Medical Criteria to Qualify with End Stage Renal Disease

End-Stage Renal Disease (ESRD), also referred to as kidney failure, is a progressive and life-limiting condition. Not only does kidney failure prevent you from living your day-to-day life, it typically inhibits your ability to maintain employment.

The Social Security Disability Insurance Program (SSDI) was developed to assist people, such as yourself, who have become disabled due kidney failure.

While most individuals who have ESRD will experience a smooth application process, this is not always the case. Unfortunately, not everyone who is diagnosed with kidney failure will be awarded the financial assistance that they so desperately need.

Each person who applies for financial support from the Social Security Administration (SSA) is responsible for providing the evidence regarding their condition and its severity.

Your ability to provide timely, accurate, and complete medical records about your illness will help your application to be processed more quickly. As a result, you will be able to focus on your health and recovery.

The Importance of the “Blue Book”

The SSA maintains a medical guide, also known as the Blue Book, to determine what evidence is required to deem a condition severe enough to warrant disability payments.

End-stage renal disease is covered in the genitourinary disorders section 6.00 of the Blue Book. Several of the listings in this section might apply to you.

For example, chronic kidney disease is listed in section 6.02 of the Blue Book. Some individuals who have kidney failure may get a kidney transplant, which is covered under section 6.04. Nephrotic Syndrome is listed in section 6.06. Those with ESRD will likely meet several listings in this category.

To fully understand which listing you meet, it is essential that you have a good working relationship with your physician and other related healthcare providers.

Your doctor can review the Blue Book and determine if additional medical tests required by the SSA are necessary. Further, he or she can help ensure that your medical evidence is in order.

Evidence Needed Related to Your ESRD Diagnosis

The first type of medical evidence that the Blue Book directly requests is a complete medical history of your kidney disease. You should be able to provide records from your physician should include your presenting symptoms, the progression of your kidney disease, as well as the results of a full physical examination.

Your physician should be certain to address any of the following symptoms you might experience:

  • Severe bone pain that interferes with activity or functioning
  • Peripheral neuropathy, such as tingling, numbness, muscle weakness, or pain in various parts of the body
  • Nausea, loss of appetite, or unintended weight loss
  • Excessive fatigue
  • Shortness of breath
  • Evidence of fluid retention such as fluid in your abdomen or swelling in your arms or legs
  • Evidence of fluid in your lungs
  • Evidence of heart failure as a result of your kidney disease

According to the Blue Book, to be approved for disability benefits, those with chronic kidney disease should have the following blood lab results:

  • Serum creatinine
  • Serum albumin
  • BUN
  • Estimated glomerular filtration rate (eGFR)
  • Imaging tests that may show evidence of your kidney disease, such as X-ray, CAT scan, MRI, or ultrasound.
  • Urine tests
  • Kidney or bone biopsy

The SSA welcomes any medical evidence that you provide. However, working with a medical specialist will add weight to your claim. Therefore, it is vital that you work with your nephrologist to gather this medical information.

Evidence Needed Related to Your ESRD Treatments

The treatment for kidney disease will depend on the primary cause and 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 health status has worsened despite those treatments.

Be certain that your doctor has documented the following:

  • Medications that you are receiving
  • Dialysis report including
  • Any procedures related to your kidney disease, such as paracentesis
  • Any surgeries or procedures, such as biopsies that you may have had, including operative notes or pathology reports, if applicable
  • Any related medical complications, such as weakness, neurological complications, respiratory difficulties, heart problems, or intellectual difficulties

If you do not meet any of the Blue Book listings for ESR, you may still qualify for financial assistance from the SSA. You will need to undergo a residual functioning capacity (RFC) evaluation so that Social Security can determine how your impairments limit your ability to work.

If you are able to demonstrate that your kidney failure is causing symptoms that make it too difficult for you to work for at least one year, you may still be able to qualify for financial help.

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

Some people with ESRD do not qualify for SSDI benefits through the Blue Book digestive listing. However, you still may be too ill to work. If this is the case, your nephrologist should provide physician notes documenting his or her opinion regarding your limitations and inability to function without unscheduled breaks or days off.

For example, those with kidney failure often experience severe fatigue, severe swelling of the legs and feet, and difficulty breathing.

The more specific that your doctor is about your limitations, such as your inability to shower without assistance or to stand for more than a few minutes, the better your chances of being approved for disability benefits through an RFC.

Steps You Can Take to Win Your Disability Claim

It can be incredibly challenging to apply for Social Security Disability benefits when you are not feeling well. After all, if you are too ill to work, additional tasks such as those required by the SSA can seem taxing.

Just remember, medical evidence listed in the Blue Book is likely to be the most significant factor in your claim for end-stage renal disease.

The entire Blue Book is available online, and the genitourinary section is quite detailed, so you may want to review section 6.00 with your nephrologist to determine what medical records you have on hand, and what may need to be supplemented to be approved.

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

  • Ensuring that your full medical history related to your kidney disease 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

If you are having difficulty gathering all of the required medical evidence, you may want to consider enlisting the help of a Social Security disability attorney or advocate in your area.

Not only can they request information for you, but they can be in constant communication with physicians and the SSA on your behalf. If you are worried about how you will afford a lawyer given your current financial situation, it is important to know that disability lawyers do not get paid unless you win your ESRD claim.

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