By Robert J. Osborne, Esq.
Fibromyalgia is a complex medical condition that involves widespread pain in the joints, muscles, tendons, or nearby soft tissues that has persisted for at least 3 months. When a person seeks disability benefits based on fibromyalgia, the Social Security Administration must evaluate that person’s symptoms to determine whether the person has an medically determinable impairment of fibromyalgia. As with all claims for Social Security disability benefits, a person must provide sufficient objective evidence to support a determination that the fibromyalgia so limits the person’s functional abilities that it precludes the person from performing any substantial gainful activity.
General Criteria
Generally, a person can establish that he or she has fibromyalgia by providing evidence from a licensed physician. However, the Social Security Administration will not rely upon the physician’s diagnosis alone. The physician must have reviewed the person’s medical history and conducted a physical exam. The Social Security Administration will review the physician’s treatment notes to see if they are consistent with a diagnosis of fibromyalgia. Additionally, the Social Security Administration will review the licensed physician’s treatment notes to determine whether the person’s symptoms have improved, worsened, or remained stable over time, and to establish the physician’s assessment over time of the person’s physical strength and functional abilities.
Specific Criteria
The Social Security Administration will find that a person has fibromyalgia if a licensed physician diagnosed fibromyalgia and provides the evidence necessary evidence. However, the physician’s diagnosis must not be inconsistent with the other evidence in the person’s case record. The necessary evidence may fall under the 1990 or 2010 criteria established by the American College of Rheumatology.
The 1990 American College of Rheumatology Criteria for the Classification of Fibromyalgia
The Social Security Administration may find that a person has fibromyalgia if he or she has all three of the following:
1. A history of widespread pain that has persisted for at least 3 months. The pain may fluctuate in intensity and may not always be present.
2. At least 11 positive tender points on physical examination. The positive tender points must be found bilaterally (on the left and right sides of the body) and both above and below the waist. The 18 tender point sites are located on each side of the body at the: base of the skull; back and side of the neck; shoulder; supraspinatus muscle (near the shoulder blade); second rib; outer aspect of the elbow; top of the buttock; below the hip; and the inner aspect of the knee. The physician considers a tender point to be positive if the person experiences any pain when applying about 9 pounds of pressure to the site.
3. Evidence that other disorders that could cause the symptoms or signs were excluded.
The 2010 American College of Rheumatology Preliminary Diagnostic Criteria
The Social Security Administration may find that a person has a medically determinable impairment of fibromyalgia if he or she has all three of the following:
1. A history of widespread pain;
2. Repeated manifestations of six or more FM symptoms, signs, or co-occurring conditions, especially manifestations of fatigue, cognitive or memory problems (“fibro fog”), waking unrefreshed, depression, anxiety disorder, or irritable bowel syndrome; and
3. Evidence that other disorders that could cause these repeated manifestations of symptoms, signs, or co-occurring conditions were excluded.
Documentation
As in all claims for disability benefits, the Social Security Administration needs objective medical evidence to establish the presence of a medically determinable impairment. When a person alleges fibromyalgia, longitudinal records reflecting ongoing medical evaluation and treatment from acceptable medical sources are especially helpful in establishing both the existence and severity of the impairment.
The Social Security Administration additionally may want evidence from other acceptable medical sources, such as psychologists, to evaluate the severity and functional effects of fibromyalgia. The Social Security Administration also may consider evidence from medical sources who are not “acceptable medical sources” to evaluate the severity and functional effects of the impairment. Information from nonmedical sources can also help the Social Security Administration evaluate the severity and functional effects of a person’s fibromyalgia.
The Sequential Evaluation Process
As with any adult claim for disability benefits, the Social Security Administration uses the 5-step sequential evaluation process to determine disability from fibromyalgia. However, fibromyalgia cannot meet a listing because fibromyalgia is not a listed impairment. So, at step 3 the Social Security Administration will determine whether a person’s fibromyalgia medically equals a listing.
The Social Security Administration assesses a person’s residual functional capacity when the person’s impairment does not meet or equal a listed impairment. The Social Security Administration will base its residual functional capacity assessment on all relevant evidence in the case record. The Social Security Administration considers the effects of all of the person’s medically determinable impairments, including impairments that are “not severe.” For a person with fibromyalgia, the Social Security Administration will consider a longitudinal record whenever possible because the symptoms of fibromyalgia may change over time.