Evaluating Claims Involving Chronic Fatigue Syndrome (CFS)
CFS is a systemic disorder consisting of a complex of symptoms that may vary in frequency, duration, and severity. In 1994, an international panel convened by the Centers for Disease Control and Prevention (CDC) developed a case definition for CFS that serves as an identification tool and research definition.  In 2003, an expert subcommittee of Health Canada, the Canadian health agency, convened a consensus workshop that developed a clinical case definition for CFS, known as the Canadian Consensus Criteria (CCC).  In 2011, a private international group developed guidelines, known as the International Consensus Criteria (ICC),  for diagnosing myalgic encephalomyelitis (ME).  Members of this international group and other medical experts consider ME to be a subtype of CFS.  We adapted the CDC criteria, and to some extent the CCC and ICC, when we formulated the criteria in this SSR. 
We consider a person to be “disabled”  if he or she is unable to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment(s)  which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months. We require that an MDI result from anatomical, physiological, or psychological abnormalities, as shown by medically acceptable clinical and laboratory diagnostic techniques.  The Act and our regulations further require that the impairment be established by medical evidence that consists of signs, symptoms, and laboratory findings; therefore, a claimant may not be found disabled on the basis of a person’s statement of symptoms alone.  In this SSR, we explain that CFS, when accompanied by appropriate medical signs or laboratory findings, is an MDI that can be the basis for a finding of “disability.” We also explain how we evaluate CFS claims.
The Social Security Administration (SSA) has two methods for determining whether a claimant is disabled and unable to work. First, the SSA will determine whether or not the claimant has a condition which is so severe it meets or exceeds a listing on the SSA Listing of Impairments. This listing, also called the SSA Blue Book, has all of the symptoms and diagnosis which the SSA considers automatically disabling and which do not allow the claimant to perform substantial gainful activity (SGA).
There is not a listing for TMJ on the SSA Listing of Impairments. This does not mean that you cannot prove that your condition is as severe as a condition which is listed, but it will be very difficult. Claimants who have suffered a severe trauma may be able to win SSDI or SSI if they have additional conditions, in addition to TMJ, that will meet a listing.
Sandra Reece was 46 years old on the alleged onset date and has past relevant work as a
molding machine operator, line worker, forklift operator, and meat cutter…
Next, the ALJ found that Reece had the residual functional capacity (“RFC”) to perform sedentary work as defined in 20 C.F.R. §§ 404.1567(a) and 416.967(a) with the following limitations: Reece must have the option to alternate between sitting and standing very hour; she cannot bend forward from the waist; she cannot rotate her head to the right completely; and she cannot climb stairs, ladders, or ropes.
Those are quite a few limitations… What business would want to hire Ms. Reece? What job doesn’t include bending forward from the waist?
At step four, the ALJ determined that Reece was unable to perform any past relevant work. At step five, the ALJ determined that, considering Reece’s age, education, work experience and RFC, there were jobs that existed in significant numbers in the national economy that Reece could perform. Therefore, the ALJ determined that Reece was not disabled…
For the reasons set forth above, substantial evidence does not support the ALJ’s conclusion that Reece was not disabled. The Magistrate Judge recommends that the Commissioner’s decision be REVERSED AND REMANDED.
Unum began paying long-term disability benefits to Ms. Holcomb on May 23, 2003. Unum advised her that its payments were “under reservation of rights,” meaning Unum did not concede present or future liability. In August 2003, one of Unum’s on-site physicians reviewed Ms. Holcomb’s medical file and filed a report that concluded that her complaints of pain were not supported by “physical exam, testing or radiological findings.” The report noted, however, that her medical records were insufficient “to allow for an independent assessment of the claimant’s functional capacity.”
In July 2005, Dr. Robert Anfield, another Unum physician, evaluated both the OSP’s review of Ms. Holcomb’s medical records and several assessments by Dr. Carson and his staff. Dr. Anfield agreed with the OSP’s analysis, concluding that Ms. Holcomb was capable of engaging in “work activities.” In addition, Dr. Anfield stated that “Ms. Holcomb’s self-reported incapacitating symptoms are primarily the feature of [fibromyalgia] … [and] the label `fibromyalgia’ provides no pathophysiologic foundation upon which to base a set of restrictions and limitations.”
In August 2005, Dr. Carson sent Unum a letter to “clarify a few matters.” Dr. Carson wrote, “[y]our antagonistic letters and disclaimers suggest a remarkable lack of understanding for systemic lupus erythematosus and its ability to cause functional limitations in patients who are so unfortunately affected.” He wrote that Unum was “try[ing] to make a case that [Ms. Holcomb’s] problems are all subjective and thus mental.” He summarized “the abnormal [laboratory] studies that have been a consistent feature of [Ms. Holcomb’s] disease,” and he urged: “What I wish you to understand is that the mental aspect of her illness is only a minor aspect. Far greater are the problems of widespread systemic inflammation in the connective tissues. This is most marked by a pronounced arthritis and [her] episcleritis,3 not by her mental problems…. My recommendations for medical retirement based on total and permanent disability [are] based solely on functional limitations apart from any mental disorder. She can no longer engage in any work related activities such as sitting, standing, walking, lifting, carrying or handling objects using her hands.”
Unum’s Vocational Rehabilitation Consultant (“VRC”) then conducted an occupational analysis to determine whether Ms. Holcomb’s stated restrictions and limitations would preclude her from her occupation…
By letter dated September 27, 2005, Unum notified Ms. Holcomb that it would no longer pay disability benefits to her. The letter explained that Unum had concluded she “would be able to perform the material and substantial duties of [her] regular occupation” and could perform at least five other “gainful occupations,” based on her restrictions, limitations, education, training, and experience. Unum also stated that it would not require her to repay the benefits it had disbursed to her after May 22, 2005, even though pursuant to the Policy she was not entitled to long-term benefits beyond that date…
Unum then requested that Ms. Holcomb undergo an independent neuropsychological examination from Dr. James Scott at the University of Oklahoma Health Sciences Center. Dr. Scott found that her response pattern on self-reported measures suggested “a considerable psychological overlay to her reported physical condition.” He determined that Ms. Holcomb “demonstrated average global intellectual functioning,” and that her “[p]erformance on measures of attention/concentration, processing speed, language, immediate verbal and nonverbal memory, and abstraction/problem solving ability all fell within the expected functional range.” Although Dr. Scott determined that Ms. Holcomb was experiencing a mild and intermittent memory problem, he concluded that “[d]ue to her intact general intellectual and problem solving ability, the utilization of compensatory strategies (e.g., memory notebook) would likely ameliorate this situation.”
GlassRose said: I assume the first diagnosis refers to my Major Joint Dysfunction of the knee bilaterally, for which I am service connected through the VA. I have NO IDEA about the second diagnosis – none of my impairments have a respitory component.
Why would the impairments not be listed specifically, and why would they refer to a condition I don’t even have? And what should I do about it? I’ve already turned in the application for reconsideration, appeal and release forms. I don’t believe it has been assigned yet.
And one more question – the VA has rated me 60% disabled due to the combination of knee and spine impairments – and that documentation was robust, to say the least – surgeries, progress notes, C&P exams. Shouldn’t those at the least been cited as serious medical conditions??
Different Perspective said: What are you calling the DDS Disability Worksheet? It sounds like you are you talking about the Disability Determination Explanation. This is in the Payment Documents/Decisions section, usually Exhibit 2A and, if a concurrent SSDI/SSI claim, 4A. This spells out the case and includes the RFC, mental or physical and many other aspects of the case… I think what you are hunting for is the Request for Medical Advice (SSA-448) prepared by the examiner and Case Analysis (SSA 416) prepared by the Medical Consultant. These forms will be found in Section F, Medical Records with the Source probably listed as DDS or whatever the State Agency is called in the state of adjudication.
It’s like they’re talking in a different language…
(Transcribed directly from Unum-provided documents.)
QPS Behavioral Health Unit: Internal Correspondence
From: Thomas M. Pendergrass RN, PhD
Chattanooga Benefits Center
CONCLUSIONS: Some degree of anxiety and depression was present and briefly described in the medical records. The treating professionals did not present formal psychiatric diagnoses and treatment [sic] of these symptoms was of relative low intensity. Treatment tended to focus on the general medical conditions and any associated psychiatric symptoms were described as reactive. In my opinion, within a reasonable degree of psychological certainty, the available records do not suggest or describe psychiatric symptoms which would result in functional limitations as a primary disorder. There is insufficient assessment or treatment data to suggest that the psychiatric symptoms would provide a major contribution to the existing general medical conditions.
DATE: Tuesday, December 7, 2004
Date of first Unum denial letter: February 27, 2004
None for Loading, either. Well, when one gets lemons, make lemonade…
Brainy quotes on Loaded
“A girl in a bikini is like having a loaded pistol on your coffee table – There’s nothing wrong with them, but it’s hard to stop thinking about it.” Garrison Keillor
“A fanatic is one who sticks to his guns whether they’re loaded or not.” Franklin P. Jones
“If the world were a bar, America would currently be the angry drunk waving around a loaded gun. Yeah, the other people in the bar may be afraid of him, but they sure as hell don’t respect him.” Wil Wheaton
“Plus, when you get in tough situations, like the bases loaded and nobody out, you never give in.” Dwight Gooden