How Do I Appeal my Social Security Denial? Social Security may deny your Social Security disability claim for several reasons. Social Security could deny your claim for non-medical reasons. They could also deny your claim for medical reasons. However, you can only appeal a denial for medical reasons.
Non-medical denials
Social Security offers two types of disability benefits. First, Social Security offers disability insurance benefits (SSDI). To qualify for SSDI, you must have worked and earned enough work credits. You cannot appeal a denial based on not having enough work credits. Second, Social Security offers Supplemental Security Income (SSI) benefits. To qualify for SSI, you must meet certain financial requirements. You cannot appeal a denial for SSI based on exceeding the financial requirements.
How can I appeal a medical denial?
You can file an appeal several ways. First, you can appeal your denial online. This can be the easiest way to appeal an unfavorable decision. Second, you can file an appeal with your local Social Security office. If you have a representative, they can help you file an appeal of your SSDI denial.
When should I appeal my Social Security denial?
You have 60 days to appeal a Social Security denial from the date on the denial letter. Social Security gives you an extra 5 days to allow you to receive your denial in the mail. Therefore, you have a total of 65 days from the date on your denial to appeal your claim. If you don’t file within the 65 days, you may have to re-file your claim. Social Security allows you to file an appeal in more than 65 days if you have good cause for missing your deadline.
What is good cause for missing my appeal deadline?
Good cause can include several reasons. Social Security considers:
What circumstances kept you from making the request on time;
Whether Social Security’s action misled you or you didn’t understand what you needed to do to appeal
Whether you had any physical, mental, education or language limitations that prevented you from appealing on time
Examples of good cause for missing your deadline
You were very sick when the appeal was due and couldn’t have contacted Social Security yourself or through someone else. You would need proof that you were seriously ill.
There was a death or serious illness in your family
Records needed for your appeal were destroyed by an accident or fire.
You never received your denial notice
Some other type of unusual or unavoidable circumstances and you could not reasonably be expected to have met the deadline
Why was my Social Security claim denied?
Many people receive a denial for SSDI benefits the first time they apply. Understanding why Social Security denied your claim can help increase your chances on appeal. Specifically, you will know what your claim was missing or where your claim can be improved. Common reasons include:
Firstly, You are working
Secondly, Lack of medical evidence
Thirdly, Not following your doctor’s orders
Finally, Ignoring requests
Appealing a denial for working
Social Security considers disability as the inability to work for at least 12 months. Not all work activity prevents you from filing for disability. Social Security considers earnings over a certain amount “substantial gainful activity” or “SGA.” If you earn over the SGA amount, you won’t qualify for Social Security disability benefits. For 2021, Social Security considers $1310 SGA for non-blind individuals. Additionally, you must be out of work for at least 12 months to qualify for Social Security benefits.
Appealing a denial for lack of medical evidence
Frequently, Social Security denies claims because there was not enough medical proof to show your condition keeps you from working. Important medical records might be missing from your claim. On appeal, you need to tell Social Security about all the doctors you’ve seen since becoming unable to work. You should see your doctors regularly so that you have documentation of your conditions and limitations. Additionally, you should see specialists for your conditions. Often, specialists keep better records about your symptoms and problems better than a general doctor.
Appealing a denial for not following your doctor’s orders
When you don’t follow your doctor’s recommendations, Social Security can decide that your limitations would be less serious than if you followed their orders. This includes refusing or declining certain treatment. For example, your doctor recommended physical therapy but you didn’t go. Additionally, it includes taking your medications as prescribed. It can also include certain lifestyle changes such as diet or exercise. You should speak with your doctors directly about any difficulty you have following their recommendations.
Appealing a denial for ignoring Social Security’s requests
Social Security often asks for additional information when processing your claim. Generally, this includes additional forms about your daily activities and work history. However, it also includes medical examinations with a Social Security doctor. Social Security may not be able to make a decision without this information. Social Security denies your claim when you don’t respond to their requests.
Why should I appeal my Social Security denial?
Appealing a denial improves your chances for approval. In fact, most cases have the best chance for approval at the hearing level. Re-filing a new application won’t increase your chances for getting approved. Actually, it only delays the appeals process.
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What Evidence Do I Need for SSDI? Social Security pays SSDI benefits when you have a medical condition or combination of conditions that prevent you from working. Your medical impairments must keep you from working for at least 12 months. Additionally, you must have worked for a certain number of years. Generally, you need to have worked for at least 5 out of the last 10 years. Social Security requires certain evidence to support your SSDI claim.
Non-medical evidence for SSDI: Disability Report
Naturally, SSDI applications require a lot of information. Part of the application process includes providing a form called the Disability Report. This form includes information about your doctors, hospital visits and medications. You should only include treatment information for the time that you have been unable to work. Social Security contacts the doctors and hospitals you provide in the Disability Report. If you don’t provide complete information, Social Security may not get important medical records. This could end up resulting in Social Security denying your claim.
Non-medical evidence for SSDI: Work History Report
Social Security requires information about your work history going back 15 years. You should provide a clear description of each of your past jobs. Social Security could deny your case if they don’t categorize your past work accurately. Social Security can deny you for not returning the work history report forms.
Non-medical evidence for SSDI: Function Reports
Social Security needs to understand how your conditions impact your daily functioning. Therefore, they send you a Function Report to complete. This form asks you to describe how you perform normal daily activities. It is important to describe any problems you have or any assistance you need for your daily activities.
Medical Evidence for SSDI
Your medical evidence should include records only for the period of time that you became disabled and unable to work. Your treatment should also be continuous and ongoing. Medical evidence can include:
Firstly, Treatment notes and physical examinations
Secondly, Imaging such as MRIs, x-rays, CT scans or nerve testing
Thirdly, Blood work or biopsy results
Fourthly, Pulmonary tests
Lastly, Mental health records
Example 1: medical evidence for SSDI
For example, Kelly injured her neck in a car accident. She required a cervical spinal fusion surgery. Despite surgery, she continued to have severe pain and difficulty moving her neck. She also still had problems using her hands due to numbness and tingling. Kelly sees her doctors regularly for her symptoms. Her records include x-rays, MRIs and nerve testing documenting her neck impairments. Her doctors also continue to note limited range of motion and decreased sensation and strength in her arms and hands in their office notes. Kelly provided proof through her medical records that her conditions caused a serious problem using her arms and hands. As a result, Social Security approved Kelly’s claim.
Medical evidence for SSDI from specialists
The type of treatment you receive can also impact your disability claim. Often, records kept by specialists record your symptoms and problems better than a primary doctor. They focus on specific information that Social Security needs to approve your disability benefits. This can include special tests or examinations. This can especially be true for any mental health impairments. Generally, receiving medication from your primary doctor will not be enough to document your mental health conditions.
Example 2: medical evidence from specialists
As an example, Julie suffers from anxiety and panic attacks. Her panic attacks happen unexpectedly. She receives medication from her psychiatrist. She also sees a therapist regularly. However, she still suffers from panic attacks many times during the day. She has even had to go the emergency room during her panic attacks. Her panic attacks make it hard for her to finish things she starts. At times, her panic attacks keep her from leaving the house. Social Security finds that Julie would miss work a lot due to her panic attacks. Therefore, Julie qualifies for disability benefits.
Medical evidence for SSDI and RFC forms
Residual functional capacity (RFC) forms can help support your disability claim. RFC forms explain how your symptoms impact your ability to work. An RFC form can include both mental and physical limitations.
Physical RFC forms
A physical RFC form includes questions about your ability to do things like:
How long you can sit, stand or walk at one time or in an 8 hour work day
How much weight you can lift or carry
If you need an assistive device such as a cane, walker, wheelchair or crutches
Using your arms and hands for activities such as reaching, pushing, pulling, gripping or grasping objects
If pain, fatigue, other symptoms or side effects from medications cause limitations with concentration, persistence or pace
Mental RFC forms
A mental RFC form includes questions about your ability to do things like:
Your ability to understand, remember or carry out instructions, interact with others such as supervisors, co-workers or the general public
Your ability to maintain attention and concentration
If your symptoms interfere with your ability to show up to work, arrive on time or have to leave early
Example 3: medical evidence and RFC forms
For example, say you are under the age of 50 and worked before as a waitress. You have a back injury that interferes with your ability to do this type of work. You also have side effects from your medications that make you drowsy. In an RFC form, your doctor states that you cannot sit for more than 3hours or stand or walk for more than 2 hours in a work day. Your doctor also states that you have problems with attention and focus due to your medications. These limitations help support your disability claim because it shows that you could not work a full 8 hour day.
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What Are the Legal and Financial Requirements of SSDI? You can file for Social Security disability benefits (SSDI) if you are unable to work. However, there are certain requirements that you must meet. First, you must meet the non-medical requirements for SSDI. Second, you must meet the medical requirements.
Legal requirements for SSDI
To qualify for SSDI, you must have worked a certain number of years. You must be between the ages of 18-65 years old. You do not need to be a US citizen. Any worker with a valid Social Security number who paid into Social Security may file for benefits. Your medical conditions must keep you from being able to work for at least 12 months.
Legal requirements for SSDI and work credits
Each year that you work and pay into Social Security, you earn work credits. Generally need to earn 20 work credits to meet the requirements for SSDI. However, if you are younger, you may meet the requirements for SSDI with fewer credits. Additionally, you must have worked recently for SSDI.
Legal requirements for SSDI and your date last insured
Your date last insured (DLI) is the last date you can qualify for SSDI benefits. Your coverage for SSDI ends after a certain amount of time from when you stopped working. Generally, your DLI expires five years after you stop working. However, your DLI may be within less than five years if your earnings were low or inconsistent. You can still meet the requirements for SSDI if your DLI has expired. You would need to prove that you meet the medical requirements for SSDI before your DLI.
Example 1: legal requirements for SSDI with an expired DLI
For example, say you stopped working in 2014. As a result, your DLI would expire in 2019. Therefore, you would need to show that your medical conditions kept you from working before 2019.
Financial requirements for SSDI
As mentioned, SSDI requires that you earn a certain amount of work credits to qualify. Therefore, there are no limits the amount of assets, cash or other resources you own. Additionally, there aren’t any limits to the amount of unearned income you make. There aren’t any limits to the amount of income your spouse makes either.
Financial requirements for SSDI and unearned income
Social Security considers any money you receive outside of a job as unearned income. Under SSDI, you can receive income from other sources and still qualify to receive benefits. Examples of unearned income include:
Income from retirement accounts, dividends or stocks
Unemployment benefits
Rental income
Alimony or child support
Financial requirements for SSDI: substantial gainful activity
Since Social Security defines disability as the inability to work, if you are working, you may not qualify for SSDI. Social Security considers work earnings over a certain amount “substantial gainful activity” or SGA. If you earn over the SGA limit, you will not qualify for SSDI. In 2020, earnings S1, 260 per month or (before taxes) are considered SGA. If you are working part-time and earning less than SGA, you may still qualify for SSDI. However, any work may make it harder for Social Security to approve your claim.
Legal requirements for SSDI – medical requirements
Social Security disability requires that your medical conditions keep you from working at least 12 months. Unlike workers’ compensation or veterans’ disability benefits, Social Security doesn’t offer partial disability. You can qualify for SSDI:
If You meet strict requirements of a Social Security impairment listing
You fall under a medical-vocational allowance
Your medical conditions prevent you from working in any job at all
Legal requirements for SSDI – Social Security’s Listing of Impairments
Social Security considers whether your medical conditions fall under their listing of impairments, known as the Blue Book. Typically, the Blue Book requires that your medical conditions meet very specific requirements. SSA reviews clinical findings and laboratory tests to determine if your disability meets the listing. If you have not had the clinical or laboratory tests required in the listing, you should ask your doctor to perform them.
Legal requirements for SSDI – Medical Vocational Allowances
Social Security uses a chart called the Medical-Vocational guidelines to evaluate your disability claim. These guidelines are known as the “grid rules”. The grid rules make it easier for people 50 or older to win their case. Social Security understands that it may be harder for older people to do new or different work. However, you must first show that you can’t do any past work. Even if Social Security thinks you can do something else, you may still qualify for SSDI. The rules are even more favorable if you are over 55.
Applying the grid rules
The grid rules consider different factors. These include your age, education, work background, work skills and your residual functional capacity (RFC.) Your RFC is what you can do despite your medical conditions. Once Social Security determines your RFC and work background, they will look to the grid rules. There are separate charts for sedentary, light and medium physical categories. For people over age 50, he more physically limited you are, the more likely the grids will show you should be found disabled.
Example 2: applying the grid rules over 55
For example, Andy, a 56 year old man previously worked as a janitor. He could no longer work because he has severe arthritis in his shoulder. He could no longer lift or carry up to 50 pounds. Since Social Security found Andy could no longer do his past work, the grid rules allowed them to approve his disability case.
Example 3: applying the grid rules over 50
As another example, Barbara, a 53 year old cashier stopped working because she had severe arthritis in her knees. She could no longer stand or walk for long periods. Social Security found that she could not perform her past work as a cashier. The grid rules allowed Social Security to approve her case, even though she could have done other types of work requiring less standing and walking.
Legal Requirements for SSDI – when you can’t do any jobs
If your conditions don’t meet the listings and you don’t fall under the grid rules, you can still qualify for SSDI. Social Security evaluates your medical records to determine your RFC. You want to provide as much documentation and records as possible related to your medical conditions. You should see your doctor consistently. Your doctor can also provide an opinion to explain how your conditions impact your functioning. If Social Security determines that your conditions keep you from working in any job, you would qualify for SSDI.
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How is Disability Amount Determined? Social Security bases your disability insurance benefits (SSDI) on the amount of earnings that you paid taxes on. Therefore, everyone’s amount is different.
How are benefits calculated?
Earnings you paid taxes on are called “covered earnings.” Social Security calls your average covered earnings Average Indexed Monthly Earnings (AIME). Social Security uses your AIME to figure your Primary Insurance Amount (PIA). Your PIA determines the amount you would receive from Social Security. Make sure your Disability Amount Determined is correct.
Average Indexed Monthly Earnings
Social Security adjusts or indexes your lifetime earnings to account for the increase in wages that happened during the years you worked. Social Security uses up to 35 working years in their calculation. First, they take the years with the highest indexed earnings and add them together. Next, they divide them by the total number of months for those years. Then, Social Security rounds down to reach your AIME which will be used to determine your disability amount.
Determining AIME for your disability amount
If you don’t have 35 years work history, Social Security calculates your AIME a little differently. Firstly, they will count the number of years between the time you turned 21 and the year you became disabled. Secondly, they subtract one-fifth of that total number of years or five years, whichever is less.
Your Social Security earnings statement
You can also check your estimated benefit amount on your Social Security benefits statement. Generally, checking your statement is the easiest way to find out your disability amount, which you can do by logging on to Social Security’s website at www.ssa.gov/mystatement. You would need to set up an account before accessing your statement. Additionally, you can request your statement from Social Security. You want to make sure your disability amount determined is accurate.
Other disability payments can reduce your disability amount
Social Security will reduce your disability payments if you receive other disability benefits. For example, these would include worker’s compensation benefits. They might also include temporary state disability benefits. Generally, you can’t receive more than 80% of the average amount you earned before you became disabled. Therefore, if both your Social Security disability benefits and other disability payments are more than 80%, Social Security reduces your disability payments.
Other disability payments that do not reduce your disability amount
Private long-term disability insurance benefits won’t reduce your Social Security disability amount. VA or SSI benefits won’t reduce your SSDI benefits either. You want to make sure your disability amount determined is accurate.
Disability back pay
Under SSDI, you can receive benefits back to the application date. However, you can also qualify to receive retroactive benefits. Social Security pays retroactive benefits for the months between when you became disabled and when you applied for benefits. Additionally, these benefits can go back one year before the application filing date. Therefore it will be involved in determining your disability amount.
SSDI back pay and the 5 month waiting period
Social Security does not pay back pay for the first five months after your disability began. This will determine your disability amount. You start receiving benefits at the beginning of the sixth month. Typically, the 5 month wait period can be much shorter than the time it takes for Social Security to approve your application.
Cost of living adjustment (COLA) and your disability amount
Each year, Social Security benefits may be increased to adjust to the increasing cost of living. Generally the Consumer Price Index (CPI) determines any COLA amounts increases each year. Therefore it will be involved in determining your disability amount.
Determining your disability amount for SSI
Unlike SSDI, SSI is a needs based program and doesn’t depend on your work history. Therefore, SSI has a maximum monthly rate. Firstly, the federal SSI payment standard for 2020 is $783 per month. Secondly, most states provide an additional small supplemental payment. Thirdly, Social Security calculates your SSI disability amount based on your income, assets and resources. Fourthly, your SSI benefit can be reduced by wages you or your spouse earn and other resources you receive. You want to make sure your disability amount determined is accurate.
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How Do I Appeal an SSDI Denial? Has Social Security denied your claim for SSDI benefits? You may think filing a new claim can be better than appealing. However, you should appeal any denials. Re-filing can delay the appeals process. Your chances for getting SSDI benefits improve when you appeal.
Where do I appeal an SSDI denial?
You can file an appeal several ways. First, you can appeal your denial online. This can be the easiest way to appeal an unfavorable decision. Second, you can file an appeal with your local Social Security office. If you have a representative, they can help you file an appeal of your SSDI denial.
How long do I have to file an appeal?
You have 60 days to appeal an SSDI denial. Social Security gives you an extra 5 days to allow you to receive your denial in the mail. Therefore, you have a total of 65 days from the date on your denial to appeal your SSDI claim. If you don’t file within the 65 days, you may have to re-file your claim. Social Security allows you to file an appeal in more than 65 days if you have good cause for missing your deadline.
What is good cause to appeal an SSDI denial for missing your appeal deadline?
Good cause can include several reasons. Social Security considers:
What circumstances kept you from making the request on time;
Social Security’s action misled you
Whether you didn’t understand what you needed to do to appeal
Whether you had any physical, mental, education or language limitations that prevented you from appealing on time
Examples of good cause for missing your deadline
You were very sick when the appeal was due and couldn’t have contacted Social Security yourself or through someone else. You would need proof that you were seriously ill.
There was a death or serious illness in your family
Records needed for your appeal were destroyed by an accident or fire.
You never received your denial notice
Some other type of unusual or unavoidable circumstances and you could not reasonably be expected to have met the deadline
What information should I include in my appeal for SSDI denial?
Most importantly, you need to include updated treatment information on your appeal. You should tell Social Security about all the doctors you’ve seen since filing your application. You should include any emergency room visits, also include any hospitalizations. On appeal, Social Security looks at any new or missing information that might change their minds.
Why was my SSDI claim denied?
Many people receive a denial for SSDI benefits the first time they apply. Understanding why Social Security denied your claim can help increase your chances on appeal. Specifically, you will know what your claim was missing or where your claim can be improved. Common reasons include:
Lack of medical evidence
You are working
Not following your doctor’s orders
Ignoring requests
SSDI denials for lack of medical evidence
Frequently, Social Security denies claims because there was not enough medical proof to show your condition keeps you from working. You must show that your symptoms cause serious problems in your functioning. Therefore, you should see your doctors regularly. Additionally, you should see specialists for your conditions. Often, specialists keep better records about your symptoms and problems better than a general doctor. They focus on specific information Social Security needs to approve your SSDI benefits. You need to Appeal your SSDI Denial on time or you will have to start over.
SSDI denials for working
Social Security defines disability as the inability to work for at least 12 months. Therefore, if you are working, you may not qualify for SSDI benefits. Social Security considers earnings over a certain amount “substantial gainful activity” or SGA. If you earn over the SGA limit, you won’t qualify for SSDI. If you have not been out of work for at least 12 months, you won’t qualify for SSDI.
SSDI denials for not following your doctor’s orders
If you don’t follow your doctor’s recommendations, Social Security could deny your case. Your doctor’s treatment plan shows that you cannot work due to your condition. Without a treatment plan, Social Security can have trouble establishing that your condition impacts your work ability. This also includes taking prescribed medications correctly. Additionally, when you don’t follow your doctor’s orders, Social Security can decide that your limitations would be less serious if you followed their recommendations. This can result in an SSDI denial. You need to Appeal your SSDI Denial on time or you will have to start over.
SSDI denials for ignoring requests
Often, Social Security requires additional information to process your SSDI claim. This may include more information about your treatment or work history. Social Security may not be able to make a decision without this information. When you don’t respond to their requests, Social Security denies your claim for failure to cooperate.
Get help appealing your SSDI denial
If you’ve been denied for SSDI benefits, you should consider working with a disability advocate. Hiring a disability advocate can significantly increase your chances of winning. A disability advocate makes sure you don’t miss any deadlines for appealing. They can help get your claim on the right track for winning your claim.
Disability Help Group, Call Now for a Free Case Review, 800-700-0652
Make sure you start your claim the right way and apply for all the benefits you deserve. Contact us now for a free consultation.
