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Medical Criteria Needed to Qualify with Spinal Fusion

At one time or another, roughly 80% of Americans experience back pain. For some individuals with chronic pain, a spinal fusion surgery may be the only option.

Unfortunately, not all people who undergo back surgery have their pain relieved. In fact, some people end up experiencing more pain after surgery than they had before.

If you have undergone a spinal fusion and you are disabled, the Social Security Disability Insurance Program (SSDI) may be of assistance to you.

The Social Security Administration (SSA) assumes that most individuals who have undergone a spinal fusion will recover within a one-year time period.

Therefore, not everyone who applies for Social Security disability benefits following a spinal fusion will be awarded financial assistance.

Whether or not you are approved for disability benefits will depend on the quality and quantity of medical information that you are able to provide to the SSA.

Each person seeking financial support is responsible for providing the evidence regarding their condition and its severity.

Your approval will rest on your ability to prove that your spinal fusion surgery was unsuccessful and that you are no longer able to earn gainful employment as a result.

The Importance of the “Blue Book”

One of the easiest ways to qualify for SSDI benefits is if your condition meets the requirements listed in the Blue Book. The Blue Book is a medical guide used by SSA examiners to determine if particular conditions are severe enough to meet the definition of disability.

Spinal fusion surgeries are not explicitly listed in the Blue Book, although you might meet several other listings for your underlying spine problem. Disorders of the spine are listed in section 1.04 of the Blue Book.

Additionally, in the rare case that your condition has resulted in a spinal cord disorder, you may be evaluated in the neurological section, 11.08, of the Blue Book.

Even if you do not meet one of the listings described in the Blue Book, you may still qualify for financial assistance if you are able to provide enough medical evidence to demonstrate that you are too disabled to work.

Evidence Needed Related to Your Spinal Fusion

The first type of medical evidence that the Blue Book directly requests is a complete medical history of your spine disorder. Medical records from your physician are of vital importance.

She or he should include your presenting symptoms, the history and progression of your spinal disease, as well as the results of a full physical examination. Be certain that your doctor addresses the following:

  • Any leg pain that you experience that is caused by nerve root compression, referred to as pseudo claudication.
  • Loss of feeling or reflexes caused by nerve root compression
  • Difficulties with mobility due to numbness, pain or weakness
  • Use of a walker, cane, wheelchair, or other assistive device
  • Any assistance that you require due to pain, numbness or weakness
  • Results of a straight leg raise test, both lying down and sitting

You can use the following diagnostic tests to support your documented symptoms:

  • Imaging results such as x-rays, MRIs or CT scans
  • A complete operative record from your surgeon needs to be included in your application
  • Any complications, such as failed back surgery syndrome (FBSS), that have occurred as a result of your surgery should also be carefully documented

If you are working with a neurologist, orthopedist, or surgeon, be certain to obtain records from these specialists. The SSA places more weight on the opinion of medical experts.

Medical Criteria Needed to Qualify with Spinal Fusion

Evidence Needed Related to Treatment of Your Spinal Fusion

THe SSA will need to know how you responded to your spinal fusion surgery, and most importantly, if your condition has worsened despite surgery.

As noted, many individuals who undergo a spinal fusion end up exhibiting continued pain and disability.

Be certain that your doctor has the following medical documentation available:

  • Any and all medications that you are receiving as a result of your back pain or spinal fusion, as well as your response to the medications
  • Complete operative reports, as well as a description of any perceived failure of the surgery
  • Any injections that you require, such as steroids
  • Any physical therapy or other related therapies that you are receiving
  • Any mental health problems, such as depression, that have occurred as a result of your failed surgery.

Only the most severe spinal fusion surgery cases will meet a particular listing in the Blue Book. Therefore, you will need to provide as much information as you can on medications, side-effects to those medications, and any unintended consequences that have occurred as a result of the failed surgery.

If you can prove that your disability limits your ability to work for at least one year, you may still be awarded SSDI benefits.

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

Most individuals who undergo a spinal fusion surgery end up qualifying for SSDI benefits through a residual functional capacity (RFC) assessment.

An RFC will document your ability to perform certain tasks, such as lifting and walking.

Many people choose to have their physician complete an RFC detailing their limitations. For example, if you have difficulty lifting or bending or if you have burning pain that prohibits your movement, this should be carefully documented by your doctor.

Your physician should carefully document your ability to take care of yourself, your home, and your activities of daily living.

Steps You Can Take to Win Your Disability Claim

Medical evidence is the number one predictor of approval for Social Security disability benefits. If you have sufficient medical documentation about your condition, you can apply for SSDI benefits.

Remember that the SSA reviewers rely on the information provided in the Blue Book to determine your level of disability.

The section on spinal disorders is quite detailed, so you may want to review the various related Blue Book criteria with your physician, such as sections 1.04 and 11.08.

Together you and your doctor can determine what medical information you have available and what additional information may be needed to be approved.

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 neurologist, orthopedic doctor, or primary care physician can help including:

  • Ensuring that your full medical history related to your spine is up to date
  • Listing your past treatments and responses
  • Documenting all of your medications and any applicable side effects

Winning a disability claim for spinal fusion surgery is very difficult. However, working with a qualified Social Security disability attorney or advocate can significantly enhance 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 spinal claim.