Medical Records Analysis for Claim Evaluation

The most important step in eligibility determination is medical records analysis. The idea is to match the claimant’s impairment to a disability listing in the SSA’s Blue Book. Mental illnesses are included in Section 12.00 and include the following.

Anxiety-related disorders

Personality disorders

Affective disorders

Autism and associated disorders

Organic mental disorders

Intellectual disabilities

Personality disorders

Somatoform disorders

Schizophrenia, paranoia, and psychotic disorders

Substance addiction

The SSA would evaluate each type of disorder based on its own set of criteria. The applicant must be able to prove that he/she meets the criteria, or that the overall disabling conditions meet the listed criteria, or otherwise completely prevents him/her from performing any gainful activity. Also, the applicant must be able to show that he or she is receiving and complying with appropriate treatment.

The medical record review should provide evidence that is consistent with the claim of disability. The records should contain the following important details.

Diagnosis: The medical chart should contain a clear indication of the claimant’s diagnosis such as anxiety, bipolar disorder, depression or any of the other above-mentioned mental illnesses.

Treatment notes: These are progress notes related to the claimant’s visits to his or her mental health provider. For the SSA to be convinced regarding the genuineness of the disability, these notes should describe the specific problems the claimant is experiencing in his/her daily life, progress since last visit to the mental health practitioner, any episodes of worsening symptoms (episodes of decompensation), and so on. The SSA expects the claimant to visit the mental health professional at least once in every one or two months.

Medical records showing ADLs or Activities of Daily Living that the claimant finds it difficult to perform. These could include difficulties in

Shopping for clothes and food
Preparing meals
Bathing and personal hygiene
Paying bills
Caring for family members or pets
Managing finances

List of medications: All past and current medications must be included in the medical records. Side effects, if any, must also be mentioned in the treatment notes.

Medical opinions: The opinions from a psychiatrist/psychologist are very valuable for the SSA. Typically, an opinion in the form of a mental RFC (Residual Functional Capacity) form or a statement highlighting the claimant’s disability and limitations would carry considerable weight.

Objective tests: Mental conditions such as memory impairment, intellectual disorder such as low IQ, and other neurocognitive disorders can be tested objectively. A claimant suffering from such conditions must provide a copy of those records to the Social Security Administration.

The SSA would be looking for records showing symptoms of mental illness such as persistent anxiety, irrational fear, compulsions and obsessions, difficulty to communicate, depression, lack of interest to engage in activities, difficulty with social interaction and so on.

Disability Benefits for Mental Illnesses

SSDI or Social Security Disability Insurance: Adults with permanent mental disabilities as well as their families may be eligible for SSDI. To be found eligible, the claimant must have a mental disability that prevents him or her from working for at least 12 months. He/she must have worked previously and paid into the Social Security program for at least five of the previous 10 years. The monthly payments will be based on the claimant’s average lifetime earnings over a certain period of years (AIME). Once the claimant has received SSDI for a period of 24 months, he/she may receive Medicare benefits.

SSI or Supplemental Security Income: These are available for adults as well as children with disabilities, and who have limited resources and low income. For a child to be eligible, he or she must have a mental disability that has lasted or is expected to last for at least 12 months. For an adult to be eligible, he or she must have a disability that prevents them from working on a regular and sustained basis. The monthly payment would depend on many factors including but not limited to the claimant’s countable unearned income and living arrangement. One cannot have more than $2,000 in assets and a married person cannot have more than $3,000 in assets (the assets do not include certain things like one’s car, primary home, wedding rings, burial savings, and so on.) A claimant qualifying for SSI may be automatically approved for Medicaid benefits.

Apart from these two federal programs for the disabled, there are other options for financial support that mentally disabled individuals could be eligible.

OASDI (Old-age, Survivors, and Disability Insurance) from the SSA that pays monthly benefits to qualified retired and disabled workers as well as the families and dependents of insured workers.

Medicaid Section 1115 Demonstration programs that provide qualified Medicaid beneficiaries with substance use or mental health services.

State-specific programs including Michigan’s Disability Assistance Program (SDA) that provide financial assistance to eligible adults who are 65 years old or older and have a disability.

SOAR (SSI/SSDI Outreach, Access, and Recovery) program for children or adults who have a severe mental impairment, medical impairment, or co-occurring substance use disorder, and are at risk of homelessness. In this program, case managers closely assist eligible people to help them obtain SSI or SSDI benefits.

Private disability programs that may be included in an employer’s benefits package. These programs are a good option for individuals with partial disabilities.

Disability claimants who work with a social security disability attorney may have a better chance of getting their claim approved. Medical record review for social security disability firms would focus on extracting crucial evidence that supports the disability claim. This medical evidence is important to convince the SSA that the claimant deserves the disability benefits requested.

Disclaimer: The content in this blog is sourced from reliable internet resources, and is meant for informative purposes only. For a professional opinion on this topic, consult an experienced social security disability attorney.