The Systems Explorer (SE) has been created as a means of introducing the disability representative to some of the more common physical and mental limitations that can be caused by a given disease state. This new CD version will be especially helpful to those who do not have formal training in a health-related field. 

In the Systems Explorer, we provide a unique perspective on medical conditions and how they are used within the Social Security disability process.  The SE is designed to be used with our Social Security Guide.  Together, the Systems Explorer and the Social Security Guide will provide you with a detailed perspective on how medical conditions are perceived by Social Security.

The older versions of our Systems Explorer focused on specific medical conditions. With the incorporation of the Social Security Guide into our program, this approach is no longer necessary.  The Social Security Guide provides an impressive discussion of each disease category and the appropriate medical listings for that disease. 

The Systems Explorer is divided into what is known as systems categories.  A systems category is simply a collection of diseases that fall within a related category of disease.  In this new version of the SE, we will focus on how a particular category of disease might restrict a person's ability to perform work. This means that instead of trying to define limitations for each and every disease within a category, we'll focus on the category itself.  We'll discuss how many diseases within a particular category can affect an individual's physical and/or mental capabilities.

Each disease category within the SE has a list of common diagnoses associated with it.  This list of common disorders will give you some idea of the types of diseases that fall within a given category.  You'll also find a narrative discussion of common physical and mental limitations that are caused by diseases within a particular category.  We'll point out supportive evidence commonly used in the evaluation of certain disease states and methods used to prove symptom severity.  We'll also discuss special disease characteristics as they pertain to Social Security disability.

Be aware that not all symptoms or limitations commonly found within a disease category will occur in every case.  You must review each case individually and use your knowledge and common sense to extract what is specific to that client's case.  If the claimant alleges a given restriction, you cannot take him at his word.  You must prove that the symptom exists via the client's medical documentation.  The client's symptoms must have a loose nexus before they can be used to support a limitation.  That is, the symptom must be related to the disease being alleged by the claimant. 

As the claimant's representative, it is your job to identify as many symptoms as possible and use those symptoms in your argument for physical or mental limitation.  Most claimants never express the full restrictive nature of their impairments.  Therefore, it is up to you to make sure that all reasonable symptoms and there restrictions are considered.  A reasonable restriction is any physical or mental limitation that is supported by the medical evidence.  
 

Identifying and learning about a disease

Let’ss say that you have just opened your first case and the disease the claimant is alleging is called a CVA or Cerebrovascular Accident (Stroke).  You have never taken a medical terminology course and you have no idea what a CVA is.  What do you do?

We recommend you use the Merck Manual to learn about any disease you'll encounter as a disability advocate.  You can purchase a Merck Manual or use the online link from the Advocate Client Manager software.  When using the Merck Manual, you need only to turn to the rear of the text and look up in alphabetical order the terms Cerebrovascular Accident.  The manual will give you a page number where the disease is discussed.  Turn to that page for a complete discussion of the disease. 

In the Merck Manual, a CVA could be listed under several disease categories.  The reason for this is because a CVA has both circulatory and neurological implications.  This is true of many diseases so don't let this fact confuse you.  Even though the Merck Manual discussion can be a bit technical, you'll learn valuable information about any disease you'll encounter as a representative. 

The key to winning disability cases does not lie in understanding the technical aspects of a disorder.  Winning disability cases is determined by how well you understand how a particular disease can limit an individual.  Learn just enough about the disease state to unable you to argue with conviction the limitations caused by the impairment.
 

 What is a symptoms category?

In medical science, the human body is divided into what is known as body systems.  Each system represents a major physiological function within the living organism.  For example, the heart is the primary organ within a major system known as the circulatory system.  The brain is the primary organ within the neurological system, and so on. 

We have chosen to focus on symptoms of a disease because symptoms are readily apparent and easy to understand.  Documented symptoms are also the primary tool used by Social Security in determining a claimant's physical and/or mental Residual Function Capacity.  It is far more accurate and easier to identify restrictions based on the symptoms of a specific disease. 

Body Systems or Disease Categories

For the purpose of representation, a body system and a disease category are the same thing.  A body system like the heart will fall into the disease category for cardiovascular or (heart disease).  Assuming that you are not familiar with the commonly used body systems, we have listed them below:

Musculoskeletal (Muscle and bone disease)
Special Senses and Speech (Sight, speech, hearing and balance)
Respiratory (Lung disease)
Cardiovascular (Heart disease)
Digestive (Diseases of the gastrointestinal track)
Genitourinary (Disease of the sex organs or bladder)
Hemolytic and Lymphatic (Blood disorders)
Skin disease (Disorders of the skin)
Hormonal (Disorders of the endocrine system)
Multiple Body Systems (Birth defects and other catastrophic abnormalities)
Immune system disease (Disorders of the immune system like HIV)
Neurological (Disease of the brain and nerve complex)
Mental (Disorders of the mind - thinking or behavioral disorders)
Neoplastic (cancers)  


Supportive Evidence  

The SE will list the types of supportive evidence you should seek when trying to evaluate a given disease state. Generally, medical evidence, with the possible exception of diagnostic tests, is written in lay terms.  You'll be able to understand most of what you are reading even if you are not familiar with medical terminology.  We'll attempt to explain some of the more common diagnostic procedures to enable you to review evidence more confidently.

 
Child Cases and Age-Related Activities

See chapter eight in the Social Security Guide for a presentation on childhood claims.

When evaluating cases involving children, you'll discover that there are no work issues to consider.  This means that when you argue child cases, you cannot use vocational factors as is used in adult cases.  In a child disability case (under age eighteen), you must try to prove that as a result of the impairment, the child cannot perform age-related activities.  In a child case, determining age-related capability is straight-forward.  For example, if a child is eight years old and is unable to dress himself as a result of his impairment, chances are this child is suffering from a severely disabling condition.

In a childhood claim, if a condition does not meet or equal the medical listings, it may still be allowed based on the child's inability to perform normal age-related activities.  The activity itself can be anything that is age related and severely limits the normal function of the child. 

The following is a list of childhood restrictions that are considered important in the eyes of the Social Security Administration.  Look for these types of restrictions in all cases you review: 

1.  Severely restricted fine or gross motor movement of the hands.
2.  Significantly reduced coordination.
3.  Limitation in movement of two or more joints.
4.  Severe gait disturbance (walking problems).
5.  Inability to perform age-related hygiene tasks.
6.  Inability to avoid environmental hazards.
7.  Significantly reduced ability to communicate in speech or manner. 
8.  Uncontrollable antisocial behavior.
9.  Uncontrollable phobias. (fears).
10. Chronic and/or severe psychological disorientation.

The foregoing symptoms are just a few of the many restrictions that can occur as a result of an impairment.  Again, these restrictions must be age appropriate and supported by the claimant's medical documentation.  Child cases are the only cases that use age-appropriate restrictions as the primary means of determining disability.  This is because kids don't usually have a work history so vocational analysis would make no sense.  Therefore, if you are dealing with a case on an individual under age eighteen, focus on how the child's impairment restricts normal age-related activities or behaviors.
 

Widower Cases

A Widower case is from the standpoint of a representative no different from any other SSDI claim.  However, the pre-application criteria to qualify for a Wisower case is slightly different. 

See Social Security Guide, chapter two.

Let’s assume that we have a case on a 51 year-old widow who has been previously denied benefits because she does not meet or equal the listings.  Social Security regulations allow us to review widow cases in the same way that all other adult cases are reviewed.  In other words, we must consider the widow's remaining ability to perform work.   In this example, the widow's only impairment is morbid obesity with a weight of 320 lbs at 5'3" inches in height.  She complains of joint pain and difficulty walking.  Because she does not have an additional significant impairment, she would not meet the medical listing criteria for obesity.  

To win this case, you could attempt to prove via the medical evidence that this claimant cannot ambulate (walk) for more than a few minutes due to her weight and severe joint pain.  It is quite reasonable to argue this point because joint pain is common with morbid obesity.  However, for the joint pain argument to be accepted by SSA, there must be physical evidence and X-ray findings that show a relationship between the joint pain and a disease state within the painful joint.  In other words, the obese client must also have evidence of at least mild arthritis of the weight bearing joint. 

The claimant is the best source for these additional allegations in cases where a single impairment is not severe enough for an allowance.  By paying close attention to the claimant's symptoms and allegations, you can identify a multitude of physical or mental restrictions. 

Genuine symptoms will often lead to the discovery of less serious disease state that cause additional physical limitations.  These additional disorders can then be used to further restrict the claimant's Residual Functional Capacity, perhaps leading to an allowance determination.  In this example, obesity with joint pain as a result of even mild arthritis could lead to an allowance determination.
 

The Symptom of Pain

Pain is the most valuable and subjective symptom in your arsenal of limiting factors.  When pain is alleged, use it to your client's advantage.  First, make sure the alleged pain has a loose nexus.  That is, the pain is reasonably related to the primary diagnosis being alleged by the claimant.  The loose nexus is determined by the findings within the claimant's medical evidence.

Once you establish a loose nexus for the pain, establish how the pain limits the claimant's ability to perform certain activities required in performing work.  Always make sure that the claimant's alleged pain is being caused by a medically documented impairment.  Don't just say the claimant is in pain and leave it at that.  Discuss the reason for the pain, the evidence supporting the pain, where it is located, the efforts made to reduce it and most importantly, how it affects the claimant's ability to perform work.  

 
Contra-lateral Impairments

A contra-lateral impairment is a condition whereby a claimant has a similar impairment in two locations on the opposite side of the body.  An example of a contra-lateral impairment would be a claimant who has a club right foot on the right side and a deformity with missing fingers of the left hand.     

If the person suffering from a contra-lateral impairment is reasonably functional despite the impairments, the case may be denied.  You must argue that due to the claimant's contra-lateral limitations, he cannot realistically find or engage in gainful employment. You would of course detail the limitations in activity and movement caused by the impairments using the medical evidence and your common sense.  It doesn't take much medical knowledge to explain how this type of condition can prevent the performance of work.
 

Multiple Impairments  

In a multiple impairment condition, you are working with a claimant who is suffering from a number of serious medical disorders.  This circumstance usually involves three or four different disease states all of which limit the claimant's functional capabilities.  Multiple impairments are common.  However, you must learn to distinguish among those that will result in meaningful limitations in order to win the case.  A meaningful impairment is any disorder that is moderate to severe in nature and causes a significant physical or mental limitation.  

A rule of thumb for determining which impairments cause meaningful restrictions is to choose those conditions that are the most serious.  Serious disorders are usually most limiting in there effect on the claimant's ability to perform work.  You can also combine severe physical and mental impairments and show how the combination results in an inability to work.  Whatever it takes to formulate the strongest argument on behalf of your client is the best approach.  A claimant who has multiple impairments, more than one disease state, can be restricted whether the impairments are unilateral or contra-lateral in nature.  
 

Requirements for Less Than Sedentary RFC

As you begin your career as a disability advocate, you'll discover that the majority of your clients will be younger individuals.  That is, most claimants will be forty-nine years of age or younger.  Because of  the claimant's young age category, you'll usually be required to lower their Residual Functional Capacity (RFC) to less than sedentary work in order to win the case.  Therefore, it is especially important that you are aware of the requirements for a less than sedentary Residual Functional Capacity. 

The requirements for less than sedentary work are met if you determine that your client is unable to lift 10lbs maximum and is unable to stand or walk for more than 20 minutes without changing position or causing painful aggravation to his condition.  The following list is also used to limit a claimant to less than sedentary work:

The individual requires a cane, walker or other device in order to ambulate (walk).

The individual cannot bend at the waist without significant pain or discomfort.

The individual cannot do prolonged sitting ( more than fifteen to twenty minutes) without experiencing pain which requires frequent postural changes for relief.

The claimant must have full use of his/her upper extremities in order to perform sedentary work.  The RFC would be limited to less than sedentary work if the claimant is limited in fine motor movements such as handling, fingering or feeling in either hand.  The RFC is also reduced if the claimant is unable to use or has a significant reduction in the use of an upper limb due to any impairment.

Poor close vision:  An inability or significant reduction in the claimant's ability to read due to poor vision. This determination is made with consideration of best corrected vision.  In other words, evaluate the claimant's vision problem with his glasses on.

Significant hearing loss:  Most sedentary jobs do not require that a person be able to hear at a normal conversational speech. Therefore, this is useful only if hearing is required for safety or performance of the job.

Mental Disorders

Less Than Simple Unskilled Work:

Less than simple unskilled work is the mental impairment equivalent of less than sedentary work.  The terms simple and unskilled are indications of the mental capacities required to perform a given type of work. When you see these RFC terms in a disability case, they are referring to the claimant's remaining mental capabilities.  

An individual is limited to less than "simple unskilled" work if due to his impairment, the claimant is unable to understand and remember very short and simple instructions.  The claimant must also be unable to carry out those simple instructions without special supervision.  

If an individual is markedly restricted in the performance of simple unskilled work, that person cannot be reasonably expected to perform any type of work.  Social Security cannot deny a claimant to a workshop job or work under special conditions.  If the claimant is only moderately restricted in his ability to understand, remember and carry out simple instructions, we may want to identify other moderate mental or physical limitations to further reduce his Residual Functional Capacity. 
 

Marked vs. Moderate Restrictions:

Using the medical evidence, you'll be able to determine whether a claimant is moderately or markedly limited by the impairment.  All mental case evidence will contain descriptions of the claimant's functional level during the period he/she was suffering from the impairment.  Using your common sense and noting how claimant's symptoms are described by the evidence, you'll get a feel for the intensity of the claimant's restrictions. 
 

Objective Substantive Evidence

Objective medical evidence is any medical finding that can be observed and reproduced.  This form of evidence is the most relevant to any disability case.  This type of evidence is usually created by independent medical sources and is therefore considered to be substantive to a case.

Examples of objective substantive evidence are results of a doctor's physical examinations, laboratory tests, x-ray findings, scans, biopsies, EKGs, etc.  Always try to find as much substantive evidence as possible to support your case argument.  The more objective evidence you have to support your position, the more likely it is that Social Security will accept the premise of your argument.
 

Subjective Substantive Evidence

Subjective evidence is defined as any finding that may or may not be reproducible and is dependent upon feedback from the claimant or other non-medical sources.  All symptoms alleged by a claimant are considered subjective evidence.   In other words, this evidence is what the claimant or family member alleges, not necessarily what the evidence shows.  Always try to support the claimant's subjective allegations with some form of objective evidence.  If you don't, SSA will simply ignore the allegation. Even the allegation of pain must be substantiated with some type of objective findings denoting the existence of an impairment that would cause the alleged pain.

Medication Side Effects

Very often, you'll argue a case on an individual who is under current therapy.  If this therapy involves large doses of pain medication or other drugs that alter the claimant's mental or physical state, this finding is relevant to determining the claimant's RFC. 

If the claimant is under treatment with a drug that causes serious adverse side-effects of any type, use this as an additional restrictive factor in your argument for a reduced RFC.  Point out how the drug affects the claimant and describe the limitations induced by the medications.  If the claimant must be on medication to control the disease or survive, you may win the case based on this approach.