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Medical Criteria Needed to Qualify with Knee Replacement

Knee replacement surgery, or knee arthroplasty, is a common surgical procedure in the United States. While most patients fully recover from knee replacement surgery, a small number of people experience complications, such as knee replacement failure.

While you are recovering from your knee replacement surgery, 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 have become disabled due to knee replacement complications.

Unfortunately, not everyone who applies for SSDI for a knee replacement will be awarded financial assistance for their disability. In fact, many people who rightfully deserve disability assistance have been denied due to their inability to provide sufficient medical documentation.

Medical evidence is one of the most important components of your Social Security claim after a knee replacement.

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 a knee replacement surgery is severe enough to warrant disability payments. 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.

SSA Medical Criteria for a Knee Replacement

You can find out more about applying with a knee replacement here:

How to Apply for SSD Benefits for a Knee Replacement

A knee replacement is evaluated under the reconstructive surgery or surgical arthrodesis of a major weight-bearing joint section, 1.03 of the Blue Book. As a general rule, the SSA considers a knee replacement to be a successful surgery, as most people recover within a year.

However, there are instances where benefits may be awarded. 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 Knee Replacement

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

  • Records from your physician should include your presenting symptoms as well as the results of a full physical examination. The physical examination notes should include:
    • Any inability to ambulate effectively, such as to walk sufficient distances at a reasonable pace
    • Your ability to ambulate up and down stairs, including whether or not you need to use a handrail
    • Any required use of assistive devices such as two canes, two crutches, or a walker or wheelchair
    • Any pain that you experience related to movement
    • Your ability, or lack thereof, to travel without a companion to and from work or school
    • Any difficulties you have grocery shopping, banking, using public transportation, preparing a meal, feeding yourself, showering, etc.
  • All of your surgical records from your orthopedic surgeon should be included, including a full operative report. For more information about getting medical records
  • X-rays, CT scans, MRIs, radio-nuclear bone scans, or other imaging results that may help to confirm any difficulty that you have had healing from your surgery.
  • Any secondary infections or complications that may have occurred as a result of your surgery, including skin infections, wound infections, and blood clots.
  • The SSA considers financial assistance for a knee replacement if the individual has not returned, or is not expecting to return, to adequate ambulation within a year. Therefore, longitudinal records are critical to your application.

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 orthopedic surgeon to gather this medical information.

Evidence Needed Related to Your Knee Replacement Medications and Treatments

Many patients who have a knee replacement take medications, which may include analgesics and NSAIDs. In rare cases, some people may still require steroid injections or pain blocks.

Other treatments for a knee surgery 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 knee replacement

Information on your reactions and side effects to your treatments are essential to provide to the SSA because not every person who requires a knee replacement will meet a Blue Book listing.

So long as you can prove that you’re still too ill to work due to your knee replacement and your condition will persist for at least one year, you might still qualify if you pursue the claim further.

Evidence About Your Quality of Life and Ability to Care for Yourself

As the SSA considers knee surgery a success, most people will not qualify for SSDI benefits. If you have experienced complications from your knee replacement, it is vital that your physician document your quality of life and ability to care for yourself.

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. You can find more about working with your doctor to present evidence for your application at our page: Getting a Letter of Support From Your Doctor

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 your knee replacement.

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 speaking with with a Social Security advocate or attorney in your area today—Disability lawyers are only paid if you win your knee replacement claim.