Medical Record Review Crucial To Prove Immune System Disorder Disability

by | Published on Jan 31, 2022 | Medical Record Review

When the immune system that is responsible for safeguarding the human body from diseases fails to function properly, it leads to disability. Immune system disorders are caused either by the abnormally low activity or conversely, the over activity of the immune system. When the immune system is overactive, the body attacks its own tissues which results in autoimmune diseases. Acquired immune deficiency syndrome is caused by HIV infection that damages the immune cells and suppresses the immune system. In abnormal immune activity, inflammation is caused and there is the buildup of antibodies that is responsible for autoimmune diseases such as multiple sclerosis, Grave’s disease, Hashimoto’s disease, myasthenia gravis, psoriasis as well as connective tissue disorders like lupus, scleroderma and rheumatoid arthritis. Medical record review is crucial to establish immune system disorder disability, which may qualify the applicant for social security disability insurance (SSDI) benefits.

Immune System Disorders – 3 Categories

The SSA (Social Security Administration) has the Blue Book that lists the impairments or medical conditions that may qualify for SSDI. Section 14 of the list is titled “14.00 Immune System Disorders – Adult.” The SSA categorizes immune disorders that may qualify for disability benefits into the following three types.

  • Autoimmune disorders – These include conditions caused when the immune system attacks the body and causes long-term impairments that affect one or more body systems. Examples include lupus, rheumatoid arthritis, and scleroderma among others.
  • Immune deficiency disorders (excluding HIV) – Include disorders where the immune system is deficient in some way, such as sepsis, endocarditis, and meningitis.
  • HIV – Distinguished by a weakening of the immune system that makes the body vulnerable to many infections, cancers, and other conditions.

Which Medical Records Are Needed for Medical Chart Review?

The SSA does request for and retrieve the applicant’s medical records; however, it is best that the disability applicant or their attorney submits the following along with the application.

  • Complete medical history
  • Physical examination report
  • Laboratory results
  • Imaging studies such as X-rays, angiography, MRI, CAT scans, bone scans
  • Tissue biopsy

As a medical chart review company assisting social security disability attorneys, we look for the above documentation that is crucial for a successful claim. So, how are the above-mentioned records important?

  • A long-term immune disorder is managed and cared for by a trained and experienced physician, and therefore medical history is important.The medical records pertaining to those visits must show the treatments and prognoses. ER records and hospital records are also important documents.
  • Physical exam records should contain details about the claimant’s past, present and possible future physical condition. They must also show how the immune system disorder affects his/her health, mobility, and quality of life.
  • Records pertaining to medical imaging procedures and medical tests must contain information regarding the severity of the claimant’s condition.

Treating Physician’s Opinion Is Significant

It is most important that the treating doctor enters accurate information regarding the applicant’s functional impairment in the records. This would include the patient’s symptoms, how they are disabling, what the applicant can and cannot perform. The SSA would be looking for the treating physician’s documentation of how much the applicant can do in an 8-hour workday in terms of standing, walking, sitting, lifting, and carrying.

Disability applications for immune system disorders are evaluated based on the specific diagnosis and condition that is preventing the claimant from working and earning wages. The SSA will assess the severity of the immune system disorder through a comprehensive medical record review. They will also evaluate whether the disorder is preventing the applicant from working because of loss of function, pain, fatigue, or medication side effects. If they find the claim to be genuine, the applicant will be granted disability benefits that are so vital to meet their living expenses and medical costs.

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