Medical Criteria Needed to Qualify with Osteoarthritis

Receiving a health diagnosis such as osteoarthritis can be a life-changing experience. Sadly, while may have permanently changed, the financial responsibilities of life do not go away.

The Social Security Disability Insurance Program (SSDI) was developed to assist people, such as yourself, who are disabled due to a diagnosis such as osteoarthritis.

Not everyone who has osteoarthritis will automatically be awarded financial assistance for the condition. In fact, many people who are medically eligible for disability benefits with osteoarthritis are denied benefits due to a lack of sufficient medical documentation.

You are responsible for providing the evidence regarding their condition and its severity by correctly stating who has treated your condition as you've received treatments for osteoarthritis.

Is Osteoarthritis a Disability?

If you have been diagnosed with osteoarthritis, your joints are most likely to be stiff, leading to severe pain which in the long term may limit your ability to undertake even the simplest of tasks. Because of the severity of osteoarthritis the Social Security Administration (SSA) has determined that it is a disability, meaning you may be eligible to receive disability benefits.

When submitting your application to the SSA your diagnosis and medical evidence should be in the SSA’s Blue Book listing. Osteoarthritis is given a mention in section 1.04 of the Blue Book which is “Disorders of the Spine.”

You need to provide evidence showing nerve root compression which limits the spine’s movement, muscle weakness and sensory or reflex loss if the lower back is involved.

Spinal arachnoiditis is another symptom of osteoporosis which should be confirmed by a pathology report of a tissue biopsy, or through medically acceptable imaging results.

It causes a severe burning sensation or painful dysesthesia, which means you have to regularly change position or posture. Lumbar spinal stenosis leading to pseudoclaudication is another example of the onset of osteoporosis and should be confirmed by established by the results from medically acceptable imaging.

It leads to chronic nonradicular pain and weakness which significantly restricts movement. If you have been diagnosed with osteoarthritis and you have the medical evidence that matches one or more of the features found in the Blue Book the SSA will confirm that you qualify for Social Security disability benefits.

The Importance of the “Blue Book”

The SSA uses its own medical guide, colloquially known as the Blue Book, to determine whether or not your unique osteoarthritis diagnosis will qualify for Social Security disability benefits. All conditions found in the Blue Book contain specific medical criteria and symptoms that you must have evidence of to be approved.

While Osteoarthritis is not specifically listed in the Blue Book, the condition is covered in the Musculoskeletal section, 1.00, of the Blue Book. Additionally, depending on the underlying disease, it may also be considered under the Inflammatory arthritis section, 14.09.

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 Osteoarthritis

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

  • An explanation of any weight-bearing joints involved, such as the hip, knee, or ankle, and how it affects your ambulation and mobility.
  • An explanation of any peripheral joints involved, such as the shoulder, elbow, wrist, and hand, and how it affects your fine and gross motor movements.
  • Any visible deformity to your joints such as subluxation, contractures, bony or fibrous ankyloses, or any instability of your joints.

As osteoarthritis is not specifically listed as a condition in and of itself, it is vital that your physician document the following:

  • Any inability to ambulate effectively, such as to walk reasonable distances or to use stairs
  • Any required use of assistive devices such as a cane, walker, or crutches
  • Any pain that you experience related to movement
  • Any inability to perform fine and gross motor movements
  • Your ability, or lack thereof to travel without a companion to and from work
  • Any difficulties you have grocery shopping, banking, using public transportation, preparing a meal, feeding yourself, showering, etc.
  • If you have had surgery, such as a joint replacement, surgical records from your orthopedic surgeon should be included. Of specific importance is any surgery that you have required on a weight-bearing joint.
  • X-rays, CT scans, MRIs, radio-nuclear bone scans, or other imaging results that may help to confirm your diagnosis or the severity of your arthritis.
  • Electro-diagnostic procedures, such as nerve conduction studies, if applicable
  • Neurological or spinal exams, as appropriate
  • Procedural notes, such as cortisone injections

Evidence Needed Related to Your Osteoarthritis Medications and Treatments

Many patients who have osteoarthritis take medications, which may include analgesics, NSAIDS, corticosteroids, and hyaluronic acid. Other treatments for osteoarthritis include physical therapy, occupational therapy, and lifestyle modifications.

It is critical that your physician documents the following:

  • Medications you receive, including the doses
  • How often you require medication
  • Any side-effects that you have experienced related to your medications
  • Any physical or occupational therapy that you receive and how often it is required
  • Any changes to your life as a result of your osteoarthritis

Information on your reactions and side effects to your treatments are essential to provide to the SSA because not every person with osteoarthritis will meet a Blue Book listing. So long as you can prove that you’re still too ill to work due to osteoarthritis complications that will persist for at least one year, you might still qualify if you pursue the claim further.

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

As osteoarthritis is not specifically listed in the Blue Book, it is vital that your physician document your quality of life and ability to care for yourself. The majority of people who have arthritis do not qualify for SSDI benefits through the Blue Book musculoskeletal listing.

However, you still may be too ill to work. If this is the case, your physician should provide 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.

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 arthritis.

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 that your physician can help including:

  • Ensuring that your full medical history 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
  • Carefully documenting your physical exam, including all limitations

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 osteoarthritis claim.