Emphysema, a chronic lung condition, progressively damages the air sacs in the lungs, making breathing difficult and reducing oxygen flow to the body. It falls under the umbrella of chronic obstructive pulmonary disease (COPD). Individuals with emphysema often experience symptoms like shortness of breath, coughing, and wheezing, which can significantly affect their daily lives and ability to work. While a serious medical diagnosis, emphysema can qualify an individual for disability benefits through the Social Security Administration (SSA) if it severely limits their capacity to perform substantial work.
Emphysema as a Recognized Disability
The Social Security Administration (SSA) defines disability as the inability to engage in “substantial gainful activity” (SGA) due to a medically determinable physical or mental impairment. This impairment must be expected to result in death or last for a continuous period of at least 12 months. The SSA determines if emphysema is a qualifying disability in two ways. An individual can meet the medical criteria outlined in the SSA’s Listing of Impairments, known as the “Blue Book.” Alternatively, if their condition does not strictly meet a listing, they can qualify by demonstrating that their emphysema, considering their age, education, and past work experience, prevents them from performing any substantial work.
Meeting Medical Qualification Standards
The SSA evaluates emphysema claims under its Listing of Impairments, Section 3.02 for Chronic Respiratory Disorders. This section outlines medical criteria based on objective test results indicating lung function impairment severity. Evidence includes a confirmed diagnosis and objective testing.
Spirometry measures how much air an individual can exhale and how quickly. The Forced Expiratory Volume in one second (FEV1) is the amount of air forcefully exhaled in the first second. The SSA specifies FEV1 values that must be met or fall below, depending on height, gender, and age, to qualify. Pulmonary function tests must be conducted when the individual is medically stable, not during an acute exacerbation.
The Diffusing Capacity of the Lungs for Carbon Monoxide (DLCO) measures how effectively oxygen moves from the lungs into the bloodstream. A reduced DLCO value, based on gender and height, indicates severe impairment of gas exchange. Arterial Blood Gas (ABG) tests, measuring oxygen and carbon dioxide levels, or pulse oximetry, assessing blood oxygen saturation, may be considered. Evidence of frequent exacerbations requiring hospitalization, specifically three hospitalizations within a 12-month period, each lasting at least 48 hours and occurring at least 30 days apart, can meet listing criteria.
If test results do not strictly meet “Blue Book” values, individuals may still qualify based on their Residual Functional Capacity (RFC). RFC assesses an individual’s remaining ability to perform work-related activities despite limitations. This considers how symptoms like severe shortness of breath, fatigue, or coughing impact their ability to sit, stand, walk, lift, or concentrate throughout a workday, preventing them from performing past or any other type of work.
Applying for Disability Benefits
Individuals seeking disability benefits for emphysema can apply for two Social Security programs: Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI). SSDI is for those with a sufficient work history who have paid Social Security taxes. SSI is a needs-based program for individuals with limited income and resources, regardless of work history.
The application process can be initiated online, by phone, or in person at a Social Security office. An application requires detailed medical records, including a confirmed diagnosis, results from spirometry, DLCO tests, and other relevant lung function assessments. Treatment records, documenting medications, supplemental oxygen use, and hospitalizations, are important. Applicants must also provide personal statements detailing how emphysema affects their daily activities and ability to perform work-related tasks.
The Appeals Process
Many initial disability applications, including those for emphysema, are denied. If an application is denied, individuals have the right to appeal the decision through a multi-stage process. The first stage is Reconsideration, where a different SSA examiner reviews the claim, including any new evidence provided, within 60 days of the denial notice.
If Reconsideration is unsuccessful, the next step is to request a hearing before an Administrative Law Judge (ALJ). This stage often provides the best opportunity for approval, as the applicant can present new evidence, testify about their condition, and may bring witnesses.
If the ALJ denies the claim, the decision can be appealed to the Appeals Council, which reviews for legal or procedural errors. The final level of appeal is a review by the Federal Court.
Throughout the appeals process, it is important to continue medical treatment and gather additional evidence to support the claim. Seeking legal representation from an attorney specializing in disability law can be beneficial in navigating these stages.