Medical Criteria Needed to Qualify with COPD

If you or a loved one has COPD, there may be financial resources available. If your COPD causes you to be out of work for at least 12 months, then yes, you could qualify for Social Security Disability Insurance (SSDI).

When you apply for SSDI with COPD, in order to be approved, you need to meet a certain medical criteria outlined by the SSA.

That medical criteria will need to be supported by sufficient medical evidence that shows that your COPD is severe enough that you cannot work.

Once an individual is approved for SSDI benefits, he or she can use that money to spend on medical treatment and medicine related to COPD, as well as basic day-to-day need. Below is more information on the medical criteria needed to help qualify you for SSDI benefits.

For individuals suffering from breathing problems, meeting the demands of a job can be difficult, if not impossible. Chronic Obstructive Pulmonary Disease (COPD), is one such respiratory disease that impacts close to 16 million Americans.

A diagnosis of COPD alone is not always enough to earn an award for financial assistance. To be considered disabled, you will need to provide sufficient medical evidence to the Social Security Administration (SSA) to illustrate that your COPD is severe enough to warrant disability payments.

The burden of proof falls on the SSDI applicant to prove that you are unable to work due to your COPD diagnosis. Your ability to provide this evidence in a timely and accurate fashion will enhance your chances for benefit approval.

IS COPD A Disability?

The SSA defines a disability as the inability to engage in what they called substantial gainful activity, which is work that involves significant and productive duties and pays more than the current monthly income limits set by the SSA by reason of any physical or mental impairment(s) which has lasted or can be expected to last for a continuing period of 12 months or more or result in death.

If you have COPD and you believe it will force you to be out of work for 12 months or if it is so severe that it will result in your death, then your COPD would be considered a disability and you could qualify for Social Security disability benefits.

The Importance of the “Blue Book”

The SSA uses a medical guide, known as the Blue Book, to determine whether or not a condition such as COPD is severe enough to warrant disability payments. COPD is listed in the chronic respiratory disorder section of the Blue Book, 3.02.

To qualify for disability benefits, you will need to meet several requirements listed in section 3.02 of the Blue Book. The SSA may also evaluate your limitations based on body systems affected by your COPD.

Therefore, your condition may also be assessed under the cardiovascular system (4.00) of the Blue Book.

To help you with the information gathering process, here is the most relevant medical evidence that you will need to provide to give you the best chance of being approved for SSDI.

Evidence Needed Related to Your COPD Diagnosis

The first type of medical evidence that the Blue Book directly requests is a complete medical history of your COPD.

You should be able to provide the following records from your physician or pulmonologist should include your presenting symptoms, the progression of your lung disease, as well as the results of a full physical examination.

Several tests will help to confirm your diagnosis, and the following should be included in your records:

  • Arterial Blood Gas
  • Pulse Oximetry Levels
  • Imaging tests that may show evidence of COPD, such as a chest x-ray or CT scan
  • Documentation of your use of supplemental oxygen, including the flow rate
  • Pulmonary (Lung) Function Tests
  • Spirometry results
  • ABG tests
  • Pulse oximetry
  • Records of hospitalizations

While any doctor can provide this information, the SSA gives more weight to the opinion of medical specialists. Therefore, you should work with your pulmonologist to gather all of your medical evidence.

Evidence Needed Related to Affected Body Systems

Cardiovascular System (4.00) – Those with COPD sometimes experience difficulties with their heart due to the decreased oxygen levels. As a result, you may need to provide the following evidence of heart problems:

  • ECG results
  • Stress test results
  • Echocardiogram results
  • Evidence of chest pain (angina), history of fainting (syncope) history of a heart attack, or a cardiac catheterization

Pulmonary Function Tests and Social Security Disability

Pulmonary function tests are noninvasive tests that show how well the lungs are working. The results from this test can help show the SSA that your COPD is severe enough that it will force you to be out of work for at least 12 months.

There are a couple of pulmonary function tests that can help show the severity of your COPD. If just one of these tests shows a severe limitation in lung function, then you may be able to qualify for Social Security disability benefits. These tests include:

  • Spirometry Test: A spirometer is a device with a mouthpiece hooked up to a small electronic machine. This measures your lung’s ability to expel air when you breathe. It’s determined using FEV value, or “forced expiratory volume”
  • Plethysmography Test: She’s much air is in your lungs after you take in a deep breath. It’s used to compare your lung function with known standards that show how well your lungs should be working.
  • These pulmonary function tests can help measure and show the affects and severity of your COPD. If you are applying for Social Security Disability Benefits with COPD, having these tests to include with your application can really help show the SSA that your COPD is so severe and that you can no longer work.

    Evidence Needed Related to Your COPD Treatments

    COPD cannot be cured, but it can often be effectively managed. The treatment for COPD will depend on the severity of the illness.

    The SSA will need to know what treatments you have received, your response to those treatments, and most importantly if your respiratory status has worsened despite those treatments.

    Be certain that your doctor has documented the following:

    • Medications that you are receiving, such as bronchodilators, inhaled steroids, and antibiotics, as well as your response to the medications:
    • Respiratory therapy or pulmonary rehabilitation that you may be receiving
    • Supplemental oxygen needs, especially if your needs have increased
    • Any surgeries or procedures that you may have had, including operative notes or pathology reports, if applicable
    • Any related medical complications, such as weakness, neurological complications, heart problems, or intellectual difficulties

    The Blue Book notes that not every patient who has COPD will meet the listing, but you may be unable to work regardless. For example, you may experience dizziness, fainting, or excessive and unintentional weight loss.

    While these symptoms are not listed in the Blue Book under section 3.02, they may still impede your ability to work.

    Doctor's looking at x-ray

    Additionally, medications that you are taking such as steroids or bronchodilators may come with side effects. Providing this information to the SSA is of vital importance. If you can prove that your condition is so severe that you are unable to work in the upcoming year, you may be considered for disability assistance.

    Evidence Needed Related Your Quality of Life and Ability to Care for Yourself

    Many people with COPD do not qualify for SSDI benefits through the Blue Book respiratory listing. However, you still may be too ill to work.

    If this is the case, your pulmonologist should provide physician notes documenting his or her opinion regarding your limitations and inability to function without unscheduled breaks or days off.

    The more specific that your doctor is about your limitations, the better your chances are of being approved for disability benefits. If you are unable to work due to limitations from your disease, you may still qualify for disability through a residual functioning capacity assessment.

    How Long Does it Take To Get Disability for COPD?

    After you send in your initial application if you are applying for Social Security disability benefits, it usually takes the SSA between three to five months to get back to you with a decision whether or not your disability claim for COPD was accepted or denied.

    Man waiting for disability benefits

    If the SSA approves your claim, your benefits should begin within a few months. If you waited for more than five months to get approved, you will be awarded back pay on top of your monthly benefits.

    Back Pay refers to Social Security Disability benefits that you would have received had your claim been approved immediately.

    The SSA calculates Back Pay is related to the date you filed your disability claim and the date that they decide that your disability began, also known as the “established onset date.”

    So, depending on the severity of your COPD, to get disability for COPD it could take anywhere from a few months to upwards of a year.

    Steps You Can Take to Win Your Disability Claim

    If you are currently in the process of applying for SSDI, or if you were denied in the past, getting your medical evidence in order is the most important step that you can take to win your disability claim for COPD.

    Working with a disability lawyer

    The entire Blue Book is available online, and the section on Respiratory Illness is quite detailed, so you may want to review section 3.00 with your pulmonologist to determine what medical records you have on hand, and what may need to be supplemented to be approved.

    You may need to contact the medical records office at your hospital to obtain some of this information.

    While you don’t need to provide medical documentation to the SSA yourself, it is helpful to be as organized as possible. When you visit your doctor, it is a good idea to present a written list of symptoms and side-effects that you are experiencing.

    A Social Security disability attorney or advocate can assist you in ensuring that your claim for disability is thorough, thus increasing your chances for approval. Consider a Free Evaluation with a Social Security advocate or attorney in your area today—Disability lawyers are only paid if you win your COPD claim.