When evaluating a claimant’s disability application, the Social Security Administration makes a medical assessment to determine whether an individual’s impairment(s) meets or equals a listing in the Listing of Impairments, or if the individual’s impairment(s) are at a level that precludes his/her ability to perform any past relevant work or any other work in the national economy.
In order for an individual’s impairment(s) to meet a listing, his/her impairment(s) must meet ALL the criteria of one of the listed impairments in the listings. If an individual’s impairment(s) meets the requirements of a listed impairment, the Social Security Administration, after reviewing your medical records, will find that individual is disabled.
As it relates to Systemic Lupus Erythematosus (“Lupus”), the Social Security Administration puts Lupus under 14.00 Autoimmune Systems Disorders, specifically under Listing 14.02 Systemic Lupus Erythematosus. In order to meet the requirements of Listing 14.02, an individual with Lupus must have:
A) Involvement of two (2) or more organs/body systems with:
- One of the organs/body systems involved to at least a moderate level of severity;
- At least two (2) of the constitutional symptoms or signs (severe fatigue, fever, malaise, or involuntary weight loss).
B) Repeated manifestations of Lupus, with at least two (2) of the constitutional symptoms or signs (severe fatigue, fever, malaise, or involuntary weight loss) and one (1) of the following at the marked level:
- Limitations of activities of daily living,
- Limitation in maintaining social function, or
- Limitation in completing tasks in a timely manner due to the deficiencies in concentration, persistence, or pace.
The Social Security Administrations considers Lupus to be a chronic inflammatory disease that can affect any organ or body system. It is frequently, but not always, accompanied by constitutional signs or symptoms, such as: severe fatigue, malaise, or involuntary weight loss.
Major organ or body system involvement can include the following:
- Respiratory (pleuritis, pneumonitis),
- Cardiovascular (endocarditis, myocarditis, pericarditis, vasculitis),
- Renal (glomerulonephritis),
- Hematologic (anemia, leukopenia, thrombocytopenia),
- Skin (photosensitivity),
- Neurologic (seizures),
- Mental (anxiety, fluctuating cognition (“lupus fog”), mood disorders, organic brain syndrome, psychosis), or
- Immune system disorders (inflammatory arthritis)
In fact, immunologically, there is an array of circulating serum auto-antibodies and pro- and anti-coagulant proteins that may occur in a highly variable pattern.
Generally, but not always, an individual will need to show the medical evidence of record establishes that his/her Lupus impairment satisfies the criteria in the current “Criteria for the Classification of Systemic Lupus Erythematosus” by the American College of Rheumatology found in the most recent edition of the Primer on Rheumatic Diseases published by the Arthritis Foundation.
According to the American College of Rheumatology’s recent “Criteria for the Classification of Systemic Lupus Erythematosus,” the definitions of Lupus classification are:
- Antinuclear antibodies (ANA): ANA at a titer ≥ to 1:80 on HEp-2 cells or an equivalent positive test at least once. Testing by immunofluorescence on HEp-2 cells or solid-phase ANA screening immunoassay with at least equivalent performance is highly recommended.
- Fever: Temperature >38.3°C
- Leukopenia: White blood cell count <4,000/mm³
- Thrombocytopenia: Platelet count <100,000/mm³
- Autoimmune hemolysis: Evidence of hemolysis, such as reticulocytosis, low haptoglobin, elevated indirect bilirubin, elevated LDH, AND positive Coombs’ (direct antiglobulin) test.
- Delirium: Characterized by 1) Change in consciousness or level of arousal with reduced ability to focus, 2) symptom development over hours to <2 days, 3) symptom fluctuation throughout the day, 4) either: 4a) acute/subacute change in cognition (e.g., memory deficit or disorientation), or 4b) change in behavior, mood, or affect (e.g., restlessness, reversal of sleep/wake cycle).
- Psychosis: Characterized by 1) delusions and/or hallucinations without insight and 2) absence of delirium.
- Seizure: Primary generalized seizure or partial/focal seizure.
- Non-scarring alopecia: Non-scarring alopecia observed by clinician*.
- Oral ulcers: Oral ulcers observed by a clinician*.
- Subacute cutaneous OR discoid lupus: subacute cutaneous lupus erythematosus observed by a clinician with annular or papulosquamous (psoriasiform) cutaneous eruption, usually photodistributed. If skin biopsy is performed, typical changes must be present (interface vacuolar dermatitis consisting of a perivascular lymphohistiocytic infiltrate, often with dermal mucin noted) OR Discoid Lupus Erythematosus observed by a clinician* with erythematosus-violaceous cutaneous lesions with secondary changes of atrophic scarring, dyspigmentation, often follicular hyperkeratosis/plugging (scalp), leading to scarring alopecia on the scalp. If skin biopsy is performed, typical changes must be present (interface vacuolar dermatitis consisting of a perivascular and/or periappendageal lymphohistiocytic infiltrate. In the scalp, follicular keratin plugs may be seen. In longstanding lesions, mucin deposition may be moted.)
- Acute cutaneous lupus: Malar rash or generalized maculopapular rash observed by clinician*. If skin biopsy is performed, typical changes must be present (interface vacuolar dermatitis consisting of a perivascular lymphohistiocytic infiltrate, often with dermal mucin noted. Perivascular neutrophilic infiltrate may be present early in the course.)
- Pleural or pericardial effusion: Imaging evidence (such as ultrasound, x-ray, CT scan, MRI) of pleural or pericardial effusion, or both
- Acute pericarditis: ≥2 of 1) pericardial chest pain (typically sharp, worse with inspiration, improved by leaning forward), 2) pericardial rub, 3) EKG with new widespread ST elevation or PR depression, 4) new or worsened pericardial effusion on imaging (such as ultrasound, x-ray, CT scan, MRI).
- Joint involvement: EITHER 1) synovitis involving 2 or more joints characterized by swelling or effusion OR 2) tenderness in 2 or more joints and at least 30 minutes of morning stiffness.
- Proteinuria >0.5 g/24 hours: Proteinuria >0.5 g/24 hours by 24-hour urine or equivalent spot urine protein-to-creatinine ratio.
- Class II or V lupus nephritis on renal biopsy according to ISN/RPS 2003 classification: Class II: Mesangial proliferative lupus nephritis: purely mesangial hypercellularity of any degree or mesangial matrix expansion by light microscopy, with mesangial immune deposit. A few isolated subepithelial or subendothelial deposits may be visible by immunofluorescence or electron microscopy, but not by light microscopy
Class V: Membranous lupus nephritis: Global or segmental subepithelial immune deposits or their morphologic sequelae by light microscopy and by immunofluorescence or electron microscopy, with or without mesangial alterations.
- Class III or IV lupus nephritis on renal biopsy according to ISN/RPS 2003 classification: Class III: Focal lupus nephritis: active or inactive focal, segmental, or global endocapillary or extra-capillary glomerulonephritis involving <50% of all glomeruli, typically with focal subendothelial immune deposits, with or without mesangial alterations.
Class IV: Diffuse lupus nephritis: active or inactive diffuse, segmental, or global endocapillary or extra-capillary glomerulonephritis involving ≥50% of all glomeruli, typically with diffuse subendothelial immune deposits, with or without mesangial alterations. This class includes cases with diffuse wire loop deposits but with little or no glomerular proliferation.
- Positive antiphospholipid antibodies: Anticardiolipin antibodies (IgA, IgG, or IgM) at medium or higher titer (>40 APL, GPL, or MPL, or >the 99th percentile) or positive anti-β2GPI antibodies (IgA, IgG, or IgM) or positive lupus anticoagulant.
- Low C3 OR low C4: C3 OR C4 below the limit of normal.
- Low C3 AND low C4: Both C3 AND C4 below their lower limits of normal.
- Anti-dsDNA antibodies OR anti-Sm antibodies: Anti-dsDNA antibodies in an immunoassay with demonstrated ≥90% specificity for SLE against relevant disease controls OR anti-Sm antibodies.
* = Either a physical examination or review of photograph
anti-β2GPI = anti-β2-glycoprotein I
anti-dsDNA = anti-double-stranded DNA
CT = Computer Tomography
EKG = Electrocardiography
ISN = International Society of Nephrology
LDH = Lactate Dehydrogenase
MRI = Magnetic Resonance Imaging
RPS = Renal Pathology Society
SLE = Systemic Lupus Erythematosus
Thus, the American College of Rheumatology considers an individual to have Lupus if he/she meets the criteria (see above) for four (4) of the following:
- Malar rash,
- Discoid rash,
- Photosensitive rash,
- Oral ulcers,
- Nonerosive arthritis in two (2) or more joints,
- Pleuritis or pericarditis,
- Glomerulonephritis or proteinuria,
- Seizures or psychosis,
- Hemolytic anemia, leukopenia, lymphopenia, or thrombocytopenia,
- Immunologic laboratory abnormalities, such as antibodies to double-stranded DNA, or the SM antigen or a false-positive serologic test for syphilis, or
- Positive ANA test that is not caused by medication.
If the Social Security Administration determines that your Lupus diagnosis does not meet or medically equal a listed impairment, the Social Security Administration will continue to evaluate your claim using the sequential evaluation process in order to determine what functional limitations, both exertional (physical) and non-exertional (mental/cognitive), result from your Lupus, or other, impairment(s).
As you can see, your medical records are vital to your claim for SSDI benefits and/or SSI payments. If your impairments do not meet or equal a listing, we must look to what functional limitations result from your impairments and then compare your restrictions with the demands of any past relevant work you have performed in the last fifteen (15) years. Furthermore, depending on your age: 18-49, 50-54, 55-59, or 60+; your education: marginal (6th grade or less), limited (7th grade to 11th grade), or high school graduate or more (12th/HS graduate+); and the degree to which your impairment(s) limit(s) you, you may or may not be found disabled.
As a result, your medical records (and medical treatment) are vital to your claim for SSDI benefits and/or SSI payments for not only the Social Security Administration but also any attorney reviewing the merits of your case.
The information contained herein is for general information purposes only and is not meant for your reliance on, or to form a basis, for any legal, business, or other decisions. As always, if you have any legal questions, consult an attorney.