What does it take to qualify for Disability if PCa isn't Enough

I took this discussion on some months ago. In order to be disabled for Social Security, you really have to be incapable of doing productive work at any wage in a regular job. They have a site which goes over the rules, and based on those, I just don't see a way. Once there is metastasis or collateral damage, it is another story.

The problem is that if you can sit or stand in the entrance of a Wal Mart for a day and be a greeter, even if you have to change pads every hour, you don't qualify. I can't easily work in an office environment anymore, but that is not enough, since I can work remotely, and am still capable of keeping myself clean, going to the store, and cooking dinner without burning down the house (as well as drinking the random beer). I have a friend who does SS claims, and her opinion is that simple PCa treatment would never qualify. Once mets set in, and you can't do at least one of what they consider the "daily functions", things change.

It isn't easy.

Here is an earlier thread:

https://www.healingwell.com/community/default.aspx?f=35&m=2140443

 

Part of the problem is that you have to be unable to do ANY job. So if you were a construction guy or a high tech computer person, if you can mop a floor, you don't qualify in general.

If you can work at home stuffing envelopes for how many cents per 100, that's work.

It takes more than PCa, and it doesn't consider the change in type of work, salary loss, or the fact that no one is hiring.

If the bar was lower - we wouldn't have anyone paying into the SS system.

I found this on the SS website---



13.24 Prostate gland- carcinoma.

A. Progressive or recurrent despite initial hormonal intervention.

OR

B. With visceral metastases (metastases to internal organs).



A. What impairments do these listings cover? We use these listings to evaluate all malignant neoplasms except certain neoplasms associated with human immunodeficiency virus (HIV) infection. We use the criteria in 14.08E to evaluate carcinoma of the cervix, Kaposi's sarcoma, lymphoma, and squamous cell carcinoma of the anal canal and anal margin if you also have HIV infection.

B. What do we consider when we evaluate malignant neoplastic diseases under these listings? We consider factors such as the:

1. Origin of the malignancy.

2. Extent of involvement.

3. Duration, frequency, and response to antineoplastic therapy. Antineoplastic therapy means surgery, irradiation, chemotherapy, hormones, immunotherapy, or bone marrow or stem cell transplantation. When we refer to surgery as an antineoplastic treatment, we mean surgical excision for treatment, not for diagnostic purposes.

4. Effects of any post-therapeutic residuals.

C. How do we apply these listings? We apply the criteria in a specific listing to a malignancy originating from that specific site.

D. What evidence do we need?

1. We need medical evidence that specifies the type, extent, and site of the primary, recurrent, or metastatic lesion. When the primary site cannot be identified, we will use evidence documenting the site(s) of metastasis to evaluate the impairment under 13.27.

2. For operative procedures, including a biopsy or a needle aspiration, we generally need a copy of both the:

a. Operative note.

b. Pathology report.

3. When we cannot get these documents, we will accept the summary of hospitalization(s) or other medical reports. This evidence should include details of the findings at surgery and, whenever appropriate, the pathological findings.

4. In some situations we may also need evidence about recurrence, persistence, or progression of the malignancy, the response to therapy, and any significant residuals. (See 13.00G.)

E. When do we need longitudinal evidence?

1. Tumors with distant metastases. We generally do not need longitudinal evidence for tumors that have metastasized beyond the regional lymph nodes because these tumors usually meet the requirements of a listing. Exceptions are for tumors with distant metastases that are expected to respond to antineoplastic therapy. For these exceptions, we usually need a longitudinal record of 3 months after therapy starts to determine whether the intended effect of therapy has been achieved and is likely to persist.

2. Other malignancies. When there are no distant metastases, many of the listings require that we consider your response to initial antineoplastic therapy; that is, the initial planned treatment regimen. This therapy may consist of a single modality or a combination of modalities; that is, multimodal therapy (see 13.00I3).

3 . Types of treatment. Whenever the initial planned therapy is a single modality, enough time must pass to allow a determination about whether the therapy will achieve its intended effect. If the treatment fails, the failure will often happen within 6 months after treatment starts, and there will often be a change in the treatment regimen. Whenever the initial planned therapy is multimodal, a determination about the effectiveness of the therapy usually cannot be made until the effects of all the planned modalities can be determined. In some cases, we may need to defer adjudication until the effectiveness of therapy can be assessed. However, we do not need to defer adjudication to determine whether the therapy will achieve its intended effect if we can make a fully favorable determination or decision based on the length and effects of therapy, or the residuals of the malignancy or therapy (see 13.00G).

F. How do we evaluate impairments that do not meet one of the malignant neoplastic diseases listings?

1. These listings are only examples of malignant neoplastic diseases that we consider severe enough to prevent you from doing any gainful activity. If your severe impairment(s) does not meet the criteria of any of these listings, we must also consider whether you have an impairment(s) that meets the criteria of a listing in another body system.

2. If you have a severe medically determinable impairment(s) that does not meet a listing, we will determine whether your impairment(s) medically equals a listing. (See §§404.1526 and 416.926.) If your impairment(s) does not meet or medically equal a listing, you may or may not have the residual functional capacity to engage in substantial gainful activity. In that situation, we proceed to the fourth, and, if necessary, the fifth steps of the sequential evaluation process in §§404.1520 and 416.920. If you are an adult, we use the rules in §§404.1594 and 416.994, as appropriate, when we decide whether you continue to be disabled.

G. How do we consider the effects of therapy?

1. How we consider the effects of therapy under the listings. In many cases, malignancies meet listing criteria only if the therapy does not achieve the intended effect: the malignancy persists, progresses, or recurs despite treatment. However, as explained in the following paragraphs, we will not delay adjudication if we can make a fully favorable determination or decision based on the evidence in the case record.

2. Effects can vary widely.

a. Because the therapy and its toxicity may vary widely, we consider each case on an individual basis. We will request a specific description of the therapy, including these items:

i. Drugs given.

ii. Dosage.

iii. Frequency of drug administration.

iv. Plans for continued drug administration.

v. Extent of surgery.

vi. Schedule and fields of radiation therapy.

b. We will also request a description of the complications or adverse effects of therapy, such as the following:

i. Continuing gastrointestinal symptoms.

ii. Persistent weakness.

iii. Neurological complications.

iv. Cardiovascular complications.

v. Reactive mental disorders.

3. Effects of therapy may change. Because the severity of the adverse effects of antineoplastic therapy may change during treatment, enough time must pass to allow us to evaluate the therapy's effect. The residual effects of treatment are temporary in most instances. But, on occasion, the effects may be disabling for a consecutive period of at least 12 months.

4. When the initial antineoplastic therapy is effective. We evaluate any post-therapeutic residual impairment(s) not included in these listings under the criteria for the affected body system. We must consider any complications of therapy. When the residual impairment(s) does not meet or medically equal a listing, we must consider its affect on your ability to do substantial gainful activity.

H. How long do we consider your impairment to be disabling?

1. In some listings, we specify that we will consider your impairment to be disabling until a particular point in time (for example, at least 18 months from the date of diagnosis). We may consider your impairment to be disabling beyond this point when the medical and other evidence justifies it.

2. When a listing does not contain such a specification, we will consider an impairment(s) that meets or medically equals a listing in this body system to be disabling until at least 3 years after onset of complete remission. When the impairment(s) has been in complete remission for at least 3 years, that is, the original tumor or a recurrence (or relapse) and any metastases have not been evident for at least 3 years, the impairment(s) will no longer meet or medically equal the criteria of a listing in this body system.

3. Following the appropriate period, we will consider any residuals, including residuals of the malignancy or therapy (see 13.00G), in determining whether you are disabled. If you have a recurrence or relapse of your malignancy, your impairment may meet or medically equal one of the listings in this body system again.

I. What do we mean by the following terms?

1. Inoperable: Surgery is thought to be of no therapeutic value or the surgery cannot be performed; for example, when you cannot tolerate anesthesia or surgery because of another impairment(s), or you have a tumor that is too large or that has invaded crucial structures. This term does not include situations in which your tumor could have been surgically removed but another method of treatment was chosen; for example, an attempt at organ preservation. Your physician may determine whether a tumor is inoperable before or after you receive neoadjuvant therapy. Neoadjuvant therapy is antineoplastic therapy, such as chemotherapy or radiation, given before surgery in order to reduce the size of the tumor.

2. Metastases: The spread of tumor cells by blood, lymph, or other body fluid. This term does not include the spread of tumor cells by direct extension of the tumor to other tissues or organs.

3. Multimodal therapy: A combination of at least two types of treatment modalities given in close proximity as a unified whole and usually planned before any treatment has begun. There are three types of treatment modalities: Surgery, radiation, and systemic drug therapy (chemotherapy, hormonal therapy, and immunotherapy). Examples of multimodal therapy include:
a. Surgery followed by chemotherapy or radiation.
b. Chemotherapy followed by surgery.
c. Chemotherapy and concurrent radiation.

4. Persistent: Failure to achieve a complete remission.

5. Progressive: The malignancy becomes more extensive after treatment.

6. Recurrent, relapse: A malignancy that was in complete remission or entirely removed by surgery has returned.

7. Unresectable: Surgery was performed, but the malignant tumor was not removed. This term includes situations in which your tumor is incompletely resected or the surgical margins are positive. It does not include situations in which a tumor is completely resected but you are receiving adjuvant therapy. Adjuvant therapy is antineoplastic therapy, such as chemotherapy or radiation, given after surgery in order to eliminate any remaining cancer cells and lessen the chance of recurrence.

J. Can we establish the existence of a disabling impairment prior to the date of the evidence that shows the malignancy satisfies the criteria of a listing? Yes. We will consider factors such as:

1. The type of malignancy and its location.

2. The extent of involvement when the malignancy was first demonstrated.

3. Your symptoms.

K. How do we evaluate specific malignant neoplastic diseases?


OF COURSE THIS IS ALL ON PAPER---AS A HOSPICE NURSE I ACTUALLY HAD A YOUNG BREAST CANCER PATIENT WITH METS EVERYWHERE ---EVEN BRAIN---WHO WORKED UNTIL THE BRAIN METS MADE HER INCAPABLE---------AND STILL GOT TURNED DOWN WHILE SHY LAY DYING-----GO FIGURE

Annie

Rule of thumb with Social Security is that the initial claim will be denied by bureaucratic routine. You must refile the claim through an appeal, often several times, taking several years in many cases. It is vital to have a very experienced and excellent attorney doing the filing. I have several clients that are on SS disability and one that has been trying for four years. If you looked at the paticulars you would see that the ones on disability really shouldn't be and the one that keeps being denied truly should be. In each case it has been the ability of the attorney not the condition of the claimant that has determined the status.

I see little chance for most of us to get on SS disability due to PCa. For most of us the truly debilitating condition won't occur until after we hit Social Security full retirement age at which time the retirement benefit replaces the disability benefit.

For other types of disability benefits, employer sponsored, individual insurance, vetrerans benefits like Agent Orange connection, etc.; you must look at the specific requirements of that coverage to determine eligibility. Generally speaking, Social Security disability is the very toughest to get.

Decided to weigh in on this one, since its all fresh with me.

To start, SS never approved my claim because of PC alone. It was approved in the end, because of all the complications, set backs, chronic fatigue and pain associated with failed and blotched treatments, that left me disabled.

There is a short list of disabilities that get instant approval, the bulk of applicants dote meet that criteria. I got rejected, expected that. My mistake was following SS agent's advice, and did my first "Reconsideration" on my own. That wasted months and months and months. It was only when I contracted with a top notch SS Attorney did things start to happen fast.

If SS would talk to my doctors first hand, could have been settled so long ago, but they won't do that. And from what the agent told me, if SS has you see their doctors, they pretty well don't believe you, and that's not a good sign.

As my attorney was working the case, at the advice of another attorney, I invoked the help of my U.S. Senator here in SC. He was great, I've gotten 4 personal letters from him.

My lawyer made sure my case was assigned to the most compassionate of the judges here, that's where a good lawyer helps. She also got my case considered a "hardship" case, which helped move it up the list.

At the time of the decision, my case was in the very next group to go before the judge, it was expected to be heard within that month. A few days later, a very shocked lawyer called me early in the morning, and said the judge had already decided favorably in my case. My lawyer never even sat with the judge. She said the judge told her, that my case was a "no brainer", and that she couldn't believe that SS had turned it down in the first place. The judge was angry, and because of that, awarded my disability all the way to the day of my original PC diagnosis in August of 2008, and marked it as a perm. disability, meaning I would never have to have my case revieiwed again by doctors or anyone else.

Two days later, a huge sum hit our checking account over night, even before getting an official letter from SS. It happened so fast it was shocking.

Because of the earlier delays, I qualified for Medicare immediately, no waiting period.

I would rather be working and making what I was use to, but am thankful (to all the players) in getting this disability money and the Medicare. It's not a hand out to me, I was fully funded in the system with 41 years of hard work paying payroll taxes, and I am not able to work.

If you feel you have grounds, do yourself a favor, and hunt out a good lawyer first. And you have to be tough and determined all the way to the end, as the SS folks will try to wear you down. With me, they picked on the wrong animal, I think in the end, they were glad to get rid of me with the approval, lol.

Good luck to you. Been there, done it, and walked away with the prize.

David in SC

Post Edited (Purgatory) : 9/1/2011 6:20:58 PM (GMT-6)