Get Social Security Disability & SSI Benefits: Bowel Diseases

Winning Your Case

You can win your Social Security disability and SSI benefits case with a bowel disease if you satisfy two rules:

1. Non-Medical Criteria, and
2. Disability Criteria.

The disability criteria means –

1. You are aware how Social Security evaluates your medical condition (reviewed on this page),
2. You satisfy a Social Security Listing for inflammatory bowel disease (also reviewed on this page) or you have disabling Functional Limitations (reviewed on the next page), and
3. You Submit Winning Evidence (reviewed after the functional limitations page).

Medical Records Are King

Social Security is aware that many people suffer from disabling inflammatory bowel diseases, the most common of which are Crohn’s disease, ulcerative colitis, inflammatory bowel disease (IBS), diverticulosis, and diverticulitis. Crohn’s disease affects the entire gastrointestinal tract from the mouth to the anus, but it mainly affects the small intestine. Ulcerative colitis only affects the colon. IBS affects the large intestine.

Other bowel disease include perinanal abscesses, fistulas, fissures, hemorrhoids, and infections.

You will need to submit to Social Security evidence of your diagnosis, but bowel diseases are often difficult to diagnose. This is primarily because the symptoms are general and common to many other medical conditions:

1. Abdominal pain, swelling, and cramping;
2. Nausea;
3. Anemia;
4. Diarrhea;
5. Constipation; and
6. Arthritis-type pain.

It is not unusual for patients to suffer for years before an appropriate diagnosis is made. The cause of both diseases is unknown. Diagnosis is primarily done by colonoscopies, endoscopies, enteroscopy, blood tests, and patient history. Occasionally MRIs and CTs are done. There is no laboratory test and no cure for either disease.

Unfortunately, treatment is often ineffective. Nevertheless, you will need to submit to Social Security evidence of your treatment which is generally amino salicylates (reduces inflammation of the GI tract), anti-inflammatories like corticosteroids (Prednisone), immunosuppressants (methotrexate, Remicade), and dietary changes. In severe cases of bowel obstruction (scar tissue), a bowel resection or a proctocolectomy (colon removal) is performed.

A Special Challenge – Functional Limitations

The next page discusses functional limitations. However, for Chron’s, Colitis, and IBS, disabling functional limitations necessary to prove disability to Social Security is unique. You will need to prove you will be off task (away from the workplace and not performing your work duties) due to bathroom breaks which include 1) the time you spend in the bathroom to defecate, 2) the urgency to get to the bathroom because of your need to defecate, and 3) the time you need to clean yourself or change clothes if you have an accident. These three work limitations are hard to prove. Essentially, the aforesaid limitations can only be proved through your testimony and the testimony of those who observe your bathroom habits and any accidents you have. Therefore, lay person statements (especially from those with whom you worked) are of significant importance in any bowel disease case.

Step 3 – The Crohn’s and Colitis Social Security & SSI Listing

At Step 3, the listing for Chron’s disease is Adult Listing 5.06 and Child Listing 105.06. You meet this listing by satisfying 1 and 2:

1. Small intestine or colon obstruction causing a hospital stay for intestinal decompression or surgery twice or more within six months; and
2. Two or more of the following six gastrointestinal complications happening in the same six-month timeframe –
   1. Anemia with low hemoglobin,
   2. Low serum albumin,
   3. Painful abdominal mass,
   4. Perineal disease with an abscess or fistula and pain,
   5. Significant weight loss, (this subpoint is not included in the child listing) or
   6. Daily nutrition administered from a gastrostomy or catheter.

A Crohn’s Disease Success Story

Mr. Gibson lived in Oakland, CA. He suffered Crohn’s disease. He was 42 years old. He suffered abdominal pain, cramping, nausea, and diarrhea, constipation. Most disabling, he required about a dozen bathroom breaks a day. About three days a week, he needed a break clean himself after an accident. Like many Crohn’s suffers, his medical providers had difficulty diagnosing his condition. At first, he was essentially dismissed and advised to change his diet. Despite a change in diet, his symptoms persisted. Then, he was diagnosed with irritable bowel syndrome (IBS) for which there is no specific diagnostic test. After about a year of persistent symptoms, he was finally able to find a primary doctor and gastroenterologist who performed two colonoscopies and properly diagnosed him with Crohn’s disease. Despite being prescribed both prednisone and methotrexate, his symptoms persisted.

Prior to the hearing, counsel obtained a statement from Mr. Gibson’s primary doctor which was needed for two reasons. First, more information was needed about his diagnosis, specifically, why it took so long. There was a danger that even if the administrative law judge (ALJ) awarded benefits, she would amend the onset date to the date of the correct Crohn’s diagnosis. This would reduce Mr. Gibson’s backpay and Medicare eligibility by about a year. Second, we needed a statement that that the bathroom breaks were reasonable considering the severity of Ms. Gibson’s Crohn’s. The statement, in fact, primarily concerned the efforts made to obtain a diagnosis and whether Mr. Gibson’s symptoms were reasonable considering his condition. His gastroenterologist worked for a medical practice with a policy that would not allow him to be involved in any legal matter. Hence, we could not obtain a statement for the specialist.

In addition to the statement, counsel updated all Mr. Gibson’s medical records. Mr. Gibson also sent counsel black and white photos of accidents he had – which were unpleasant to view but demonstrated how significant his accidents were, and what was needed to clean up. Counsel also obtain layperson statements from Mr. Gibson’s wife and son, and Mr. Gibson’s past supervisor about the number of bathroom breaks needed in the day and how long the breaks lasted.

At his hearing, the ALJ called counsel in to the hearing room prior to the hearing. These situations are either very good or very bad. In this particular case, the ALJ was angry counsel submitted the pictures. He explained that viewing the pictures was gross. Counsel explained that as gross as they may be, they demonstrated the very nature of Mr. Gibson’s symptoms, and that the purpose of the pictures was to establish the time away from work Mr. Gibson needed to deal with his Crohn’s symptoms (off task). The conversation was somewhat unpleasant, but still to this day, counsel stands by the decision to submit the photos. And, in the end, the ALJ did grant a fully favorable decision.