Chronic Heart Failure Disability Benefits Under Listing 4.02

Listing 4.02 applies to chronic heart failure while you are on a regimen of prescribed treatment. It is met by paragraphs A and B together, by paragraph C alone, or by paragraph D alone.

Paragraph A is the structural proof, documented by imaging during a period of stability and not during an episode of exacerbation:

• HFrEF: a left ventricular end diastolic dimension greater than 6.8 cm for males or 6.1 cm for females, or an ejection fraction of 30 percent or less.
• HFpEF: left ventricular posterior wall plus septal thickness totaling 2.5 cm or more with an enlarged left atrium of 4.5 cm or more, or a left atrial volume index (LAVI) of 40 ml/m2 or more.

Paragraph B is the functional proof, and any one of three routes satisfies it:

• Recurrent heart failure symptoms, where a medical source has concluded that an exercise test would present a significant risk to you, together with a very serious limitation in performing daily activities independently, appropriately, effectively and on a sustained basis.
• Inability to perform an exercise tolerance test at a workload of 5 METs or less on a standard treadmill or bicycle test, or at 15 ml/kg/min peak VO2 on a cardiopulmonary exercise test, because of breathlessness, fatigue, palpitations or chest discomfort, or because systolic pressure drops 10 mmHg or more from left ventricular dysfunction despite a rising workload.
• Three hospitalizations for exacerbations or complications of heart failure within a consecutive 12-month period, at least 30 days apart, each lasting at least 48 hours, counting hours in the emergency department immediately before admission.

Paragraph C stands alone: a left ventricular ejection fraction of 20 percent or less while on prescribed therapy, on two evaluations at least 90 days apart within a consecutive 12-month period, both during a period of stability.

Paragraph D also stands alone. An implanted mechanical circulatory support device, such as a left or right ventricular assist device, means SSA considers you disabled for 1 year from the date of implantation. So does continuous intravenous inotropic medication, such as milrinone, given for at least 30 consecutive days, with the year counted from the date the treatment began. Either applies while you are hospitalized, at home, or both. After that year, SSA evaluates whatever impairment remains.

The first pattern to check for is an ejection fraction measured at the wrong moment. Paragraphs A and C both require measurements during a period of stability. An echocardiogram taken in the hospital during an exacerbation does not satisfy either one, and paragraph C needs two qualifying evaluations at least 90 days apart, so one low reading is not enough on its own.

A second pattern to check for is hospital stays that do not count. An admission shorter than 48 hours, including the emergency department time just before it, or two admissions less than 30 days apart, may not meet the paragraph B hospitalization rule. A third is a file with no medical source statement about the risk of exercise testing, which leaves the recurrent-symptoms route resting on an inference. A fourth is reliance on the listing alone: if the measurements miss paragraph A, a file with no functional detail has little left for the RFC route.

If a denial letter has already arrived, our page on disability appeals covers the next stage. Many heart failure claims also involve coronary disease or rhythm problems; see our pages on ischemic heart disease claims and arrhythmia claims.