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Winning Disability Benefits for Fibromyalgia

Last updated: November 19, 2023

Fibromyalgia (FM) is a chronic disorder characterized by persistent pain or numbness throughout the body, accompanied by muscle and joint stiffness. These symptoms may come and go depending on the person. It is characterized by fatigue, sleep disruptions, waking unrefreshed, headaches, poor memory ("fibro fog"), depression, anxiety disorder, and irritable bowel syndrome.

A person living with fibromyalgia may experience several symptoms that interfere with their ability to work. When this happens, it's important to know the following:

  • You may be eligible for Social Security disability benefits if you have fibromyalgia.
  • If you have long-term disability insurance coverage, either through an employer plan or privately, you may be able to claim benefits.
  • Veterans with fibromyalgia are rated at 10% to 40% by Veterans Affairs (VA). It is a presumptive diagnosis for Gulf War veterans. Moreover, VA now accepts "pain alone" as a reason for disability. Fibromyalgia veterans may have a better chance of obtaining disability benefits under these rules.

Proving That Your FM Is A Disability Is Difficult

FM can be extremely challenging to diagnose. There is no standard diagnostic testing for fibromyalgia because the symptoms are similar to those of other diseases. Insurers and disability programs view "invisible" conditions with suspicion and doubt.  

There is no doubt FM exists. Fibromyalgia attorneys assist individuals who cannot work due to their condition and help them obtain the rightful benefits they deserve. Your attorney can assist you if your claim was recently denied and you want to appeal the decision.

All disability programs and insurance companies have a different view of and approach to fibromyalgia claims. While there may be obstacles, you need a strategy for crafting a claim that will be as competitive as possible.

Social Security Disability Benefits For FM

The Impairment Listing of the Social Security Administration (SSA) does not list fibromyalgia. Nevertheless, you may still be eligible for Social Security Disability Insurance (SSDI). Social Security will evaluate medical conditions to see whether they "meet or equal" one of the listings. If your disability is based on a vocational standard, you may qualify for additional benefits.

Specific Medical And Vocational Evidence To Win SSDI Benefits For FM 

The SSA will ask you whether you have: 

  1. A medically determinable impairment.
  2. Your condition restricts your abilities so much that it prevents you from working - or performing any “substantial gainful activity.”

Evidence The SSA Needs To Prove That FM Is Disabling

The following are the pieces of evidence that you must present to the SSA to prove that your FM is disabling.

Objective, Diagnostic Medical Evidence

In fibromyalgia disability cases, the SSA wants to establish that the patient has a medically determinable impairment. The SSA may diagnose FM based on the following two sets of criteria:

1990 American College Of Rheumatology Criteria For The Classification Of FM.

There are three criteria to exclude other disorders that might cause these symptoms or signs: 

  1. A history of widespread pain in your body for at least three months
  2. A test to determine tender points in the body
  3. Evidence the other disorders could be responsible

– or –

2010 American College Of Rheumatology (ACR) Preliminary Diagnostic Criteria.

As part of the criteria, you must have: 

  1. Widely distributed pain for a minimum of three months
  2. Six or more FM symptoms, signs, or co-occurring conditions
  3. No evidence of another disorder causing the symptoms or signs

Diagnosis From A Specialist

You'll need a thorough medical history and treatment from a physician such as a rheumatologist, who can be an important factor in your treatment. Because the symptoms are often self-reported, you'll need thorough medical care.

Longitudinal Records

Fibromyalgia can have waxing and waning symptoms. Medical records that prove you've been evaluated and treated by reputable medical professionals constitute longitudinal records. A fibromyalgia expert rheumatologist can be invaluable in substantiating your impairment based on longitudinal records. A disability application usually requires evidence from the 12 months preceding the application date.

Supporting Medical Evidence 

Fibromyalgia disability benefits are obtained by presenting medical evidence supporting your claim. For example, we encourage our clients to keep a fibromyalgia journal documenting pain and other symptoms. If your FM is severe, we may recommend a psychological evaluation to determine how it affects your day-to-day functioning and your ability to cope in the long term.

Relevant Non-Medical Evidence 

The statements of family members, friends, employers, clergy members, and others further support the claim that you have fibromyalgia, strengthening your claim's credibility.

SSA’s 5-Step Sequential Evaluation Process

Your case file is reviewed by Social Security using the following process:

Step 1

Are you currently employed in a substantial, gainful position? The SSA will not consider you disabled if your answer is yes. You could proceed to Step 2 if you answered no.

Step 2

Have you been diagnosed with a severe impairment? A severe impairment is determined if the Social Security Administration finds that your pain (or any other fibromyalgia symptoms) substantially limits your ability to perform work activities. Now you proceed to Step 3.

Step 3

Can your impairment be compared to those listed by the SSA? In addition, fibromyalgia is not included as an impairment, so it cannot meet the listing requirements. If you have fibromyalgia, the SSA will assess whether it qualifies for any listing or if it qualifies if combined with at least one other impairment. 

Your FM will be considered disabled if it meets the criteria for another listing at Step 3. You can still proceed to Steps Four and Five if you successfully prove your claim. 

The SSA will assess the remaining functional capacity (RFC) at this point and consider all relevant evidence contained in your case record in determining the RFC. You can qualify for SSA benefits even if your impairments are deemed "not severe." 

Long-term records are likely to be crucial if you are applying for disability benefits for fibromyalgia at Steps 4 and 5. To support a finding of disability, you will need documentation, over time, demonstrating that you have good and bad days with your fibromyalgia. 

Step 4

When reviewing your RFC assessment, SSA determines if you can do any past relevant work, and if not.

Step 5

SSA considers your RFC, age, education, and work experience to see if you can adjust to any other work. SSA will consider you disabled if you cannot meet Steps 4 and 5. Fibromyalgia disability benefits will then be granted.

What The SSA Looks For In Steps 4 And 5

  • Fibromyalgia is often accompanied by severe pain, exhaustion, and other symptoms that prevent you from performing many types of unskilled work.
  • If you have pain, fatigue, or other symptoms, you might be burdened with cognitive or physical limitations or need to restrict your work environment.
  • The SSDI adjudicators should account for exertional and non-exertional limitations (such as postural limitations or environmental restrictions) that reduce your capabilities to perform multiple jobs, thus reducing your occupational base.

Don't file an initial claim or appeal a denied claim blindly. Our Social Security disability lawyers can help you construct a compelling case for benefits when you need assistance with your initial application. Having an experienced attorney on your side becomes even more essential if your claim has been denied.

Were Long Term Disability Benefits For Fibromyalgia Denied By Your Insurance Company?

Fibromyalgia and other chronic pain diagnoses often result in disability claims being denied. There are many ways insurers will try to avoid paying benefits by finding weaknesses in a claim. Unfortunately, this disease is subjective because that creates further incentives to deny it. 

For your LTD claim to meet the insurance company's threshold, you must prepare your medical and vocational evidence with the same level of strength and significance as your Social Security disability claim. Your case will be well developed in case of a denial, and it will be able to hold up in court.

Prepare For Every Attempt By The Disability Carrier To Invalidate Your Claim.

As part of dealing with insurance companies, you need to be prepared for any strategies a disability carrier may use to deny benefits and hold them responsible when wrongful denials occur. Disability companies may claim the following:

  • There was a mistake in your diagnosis
  • Your doctor's restrictions and limitations do not have any objective basis
  • In a passive capacity, you can still do your work
  • You aren't getting the proper treatment
  • Fibromyalgia claims are often denied by insurance companies using biased independent medical examinations (IMEs)

With multiple arguments in your favor to help you win disability benefits for fibromyalgia, our disability insurer lawyers fight the denial with every "reason" the carrier uses to deny your claim.

Claiming Veterans Disability Benefits For Fibromyalgia

You may want to work with an accredited veteran's claims attorney if you were denied VA disability compensation for fibromyalgia or you’re unhappy with your disability payment.

The VA’s Schedule for Rating Disabilities evaluates fibromyalgia under The Musculoskeletal System: Diagnostic code 5025 Fibromyalgia (fibrositis, primary fibromyalgia syndrome), as follows:

VA Fibromyalgia Ratings: From 10% to 40% disabling

The following table depicts how the VA’s ratings for disability due to Fibromyalgia vary from 10% to 40%:

Constant, or nearly constant, symptoms that resist treatment40% rating
Symptoms are episodic with frequent exacerbations caused by environmental or emotional stress and20% rating
Consistent medication is required to control symptoms10% rating

Fibromyalgia is a Presumptive Condition for Gulf War Veterans 

The nexus between fibromyalgia and military service is unnecessary if you are diagnosed with fibromyalgia during the Gulf War.

VA presumes Gulf War service-related health conditions are present if the veteran has suffered from them for six months or more. Fibromyalgia is considered a Gulf War-related health condition. The illness must have also manifested during active duty in the Southwest Asia theater of military operations by December 21, 2021, and have caused at least 10% disability.

The theaters of military operation eligible for this presumption include Saudi Arabia, Kuwait, Iraq, Oman, UAE, Oman, Qatar, Persian Gulf, the neutral zone between Iraq and Saudi Arabia, Gulf of Aden, Arabian Sea, Red Sea, and Bahrain.

Veterans’ Disability Benefits For FM Based On “Pain Alone”

No matter the underlying cause, pain can be considered a functional impairment for VA disability compensation. Saunders v. Wilkie, a case decided by the US Court of Appeals in 2018, held that pain affects a veteran's earning capacity regardless of the cause of the pain or a doctor's diagnosis. A veteran needs to demonstrate that their pain is severe enough to interfere with their ability to earn a living to prove that they have a disability, such as fibromyalgia. 

Applying for Social Security benefits can be an overwhelming process. If you are interested in seeking SSDI benefits, check out our article on who is eligible for Social Security Disability benefits. To learn more, visit DisabilityHelp.org today!

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Chloe Powers
Chloe works with policymakers on behalf of Disability Help to support their work at a strategic level, ensuring the conditions are in place for creative individuals and organizations to grow, reach their potential and effect relevant, sustainable change.
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