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Medical Criteria Needed To Qualify With Breast Cancer

Receiving a health diagnosis such as breast cancer can be a devastating, life-altering moment. Often, the weeks and months following diagnosis are filled with additional medical tests, doctor’s appointments, and treatment therapies.

Sadly, while life has permanently changed for you, the financial responsibilities of life do not go away. The Social Security Disability Insurance Program (SSDI) was developed to assist people, such as yourself, who have become disabled due to a diagnosis such as breast cancer.

Not all cases of breast cancer will be classified as a disability. In fact, many women suffering from breast cancer have been denied financial assistance from the Social Security Administration (SSA) due to their inability to provide sufficient medical documentation.

Some applicants with advanced breast cancer, however, might qualify for a Compassionate Allowance (CAL).

Individuals with inoperable breast cancer or breast cancer that has spread throughout the body may have their applications expedited.

The Importance of the “Blue Book”

To determine whether or not your condition qualifies as a disability, Social Security representatives will consult their medical guide, known as the Blue Book.

The Blue Book is SSA’s official publication of disabling conditions.

Breast cancer is listed under Section 13.10 of the Blue Book. Additionally, if you have a sarcoma of the breast, you may be evaluated under section 13.04.

The easiest way to win your Social Security disability claim is to meet the listings as described in the Blue Book. You should work with your doctor to determine the type and severity of breast cancer that you have, and to determine if you meet the Blue Book listing for breast cancer.

To help you with this process, below is the most relevant medical evidence that you will need to provide to the SSA.

Evidence Needed Related to Your Breast Cancer Diagnosis

The first type of medical evidence that the Blue Book directly requests is a complete medical history of your breast cancer.

Medical Criteria Needed to Qualify with Breast Cancer

You should be able to provide evidence of your breast cancer diagnosis, and the extent to which it has spread or grown. Evidence for both of these include:

  • Progress reports from your oncologist, including the results of your mammography or ultrasound, if performed, as well as any other evidence your oncologist has found verifying your cancer.
  • If you have had any procedures or surgery related to the diagnosis of your breast cancer, such as a biopsy, a needle aspiration, a lumpectomy, or an exploratory surgery, you will need to provide those records. Documentation should be in the form of a pathology report and an operative note from your oncologist or surgeon.
  • All blood lab work should be included in your records.
  • Imaging results such as an X-ray, Bone scan, CT scan, MRI, or a PET scan
  • Lymph node biopsy results
  • Blood lab results
  • After determining the spread of your disease, your oncologist will document the stage and grade of your breast cancer. The SSA will use this information to assist in determining the extent of your illness.

The Blue Book indicates that any spread (metastases) of your breast cancer to the chest wall, skin, distant organs, or to particular lymph nodes, will qualify you for SSDI benefits.

Evidence Needed Related to Your Breast Cancer Treatment

Breast cancer is treated differently depending on the severity and spread of the cancer. The SSA will need to know what treatments you have received, your response to those treatments, and if your breast cancer has come back, or recurred, despite those treatments.

Possible treatments for breast cancer may include oral medications, chemotherapy, radiation, hormone intervention, and surgery.

According to the Blue Book, if you experience secondary lymphedema caused by your cancer treatments, and it requires surgery, you will qualify for benefits for one year from your surgery.

Evidence Needed Related to Side Effects from Your Treatment

The Blue Book notes that not every breast cancer patient will meet a particular qualifying condition’s listing, but you may be unable to work regardless. If this is the case, you may still be able to qualify under a medical vocational allowance.

This means that the SSA will evaluate you with a residual functional capacity (RFC) assessment, and determine if you can work at your previous job or any job that you are qualified for.

Some information you will need to provide includes, but is not limited to, the following:

  • Medications that you receive, including the doses
  • How often you require medication
  • Your plan for continuing medication
  • Your chemotherapy or radiation schedule
  • Any related medical complications, like weakness, neurological complications, heart problems, or intellectual problems
  • Any mental health issues that you are experiencing as a result of your breast cancer diagnosis, including anxiety or depression.

Evidence Needed Related Your Quality of Life and Ability to Care for Yourself

As noted above, you may not qualify for SSDI under the Blue Book listing, but you may not feel well enough to hold down a job. For example, you may have required breast surgery and are now unable to lift objects or move your arm without great pain.

You may now experience difficulty dressing yourself or driving to work. Your doctor should be sure to document these types of limitations in your medical record, in order to establish how disabling your breast cancer is in your daily life.

Steps You Can Take to Win Your Disability Claim

Unfortunately, many individuals who need SSDI benefits due to their breast cancer are initially denied. If you are one of those women, or if you have not yet applied, keep in mind that providing the SSA with sufficient medical evidence is the best way to win your Social Security disability claim for breast cancer.

If you have not done so already, schedule an appointment with your oncologist to discuss your Social Security application. The entire Blue Book is available online, so you may want to print section 13.10 to review at this appointment.

Together you can determine whether or not you meet the listing, as well as what additional documentation that you might need to provide.

You may need to contact the medical records office at your hospital for additional information.

There are several ways your oncologist can help including:

  • Ensuring that your full medical history related to your breast cancer is up to date
  • Listing your upcoming treatments and their durations
  • Documenting all of your medications and experienced side effects
  • Performing any additional blood tests or procedures that you are missing
  • Performing a comprehensive RFC assessment.

Social Security disability lawyers are experts in this area. Hiring an attorney or advocate who can assist you with your breast cancer claim is highly recommended.

An experienced attorney can help you navigate the cumbersome SSDI process, thus giving you more time to heal. And remember, your lawyer will not get paid unless you win your claim.