Social Security Questions and Answers
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I am posting the Listing for breast cancer from the SS website. If you meet this definition and are not actively working (of work, out on leave, etc. ) then you may be eligible to have your claim picked up quickly under the compassionate allowance provision I will post below the listing.
13.10 Breast (except sarcoma—13.04) (See 13.00K4.)
A. Locally advanced cancer (inflammatory carcinoma, cancer of any size with direct extension to the chest wall or skin, or cancer of any size with metastases to the ipsilateral internal mammary nodes).
B. Carcinoma with metastases to the supraclavicular or infraclavicular nodes, to 10 or more axillary nodes, or with distant metastases.
OR
C. Recurrent carcinoma, except local recurrence that remits with anticancer therapy.
OR
D. Small-cell (oat cell) carcinoma.
OR
E. With secondary lymphedema that is caused by anticancer therapy and treated by surgery to salvage or restore the functioning of an upper extremity. (See 13.00K4b.) Consider under a disability until at least 12 months from the date of the surgery that treated the secondary lymphedema. Thereafter, evaluate any residual impairment(s) under the criteria for the affected body system.
The compassionate allowance provision for breast cancer is listed here:
DI 23022.125 Breast Cancer
COMPASSIONATE ALLOWANCE INFORMATION
BREAST CANCER
DESCRIPTION
Breast cancer forms in tissues of the breast, usually the ducts and lobules. It occurs in both men and women, although male breast cancer is rare. Individuals with breast cancer meeting the criteria under the Listing of Impairments have a poor prognosis.
ALTERNATE NAMES
Breast Carcinoma (Stage IV), Metastatic Breast Carcinoma, Metastatic Breast Cancer, Ductal Carcinoma of the Breast (Stage IV), Metastatic Ductal Carcinoma, Metastatic Ductal Cancer, Lobular Carcinoma of the Breast Stage (IV), Metastatic Lobular Cancer, Metastatic Lobular Carcinoma, Recurrent Breast Cancer
DIAGNOSTIC TESTING AND CODING
The following may be used to diagnose the disease: mammogram, clinical breast exam, ultrasound, MRI, or biopsy (needle or incision).
TREATMENT
Treatment may include surgery, chemotherapy, radiation, and hormone therapy.
PROGRESSION
If the cancer is inoperable or unresectable, treatment with radiation or radiation and chemotherapy/hormonal therapy can be employed for palliation.
The 5-year survival rate for individuals with stage IV breast cancer when appropriately treated is 20%. Prognosis is usually poor.SUGGESTED PROGRAMMATIC ASSESSMENT*
Suggested MER for Evaluation: A pathology report and an operative report are the preferred methods for documentation.
In the absence of these reports, the adjudicator may use a physician's opinion that indicates the cancer is inoperable or unresectable based on described objective findings.
"Inoperable" refers to a physician's opinion that surgery would not be beneficial based on a review of imaging studies, laboratory results, and physical examination findings. Unresectable cancer is established when the operative report indicates that the cancer is not completely removed or the pathology report notes that the surgical specimen has positive margins.Suggested Listings for Evaluation:
DETERMINATION
LISTING
REMARKS
Meets Listing
13.10A, B, or C
Medical Equals
13.10 A
Inoperable or unresectable Breast Cancer equals Listing 13.10A as its prognosis is similar to this listing. (A physician's opinion stating that the cancer is inoperable or an operative note stating that the cancer was not completely resected is required. In place of an operative note, a pathology report indicating positive margins may be substituted.)
* Adjudicators may, at their discretion, use the Medical Evidence of Record or Listings suggested to evaluate the claim. However, the decision to allow or deny the claim rests with the adjudicator.
Last Updated: 9/30/08
Office of Disability Programs
To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0423022125DI 23022.125 - Breast Cancer - 10/24/2008
Hope this is helpful for those of you dealing with a Stage IV diagnosis.
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I am getting ready to apply for SSDI. February 26 will be my last day. I'm going to use up my sick leave (50 days) and then will be retired on disability. I'm scared I will be denied SSDI. I will send in my application on the February 29th. I'm stage 4 with mets to bone. I'm sick and miss a lot of days, not to mention all of my doctor appointments. I catch everything because my white blood cells are always low due to Ibrance. Will they deny me because I will still be earning a paycheck for my sick leave? I know I will have to wait 5 months or more before I receive my first check but I don't want to be denied on my initial application. What symptoms did/do you have when you applied? Did anyone help you with your SSDI application? I don't know how to answer some of the questions? I am a gifted teacher and I am pushing it so I can finish at the end of the semester.
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Kaluha:
Don't wait to apply. Do it ASAP. Use the last day you actually WORKED. SS will not consider paid sick leave as work but you will want to be prepared to show them the last date you actually went into work and taught and that any money received after that was for paid leave. You can get something from HR to show this. If you have been on leave a few months use the earliest date,. This will help with the 5 month wait period. When you apply tell them you want to be considered for Compassionate Allowance as you have stage 4 breast cancer with mets to the bone. If your doctor is familiar with the SS listings get a letter explaining that you meet a listing. I would recommend you get ALL your medical records and submit them don't rely on SS to get it all. I will PM you to see if I can offer any more help.
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Kaluha, I found it rather simple to apply for SSDI. I did it all on line. Near the beginning of the application, it has a question if your illness/disability will result in death. Say yes. Because that is the prognosis. You may live many years, but know one can say. You will then receive an expedited review since this qualifies you for compassionate Allowance. I filled out all the rest of the info they requested about my illness, symptoms, and doctors which are my onc and gp. I did not submit any medical reports. Itwas pretty easy and really didn't even take that long. At the end of the application, it told me to contact my local social security office to let them know I had applied for disability and filed the compassionate allowance. I did that, even tho the woman at the social security office sounded like, why the heck are you calling. I received approval for SSDI in the mail within a month or six weeks or so. That was it.
I also had worried that I wouldn't approved but I was. Best wishes with your application.
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Is stage 4 with mets to bone considered a TERI case? Should I put TERI on my SSDI application or just compassionate allowance?
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I never heard of TERI
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yes. Stage 4 constitutes a TERI case.
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If you file on line, the prompts will explain themselves as you go along. Once it identifies you as having a terminal illness, it recognizes that information and tells you that you will have your application fast tracked. It will make sense as you fill out each page.
You do not have to be at death's door. I also have mets to the bone. Even tho we are able to function normally on some levels, do not minimize to yourself the fact that you have this disease and it has metastasized. Sometimes I think we do this because after living with it for so long, it *seems* normal, it's become our normal. I don't mean to make you feel bad or belabor the point, it's just the facts of the situation.
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I agree. I just realized that about myself. I never really emphasize my pain to my oncologist because at the CTCA the patients are so sick.
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the DivineMrsM makes an excellent point. Your application is not the place to downplay your pain, fatigue and limitations. It is important to document these things honestly in your application and to your physician. We have a natural tendency to want to stay strong and not complain. But you have to make SS and your doctors aware of the difficulties you are having with your activities of daily living, focus and concentration, dealing with stress, pain, fatigue, etc.
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I had my hearing in November and received my decision just before Christmas. This week I received my back payments less the $6k for the attorney. It was a very simple process once I had an attorney. I was told that I would have been approved immediately because of stage 4 dx, my issue was date of last insured. So please do not hesitate and apply! Do not downplay anything on the application. I made the mistake of always not complaining to my MO about everything and that came back to haunt me at the hearing, the judge referenced how my MO always had positive notations in my file, but luckily my other drs all made mention of aches and pains that I would mention to them.
Good luck!
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GatorGirl, you seem to be well informed on all of this stuff. I have 9 year old twins, how do I apply for their benefits?
thanks!
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Basia, if you have been awarded your SS disability benefits ( not just SSI- supplemental security insurance) then all you should have to do is contact your local office and make sure they have the info for your children. If you noted your children on your initial application these should start automatically. There are a small percentage of people with low entitlement amounts whose primary insurance amount (PIA) is the same as the family maximum (FMAX) . For most folks however there is usually a few hundred dollars more per month available for the children. It is based on your earnings record. If you have any questions call your attorney 's office. They will tell you what to do. Thanks for the compliment. I am a social security attorney and have done this for over 33 years so I hope I can be of help to my fellow BC survivors. Just remember I am not giving any specific advice here just general tips to help educate. Good luck. I am glad you got your benefits despite your date last insured issue.
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Steven, I like many others are facing this with the terror of how to afford it. I however came into the DCIS already on SSDI due to MS and the destroyed Disc in my Lumbar from a anesthesiology student learning how to do Lumbar Punctures. She managed to poke enough holes in the disc that it simply collapsed as two raggedy sides.. Pain has been my constant companion. I have a 0.6 area they want to do a lumpectomy on and then radiation treatments..I am 53 and I could barely make it with one Major medical issue let alone now another in my life. Then to top it all off the Dr's clerk say disabled and wrote UNEMPLOYED in my Hospital records.. so guess how much assistance I can look forward to. Like you I have some advice to those going thru the system. Don't take it personally, they are trying to weed out the false claims, and yea they will push every button they can to see if you slip up.. Your Best bet is From DAY 1 Get a copy of your records. Make copies for others but never loose YOUR ONE FREE COPY.. Read EVERYTHING carefully, cause if they misrepresent something you are as my Grand Mother would say UP A UNSANITARY TRIBUTARY WITHOUT SUFFICIENT MEANS OF LOCOMOTION... So correct any errors as fast as possible, don't let them even claim BP R arm Sitting if they did it in your left arm standing.. Why you may ask, because if you are in pain Standing and yet you allow them to take your vitals standing and they are normal you have just handed someone a hand grenade against you unless you have them mark by it Patient was in Pain during Vitals. Everything can and will be used against you if they don't see a disability. Your Breasts are not your wage earning, so what about them makes this a disability, ok the fatigue, the illness of the treatments, the stress of the live or die questions let alone the body image. You can get thru this but grow a thicker skin and fight the CANCER not the world. Pick your Battles, which are worth fighting and what can wait a day or two.. YOU ARE ALWAYS GOING TO BE YOUR BEST HEALTH CARE ADVOCATE, no matter how much support family and friends are, you know what your body feels like and when something is off. Don't allow some nitwit in a white coat who is PRACTICING medicine instead of being a informed and competent Medical professional try to steer you in a way you don't want to go. My First surgical consult I wouldn't allow to treat my CAT in a life or death event because I know better.. I was told in College that I'd never cut it in the Nursing program, so I quit, I worked saved, became a phlebotomist , did the granny wake ups at 3 am before breakfasts runs and then worked in a plasma center, and entered a LPN program working up until the last semester.
Then as a LPN and EMT I went to work at the doc in a box type clinics for urgent care, but not quite Emergency care.. I had to teach Residents fresh from Med school the 18 mo in room three has Oitits Media... uhh and that is as they pull a pocket size book out.. ear ache doc.. How do you know?? well holing the ear not wanting me to touch them and temp plus no other signs of issue other then holding their ear.. Ohh ok what do you give.. Doc come on Amoxicillin unless allergic parents or never had before you know the bubble gum stuff, How... Their weight which is on the for in your hand and YOU get paid to figure the dose out Not me.. if I ad a dollar.. I have been a Prison Nurse and a Home Vent Nurse. that last is why my surgical lumpectomy will be under nerve block and conscious sedation I am not getting intubated for a lumpectomy, had too many patients that I had to care for on a vent because something went wrong in a routine surgery.. THERE IS NO SUCH THING AS ROUTINE SURGERY.. it's all abnormal to the human body to cut it open for any reason..
My surgery isn't scheduled yet, I have been checking to see what is causing a lot of flare ups and just plain something isn't right and looking first. I have lost 30 pounds in the last 4-5 months.. no explanation.. Colonoscopy the cancer that has hit generations of my family clear.. now we start on all the labs and the X rays.. I'd love to find nothing wrong.. but something tells me there is something and a 0.6 oval breast DCIS isn't it..
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I am so upset!! I have stage 4 bc with innumerable mets in bones. I'm on Ibrance, letrozole and zometa. CTCA just called to say they can't support my Virginia retirement disability. WTF? I can't take care of myself properly while working full time. I'm not scamming anyone. I come home every night and can't do anything because I'm so tired. My memory is shot and because of my white blood cell count I catch everything. I'm a teacher of k-3 students and I just can't do it!! ANy suggestions!?
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I am not familiar with CTCA but is this coming from a main office or your individual oncologist? You need to have a heart to heart with your oncologist and have him/ her take you off work. You need to clearly explain what you are going through. Bring in a copy of the listing for SS I posted and make sure they agree you meet it, though state retirement is a different standard. Do you have a supportive GP? Any other doctors you see?How many doctors does your Virginia retirement board require? Can you get another opinion? This is very surprising. One would hope oncologists would be supportive of their Stage 4 patient's needs.
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I think it is coming from office of my oncologist. I'm seeing my GP today and I will see my local oncologist March 7th. I'll have to reschedule that appt for an earlier date because I already told my work that I cannot continue after the 26th of this month. This is not what I need!...More stress!
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I thought CTCA was Cancer Treatment Centers of America. Are you saying they are denying you for medical treatment because they won't accept VA disability health insurance? You will still be able to find good health care, even if you do not go to CTCA. It's always been said that they are a place particular with what insurances they accept. This is a blip in the road, you may have to make the adjustment to a different facility and with a different oncologist, but there are plenty of good ones out there, it's not like CTCA have the only good ones.
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I've been going to CTCA since May. They did not want to fill out my form so I could retire on disability. I will have a conversation (a piece of my mind) tomorrow. I had an appt with my primary care doctor and he took the papers out of my hand and filled them out on the spot -No issues. I don't know why CTCA was having such an issue. i've been good with the care I receive but I haven't been happy at my last two appts with my oncologist. I just feel he doesn't listen to my symptoms. He only seems interested in the scans.
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Ok. I understand what you're saying now. Does CTCA assign a case manager to you? Is there some type of patient advocate there who can address your situation? Certainly they have had to had many patients file for disability. I also do not think the onc fills out that paper work. It would be sent to the onc's office, the paperwork filled out and the onc signs off and approves it.
I would be firm but respectful when speaking to them at the onc's office. As I mentioned before to someone on this thread, we learn to live with this disease and it becomes a different type of normal, but it is not the life of a healthy, able bodied person. There are also emotional issues to deal with. Do you take meds to help you cope? if so, it is even more proof of the burden you bear in dealing with metastatic breast cancer. We know you are not trying to scam the system. I am hoping you can make a few phone calls and get an approval for filing the claim.
However, it may even be that you have to threaten legal action. Do you have access to free legal advice from your employer? You might want to put a call in to them if you do and see what they advise.
It is all a big pain in the ass and stressful, but you are looking after you. You are your own best advocate and are worth the time and effort it takes to get the results you're after
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I would like to recommend Centers for Independent Living for anyone who is in need of assistance in actually applying for or understanding the enormous confusion of applying for SSDI. I worked at one as an advocate for Oakland and Macomb counties in Michigan for eight years. They are all over, nationally. A huge part of my job was assisting people in applying for SSDI, SSI, state benefits and county benefits. If anyone is struggling and facing timelines to get their questions answered, this is a terrific resource! Call yours now and make an appointment. Make sure you let them know what you are in need of help with so you get scheduled with the appropriate person.These services are free and mandated by the rehabilitation Act. You can find the one closest to where you live by using the following national locator: http://www.ilru.org/projects/cil-net/cil-center-an...
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For those of us who are using LTD from our employers (especially UNUM) the following link provided me with all the answers I needed to know. LTD & STD can be really tricky! So be careful out there! You don't want to end up with an overpayment!
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