ff.

4. Steps

For those impairments that do not meet or equal the severity of a listing, an assessment of residual functional capacity (RFC) must be made, and adjudication must proceed to the fourth and, if necessary, the fifth step of the sequential evaluation process. In assessing RFC, all of the individual's symptoms must be considered in deciding how such symptoms may affect functional capacities. See SSR 96-7p, "Titles II and XVI: Evaluation of Symptoms in Disability Claims: Assessing the Credibility of an Individual's Statements" and SSR 96-8p, "Titles II and XVI: Assessing Residual Functional Capacity in Initial Claims."

If it is determined that the individual's impairment(s) precludes the performance of past relevant work (or if there was no past relevant work), a finding must be made about the individual's ability to perform other work. The usual vocational considerations (see 20 CFR 404.1560- 404.1569a and 416.960-416.969a) must be applied in determining the individual's ability to perform other work.

Many individuals with CFS are "younger individuals," ages 18 through 49 (see 20 CFR 404.1563 and 416.963). Age, education, and work experience are not usually considered to limit significantly the ability of individuals under age 50 to make an adjustment to other work, including unskilled sedentary work. However, a finding of "disabled" is not precluded for those individuals under age 50 who do not meet all of the criteria of a specific rule and who do not have the ability to perform a full range of sedentary work. The conclusion about whether such individuals are disabled will depend primarily on the nature and extent of their functional limitations or restrictions. Thus, if it is found that an individual is able to do less than the full range of sedentary work, refer to SSR 96-9p, "Titles II and XVI: Determining Capability to Do Other Work - Implications of a Residual Functional Capacity for Less Than a Full Range of Sedentary Work." As explained in that Ruling, whether the individual will be able to make an adjustment to other work requires adjudicative judgment regarding factors such as the type and extent of the individual's limitations or restrictions and the extent of the erosion of the occupational base for sedentary work.

5. Duration

The medical signs and symptoms of CFS fluctuate in frequency and severity and often continue over a period of many months or years. Thus, appropriate documentation should include a longitudinal clinical record of at least 12 months prior to the date of application, unless the alleged onset of CFS occurred less than 12 months in the past, or unless a fully favorable determination or decision can be made without additional documentation. The record should contain detailed medical observations, treatment, the individual's response to treatment, and a detailed description of how the impairment limits the individual's ability to function over time.

When the alleged onset of disability secondary to CFS occurred less than 12 months before adjudication, the adjudicator must evaluate the medical evidence and project the degree of impairment severity that is likely to exist at the end of 12 months. Information about treatment and response to treatment as well as any medical source opinions about the individual's prognosis at the end of 12 months are helpful in deciding whether the medically determinable impairment(s) is expected to be of disabling severity for at least 12 consecutive months.

6. Continuing Disability Reviews

In those cases in which an individual is found to have a disability based on CFS but medical improvement is anticipated, an appropriate continuing disability review should be scheduled based on the probability of cessation under the Medical Improvement Review Standard. This standard takes into account relevant individual case facts such as the combined severity of other chronic or static impairments and the individual's vocational factors.

Documentation

1. General

As with all claims for disability under both title II and title XVI, documentation of medical signs or laboratory findings in cases involving CFS is critical to establishing the presence of a medically determinable impairment. In cases in which CFS is alleged, longitudinal clinical records reflecting ongoing medical evaluation and treatment from the individual's medical sources, especially treating sources, are extremely helpful in documenting the presence of any medical signs or laboratory findings, as well as the individual's functional status over time. Every reasonable effort should be made to secure all available, relevant evidence in cases involving CFS to ensure appropriate and thorough evaluation.

Generally, evidence for the 12-month period preceding the month of application should be requested unless there is reason to believe that development of an earlier period is necessary, or unless the alleged onset of disability is less than 12 months before the date of the application.

2. Recontacting Medical Sources/Consultative Examinations

If the adjudicator finds that the evidence is inadequate to determine whether the individual is disabled, he or she must first recontact the individual's treating or other medical source(s) to determine whether the additional information needed is readily available, in accordance with 20 CFR 404.1512 and 416.912. Only after the adjudicator determines that the information needed is not readily available from the individual's health care provider(s), or that the necessary information or clarification cannot be sought from the individual's health care provider(s), should the adjudicator proceed to arrange for a consultative examination(s) in accordance with 20 CFR 404.1519a and 416.919a. The type of consultative examination(s) purchased will depend on the nature of the individual's symptoms and the extent of the evidence already in the case record.

3. Resolution of Conflicts

It should be noted that conflicting evidence in the medical record is not unusual in cases of CFS due to the complicated diagnostic process involved in these cases. Clarification of any such conflicts in the medical evidence should be sought first from the individual's treating or other medical sources.

Medical opinions from treating sources about the nature and severity of an individual's impairment(s) are entitled to deference and may be entitled to controlling weight. If we find that a treating source's medical opinion on the issue(s) of the nature and severity of an individual's impairment(s) is well-supported by medically acceptable clinical and laboratory diagnostic techniques and is not inconsistent with the other substantial evidence in the case record, the adjudicator will give it controlling weight. (See SSR 96-2p, "Titles II and XVI: Giving Controlling Weight to Treating Source Medical Opinions," and SSR 96-5p, "Titles II and XVI: Medical Source Opinions of Issues Reserved to the Commissioner".)

4. Assessing Credibility

In accordance with SSR 96-7p, if the existence of a medically determinable impairment that could reasonably be expected to produce the symptoms has been established, as outlined above, but an individual's statements about the intensity, persistence, or functionally limiting effects of symptoms are not substantiated by objective medical evidence, the adjudicator must consider all of the evidence in the case record, including any statements by the individual and other persons concerning the individual's symptoms. The adjudicator must then make a finding on the credibility of the individual's statements about symptoms and their functional effects. When additional information is needed to assess the credibility of the individual's statements about symptoms and their effects, the adjudicator must make every reasonable effort to obtain available information that could shed light on the credibility of the individual's statements.

5. Treating and other medical sources

In evaluating credibility, the adjudicator should ask the treating or other medical source(s) to provide information about the extent and duration of an individual's impairment(s), including observations and opinions about how well the individual is able to function, the effects of any treatment, including side effects, and how long the impairment(s) is expected to limit the individual's ability to function. Opinions from an individual's medical sources, especially treating sources, concerning the effects of CFS on the individual's ability to function in a sustained manner in performing work activities or in performing activities of daily living are important in enabling adjudicators to draw conclusions about the severity of the impairment(s) and the individual's RFC. In this regard, any information a medical source is able to provide contrasting the individual's impairment(s) and functional capacities since the alleged onset of CFS with the individual's status prior to the onset of CFS will be helpful in evaluating the individual's impairment(s) and its functional consequences.

Third-party information, including evidence from medical sources who are not "acceptable medical sources" for the purpose of establishing the existence of a medically determinable impairment, but who have provided services to the individual, may be very useful in deciding the individual's credibility. Information other than an individual's allegations and reports from the individual's treating sources helps to assess an individual's ability to function on a day- to-day basis and to depict the individual's capacities over a period of time. Such evidence includes, but is not limited to:

  • Information from neighbors, friends, relatives, or clergy

  • Statements from such individuals as past employers, rehabilitation counselors, or school teachers about the individual's impairment(s) and the effects of the impairment(s) on the individual's functioning in the work place, rehabilitation facility, or educational institution

  • Statements from other practitioners with knowledge of the individual, e.g., nurse-practitioners, physicians' assistants, naturopaths, therapists, social workers, and chiropractors

  • Statements from other sources with knowledge of the individual's ability to function in daily activities

  • The individual's own record (such as a diary, journal, or notes) of his or her own impairment(s) and its impact on function over time

The adjudicator should carefully consider this information when making findings about the credibility of the individual's allegations regarding functional limitations or restrictions.

EFFECTIVE DATE: This Ruling is effective on April 30, 1999.

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Short-Term Disability

If your FM and/or CFS/ME is preventing you from doing your job or going to work, the best place to begin is with your employer's Human Resources (HR) Department. You need to ask about the company's policy for short-term disability and what the requirements are to be eligible for it. Often two to three months of rest and lack of stress can improve FM and/or CFS/ME symptoms to the point where it's possible to return to work. The reassuring news is that if your company employs more than 50 people your employer is required to keep your job open for you under the Family Medical Leave Act, which protects those who need to take time off for a medical condition.

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Long-Term Disability

Long-term disability insurance is offered through private employers and also through the federal government as Social Security Disability Insurance (SSDI). If a person qualifies, disability insurance will provide a reasonable replacement of monthly earnings for extended periods of time.

According to government statistics, only 15 to 20 percent of FM and/or CFS/ME sufferers are currently on long-term disability; however, because many people with FM and/or CFS/ME also suffer from overlapping conditions, these other illnesses may be cited as the reason for long-term disability rather than the FM and CFS/ME itself.

If your employer provides long-term disability insurance, your first step should be to talk to the HR department and find out how to apply for it.

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Who Qualifies for Disability?

In order to qualify for long-term disability, you must have been employed in the past five years and stopped working because you became disabled. Other qualifications the Social Security Administration (SSA) will look at include whether your condition is on the list of disabling medical conditions, and if not, if it's severe enough to keep you from holding down a job. Currently, FM and CFS/ME are on the list of disabling impairments, which should make proving a case for long-term disability easier, though by no means makes it a sure thing. Good record keeping and symptom tracking is very important.

The SSA also examines the type of work you've been doing over the last 15 years, and if you are able to perform other types of work. To qualify for long-term disability benefits, you must be unable to return to full-time work of any kind because your activities of daily living have been so severely impaired by your illness. These "activities of daily living" might include your ability to shop for groceries, to drive, to make your own food, or even to take a shower on your own.

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Applying for Long-Term Disability

If you do decide to file for long-term disability, the first thing you should do is contact your local social security office and request a disability application. (You can also apply online at http://www.ssa.gov/.)

The Social Security Administration can then request your medical records directly, so make sure they include a clear diagnosis, preferably from a rheumatologist or other specialist, before submitting this paperwork. Sometimes, a medical record will say something like "displaying symptoms of FM and/or CFS/ME," without offering a clear diagnosis, and this can cause a denial of disability benefits. The more specific your doctor can be, the better - for example, rather than just stating that you have FM and/or CFS/ME, have your doctor note all the finer points of your symptoms and how those symptoms are interfering with your ability to perform your job.

After your forms are submitted, you may be asked to take what is called an independent physical examination (IME), which is often conducted by a physician hired by an insurance company. Your application will then either be accepted or denied. Unfortunately, only 35 percent of all disability applications are accepted at this point, so it's common to have to appeal the SSA's decision. Applicants have the option to appeal within 60 days by filing the Appeal Disability Report form (which can also be done online). Some people also hire an attorney who specializes in disability law and, though this is not a requirement, it can be very helpful to have an experienced advocate guiding you through the application process.

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Staying in the Workforce

If you're not sure that the idea of leaving work is right for you just yet, consider these options:

Job modifications: Are there any adjustments you could make, so that you could continue working instead of going on disability? (An ergonomic desk or keyboard, for example.) What about more frequent rest periods? Talk your situation over with your doctor. He or she will be able to tell you if your job complicates your condition and if it would be best to go on disability.

Job change: You may also want to explore other jobs within the company, or consider cutting down on your hours. There's an emotional component to being on disability: besides providing an income, one's job also often provides a social network and sense of purpose. That said, remember that if you cut down your hours now and then go on disability later, you'll be paid at the lower rate; or, in the event that you can't keep up with a new position and are fired, you'll have no recourse.

It is well to remember that applying for long-term disability is a process that can take months to years to complete, especially with a complicated disorder like FM and/or CFS/ME. However, if you're unable to work, it might be the best option for you.


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