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Functional Capacity Worksheet

Daily Symptom & Limitation Log for SSA Disability and Insurance Appeals

Patient Information

Patient Name Date of Birth Log Period (Week of) Treating Rheumatologist

Primary Diagnoses Last Date of Sustained Employment Required for SSA §14.00 & SSD onset documentation

📋 What This Worksheet Does

Every field you complete builds your evidentiary record under SSA Blue Book rules. Three listings protect you:

SSA §1.00 — Musculoskeletal: standing, walking, lifting, fine motor.
SSA §14.00 — Immune System (§14.02 SLE · §14.06 MCTD): documents multi-system involvement and functional severity.
SSR 12-2p — Fibromyalgia: requires a longitudinal log showing symptom variability — exactly what this log produces.

Tip: Fill this out on paper or a phone if screens are hard. Accuracy matters more than neatness.

Section A — Daily Log (Complete Each Day)

📅 Fill this out daily for at least 14 days in a row before you submit. Record both good days and bad days — inconsistency isn't a problem, it's evidence. Honest entries carry more weight than perfect ones.

Date Day of Week

Overall Day Classification: Good Day Moderate Day Bad Day Flare Day

A1. Pain & Symptom Rating (Scale 0–10; 10 = worst imaginable)

Symptom	AM	Midday	PM	Notes / Location
Joint pain (hands, wrists, knees)
Joint stiffness (AM duration in min)
Muscle pain / tender points (FM)
Fatigue (1=energetic, 10=bedbound)
Numbness / tingling (specify limb)
Raynaud's episodes (# today; triggers)
Cognitive fog ("lupus fog" / FM fog)
Photosensitivity / malar rash
Sleep quality (1=restful, 10=nonrestorative)

A2. Functional Capacity — §1.00 Musculoskeletal: Exertional Limitations

Activity	Max Before Symptom Onset	Symptom That Forced Stop	Assistive Device Used
Standing (continuous, min)
Walking (continuous, min or ft)
Sitting (continuous, min)
Lifting / Carrying (lbs)
Climbing stairs (# flights)
Bending / Stooping / Kneeling

A2. §1.00 — Fine & Gross Motor (Upper Extremity Function)

Task	Able?	Difficulty (0–10)	Notes
Buttoning shirt / zipping pants
Writing with pen ≥10 minutes
Typing on keyboard (min before pain)
Opening jars, doorknobs, keys
Picking up coins / small objects
Holding coffee cup without dropping
Reaching overhead (both arms)
Gripping steering wheel

A2. §14.00 — Constitutional & Cognitive Limitations

Domain	Impact Today (0–10)	Specific Example
Activities of Daily Living (bathing, dressing, cooking)
Social functioning
Concentration, persistence, pace
Fatigue / malaise preventing task completion
Time spent reclining or in bed (hours)

A3. Raynaud's & Vascular Documentation

Number of episodes today Duration of longest episode (min) Triggers Digits affected

Color changes observed (white → blue → red)? Digital ulceration / numbness >30 min?

A4. Medications Taken Today & Side Effects

Medication	Dose	Time	Side Effect Experienced

A5. Tasks Attempted vs. Completed

Planned Task	Completed?	Reason for Stop / Who Completed It

Section B — Good Days vs. Bad Days Analysis

⚖️ SSA §14.00 & SSR 12-2p require proof of unpredictability. You can't hold a job you can't show up to reliably. This section documents exactly that — the gap between your best day and your worst.

B1. Weekly Tally

Week Of	# Good Days	# Moderate	# Bad Days	# Flare Days

B2. Contrast Narrative

On my BEST day this week, I was able to: On my WORST day this week, I was unable to: Unpredictability: Was I able to reliably predict which type of day I would have?

Yes No

If no, explain: Missed obligations this week due to symptoms:

Section C — Objective Evidence Log

🔬 Enter your most recent lab values below. These numbers satisfy the objective-evidence requirement for SSA §14.02 (SLE) and §14.06 (MCTD). Ask your doctor's office for a printed lab report if you don't have the values handy.

Test	Most Recent Value	Date	Reference Range	Trending
ANA (titer & pattern)
Anti-U1 RNP (diagnostic for MCTD)			Negative
Anti-dsDNA
Anti-Smith			Negative
Anti-Ro / Anti-La
Complement C3			90–180 mg/dL
Complement C4			10–40 mg/dL
CH50
ESR (sed rate)
CRP
CBC (WBC, Hgb, platelets)
UA with protein/creatinine ratio
Creatinine / eGFR
Nailfold capillaroscopy
Imaging (MRI, X-ray hands/SI joints)
Pulmonary (PFTs, DLCO, HRCT)
Echocardiogram / PASP

🚨 Key Flare Signals

C3 or C4 low / falling — active immune consumption (core SLE marker)
Anti-dsDNA rising — SLE disease activity
Anti-U1 RNP positive at high titer — confirms MCTD (ICD-10 M35.1)
ESR or CRP elevated — systemic inflammation

Section D — Patient Certification

I certify under penalty of perjury that the entries in this log are true and accurate to the best of my knowledge and reflect my actual day-to-day function.

Patient Signature Date Witness / Caregiver (optional) Date

Document 2 of 3

Medical Necessity Letter Template

For Completion by Treating Rheumatologist

🩺 For the Physician: Complete & Sign on Practice Letterhead

Fill in every field, delete sections that don't apply, and attach to the patient's appeal packet. This letter is designed to satisfy MCG/InterQual medical-necessity criteria and SSA §14.00 evidentiary standards.

Date Insurance Carrier Patient Name Date of Birth Member ID / Policy # Group # Claim / Auth Reference # Service / Medication at Issue

1. Confirmed Diagnoses and ICD-10 Codes

Condition	ICD-10	Date of Onset	Diagnostic Basis
SLE, organ involvement	M32.10
Mixed Connective Tissue Disease	M35.1
Fibromyalgia	M79.7
Raynaud's	I73.00/I73.01

2. Objective Supporting Evidence

Marker	Reference	Clinical Interpretation
ANA	<1:80
Anti-U1 RNP	Negative	Confirmatory for MCTD (M35.1)
Anti-dsDNA
Anti-Smith	Negative
Complement C3	90–180 mg/dL
Complement C4	10–40 mg/dL
ESR / CRP
CBC (cytopenias)
UA / UPCR
Imaging

SLEDAI-2K score PGA score FIQR score Tender point count

3. Clinical Course and Treatment Duration

Patient under care since: Disease course narrative:

Current Treatment Regimen

Medication / Therapy	Dose	Start Date	Ongoing?	Outcome

4. Trial and Failure of Alternative Therapies

⛔ Each medication listed below was tried and stopped due to failure, toxicity, or contraindication. Document dates and doses — insurers require this to justify the requested treatment.

Prior Therapy	Dates of Trial	Max Dose	Reason for Discontinuation	Objective Evidence of Failure
NSAIDs (naproxen, meloxicam)
Hydroxychloroquine
Oral corticosteroids
Methotrexate
Azathioprine
Mycophenolate mofetil
Physical therapy
Gabapentinoids / SNRIs
CCBs (Raynaud's)

5. Rationale for the Requested Treatment

Requested treatment Billing codes

Why this treatment is medically necessary:

Guideline alignment.

Mechanism-specific indication.

Documented failure of alternatives.

Risk of non-treatment.

Functional preservation.

6. Expected Outcomes and Monitoring Plan

Clinical endpoints: Objective endpoints: Monitoring cadence: Stopping rules:

7. Physician Attestation

I have personally examined this patient, reviewed her complete medical record, and determined in my professional medical judgment that the requested treatment is medically necessary, appropriate, and the least restrictive effective option available.

Physician Name, MD Board Certification NPI State License Phone Fax

Enclosures: Office visit notes; laboratory reports; imaging reports; medication trial documentation; Functional Capacity Worksheet.

Document 3 of 3

Appeal Letter Framework

Formal Response to Claim Denial

⏰ Act within your deadline

Commercial plans: 180 days from denial date
Medicare Advantage: 60 days from denial date
ERISA plans: Two internal appeal levels required before external review

Find your denial code on the Explanation of Benefits (EOB). Fill the letter fields below, then click the matching code button to add your legal argument. Mail everything certified mail, return receipt requested.

Master Appeal Letter

Patient Name Date Member ID Group # Date of Birth Claim Number(s) Date(s) of Service Provider / Facility CPT / HCPCS / ICD-10 Codes at Issue Insurance Carrier Denial Code(s) Cited Amount in Dispute Denial Notice Dated

Select Your Denial Code

Find the code on your EOB and click it — the ready-to-copy argument appears below.

CO-97

Payment adjusted because the benefit for this service is included in the payment/allowance for another service that has already been adjudicated.

The service is medically necessary and independently reimbursable. The service was ordered by a board-certified rheumatologist to manage documented, active autoimmune disease involving multiple organ systems (see Exhibit A, Letter of Medical Necessity). It is not incidental to any other procedure performed on the date of service.
Plan definition of "medical necessity" is met. The plan defines medically necessary services as those that are (i) appropriate for the diagnosis, (ii) consistent with accepted standards, (iii) not for convenience, and (iv) the most appropriate level of service. The requested service satisfies each prong, supported by ACR and EULAR guidelines (Exhibit G).
Objective evidence confirms active disease. Recent labs — including anti-U1 RNP positive, C3 low, C4 low, and elevated inflammatory markers — establish active immune dysregulation.
Alternative therapies have failed or are contraindicated. Prior step-therapy agents were trialed and discontinued due to inefficacy/toxicity, as documented in Exhibit E.
Reviewer qualifications. An adverse medical-necessity determination must be made by a health-care professional with appropriate training. Please confirm the reviewer was a board-certified rheumatologist; if not, the denial must be overturned on that ground alone.

If CO-97 indicates bundling rather than medical necessity: The service billed represents a distinct, separately identifiable service. The appropriate modifier (25 / 59 / XS / XU) was appended and the documentation supports separate payment.

CO-16

Claim/service lacks information or has submission/billing errors needed for adjudication.

Enclosed is the information required. See Exhibits A–H:
- Diagnosis documentation — ICD-10 codes M32.10, M35.1, M79.7, I73.0x
- Rendering provider info — NPI, Tax ID, Specialty: Rheumatology
- Service details — Place of service, dates, CPT/HCPCS codes
- Medical records — Notes, labs, imaging, letter of medical necessity
Specific Remark Codes (RARCs) referenced in the EOB are addressed individually in this submission.
The denial is procedural and should be reversed. Federal regulations require re-adjudication once deficiencies are cured.
If additional information is needed, contact in writing within 15 days specifying each item. A general request is insufficient under 29 C.F.R. § 2560.503-1(g)(1)(iii).

CO-50

Non-covered services because this is not deemed a "medical necessity" by the payer.

Clinical justification. The Letter of Medical Necessity (Exhibit A) establishes diagnoses, objective markers of active disease (positive anti-U1 RNP, suppressed C3 and C4), failure of alternatives, and consensus-guideline basis.
Guideline support. EULAR 2019, ACR 2023 lupus nephritis guideline, ACR fibromyalgia guidelines, and Raynaud's consensus statements all support the requested service.
Risk of denial. Without this service, the patient faces documented risk of organ damage, digital ischemia, irreversible joint destruction, and corticosteroid-related morbidity.
Specialty-matched reviewer required. Confirm the denying reviewer is a board-certified rheumatologist. If not, the determination does not constitute a "full and fair review."

CO-197

Precertification / authorization / notification absent.

Authorization was obtained or was not required. Prior authorization was secured on the documented date, or the service does not require it under the plan's published schedule of benefits.
Retroactive authorization is warranted. The urgent clinical presentation (active flare, digital ischemia, ER evaluation) precluded pre-service review. Plan language permits retroactive authorization where the service was medically necessary.
No member financial responsibility. Any alleged failure of pre-authorization lies with the provider, not the patient. The member may not be balance-billed under in-network contractual arrangements.

CO-167

This diagnosis is not covered.

The diagnoses — M32.10, M35.1, M79.7, I73.0x — are neither excluded nor experimental under the plan's Summary Plan Description or Certificate of Coverage. Please identify the specific plan-document section relied upon.
If the denial rests on treating fibromyalgia (M79.7) or MCTD (M35.1) as "non-covered," this conflicts with the American College of Rheumatology's recognition of these as distinct, medically treatable conditions. Coverage cannot lawfully be denied based solely on the label of a recognized diagnosis.

Supporting Evidence Enclosed

Check each item as you attach it. Checked boxes print as ✓ in the PDF.

Exhibit A: Letter of Medical Necessity (Rheumatologist) Exhibit B: Chart notes & progress notes Exhibit C: Lab reports — ANA, Anti-U1 RNP, Anti-dsDNA, C3, C4, ESR, CRP, CBC, UA Exhibit D: Imaging reports (MRI, X-ray, etc.) Exhibit E: Medication trial & discontinuation records Exhibit F: Completed Functional Capacity Worksheet (Document 1) Exhibit G: ACR / EULAR clinical guidelines Exhibit H: Copy of original denial notice (EOB)

Escalation Pathway

Step	Deadline	Action
1. Internal Appeal, Level 1	180 days (60 for Medicare Advantage)	Submit this letter; request written determination within 30 days (pre-service) or 60 days (post-service)
2. Internal Appeal, Level 2	As specified in Level 1 denial	Submit with new evidence; request peer-to-peer with rheumatology-trained reviewer
3. External / IRO Review	Typically 4 months from final internal denial	File with state DOI or plan-designated IRO; decision is binding on the plan
4. State DOI Complaint	Any time	File parallel consumer complaint
5. ERISA Civil Action	Plan-specified limitations	After exhausting internal appeals; consult counsel
6. Expedited Appeal	72 hours	If delay would seriously jeopardize life, health, or ability to regain function

🗂 Keep a Paper Trail

Check each item as you gather it. If your appeal is escalated, these documents are your proof.

Original denial notice / Explanation of Benefits (EOB) Signed, dated copy of this appeal letter Certified mail receipt + green return-receipt card All exhibits (A–H) in the order referenced Phone call log — date, time, rep name, reference number, what was said Summary Plan Description or Certificate of Coverage (from HR or insurer) Plan's written clinical criteria — you are entitled to a free copy; request it in writing

Patient Signature

Patient / Authorized Representative Date

cc: Treating Physician; State Department of Insurance (if escalating); Plan Administrator / Employer (if ERISA); Personal file.

Quick Reference & Resources

Key codes, listings, and contacts for your appeal

ICD-10 Codes

M32.10 — SLE, organ involvement unspecified
M35.1 — MCTD (Mixed Connective Tissue Disease)
M79.7 — Fibromyalgia
I73.00/I73.01 — Raynaud's syndrome

SSA Blue Book Listings

§1.00 — Musculoskeletal Disorders
§14.00 — Immune System Disorders
§14.02 — Systemic Lupus Erythematosus
§14.06 — UCTD / MCTD
SSR 12-2p — Evaluation of Fibromyalgia

Key Lab Markers

Anti-U1 RNP — Diagnostic for MCTD
C3 — Reference: 90–180 mg/dL
C4 — Reference: 10–40 mg/dL
Anti-dsDNA — SLE activity marker
ESR / CRP — Inflammatory activity

Common Denial Codes

CO-97 — Bundled / Not Medically Necessary
CO-16 — Claim Lacks Information
CO-50 — Not Medically Necessary
CO-197 — No Prior Authorization
CO-167 — Diagnosis Not Covered