Can You Get SSDI for a Hard-to-Prove Condition?

A condition that is difficult to document, sometimes called an invisible disability, can be approved for Social Security Disability Insurance (SSDI) if the evidence meets the Social Security Administration's (SSA) requirements. 

With hard-to-prove SSDI conditions, it can be difficult to establish the medical impairment, show how severe or recurring it is, or show how the condition affects your ability to work.

Two people with the same diagnosis may have different evidence gaps in their claims. This article explains how those gaps differ. It uses fibromyalgia, migraines, and mental health conditions as examples to show how gaps may happen and how you can identify which issue may be affecting your claim.

What Makes a Condition Hard to Prove?

"Hard to prove," a label often given to invisible disabilities, means the evidence may not clearly answer one or more of the five questions the SSA asks during evaluation. The questions in the agency’s five-step process are:

• Are you working and earning above the limit? 
• Is your condition severe? 
• Is your condition on the list of disabling conditions (or does it meet a condition)?
• Can you do the work you did previously?
• Can you do any other type of work?

Those five questions guide the SSA’s evaluation. This article focuses on the evidence issues that can make some of those questions harder to answer.

The SSA needs evidence of a medically determinable impairment (MDI). An MDI is a physical or mental impairment established by objective medical evidence from an acceptable medical source. Symptoms alone do not establish an MDI.

In addition to establishing an impairment, the SSA evaluates how severe it is and how it limits your ability to work. For conditions that change over time or happen in episodes, the evidence should show how often symptoms occur, how long they last, and how intense they are. A symptom diary kept alongside treatment can help show that pattern. The evidence also needs to show how those symptoms affect your ability to work, including any physical or mental limitations. 

A diagnosis only establishes what condition you have. It doesn’t show how severe your symptoms are or how they affect your ability to work.

Three Evidence Gaps in Hard-to-Prove SSDI Claims 

Gap 1: Establishing the Impairment

The first evidence gap happens when your symptoms are documented, but the record doesn’t clearly establish the condition causing them. Establishing an MDI can be harder when a single scan or test can’t confirm a condition. The SSA may need a combination of medical findings that, together, support a diagnosis under its rules.

Fibromyalgia is one example. Under Social Security Ruling (SSR) 12-2p, the SSA can establish fibromyalgia as an MDI using one of two sets of criteria. Both require a history of widespread pain and evidence that another condition isn’t causing the symptoms.

Under one set of criteria, the SSA also looks for pain in at least 11 of 18 specific points on the body during a physical exam. The other set of criteria looks for repeated signs or symptoms such as fatigue, memory or concentration problems, waking unrefreshed, depression, anxiety, or irritable bowel syndrome.

Learn more about how the SSA evaluates pain and symptoms.

Gap 2: Showing Severity and Pattern

The second evidence gap happens when the condition is established, but the record doesn’t clearly show the pattern or severity of symptoms.

This is common when you have episodes of symptoms or the severity of symptoms varies. The diagnosis may be well documented, while the records say little about the pattern of episodes.

Migraines are a good example. Under SSR 19-4p, the SSA looks at details such as how often you have migraines, how long they last, how intense they are, and what other symptoms you have with migraines. 

You can have a medical record that spans years but still doesn't clearly show your pattern of symptoms. A headache diary you share with your doctor can fill in what appointment notes leave out. 

Gap 3: Showing Work Limitations

The third evidence gap happens when your condition and symptoms are documented but the record doesn’t clearly show how they limit your ability to work.

The SSA assesses your residual functional capacity (RFC), which is the most you can still do despite your physical or mental limitations. Physical limitations can affect things like sitting, standing, walking, lifting, reaching, or using your hands. Mental limitations can affect your ability to follow instructions, concentrate, keep pace, interact with others, or handle changes at work.

Mental health conditions are a good example for this gap. Your records may document anxiety, depression, or problems concentrating without clearly showing how those symptoms affect your ability to complete work tasks or stay on task throughout a workday. A diagnosis and a list of symptoms don't necessarily show what you can and can't do at work. A medical source statement from your treating provider can describe those limits directly.

Why Different Conditions Require Different Evidence

Different conditions can create different evidence gaps. The same condition can also create a different gap from one claim to another.

These examples show common evidence gaps, not fixed rules for each condition. Your claim may involve a different gap even if you have one of these diagnoses.