Recurrent Arrhythmias

How to Get Disability Benefits for Recurrent Arrhythmias by Meeting a Listing

To determine whether you are disabled at Step 3 of the Sequential Evaluation Process, the Social Security Administration will consider whether your condition is severe enough to meet or equal the recurrent arrhythmias listing. The Social Security Administration has developed rules called Listing of Impairments for most common impairments. The listing for a particular impairment describes a degree of severity that Social Security Administration presumes would prevent a person from performing substantial work. If your condition is severe enough to meet or equal the listing, you will be considered disabled.

The listing for recurrent arrhythmias is listing 4.05. To satisfy the listing, you must demonstrate recurrent arrhythmias, not related to reversible causes, resulting in uncontrolled, recurrent episodes of cardiac syncope or near syncope, despite prescribed treatment and documented by resting or ambulatory (Holter) electrocardiography, or by other appropriate medically acceptable testing, coincident with the occurrence of syncope or near syncope.

Meeting Social Security Administration Listing 4.05 for Recurrent Arrhythmias

The important elements of the listing are:

Not related to reversible causes: These include the toxic effects of digitalis glycosides that are frequently used to treat both heart failure and the arrhythmia of atrial fibrillation. Digitalis toxicity can be suspected from the appearance of EKG tracings and definitely diagnosed with digitalis blood levels; adjustment of medication will solve the problem. Electrolytes—particularly potassium and calcium— must be within normal range or cardiac arrhythmias will result. Finally, the listing notes that the antiarrhythmic drugs used to treat arrhythmias may themselves cause arrhythmias, especially when blood levels are too high. Of course, this situation can be remedied by decreasing the medication dose or stopping the medication, but some patients die from the very drugs meant to save their lives. In these unfortunate instances, the arrhythmia would qualify under the listing rather than being treated as a reversible cause.

Cardiac syncope or near syncope: The various types of tachycardia and bradycardia can all decrease cerebral perfusion, as can severe heart blocks. Full loss of consciousness (syncope) implies involuntary and complete loss of awareness; if standing, the patient would fall. If the arrhythmia self-terminates or is terminated by treatment, then the symptoms will resolve until the arrhythmia returns. If the arrhythmia is severe enough, such as ventricular fibrillation, permanent brain death will follow within minutes without effective intervention. In other instances, such as chronic atrial fibrillation, the arrhythmia is not intrinsically lethal and may persist for years. Although lethality is not a specific issue for satisfying the listing, it enters the picture indirectly. Arrhythmias that are severe enough to induce syncope are severe enough to kill, either from cardiac arrest, as a consequence of falling with a resultant head injury, or as a result of loss of consciousness in dangerous situations like driving. Therefore, cases of arrhythmia-induced and repetitive syncope are rarely seen by the SSA, because they either are treated effectively or they die. Most claimants with chronic symptomatic arrhythmias have near-syncope. Near-syncope from a ventricular arrhythmia like ventricular tachycardia (which may lead to cardiac arrest) is much more life-threatening than near-syncope from sick sinus syndrome or atrial fibrillation. Yet the listing is not concerned with these facts, but of the question of the documentation of near-syncope itself.

• The SSA defines near syncope as “…a period of altered consciousness…not merely a feeling of light-headedness, momentary weakness, or dizziness.” It is reasonable to assert that near-syncope means a decline in awareness that is severe enough to cause an inability to continue ongoing activities or think clearly during the period in question. For example, a momentary feeling of lightheadedness or dizziness would not reasonably qualify under the listing. On the other hand, a person whose symptoms cause them to have an accident in their car, or who involuntarily stops typing at their computer and slumps in their chair has near-syncope. Syncope is a loss of consciousness.

Resulting in uncontrolled, recurrent episodes: The word “recurrent” is not defined in regard to frequency, and consequently there is room for medical judgment. More severe episodes of syncope as determined in medical records and treatment required could reasonably satisfy the listing with a lesser frequency than less severe episodes. If one uses as precedent the frequency of major epileptic seizures, then severe episodes of near-syncope occurring more than once monthly would certainly qualify. However, it is possible to envision an even lesser frequency when the near-syncope is severe enough to require hospitalization and is poorly responsive to treatment.

Documented by… appropriate medically acceptable testing: The listing requires that the syncope or near-syncope occur in documented association with arrhythmia. The chances of these events happening during the minute taken to run a resting EKG are remote. It is more likely that they will happen during a 24-hour Holter monitor recording; however, it may take multiple such recordings to detect the arrhythmia since symptoms might not occur on the day the test is being done. If the individual reports syncope or near-syncope at a certain time and the recording shows an arrhythmia at that time which is severe enough to explain those symptoms, then it is reasonable to conclude that the arrhythmia is the cause of the symptoms. Most Holter monitor recordings purchased by the SSA do not show significant abnormalities at the time of alleged symptoms. Perhaps this is because the majority of individuals with severe arrhythmias are already under treatment when they apply for disability benefits. If Holter monitor testing is performed, it is extremely important that you keep a symptom diary. This diary should note the time you experience the symptom (including syncope or near syncope), the nature of the symptoms, the duration, and any particular activities that made symptoms better or worse (if any).

Despite prescribed treatment: ICDs are placed in claimants with difficult to control, life-threatening ventricular arrhythmias. The fact that an ICD shocks the individual out of a dangerous arrhythmia and associated near-syncope could technically prevent qualification under the listing. However, if discharge of the ICD into the individual is as debilitating in the total context of clinical severity, a finding of equivalent is warranted. To make this statement less vague, functional loss (as a result of appropriate or inappropriate ICD discharge frequency) that is as severe as that associated with uncontrolled arrhythmias and no ICD should result in an Equal code. Since the frequency of uncontrolled arrhythmia is left undefined by the SSA, a respectable latitude in judgment is apparently possible in interpretation of the listing.

Although every disability claim must be evaluated on a case-by-case basis, any history of cardiac arrest in any claimant should be a red flag to the adjudicator to be extra careful in making a denial determination and be able to articulate why the particular person is an exception to poor prognosis. However, listing-level severity for arrhythmias is difficult to document, both in regard to severity and duration. Most claimants with arrhythmias receive an RFC.

Continue to Residual Functional Capacity Assessment for Recurrent Arrhythmias.

Go back to About Recurrent Arrhythmias and Disability.