I Have Been Denied
I HAVE FILED
I Have Been Denied
So you have received correspondence from SSA that you think might be a denial. If you’re confused, you’re not alone. Often times, SSA’s formal written communications and correspondence are quite confusing. The first thing you want to do is review the date stamped on the correspondence. Although SSA regulations assume you received the correspondence five days after it was printed, that may not necessarily be the case. If it’s not, you need to act quickly and call us immediately!
The next step is to review the documentation to see if it’s a Medical or Non-Medical denial.
MEDICAL vs. NON-MEDICAL DENIALS
The second thing you want to confirm is whether or not the document is a Medical or Non-Medical denial. Sometimes, if you’re receiving a pension, Short- or Long-Term Disability payments, or have assets or income that exceed the limits for Supplemental Security Income (SSI), you may get a notice telling you that you don’t qualify for SSI because you exceed the resource limits. If you receive such a notice, then your medical case is still pending at Disability Determination Services (DDS) and in progress.
A Medical Denial is very different and is more serious. You only have 60 days to appeal a Medical Denial. It is a Medical Denial if either the first or second paragraph of your written notice has the following verbiage or something very similar:
We are writing about your claim for Social Security benefits. Based on a review of your health problems, you do not qualify for benefits on this claim. This is because you are not disabled under our rules.
The next thing you want to do is carefully review the medical sources that the Agency used in making this determination. These are usually listed on page 1 or page 2. If there are medical sources who treated you that are not listed in this section, this means that DDS either did not request this medical evidence, or they requested the evidence and your treating source did not furnish it to them. So, they made a decision with incomplete information, which is never good.
From there, the decision would state something like the following:
We have determined that your condition does not keep you from working. We considered medical and other information such as your age, education, training, and work experience in determining how your condition affects your ability to work.
The decision will next read: ”you said you were disabled because….” It will then list all of the disabling conditions/symptoms/diagnoses you listed on your Initial Application.
When Americans file a Social Security Disability (SSD) claim on their own, they use statements like “back pain” as a disabling condition. That is not specific enough for the Agency. We would list the formal diagnosis for which you were treated, which corresponds to an ICD-10 code that was issued by your doctor at the time of treatment. This may seem trivial, but those words you place on your Initial Application will find their way into just about every document from here on out. This is why we believe it’s critical that you hire an attorney at the start of the process, not after you’ve attempted it on your own and possibly botched it.
Getting the SOCIAL SECURITY LAW GROUP involved at the Reconsideration Stage
When you call us, we will assess the viability of your claim at no cost to you. We call this your initial consultation. If we believe that you have a viable SSD claim, and you want us to represent you, we’ll get the process started. Once we get the SSA forms back from you, we will collect the medical records from those treating sources that were missing on your Initial Application. We will then prepare an online appeal. Quite often, we have to appeal immediately in order to preserve your 60-Day appeal window.
What is a Reconsideration
A Reconsideration is the first level of appeal after your Initial Application is denied. You file a Request for Reconsideration because the Agency missed something like a doctor’s report or a diagnosis that you did not list on your Initial Application because you may not have realized it affected you. Or perhaps your medical condition worsened since the Initial Application was filed.
Most Americans don’t realize this, but if you file a Reconsideration appeal and there is no new diagnosis, no change in your condition, or any treating source that was missed, then the Agency will issue what we at SSLG call a Summary Denial. We often get calls from clients who filed a Reconsideration appeal on their own two weeks ago and it was denied already. It was denied because there was nothing new for DDS to reconsider.
The other thing most Americans don’t realize is that nationally, only 11% of Reconsideration appeals are approved by SSA. That means the other 89% are going to be denied again. This is why we believe it’s critical to hire an SSLG Attorney at the start of the process.
When you work with the lawyers of the Social Security Law Group, we will overturn every stone to make sure your case doesn’t qualify for Summary Denial. If you have treating sources that were not listed, and we have the time in your appeal window to request that medical evidence, we will work with you and your doctors to get that evidence to us so WE can submit that new medical evidence with your appeal.
In addition, since almost 90% of Reconsiderations are denied, we’ll begin preparation for the Hearing stage, which statistically has a higher approval rate. Many claims are denied based on the entries that Americans make in their Function Reports. We use Status Star, our advanced claims platform and mobile app, along with detailed training tools on how to complete these reports truthfully, accurately, but most importantly, stressing your functional limitations (the things you are no longer able to do that you could before your disabling condition began).
Once you’re officially an SSLG Client, we will introduce you to Status Star. Status Star is our home-grown, state-of-the-art, user-friendly and secure claims and mobile platform unmatched by any law firm in the United States! Built exclusively for our Social Security Disability practice, you will use Status Star as much or as little as you prefer, or as your technological capability and appetite dictates. In addition to communicating with us and checking your claim status, you can begin cataloguing your doctor visits and treatments in a way that will help us at your Hearing. As a client, you will have access to a whole host of training tools that will better assist you in preparing for your Hearing and reversing your denial.
The SSA Reconsideration Process
Like the Initial Application, which is generally done online, you are required to enter the contact information of all your treating sources for a second time. They will ask you to list all the medications, visit dates, reasons for treatment etc. This is a lot of repetitive, redundant, aggravating, bureaucratic work. When we at SSLG assist you at the Initial Application phase, we compile and save all this information in Status Star, our advanced claims platform and mobile app. As a result, filing an Appeal takes minutes rather than hours.
Once you finish the Reconsideration appeal online and enter “Submit,” those entries are compiled and sent to your local SSA Field Office. (You can check the “Home” page of our website to find your local SSA Field Office). From there, the Agency determines whether or not there is any new information to reconsider. As we stated previously, if you allege no worsening of your medical condition, no new treating sources, no new diagnosis, or no real changes from your Initial Application, the assigned SSA staffer at your local Field Office is authorized to issue a Summary Denial. If that’s the case, you’ll get a denial notice in about 2 to 3 weeks.
If there are changes or a worsening of your condition, your file is then forwarded to your assigned Disability Determination Services (DDS) office. From there, a new DDS Examiner who was not involved in the Initial Application denial will be assigned to your case at the Reconsideration level.
The Examiner will call us to ensure there are no additional treating sources that we missed. He or she will then make requests for new treating source records (including treating source records they requested at the Initial Application level but that were not furnished by a medical provider). They will also send you a second Function Report. They may even send Function Reports to friends or relatives if you listed them on the Initial Application or Appeal. These Function Reports are critical in determining your limitations and what SSA calls your Residual Functional Capacity (RFC). We see time and again an Administrative Law Judge (ALJ) offhandedly dismiss a person’s limitations because of something he or she entered into their Function Report. This is why we provide significant assistance with this task. It’s too critical to blow-off.
It’s likely the DDS Examiner will send you to a second SSA Consultative Exam in which an SSA doctor will perform a physical or mental status exam. We ask that you use our advanced claims platform and mobile app, Status Star, to document and provide details of this exam before you leave the parking lot immediately after the Consultative Exam is completed. As we stated previously, this Consultative Exam is at the government’s expense, and is often a superficial, summary exchange of information with you and a doctor. To give you an idea of what we mean, here is an excerpt from an actual ALJ decision:
Despite this, the claimant’s memory was generally within normal limits…during a consultative exam where he was able to recall a recent news story and knew his own age, birth date, and SSN by memory.
If you’re thinking….WOW! You are not alone.
Once the DDS Examiner has compiled all of the new or unavailable medical evidence that your treating sources have furnished, the DDS Examiner performs a task they call the Medical Workup. The Medical Workup is a worksheet that describes all of your impairments, the medical sources used, and the recommendations of the Examiner. The Examiner will then analyze your medical records to determine if your impairment(s) is severe enough to meet what they call a Social Security Listing. Absent a significant piece of medical evidence that was missing from the Initial Application, it’s not likely that upon Reconsideration the Examiner is going to recommend that your claim meets a Social Security Listing. Simply put, the previous DDS Examiner would have done that when reviewing the Initial Application.
In some instances, at the Reconsideration level, the Examiner may make the recommendation that the combination of your impairments equals a Social Security Listing. Only a Doctor at DDS can make the determination that a combination of impairments equals a Social Security Listing. That would be part of his or her workup to the Medical Advisor.
If they’re going to approve your case at this Reconsideration level, it is more likely due to your Residual Functional Capacity (RFC). So if the DDS Examiner does not believe your medical condition is severe enough to meet or equal a Social Security Listing, then he or she will make a recommendation to the Medical Advisor (who is always a medical doctor) of what they believe is your Residual Functional Capacity.
A person’s Residual Functional Capacity is the amount of bandwidth/ability/endurance, etc. that a particular person is capable of, in spite of their medical conditions. For example, the DDS Examiner may make the determination that you cannot perform your past work which was considered Light, but is of the opinion that you can perform Sedentary work. As a result, he or she would make a recommendation to the Medical Advisor that you have the residual functional capacity to perform Sedentary work. Having a capacity to perform Sedentary work generally results in a denial.
Once the workup is delivered to the Medical Advisor, the Doctor will either agree or disagree with the Residual Functional Capacity recommendation of the DDS Examiner. On occasion, the Medical Advisor may not agree with the DDS Examiner’s opinion, and send the case back to him/her for further workup.
If the Medical Advisor agrees with the DDS Examiner that you have the Residual Functional Capacity for other work, the Medical Advisor will make that certification, and DDS will deny your claim once again. The official terminology within DDS is that your claim has been “Closed.”
When your claim has been Closed, that means they have made a decision, and responsibility for sending out the decision is kicked back to the Claims Representative at your local SSA Field Office. In reality, a computer generates all of these notices and they’re mailed to you.
When they deny your claim, they will send you a Notice of Reconsideration which will list the treatment sources that they considered, any Consultative Exams you may have attended, and again provide a brief, very simple rationale for why they denied your claim at this stage.
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