Diabetes

The Social Security disability laws provide that you are entitled to benefits if you can prove that your medical condition leaves you unable to perform even simple, unskilled, entry-level type of work.  Activity limitations arising from diabetes mellitus can support a disability claim.  Diabetes patients often suffer with many symptoms that would interfere with work, including:

  • numbness in the hands or feet (neuropathy)
  • vision issues (retinopathy)
  • mood swings, anger control problem and emotional impairments
  • poor recovery from surgery

There are a variety of arguments I use in disability cases involving diabetes. The argument that I use will depend on a number of factors:

  • does your inability to work arise primarily from your diabetes and diabetic complications?
  • do you have some problems with diabetes but you also have another, more serious medical problem
  • have you had diabetes for a long time but you were able to work despite the complications arising from your condition
  • are you unable to control your blood sugar despite medications and diet restrictions
  • are you on insulin or pills

Arguments Used in Diabetes Disability Cases

There are two main arguments I use in diabetes disability cases.  The first argument asks “do you meet the diabetes listing at 9.08?”  The second argument (called a functional capacity argument) asks if your diabetes has interfered with your functioning to the point where you would not be able to reliably perform even a simple, entry-level, low stress type of job.

Meeting a Diabetes Listing at 9.08

Social Security recognizes that certain medical conditions are so severe and significant that any person so afflicted would not be able to work.  These medical conditions are documented in a Social Security publication called the Blue Book of Disability Evaluation for Social Security.  You can view the Blue Book online by clicking on the link.

The Blue Book organizes medical impairments by “body systems.”  Currently there are fourteen (14) body systems that include both physical and mental health impairments.

Diabetes is described at Listing 9, which covers the Endocrine System.  In addition to diabetes, other endocrine system diseases include thyroid problems and adrenal problems.  The listing for diabetes is quite short – it reads as follows:

5. Diabetes mellitus and other pancreatic gland disorders disrupt the production of several hormones, including insulin, that regulate metabolism and digestion.  Insulin is essential to the absorption of glucose from the bloodstream into body cells for conversion into cellular energy.  The most common pancreatic gland disorder is diabetes mellitus (DM).  There are two major types of DM:  type 1 and type 2.  Both type 1 and type 2 DM are chronic disorders that can have serious disabling complications that meet the duration requirement.  Type 1 DM–previously known as “juvenile diabetes” or “insulin-dependent diabetes mellitus” (IDDM)–is an absolute deficiency of insulin production that commonly begins in childhood and continues throughout adulthood.  Treatment of type 1 DM always requires lifelong daily insulin.  With type 2 DM–previously known as “adult-onset diabetes mellitus” or “non-insulin-dependent diabetes mellitus” (NIDDM)–the body’s cells resist the effects of insulin, impairing glucose absorption and metabolism.  Treatment of type 2 DM generally requires lifestyle changes, such as increased exercise and dietary modification, and sometimes insulin in addition to other medications.  While both type 1 and type 2 DM are usually controlled, some persons do not achieve good control for a variety of reasons including, but not limited to, hypoglycemia unawareness, other disorders that can affect blood glucose levels, inability to manage DM due to a mental disorder, or inadequate treatment.

a. Hyperglycemia.  Both types of DM cause hyperglycemia, which is an abnormally high level of blood glucose that may produce acute and long-term complications.  Acute complications of hyperglycemia include diabetic ketoacidosis.  Long-term complications of chronic hyperglycemia include many conditions affecting various body systems.

(i) Diabetic ketoacidosis (DKA).  DKA is an acute, potentially life-threatening complication of DM in which the chemical balance of the body becomes dangerously hyperglycemic and acidic.  It results from a severe insulin deficiency, which can occur due to missed or inadequate daily insulin therapy or in association with an acute illness.  It usually requires hospital treatment to correct the acute complications of dehydration, electrolyte imbalance, and insulin deficiency.  You may have serious complications resulting from your treatment, which we evaluate under the affected body system.  For example, we evaluate cardiac arrhythmias under 4.00, intestinal necrosis under 5.00, and cerebral edema and seizures under 11.00.  Recurrent episodes of DKA may result from mood or eating disorders, which we evaluate under 12.00.

(ii) Chronic hyperglycemia.  Chronic hyperglycemia, which is longstanding abnormally high levels of blood glucose, leads to long-term diabetic complications by disrupting nerve and blood vessel functioning.  This disruption can have many different effects in other body systems.  For example, we evaluate diabetic peripheral neurovascular disease that leads to gangrene and subsequent amputation of an extremity under 1.00; diabetic retinopathy under 2.00; coronary artery disease and peripheral vascular disease under 4.00; diabetic gastroparesis that results in abnormal gastrointestinal motility under 5.00; diabetic nephropathy under 6.00; poorly healing bacterial and fungal skin infections under 8.00; diabetic peripheral and sensory neuropathies under 11.00; and cognitive impairments, depression, and anxiety under 12.00.

b. Hypoglycemia.  Persons with DM may experience episodes of hypoglycemia, which is an abnormally low level of blood glucose.  Most adults recognize the symptoms of hypoglycemia and reverse them by consuming substances containing glucose; however, some do not take this step because of hypoglycemia unawareness.  Severe hypoglycemia can lead to complications, including seizures or loss of consciousness, which we evaluate under 11.00, or altered mental status and cognitive deficits, which we evaluate under 12.00.

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As you can see, the diabetes listing refers to other listings – for example if you have neuropathy, your ability to engage in gross or fine motor movement needs to be impaired similarly to someone with neurological problems.  If you have retinopathy, your vision issues would be evaluated using the test scores from the visual impairment listing.

In theory, a Social Security adjudicator or judge could reach the conclusion that your condition meets a listing by reviewing your medical records.  In reality, however, adjudicators do not have the time or expertise to interpret medical records and judges expect will want expert help to reach a medical conclusion.

In my practice I have found that the best way to argue for approval based on a listing is to create a listing checklist which tracks both the listing as well as my client’s medical records and ask my client’s treating physician to complete the checklist.  A completed checklist + supporting treatment notes, I believe, offer the best chance at proving a listing.

At hearings, I usually find that judges are reluctant to reach medical conclusions.  In cases where a listing may be appropriate and no medical expert has previously been scheduled, I will ask the judge to call a medical expert to testify at the hearing.

I sense that Social Security trains its adjudicators to limit approvals based on the 9.00 listing to cases where a claimant’s diabetes is out of control and where permanent organ or nerve damage has occurred.  Diabetes is a very common disease in American society and Social Security wants to limit listing approvals to cases where all applicable medical treatment has failed to bring a claimant’s blood sugar under control for an extended period of time.

Arguing for a Functional Capacity Approval in a Diabetes Case

Most of the diabetes cases I see are not listing level cases.  This may be because the cases that do meet a listing (i.e. the case of a brittle diabetic) have already been approved at the initial application or reconsideration appeal stage.

State Agency adjudicators rarely approve cases under a functional capacity basis because a functional capacity decision involves a review of both objective medical records an a subjective consideration of a claimant’s credibility.  Adjudicators are not trained or authorized to evaluate credibility so most initial application and reconsideration cases are evaluated in terms of the listings only.

Most of the diabetes cases I see involve a variety of complications, including numbness and tingling in the hands and feet, blurred vision, fatigue, out of range blood chemistry levels, frequent urination and other complications.  I suspect that many of my diabetes clients may fulfill the requirements of the 9.08 Listing but they may not have good enough medical care to produce needed documentation.  Usually, but not always, judges expect to see diabetics who are on insulin, as opposed to pills if diabetes in the primary disabling medical condition.

A functional capacity argument is premised on the idea that your diabetes complications are significant enough that you would not be able to perform a simple, entry level job.  Some of the evidence I have used includes:

  • testimony from my client that he needed unexcused breaks to urinate every 45 minutes to an hour
  • testimony from my client that his lower legs and feet were totally numb and that his vision would deteriorate rapidly in the event of a change in his blood sugar
  • testimony from my client about vision issues, and extensive numbness in the hands and feet that had lasted for several years, and testimony that he frequently ran out of insulin and testing equipment because of lack of income
    Functional capacity arguments often boil down to questions of credibility (believeability) and reliability, so it is important that your testimony paints a picture of a person who wants to work, has suffered financially and emotionally by not working, but who simply cannot reliably perform work.

Grid Rule Arguments and Diabetes Disability Cases

Diabetes complications can also support an argument that a claimant meets a grid rule.  For example, numbness in the feet can leave a claimant unable to stand and walk for more than a few minutes at a time.  If a judge accepts this testimony as being credible, then it might lead to a reduction of a claimant’s capacity from medium to light or from light to sedentary.  Take a look at the section about Social Security’s grid rules for more discussion about how these guidelines work.

Case Studies

Diabetes Case Study #1: 53 year old obese female with high school education and work background as certified nursing assistant

Diabetes Case Study #2: 29 year old man with special education background, insulin dependent diabetes and gastroparesis

Diabetes Case Study #3: 23 year old man with Type I (childhood diabetes), under sub-optimal control, with significant complications