HEARTS, VEINS, ARTERIES: SOCIAL SECURITY DISABILITY AND THE CARDIOVASCULAR SYSTEM How Social Security Views Cardiovascular Impairments The heart and circulatory system make up the cardiovascular system. Cardiovascular diseases can be debilitating and potentially fatal, but Social Security does not automatically award cases if there is a diagnosis of a serious condition or if the claimant has undergone a major surgical procedure. This policy makes the disability application process frustrating for individuals who have serious heart or vascular disease. Many claimants wonder why their case was denied by Social Security even though their own doctor told them they cannot work. Even individuals who had a heart transplant might be told by Social Security that they can return to work one year after the surgery. During the disability evaluation process the claimant has the burden of proof. This means the claimant and his or her attorney must prove that the claimant's medical conditions keep them from working. A big part of presenting a disability claim effectively is being familiar with Social Security's disability rules and regulations. An important part of the regulations are the "Listings" The Listings Social Security maintains a set of Listings for disorders of the cardiovascular system and for the other major body systems. The Listings are targeted at specific disorders and look for particular medical findings in order to establish the severity of the disorder. The following cardiovascular disorders are contained in the Listings: * Chronic Heart Failure (often due to heart attack) * Ischemic Heart Disease (typically due to coronary artery disease) * Recurrent Arrhythmias * Symptomatic Congenital Heart Disease * Heart Transplant (typically considered disabling for at least one year) * Aneurysm of Aorta or Major Branches * Chronic Venous Insufficient of a Lower Extremity * Peripheral Arterial Disease The criteria for each Listing are different. Several require advanced medical testing such as an echocardiogram, resting or ambulatory cardiography, exercise tolerance testing, exercise Doppler studies, or cardiac catheterization. If the claimant hasn't received the necessary testing, and most haven't, they still might meet the disability criteria. Other medical evidence can make up for the testing required by the Listings. Also, Social Security must also look at all of the claimant's medical conditions as well as their age, acquired work skills, and education to determine if they have the physical and mental capacity to sustain work. The Importance of Medical Opinion Statements Cardiovascular disease cases are complex, mostly because individuals with heart or circulatory disorders usually suffer from other conditions that can worsen their symptoms and risk factors. Such conditions include kidney or liver disease, COPD, diabetes, obesity, high blood pressure, and high cholesterol. Cardiovascular diseases can also be the cause of other medical problems, both mental and physical. Social Security rarely has access to a qualified cardiologist to help evaluate your claim. As a result, Social Security often underestimates the combined effect of all of your medical impairments. To prevent this it's advantageous to use your treating doctor to help Social Security understand your case. The disability rules and regulations require that Social Security's decision makers give careful consideration to medical statements by your treating physicians. Your disability attorney can help you capitalize on these favorable rules by getting an effective medical opinion statement from your treating doctor. An effective statement should be detailed and consistent with your medical records. Your attorney can strengthen the impact of your doctor's medical opinion statement in three ways. First, by emphasizing the credentials of the doctor who filled it out. Second, by detailing the nature and duration of the your treating relationship with the doctor. Third, by identifying what medical evidence, testimony, and other documentation support the medical opinion statement. A long history of medical treatment can strengthen your case, especially if you are able to see a vascular specialist or cardiologist. If you have a cardiologist ask them how you rate on the NYHA scale (New York Heart Association Functional Classification Scale). If they believe you are Class III or Class IV ask them to write a letter stating this and explaining their opinion. Social Security decision makers and medical experts are familiar with the NYHA scale and understand that Class III and Class IV patients have serious or extreme heart disease. If your doctor advises you to elevate your legs ask them for a written statement explaining how high you are supposed to elevate them, how often, and why. As you might expect, having to elevate your legs seriously interferes with work. Whether or not you need to elevate your legs might be crucial to your claim. Frequently doctors advise their patients to elevate their legs during the day but they do not record this recommendation in their medical records. Make sure to get it in writing! Medical Improvement Many people with severe cardiovascular disorders see improvement in their health after medical treatment. Procedures like stent placements for arterial stenosis or cardiac ablations or pacemaker implants to control arrhythmias can restore the ability to work. However, few patients recover enough to do more than light work and many are never the same again emotionally. For example, some patients who have experienced heart attacks or painful discharges from cardioverter defibrillators can develop anxiety disorders. Others fall victim to depression caused by concern for their health, loss of quality of life, lowered sense of self-worth, or stress from financial difficulties. If you are pursuing Social Security disability benefits and your cardiovascular health improves there are two options available. The first is to request a "closed period" of disability. This means arguing that you were disabled up to the time when you experienced enough medical improvement to return to the work you did previously or to less demanding work. To be eligible for a closed period you must be disabled for at least one year. If you have already returned to work and continued working for several months seeking a closed period might be your only option. The second option is to argue that you remain disabled in spite of your medical improvement. Some improvement in your health does not necessarily mean you can return to work. Furthermore, other medical problems might keep you from doing lighter work. Let's use "Clara Claimant" to illustrate. Clara met a cardiovascular listing due to her ischemic heart disease. After angioplasty and stent placement she has much less chest pain and shortness of breath, but she still could not return to her prior work as a security guard. Social Security denied her claim and told Clara she can do a desk job that doesn't require heavy lifting. Clara appealed and had a hearing before a judge. Clara testified that she developed depression after falling ill and losing her job. She has been taking medication for depression prescribed by her family doctor. The judge believes Clara's testimony and awards her case, concluding that her concentration problems caused by depression prevent her from doing office work or other seated work. Last Tips on How to Help Present Your Claim Social Security will ask you about your activities of daily living ("ADLs"). ADLs are things like bathing and dressing yourself, cooking, and cleaning. They also include managing your money, shopping, and caring for children or disabled adults. Social Security looks closely at your ADLs to determine how your medical problems affect your mental and physical functioning. You will probably be asked about your ADLs during the initial application phase, during any consultative examinations, and during any hearing with an Administrative Law Judge. Questions about your daily routine might seem harmless but they definitely are not. Social Security judges often use a claimant's ADLs in support of a decision denying the claim. It's not an exaggeration to say that anything you say about your ADLs can and will be used against you. The problem is that Social Security only gets a distorted picture of your ADLs because they ask only about what you can do. ADLs are, after all, activities of daily living, not limitations of daily living. This means it is up to you and your disability attorney to present the whole picture. People with cardiovascular impairments might do some housework but have to take frequent breaks due to shortness of breath, fatigue, or chest pain. On days where their symptoms are worse they might not be able to do much at all. When discussing your ADLs make sure to say what you can do but also what problems you have while doing it. Lastly, consider keeping a treatment journal. Some disability claimants aren't able to see a specialist or even a general practitioner on a regular basis. Those with serious cardiovascular problems and limited medical care often make frequent visits to the Emergency Room. It's important that your disability attorney knows when and where you received medical care. Every time you go to a physician write down the date, the hospital or clinic you attended, and the reason for the visit. This will allow your disability attorney to gather your medical records in order to show the persistence and severity of your cardiovascular symptoms.