If you have undergone knee replacement surgery, and you are unable to work during your recovery period or because you have suffered complications from the surgical procedure, you may be eligible to receive Social Security Disability benefits. The Social Security Administration (SSA) offers a Social Security Disability Insurance (SSDI) program for those who have worked enough to earn adequate credits and who have paid in enough taxes.
In order to be eligible to earn monthly disability benefits through the SSDI program, you have to be completely disabled. The medical manual used by the SSA’s Disability Determination Services is called the Blue Book. While almost a quarter of a million Americans undergo knee replacement every year according to the National Institutions of Health, some people have lengthier recoveries or may have serious joint issues that may require additional replacement surgeries.
Some people may qualify for SSDI benefits because of degenerative diseases that have caused the joints to degrade, congenital disorders that have caused joint degradation throughout time, or suffered an injury from an accident that has caused joint degradation that requires surgery. In some cases, the SSA may be able to help you cover the costs of joint replacement surgery if your condition is severe enough that you can be awarded benefits prior to the surgical procedures. You can then you use your monthly disability check to help you pay for your medical expenses. After having been disabled for two years, you may be eligible for Medicare benefits, which is the government insurance plan.
The Cost of Knee Replacement
According to Healthline, the average hospital charge for knee replacement in the United States is $49,500. Blue Cross Blue Shield indicates that the price varies from state to state and hospital to hospital ranging from $16,772 to $61,585 throughout the U.S.
There are additional costs for pre-op and post-op physician visits, prescriptions, and additional charges for extensive physical therapy which is required to assist with the recovery process. So a knee replacement surgery does require extensive medical treatment. There are some patients who develop complications after the surgery as well.
The Evaluation Conducted by the Social Security Administration and the Medical Qualifications
The SSA adheres strict guidelines that pertain to determining whether an individual meets the requirements of being disabled and eligible for SSDI benefits. If you are unable to work during your recovery period after knee replacement or because you have suffered from surgical complications, you may be eligible for SSDI.
Knee replacement surgery claims are evaluated using several different SSA listings under the Blue Book. Here are two examples of listings that may apply for knee replacement surgery:
- Section 1.02 – Major Dysfunction of a Joint
- Section 1.03 - Reconstructive Surgery or Surgical Arthrodesis of a Major Weight-bearing Joint
Individuals decide to undergo knee replacement surgery because they want to restore joint function and ease pain. Unfortunately, the surgery is not always successful. Patients are no always able to return to their regular lifestyles and former employment without experiencing severe limitations. Depending upon the kind of work you have been doing in the past, knee replacement surgery may keep you from working. Lasting impairment can result if the surgery results in complications.
Some patients have longer recovery periods and need extra therapy and treatment. Those individuals may not be able to walk for several months. The minimum length an individual has to be disabled in order to qualify for SSDI is 12 months. However, joint replacement surgery is often because of degenerative diseases such as osteoarthritis or rheumatoid arthritis, congenial defects, or an injury.
In those cases, the underlying cause and its other symptoms have to be considered as well. So you need to indicated your arthritis or other problem and what other symptoms that you suffer from the disorder and how those symptoms also impact your life.
Meeting Disability Criteria with an RFC
If you are unable to work but you do not meet the disability criteria per the Blue Book that is used by the SSA Disability Determination Services, you may meet the requirements of a medical vocational allowance using a residual functioning capacity form completed in detail by a physician.
When a physician completes a RFC, it must be done in detail. As an example, if your knee replacement requires you to reposition at least once every hour or hour-and-a-half that needs to be noted in the RFC. If you cannot bend and lift because of your problems, that should also be indicated.
If a medical vocational allowance is used, your age, educational background, skills, and work experience are taken into consideration. The disability determination team will check to see if your skills and education will enable you to do some other kind of job other than your most recent kind of employment.
Any medications that you take, including side effects, and any other medical conditions along with those symptoms and how they impact your daily life and ability to work should also be indicated. The more documentation and evidence that you include with your disability claim, the stronger your case.
You should also provide evidence with your claim if you have to use a cane to walk, are unable to climb stairs or ladders, how much you can lift and how frequently, the pace at which you can walk and at what distance you can walk. It is important that your medical provider include detailed notes in your medical files.
Applying Specific Medical Tests to Your Case for Disability
If your disability pertains to knee replacement, pertinent tests will include x-rays, scans, and MRIs. There should be tests done before the procedure and after as well. If you suffer from a degenerative or congenital disorder there should be tests, including lab work, that applies to that and that can be used as background evidence and as a way to prove your diagnosis.
The SSA may order a medical evaluation to determine that your condition does match the symptoms and condition that you have presented during the presentation of your case. This evaluation is with the physician they choose and they cover the costs. It is not for medical treatment, but for informational purposes only and to help them with their decision process.
Your disability claim can be denied twice and you can appeal those rulings. The final step is to request a hearing before an administrative law judge who will rule on the findings presented in the case.
Getting Help with Your Knee Replacement SSD Application
As the majority of knee replacements are successful in restoring most joint function for patients, being approved for disability benefits after a knee replacement can be tricky. You’ll need to work in coordination with your doctor to ensure your medical records are thorough and accurately reflect the limitations your condition imposes on you.
You may additionally want to consider seeking help with completing your SSD application from either a Social Security advocate or disability attorney. An attorney or advocate can improve your chances of being found eligible for benefits and ensure your application and documentation meet the SSA’s disability criteria.