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Medical Criteria Needed to Qualify with Emphysema

If you have been diagnosed with emphysema, you might be eligible for Social Security disability benefits. The Social Security Administration (SSA) offers financial aid for people who are unable to work due to a serious condition like emphysema.

The Importance of the “Blue Book”

The SSA uses the Blue Book, to determine whether or not a condition such as emphysema is severe enough to warrant disability payments. The Blue Book is a medical guide outlining exactly what's needed to be approved for benefits. Each condition in the Blue Book lists specific criteria and symptoms that you must have to be approved.

Many of the listings include information on the specific evidence required, such as clinical and laboratory tests. It is of vital importance to work with your health care providers to ensure that you have completed all of the medical tests required by the SSA and that all of your medical evidence is in order.

Emphysema is a respiratory disorder that is covered in section 3.02 of the Blue Book. The SSA may also evaluate your limitations based on body systems affected by your emphysema. 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 Emphysema Diagnosis

The first type of medical evidence that the Blue Book directly requests is a complete medical history of your emphysema. You should be able to provide the following evidence:

  • 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: Arterial blood gases (ABG) are a measurement of how well your lungs are functioning. People with emphysema, also called restrictive lung disease, often have difficulty expelling carbon dioxide. As a result, the pH of their blood may become acidic. This blood test will help to measure how well your body is taking in oxygen and releasing carbon dioxide, as well as keeping your body’s pH in balance.

Pulse Oximetry Levels: Oxygen saturation, often referred to as O2 sats, is a measure of the oxygen level in your blood. A normal O2 sat is 98-100%, but those with emphysema often have much lower readings. You should be able to provide records of your O2 levels over time, specifically if they have trended down.

Imaging tests that may show evidence of emphysema, such as a chest x-ray or CT scan, documentation of your use of supplemental oxygen, including the flow rate. Pulmonary (Lung) Function Tests are for those with emphysema will need to show limited air flow through the lungs. Pulmonary function tests should include the following four things:

  • Spirometry results – Spirometry measures how well you move air in and out of the lungs. Spirometry results are based on age, gender, and height, and the appropriate tables can be found in Section 3.02 of the Blue Book. The results should include:
  • FEV1 (The amount of air you can force out of your lungs in 1 second)
  • FVC levels (Forced vital capacity is the total amount of air exhaled during the test)
  • DLCO – Diffusing capacity of the lungs for carbon monoxide is a test that measures gas exchange across cell membranes in your lungs, specifically how well oxygen travels from the sacs of your lungs to the bloodstream. DLCO tests are based on gender and height and can be found in Section 3.02 of the Blue Book.
  • ABG tests – Arterial blood gases measure carbon dioxide and oxygen levels in the arteries. The test should be done while at rest or during steady exercise, on room air. In other words, supplemental oxygen should not be used at the time of the test.
  • Pulse oximetry – As discussed earlier, pulse oximetry measures oxygen levels. Results vary depending on altitude but typically are below 87% for those diagnosed with emphysema.
  • Records of hospitalizations – If you have experienced an exacerbation of your illness that has required at least three hospitalizations that occurred at least 30 days apart over the course of a year, you should provide documentation of your hospital stays.

While any doctor can provide this information, the SSA gives more weight to the opinion of medical specialists. Therefore, it is important that you work with your pulmonologist to gather this medical information.

Evidence Needed Related to Affected Body Systems

Cardiovascular System (4.00) – Those with emphysema 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

Evidence Needed Related to Your Emphysema Treatments

Emphysema cannot be cured, but it can often be effectively managed. The treatment for emphysema 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 will meet a particular qualifying condition’s listing, but you may be unable to work regardless. Information on your reactions and side effects to your treatments or medications are essential to provide to the SSA.

So long as you can prove that you are too ill to work due to complications that will persist for at least one year, you may still qualify for financial assistance.

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

Many people with emphysema 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, such as your ability to walk without severe breathlessness or your ability to take a shower without assistance, the better your chances are of being approved for disability benefits.
  • If you are suffering from severe shortness of breath, coughing, or wheezing, and if you are unable to work due to limitations from your disease, you may still qualify for disability through a residual functioning capacity assessment.

Steps You Can Take to Win Your Disability Claim

If you haven’t applied yet, or if you have applied and were denied, remember that medical evidence listed in the Blue Book is arguably the most important factor in your Social Security disability claim for emphysema.

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.

There are several ways your pulmonologist or primary care physician can help including:

  • Ensuring that your full medical history related to your emphysema is up to date
  • Listing your past treatments and responses, as well as the plan for the future
  • Documenting all of your medications and experienced side effects
  • Performing any additional blood tests or procedures that you are missing

A Social Security disability attorney or advocate can assist you in ensuring that you 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 emphysema claim.