Listing 4.04 in 2026: How Social Security Decides Ischemic Heart Disease Claims Under 4.04A, 4.04B, and 4.04C, Why the 5 METs Threshold and the Three-Episode Rule Decide Most Cases, and the Imaging Findings That Win Without an Exercise Test

By Anthony Albert, Benefits Research Director · Published June 17, 2026 · 14 min read

Ischemic heart disease is one of the most common cardiac impairments at Social Security, and one of the most frequently denied. People file with a coronary artery disease diagnosis, a few stent placements, and a cardiology note saying they get short of breath. That file usually goes to denial because Listing 4.04 is not about the diagnosis. It is about specific lab values, specific imaging findings, and a specific functional threshold expressed in metabolic equivalents.

If you want to win at Step 3 on ischemic heart disease, you have to know which of the three subparts your case fits, what evidence each one demands, and how your cardiologist has to phrase the report so SSA can match it to the listing. This is the 2026 walkthrough.

What ischemic heart disease covers at SSA

Listing 4.04 sits inside section 4.00 of the Blue Book, the cardiovascular system. SSA uses it for any disease that reduces blood flow to the heart muscle. That includes:

• Atherosclerotic coronary artery disease (the most common cause)
• Coronary artery spasm (Prinzmetal's angina)
• Microvascular dysfunction (cardiac syndrome X)
• Coronary artery dissection
• Anomalous coronary anatomy with ischemic consequences
• Post-bypass disease with residual ischemia
• Post-stent disease with residual or recurrent ischemia

Section 4.00E of the Blue Book is the long technical preface for ischemic heart disease. It defines myocardial ischemia, the symptoms SSA recognizes (typical angina, atypical angina, anginal equivalents, syncope from cardiac causes, central cyanosis from right-to-left shunting), and the testing protocols SSA accepts. You should read it once before you read 4.04, because the listing itself is short and the definitions live in 4.00E.

The threshold issue across all three subparts: SSA requires that your symptoms occur "while on a regimen of prescribed treatment." An untreated claimant cannot meet 4.04, even with severe disease, because SSA cannot tell whether treatment would resolve the ischemia. If you are not on an evidence-based medical regimen (typically aspirin, statin, beta blocker, and a vasodilator, with revascularization as indicated), your file needs documentation explaining why.

4.04A: exercise tolerance test at 5 METs or less

4.04A is the most common pathway. It applies when you can safely undergo an exercise tolerance test (ETT) and the test produces an ischemic response at low workload. The listing accepts four different ischemic findings, any one of which satisfies 4.04A:

1. ST-segment depression of at least -0.10 millivolts of horizontal or downsloping depression in at least 3 consecutive complexes that are on a level baseline, with the depression lasting at least 1 minute into recovery. The depression must occur during exercise and persist into recovery. You cannot be on digitalis glycoside or have low potassium, because both produce ST changes that look ischemic but are not.
2. ST-segment elevation of at least 0.10 millivolts above resting baseline in non-infarct leads during both exercise and at least 1 minute of recovery. ST elevation during exercise (outside areas of known prior infarct) is severe ischemia and usually requires immediate test termination.
3. Dropping systolic blood pressure of at least 10 mm Hg below the standing baseline taken immediately before exercise, or below any preceding systolic reading during exercise, caused by left ventricular dysfunction despite an increase in workload. Normal physiology is that systolic pressure rises with exercise. A pressure drop signals that the left ventricle cannot keep up.
4. Imaging-confirmed ischemia on radionuclide perfusion scan or stress echocardiography at an exercise level of 5 METs or less.

All four findings have to occur at a workload of 5 METs or less. Five METs is roughly the energy cost of walking briskly on flat ground, climbing a flight of stairs at normal pace, or carrying groceries up one flight. If your heart shows ischemia at that exertion level, SSA treats it as listing-level disease.

The ETT has to be a sign- or symptom-limited test. The patient exercises until they develop a sign or symptom that indicates as much exertion as is safe. That can be chest pain, dyspnea, ST changes, ventricular ectopy, or hypotension. A test stopped purely because the patient asked to stop, without an objective endpoint, may not count.

For the ETT result to support 4.04A, the cardiology report has to say:

• The METs achieved at the point of the ischemic finding (or the Bruce stage and the conversion to METs)
• The specific ischemic finding (which of the four)
• That the test was sign- or symptom-limited
• That the patient was on prescribed cardiac medication at the time

If any of those four pieces is missing, the file is weaker than it looks. A good cardiologist's stress test report walks through the workload, the Bruce stage, the METs, the heart rate response, the blood pressure response, the ECG findings, and the perfusion findings if imaging was used. Generic "abnormal stress test" wording does not move the file.

4.04B: three ischemic episodes in 12 months

4.04B is the path for claimants whose disease is bad enough to send them back to the cath lab multiple times. It requires three separate ischemic episodes within a consecutive 12-month period, each requiring revascularization or each not amenable to revascularization.

"Revascularization" means percutaneous coronary intervention (PCI), which covers angioplasty with or without stent placement, or coronary artery bypass graft (CABG) surgery. Each of the three episodes has to either get a revascularization procedure or have cardiology decide the vessel could not be bypassed or stented.

"Not amenable to revascularization" means a cardiologist looked at the lesion and decided the procedure was either too risky or technically impossible. Reasons that count include:

• The vessel is too small or too diffusely diseased to bypass
• The patient has another comorbidity (uncontrolled bleeding risk, severe lung disease, recent stroke) that makes the procedure unsafe
• The lesion is in a vessel already bypassed and the graft is occluded
• The patient has had multiple prior interventions and there is no remaining target

The Blue Book is specific that reocclusion during the same hospitalization that requires a second procedure does not count as a new episode. The three episodes have to be separate hospitalizations or separate clinical events.

The strongest 4.04B files contain:

• Hospital discharge summaries for each of the three episodes
• Cath lab reports documenting the lesion and the procedure
• Operative notes for any CABG
• Cardiology consult notes naming the lesions deemed "not amenable to revascularization" with the reason
• Dates of each episode clearly within a 12-month window

The dates matter. SSA reads the 12 months as any 12 consecutive months. If your three episodes are spread over 18 months, you do not meet 4.04B even if the disease is identical. Cardiologists writing summaries should be encouraged to lay out the timeline clearly so the adjudicator does not have to reconstruct it from raw records.

4.04C: angiographic evidence when exercise testing is too risky

4.04C is the path for claimants who cannot safely undergo an ETT. The listing applies when a medical consultant, preferably one experienced in cardiovascular disease, concludes that an exercise test would present significant risk. The Blue Book at 4.00C8 lists the conditions that make exercise testing unsafe:

• Acute myocardial infarction (recent)
• Surgical myocardial revascularization (recent bypass)
• Other open-heart surgical procedures (recent)
• Recent percutaneous transluminal coronary angioplasty with or without stenting
• Implanted cardiac defibrillator
• Symptomatic severe aortic stenosis
• Uncontrolled symptomatic heart failure
• Aortic dissection
• Severe pulmonary hypertension (PA systolic above 60 mm Hg)
• Left main coronary stenosis of 50 percent or more not bypassed
• Moderate stenotic valvular disease with systolic gradient across the aortic valve of 50 mm Hg or more
• Severe arterial hypertension (systolic above 200 or diastolic above 110)
• Hypertrophic cardiomyopathy with systolic gradient of 50 mm Hg or more

If one of those applies and the cardiology consultant signs off that an exercise test would be unsafe, 4.04C is on the table. The imaging then has to show one of these:

• 50 percent or more narrowing of a non-bypassed left main coronary artery
• 70 percent or more narrowing of another non-bypassed coronary artery
• 50 percent or more narrowing over a long segment (greater than 1 cm) of a non-bypassed coronary artery
• 50 percent or more narrowing of at least two non-bypassed coronary arteries
• 70 percent or more narrowing of a bypass graft vessel

"Non-bypassed" means the vessel either was never bypassed, or was bypassed and the graft has occluded so the original vessel is again the conduit. A vessel that has reoccluded after angioplasty or stenting and remains obstructed counts as non-bypassed for 4.04C purposes.

The second piece of 4.04C, which is where most claims fail, is the functional limitation. SSA requires "very serious limitations in the ability to independently initiate, sustain, or complete activities of daily living" because of the coronary disease. The imaging alone does not satisfy 4.04C. You need both the angiographic findings and the functional documentation.

That functional documentation has to come from treating sources. Cardiology notes describing severe symptoms with minimal exertion, primary care notes documenting limitations in ADLs, and a treating physician medical source statement using the "very serious" language all build the file. Self-report alone does not carry the day.

How METs translate to real-world activity

The 5 MET threshold in 4.04A maps to specific activities. SSA's view of what 5 METs looks like in daily life:

SSR 96-8p on residual functional capacity does not require a METs measurement, but cardiology stress tests use it. If your stress test shows ischemia at 4 METs, that maps directly to inability to walk briskly on flat ground or climb a flight of stairs without provoking ischemia. That is well below sedentary work demands, which top out at around 1.5 to 2 METs sustained.

What if 4.04 does not fit? The RFC fight

Most ischemic heart disease claims do not meet 4.04. They win at Steps 4 or 5 on residual functional capacity. The RFC factors that decide cardiac cases:

• Walking and standing tolerance (often limited to 2 to 4 hours in an 8-hour day)
• Lifting and carrying (often limited to 10 to 20 pounds occasionally)
• Climbing limitations (stairs and ramps occasionally, ladders and scaffolds never)
• Environmental limitations (avoid concentrated exposure to heat, cold, humidity, fumes, dust)
• Off-task time and absences (chest pain episodes, medication side effects, frequent cardiology follow-up)

The combination of sedentary exertional limits and moderate environmental restrictions can grid out an older claimant. The grid rules at 20 CFR 404 Subpart P Appendix 2 are friendly to claimants aged 50 and above with sedentary RFC and no transferable skills.

For younger claimants, the path is usually proving that the cardiac symptoms combined with required environmental controls and frequent absences for cath lab follow-up erode the unskilled sedentary base. SSR 96-9p describes that erosion. Documented chest pain provoked by minimal exertion plus three or more medical appointments per month makes a credible case that no employer would tolerate the attendance pattern.

Common reasons 4.04 claims fail

1. Stress test report is missing METs. The cardiology report says "ischemic at Bruce stage 1" without specifying the corresponding METs. Bruce stage 1 is roughly 4 to 5 METs, but SSA wants the number stated. Have your cardiologist write the METs into the report.
2. Stress test was symptom-limited but no objective endpoint. The patient stopped because of fatigue with no ECG or imaging change. SSA reads that as inconclusive.
3. The three episodes are spread over more than 12 months. Two episodes 14 months apart from a third do not meet 4.04B. Watch the timeline.
4. 4.04C file has the imaging but not the functional documentation. Angiography showing 70 percent stenosis without a treating physician statement on ADL limitation does not meet the listing.
5. Treatment regimen is undocumented. The file has stents but no medication list. SSA assumes non-compliance unless the medication record is in the file.

Worked Step 3 example

How to apply this listing to your case

1. Identify the subpart. Can you safely do an exercise test? 4.04A. Have you had three or more events in 12 months? 4.04B. Is exercise testing too risky? 4.04C.
2. Get your stress test report rewritten if it lacks METs, the specific ischemic finding, or the symptom-limited language.
3. For 4.04B, build a one-page chronology of every ischemic episode in the past 18 months with dates, hospitals, procedures, and "not amenable" determinations where applicable.
4. For 4.04C, get a cardiology consult note that explicitly states exercise testing would be unsafe and lists the reason from 4.00C8.
5. For 4.04C, also get a treating physician medical source statement on ADL limitation using the "very serious" terminology.
6. Document your medication regimen. SSA wants to see you on appropriate cardiac medications during the relevant period.
7. Build the RFC file in parallel. Most cardiac cases win on RFC, not on meeting 4.04.

Bottom line

Listing 4.04 is winnable but only on a complete file. The three subparts cover three different ways ischemic heart disease can disable you, and your medical evidence has to match one of them precisely. The 5 METs threshold, the three-episode rule, and the angiographic percentages are not flexible. Stress test reports that lack METs, episode lists that span more than 12 months, and angiograms without functional documentation will lose at Step 3 even when the underlying disease is severe.

If you have ischemic heart disease and you are filing or appealing, See If You Qualify and we will audit your file against the 4.04 criteria before SSA does.

Related reading

• Listing 4.02 chronic heart failure
• Medical equivalence under 20 CFR 404.1526
• SSR 96-8p RFC assessment
• Borderline age rule and grid rules
• Disability resources in Texas
• Disability resources in California

Frequently asked questions