SSI vs SSDI: Denial Appeal Guide for Virginia, VA

Introduction: Why SSDI Denials Matter to Virginians

The Social Security Disability Insurance (SSDI) program is the federal safety net for workers who can no longer earn a substantial income because of a medically determinable impairment. Yet, according to the Social Security Administration’s (SSA) own Annual Statistical Report on the Social Security Disability Insurance Program, roughly 67% of initial SSDI applications are denied nationwide—and Virginia residents are no exception. Whether you live in Richmond, Virginia Beach, Roanoke, or a rural county near the Blue Ridge Mountains, the appeals process is the same, but local nuances—such as hearing office backlogs and regional medical networks—can influence your timeline and evidence gathering. This guide explains, step by step, how claimants in Virginia, VA can protect their rights after an SSDI denial, referencing only authoritative sources such as the Social Security Act, the Code of Federal Regulations (CFR), and published SSA guidelines.

Understanding Your SSDI Rights in Virginia

When you paid FICA taxes, you earned “work credits.” Under 42 U.S.C. § 423 (Section 223 of the Social Security Act), those credits entitle you to file for SSDI if you meet the definition of “disability.” The SSA’s five-step sequential evaluation is codified at 20 C.F.R. § 404.1520. In Virginia—as in every state—the SSA must determine whether:

Step 1: You are engaging in substantial gainful activity (SGA). For 2024, SGA is generally $1,550 per month for non-blind claimants (SSA SGA Table).

• Step 2: You have a severe medically determinable impairment lasting (or expected to last) at least 12 months or result in death.

• Step 3: Your impairment meets or equals one of the listings in 20 C.F.R. Part 404, Subpart P, Appendix 1.

• Step 4: You can perform your past relevant work.

• Step 5: You can adjust to other work that exists in significant numbers in the national economy, considering your age, education, and residual functional capacity (RFC).

Under Richardson v. Perales, 402 U.S. 389 (1971), the SSA’s decisions must be supported by “substantial evidence.” This standard does not require every shred of possible proof, but it does require more than a mere scintilla. Claimants have the right to:

• Receive a Written Notice of Decision.

• Examine the evidence in their claims file (including electronic records on SSA’s Disability Determination Services portal).

• Request representation by an attorney or qualified non-attorney under 42 U.S.C. § 406.

• Appeal within 60 days of receiving an adverse decision, per 20 C.F.R. § 404.909.

Common Reasons SSA Denies SSDI Claims

Understanding why SSA issues denials can help you craft a stronger appeal. Based on SSA’s Program Operations Manual System (POMS) and Virginia Disability Determination Services (DDS) feedback, the most frequent denial rationales include:

Insufficient Medical Evidence An RFC assessment may conclude your limitations are not severe enough. Common in musculoskeletal disorders where imaging is inconclusive. Failure to Follow Prescribed Treatment (20 C.F.R. § 404.1530) If medical records show you did not take prescribed medication or attend therapy without a “justifiable cause,” the SSA can deny benefits. Earnings Above SGA Part-time work or gig-economy income occasionally pushes gross earnings over the SGA threshold. Short Duration Impairments SSA denies claims that do not satisfy the 12-month duration requirement. Prior Adverse Decisions Res judicata applies if you file repeatedly with no new evidence or altered onset date.

Virginia-specific data published in SSA’s State Disability Factsheet show that in Fiscal Year 2023, the DDS in Richmond denied approximately 65% of initial SSDI claims, closely tracking the national average. Understanding why denials occur can guide your next steps.

Federal Legal Protections & Regulations

Several federal laws and regulations protect claimants:

• Social Security Act Section 205(b) (42 U.S.C. § 405(b))—guarantees a right to a hearing before an Administrative Law Judge (ALJ).

• 20 C.F.R. §§ 404.929 – 404.996—outlines the four-level administrative review process.

• 5 U.S.C. § 552a (Privacy Act)—gives you access to your SSA file.

• Equal Access to Justice Act (28 U.S.C. § 2412)—may allow recovery of attorney’s fees if you prevail in federal court and the government’s position was not “substantially justified.”

ALJs in Virginia are bound by precedential decisions from the U.S. Court of Appeals for the Fourth Circuit (which covers Virginia). Noteworthy cases include:

• Bird v. Comm’r of Soc. Sec., 699 F.3d 337 (4th Cir. 2012)—held that retrospective medical opinions can establish disability onset.

• Coffman v. Bowen, 829 F.2d 514 (4th Cir. 1987)—ALJ must explicitly consider non-exertional limitations such as pain.

Steps to Take After an SSDI Denial

1. Review Your Denial Letter

The SSA’s Notice of Disapproved Claim explains the technical or medical reasons for denial. It also recites your 60-day deadline (20 C.F.R. § 404.909). Mark the date you received the letter; the SSA presumes five days after mailing, but you can rebut this with evidence.

2. File a Request for Reconsideration

Submit SSA-561 and an updated SSA-3441 (Disability Report—Appeal) electronically through SSA’s Appeal Portal. In Virginia, reconsiderations are processed by the DDS located at 2100 Colonia Farm Circle, Richmond, VA 23230.

3. Gather Additional Evidence

• Medical Source Statements—Ask your treating physicians to complete a functional capacity form aligned with SSA listing criteria.

• Updated Diagnostics—MRIs, X-rays, neuropsychological testing, or blood work conducted after the initial decision.

• Third-Party Statements—Sworn declarations from family or coworkers describing your limitations.

4. Request a Hearing Before an ALJ

If Reconsideration fails, you have 60 days to request an ALJ hearing (20 C.F.R. § 404.933). Most Virginians appear before ALJs at the Office of Hearings Operations (OHO) in Richmond (400 North Eighth Street, Suite 600, Richmond, VA 23219) or the Falls Church National Hearing Center for video hearings. According to SSA’s 2024 workload data, the average wait time in the Richmond OHO is approximately 9.5 months.

5. Appeals Council Review

An unfavorable ALJ decision can be appealed to the SSA’s Appeals Council in Falls Church, VA. You must file within 60 days using Form HA-520. The Council can affirm, reverse, remand, or dismiss your case.

6. Federal Court Review

Your final administrative remedy is filing a civil action in the U.S. District Court for the Eastern or Western District of Virginia (42 U.S.C. § 405(g)). The statute of limitations is 60 days from the Appeals Council’s notice of denial or dismissal.

When to Seek Legal Help for SSDI Appeals

Hiring a Virginia disability attorney is not mandatory, but data from the Government Accountability Office (GAO-18-37) indicate claimants represented by an attorney at the ALJ level are nearly three times more likely to be approved. Attorneys’ fees are capped by 42 U.S.C. § 406(a)(2) at 25% of past-due benefits or $7,200, whichever is lower, unless the fee petition process is used.

Attorneys admitted to the Virginia State Bar must meet continuing legal education (CLE) requirements (Rule 17, Rules of the Supreme Court of Virginia) and are subject to disciplinary oversight by the Bar’s Standing Committee on Lawyer Discipline. Always verify a representative’s credentials on the Virginia State Bar website.

Local Resources & Next Steps

Key SSA Offices in Virginia

Richmond SSA Field Office 1834 West Cary Street, Richmond, VA 23220 Phone: 866-590-7827 Virginia Beach SSA Field Office 2875 Sabre Street, Suite 100, Virginia Beach, VA 23452 Phone: 888-377-5237 Roanoke SSA Field Office 612 South Jefferson Street, Suite 100, Roanoke, VA 24011 Phone: 866-701-7155

Medical & Vocational Evidence Sources

• VCU Health System—Level I trauma center; maintains electronic health records compatible with SSA’s Health IT record request process.

• University of Virginia Medical Center, Charlottesville—specialized neurology and cardiology departments.

• Virginia Department for Aging and Rehabilitative Services (DARS)—offers vocational rehabilitation reports that can corroborate functional limitations.

Helpful Non-Profit Organizations

Judge David L. Bazelon Center for Mental Health Law—advocacy for mental-health-related disability claims. disAbility Law Center of Virginia—state-designated Protection & Advocacy agency.

Conclusion

An SSDI denial is not the end of the road. Under federal law and SSA regulations, Virginia residents have multiple layers of appeal and powerful rights to gather evidence, present testimony, and obtain legal representation. Exercising these rights promptly—especially within the 60-day deadlines—is crucial to safeguarding your financial security and healthcare access.

Disclaimer: This article provides general information for Virginia residents. It is not legal advice. Consult a licensed Virginia attorney regarding your specific situation.

If your SSDI claim was denied, call Louis Law Group at 833-657-4812 for a free case evaluation and claim review.