How lower back problems are reviewed to determine Social Security Disability after April 2nd, 2021

Lower back pain is one of the most common reasons people file for disability. Problems with your lower back affect everything you do during the day. Many of our clients suffering from lower back pain tell us that you do not realize how much you use your lower back until it gets injured.

On April 2nd of 2021, new regulations were put in place as to how the government reviews the severity of lower back problems. The criteria used by the government to determine whether a person is disabled for a particular problem are known as listings. These listings are periodically updated at the government’s discretion. Listings are assigned a number for easy reference. The first number indicates what category of the listing you are looking at. Number 1.00 is Musculoskeletal Disorders and covers back problems, joint abnormalities, fractures, and amputations. The last two digits change based on the specific listing.  

Before April 2nd, 2021, to be found disabled due to low back problems, you had to meet or medically equal what was then known as 1.04 Disorders of the Spine.

What does this mean for my Social Security Disability claim?

By being aware of the new requirements to be found disabled, you can work with your doctors to ensure your medical records support your disability. Doctors are concerned with diagnosing and treating your conditions and do not always fully document the severity of your symptoms in medical records. 

The new listing 1.16 has four parts. To be found disabled under this listing, you must meet all four parts. This listing is titled 1.16 Lumbar Spinal Stenosis resulting in compromise of the cauda equina. The cauda equine, Latin for horse’s tail, is the spinal nerves from the second through fifth lumbar nerves, the first through fifth sacral nerve pairs, and the coccygeal nerve.  

In layman’s terms, this covers the most common injuries which occur at the L4-L5 and L5-S1 discs in your lumbar spine. If you have a lumbar injury or a lumbar fusion, the government will look to see if you qualify for disability.

1.16 A- The first part. Pain, sensory loss, tingling, or cramping

In order to meet this listing, you must first have symptoms of some form of neurological compromise. You will want to discuss these conditions with your doctor and confirm they are documented in your medical record. Your doctor should be able to perform tests or refer you for tests to determine if your back pain meets one of these requirements. To meet the listing, you must have one of the following:

1. Nonradicular pain in one or both of your lower extremities- This means the pain radiates to the affected area. This could be a sore back, buttocks, thighs, legs, or feet.  
2. Nonradicular sensory loss in one or both lower extremities- This means you experience the loss of sensation in a part of your back, buttocks, thighs, legs, or feet but not along a particular nerve root
3. Neurogenic Claudication -The symptoms of neurogenic claudication include pain, tingling, or cramping in the lower back and one or both legs, hips, and buttocks.

1.16 B- The second part. Muscle weakness and sensory changes or decreased deep tendon reflexes.

Now that your doctor has performed a physical examination or diagnostic test to confirm you meet part A, what now? You have to have certain symptoms due to your condition. 

Just because your back hurts or you have pain does not mean the government will consider your injuries severe enough to prevent you from working. You want your doctor to document you have the following:

First, you have to have muscle weakness. Have your doctor check you for this. We all get older, we all slow down, and following an injury, people tend to give injured parts of their bodies time to heal. Have your doctor check you for muscle weakness in your lower back and legs. 

(If you have muscle weakness next, you will need documentation of either 2 or 3.)

Second, sensory changes are shown by decreased sensation or sensory nerve deficits on electrodiagnostic testing; or documentation of areflexia, trophic ulceration, or bladder or bowel incontinence. Your doctor will be able to explain, document, or test for these conditions.

Third, decreased deep tendon reflexes in one or both lower extremities. Have your doctor test your deep tendon reflexes and document their findings.

(Remember, if you have muscle weakness, you just need to meet the 2 or 3, not both.)

1.16 C- The third part. MRI’s CT scans or an operative report.

For the third condition to be met, you need to have imaging that shows lumbar spinal stenosis either as part of a CT scan, MRI, or operative report. You want your doctors to perform the necessary imaging and document any findings of lumbar spinal stenosis.

1.16 D- The last part. Duration and documentation of the need for assistive devices to walk.

First, to meet the last part, you have to show your impairment has lasted or is expected to last at least 12 months. An injury that leaves you recovering for a couple of months, even if it meets all the criteria above, is not enough. The condition has to be expected to last at least 12 continuous months. If your condition is unlikely to improve in the short term, get your doctor to document your projected recovery time.

Secondly, you have to be able to demonstrate documentation that you have a medical need for a walker, bilateral canes, or bilateral crutches, or a wheeled and seated mobility device that requires the use of both hands. Unfortunately, a single cane, crutch, or motorized wheelchair can be operated one-handed is not enough. 

The other alternative is if you can only use one upper extremity. If you can only use one of your arms and require a device that requires your other arm to operate, such as a cane, or motorized wheelchair, you would qualify. 

If you have been prescribed or need assistive devices, make sure to document your need to use them with your doctor. Doctors visits are not the time to forgo assistive devices because you have a better than a typical day with your health or too bulky for a short trip. Further, if you have the use of both hands and only need a single cane to get around, unfortunately, you would not meet the criteria. 

What if I cannot get my doctor to document one of these requirements, but my lower back prevents me from working. What do I do? 

Not meeting all of these criteria does not mean you are not disabled. But, it does mean you are likely to need to go through the process and have your claim reviewed by an Administrative Law Judge. Typically, you can expect to be denied at the initial and reconsideration levels and file an appeal for a review by a Judge. 

Typically, this takes two years from start to finish. This means it is important to start the process early, continue treatment, and ensure your doctors fully document the severity of your condition. 

At Shook & Stone, we can help you file your claim, handle getting all of your medical records, and assist you with all stages of the disability process. 

Our team of attorneys will prepare you for the hearing, give you important information on what to expect, and the following:

• Prepare you for your hearing.
• Ensure that your story is told about why your back pain prevents you from working.
• Cross-examine vocation experts on your behalf
• Make sure that your past work is classified correctly and that your limitations are reviewed.

If you can no longer work due to low back pain, contact us. We can help.