Lyme disease, a bacterial infection transmitted by ticks, can lead to persistent and debilitating health issues. While many cases are successfully treated with antibiotics, some patients experience prolonged symptoms that significantly interfere with daily life and the ability to work. Qualification for disability benefits depends entirely on the documented severity of these resulting symptoms. This determination is made through a rigorous administrative process that focuses less on the diagnosis itself and more on the functional limitations the condition imposes on a person’s capacity to maintain gainful employment.
Defining Disability Under Social Security
The Social Security Administration (SSA) operates two main programs for people with disabilities: Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI). For both programs, the legal definition of disability is the same: an individual must have a medically determinable physical or mental impairment that is expected to result in death or has lasted, or is expected to last, for a continuous period of at least 12 months. Furthermore, this impairment must prevent the applicant from engaging in Substantial Gainful Activity (SGA).
SGA is defined by the SSA as work activity that brings in earnings above a certain monthly threshold, which is adjusted annually. If an applicant is earning more than this amount, they are generally found not disabled, regardless of their medical condition. If the applicant is not performing SGA, the SSA proceeds through a five-step sequential evaluation process to determine eligibility.
This process first assesses if the condition is severe enough to limit basic work-related activities. Next, the SSA checks if the impairment meets or equals the severity of a condition listed in its Listing of Impairments, often called the Blue Book. If a listing is not met, the process continues by evaluating the applicant’s Residual Functional Capacity (RFC) to determine if they can perform any work they have done in the past. Finally, the SSA considers the applicant’s age, education, and work experience to decide if they can adjust to any other type of work in the national economy.
Specific Evidentiary Hurdles for Lyme Disease Claims
A significant challenge for Lyme disease applicants is that the condition does not have a dedicated listing in the SSA’s Blue Book. This means a claim cannot be automatically approved at the third step of the evaluation process, forcing the applicant to rely on proving functional limitations through a detailed Residual Functional Capacity (RFC) assessment. The symptoms of chronic Lyme disease, such as persistent fatigue, widespread pain, and cognitive impairment often referred to as “brain fog,” are frequently subjective and variable.
The SSA places a high value on objective medical evidence, including laboratory tests, imaging results, and physical examination findings, to confirm a diagnosis and substantiate the reported symptoms. While a positive test for Borrelia burgdorferi confirms exposure, the ongoing, post-treatment symptoms are often difficult to correlate with specific objective markers, leading to skepticism from disability examiners. Applicants must demonstrate that their symptoms are medically equivalent in severity and duration to a condition that is listed in the Blue Book, such as inflammatory arthritis, neurological disorders, or certain immune system disorders.
To overcome the lack of objective markers, the claim must be supported by consistent, longitudinal medical records from treating physicians who specialize in the condition. These records must meticulously document the frequency, intensity, and duration of symptoms and provide specific medical opinions on the resulting functional restrictions. A doctor must clearly state what the patient can no longer do, including:
- Sitting
- Standing
- Lifting
- Concentrating
The doctor must also specify the length of time these limitations are expected to endure. Without this detailed functional assessment from a treating source, the SSA often defaults to an RFC determination that assumes the applicant can still perform some level of work.
Navigating the Application and Appeals Process
The initial application for disability benefits often results in a denial, particularly for conditions like Lyme disease that are difficult to prove with traditional objective measures. Applicants must adhere strictly to procedural deadlines, as there is typically only a 60-day window to file an appeal after receiving a denial notice. The first level of appeal is Reconsideration, where a new examiner reviews the case, but the approval rate remains low at this stage.
If the claim is denied at Reconsideration, the next step is requesting a hearing before an Administrative Law Judge (ALJ). This hearing is often where many chronic illness claims are ultimately won, as it provides the opportunity for the applicant and their representative to present live testimony and cross-examine vocational and medical experts. Comprehensive documentation is crucial, and applicants should use this stage to submit all updated medical evidence, including new test results and detailed statements from treating physicians.
The complexity of the medical evidence required makes obtaining legal representation highly advisable before the ALJ hearing. A representative can help translate subjective symptoms into the functional limitations the SSA requires for an RFC assessment. If the ALJ issues an unfavorable decision, the final administrative step is to request a review by the SSA’s Appeals Council, which primarily looks for legal or procedural errors in the ALJ’s decision.