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Medical Criteria Needed to Qualify with Chronic Heart Failure

Receiving a health diagnosis such as chronic heart failure (CHF) can be a devastating, life-altering moment in your life. Fortunately, you might be eligible for Social Security disability benefits to help pay for medical bills while you're unable to work. As a result, you will be able to focus on what is most important: your health and recovery.

The Importance of the “Blue Book”

The SSA uses a medical guide, known as the Blue Book, to determine whether your specific heart failure is severe enough to warrant disability payments. Each condition in the Blue Book lists specific criteria and symptoms that you must have in order to be approved.

It is of vital importance to work closely 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.

Chronic heart failure is listed in the cardiac section, 4.02, of the Blue Book. In some cases, CHF is caused by lung disease. If this is the case for you, you will be evaluated under the respiratory section, 3.09, of the Blue Book.

To help you navigate this 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.

Medical Criteria Needed to Qualify with Chronic Heart Failure

Evidence Needed Related to Your Heart Failure

The first type of proof that the Blue Book directly requests is a complete medical history of your chronic heart failure.

Your cardiologist should perform a thorough physical exam and obtain your medical history. He or she should be certain to document any of the following symptoms that you may experience:

  • Excessive fatigue
  • Weakness, dizziness, or lightheadedness
  • Shortness of breath
    • If you require the use of more than one pillow to sleep due to shortness of breath, be certain to report it to your doctor. Difficulty breathing while lying flat, or orthopnea, is a common side-effect of CHF.
    • If your shortness of breath awakens you from a sleep, be certain that this is documented in your chart.
  • Cough, especially with wheezing or rales
  • Chest discomfort both at rest or with activity
  • Heart [palpitations
  • Fainting (syncope) episodes
  • Swelling or fluid in your abdomen (ascites) or in your arms or legs
  • Be certain that your cardiologist addresses the following in your record:
    • Any evidence of a swollen liver
    • Increased jugular venous distention (JVD)
    • Evidence of fluid retention

Imaging such as a chest x-ray, echocardiography, radionuclide studies, or cardiac catheterization are paramount to have in your record. The following evidence may help to determine your eligibility for benefits:

  • An enlarged heart (cardiomegaly)
  • Systolic heart failure (inability of the heart to contract normally and expel blood) with either:
    • Decrease in the percentage of blood that the heart’s ventricle is able to pump out, which is also called the ejection fraction (EF). Typically, an EF of 30% or less determines CHF
    • Left ventricular end diastolic dimensions (LVEDD) greater than 6 cm.
  • Diastolic heart failure (inability of the heart to relax and fill with blood) with either:
    • Left ventricular posterior wall plus septal thickness totaling 2.5 cm or greater
    • An enlarged left atrium greater than or equal to 4.5 cm
    Hospitalization records and careful documentation of any acute episodes of congestive heart failure can also be contributed as evidence. If you have had 3 episodes of acute heart failure within a year, you may be eligible for benefits from the SSA. You can help prove this with test results such as:
    • CBC and BMP: These blood tests will measure how well other organs, such as your kidney and liver, are functioning given your CHF
    • B-type natriuretic peptide (BNP) or N-terminal pro-BNP: These tests will measure the hormone that indicates how well your left ventricle is working
    • Thyroid hormones: An imbalanced thyroid can sometimes cause heart failure
    • 12 lead ECG/EKG tests
    • Exercise Tolerance Test (ETT), also sometimes called a stress test, if indicated safe by your cardiologist

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 cardiologist to gather this medical information.

Treatments for Chronic Heart Failure as Evidence

The treatment for CHF is quite complex and 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 heart failure has progressed despite those treatments.

Possible treatments for CHF may include:

  • Medications, such diuretics, beta blockers, ACE inhibitors, Digoxin, aldosterone antagonists
  • Sometimes those with CHF will have an internal defibrillator (ICD) placed in the chest or an LVAD, which helps the heart to pump through the body
  • Coronary bypass surgery
  • Oxygen supplementation
  • Heart transplant

Many people with heart failure will not meet the Blue Book’s qualifying conditions. However, you may still be unable to work. The SSA will want detailed evidence regarding any medications that you’re taking while undergoing therapies, side effects that you might experience, and your response to treatment.

Some information needed includes, but is not limited to:

  • Medications you receive, including the doses and timing
  • Your plan for continuing medication
  • Any related medical complications, like weakness, neurological complications, breathing problems, or intellectual problems
  • Common side effects of CHF include weight loss, extreme fatigue, malaise, kidney and liver problems. If you experience any of these symptoms and they cause severe or “marked” limitations, be certain to tell your physician so that he or she can document these side effects in your record.
  • If you have received a heart transplant, you will be awarded disability benefits for at least one year from the day of your treatment. Be certain that this is accurately documented.

Information on your reactions and side effects to your treatments is essential to provide to the SSA because not every person with heart failure will meet a Blue Book listing.

So long as you can prove that you’re still too ill to work due to 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 noted above, you may not qualify for SSDI under the Blue Book listing. However, you still may be too ill to work. If this is the case, your cardiologist should provide physician notes documenting his or her opinion regarding your limitations and inability to function without unscheduled breaks or days off.

Your physician should also document any new difficulties that you have around maintaining social contacts and your ability to communicate with others.

In addition, if you are in the care of other health care practitioners because of your heart failure, such as a psychologist or a cardiac rehabilitation therapist, you should obtain progress notes from them as well.

The more accurate and detailed that your doctor is about your limitations, such as your ability to prepare meals or dress yourself, the better your chances are of being approved for disability benefits.

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 chronic heart failure.

The entire Blue Book is available online and is quite complex and detailed, so you may want to review sections 4.02 with your cardiologist 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.

For more tips on applying for disability benefits with heart failure, please see our page: Tips on Applying for Disability Benefits with Heart Failure

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 hematologist can help including:

  • Ensuring that your full medical history related to your heart failure is up to date
  • Listing your upcoming treatments and their durations
  • 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 CHF claim.