TN 33 (07-24)
5.00 DIGESTIVE DISORDERS (Effective Date: 10/06/23)
A. Which digestive disorders do we evaluate in this body system? We evaluate digestive disorders that result in severe dysfunction of the liver, pancreas,
and gastrointestinal tract (the large, muscular tube that extends from the mouth to
the anus, where the movement of muscles, along with the release of hormones and enzymes,
allows for the digestion of food) in this body system. Examples of these disorders
and the listings we use to evaluate them include chronic liver disease (5.05), inflammatory
bowel disease (5.06), and intestinal failure (5.07). We also use this body system
to evaluate gastrointestinal hemorrhaging from any cause (5.02), weight loss due to
any digestive disorder (5.08), liver transplantation (5.09), small intestine transplantation
(5.11), and pancreas transplantation (5.12). We evaluate cancers affecting the digestive
system under the listings in 13.00.
B. What evidence do we need to evaluate your digestive
disorder?
1. General. To establish that you have a digestive disorder, we need medical evidence about the
existence of your digestive disorder and its severity. Medical evidence should include
your medical history, physical examination findings, operative reports, and relevant
laboratory findings.
2. Laboratory findings. We need laboratory reports such as results of imaging (see 5.00B3), endoscopy, and
other diagnostic procedures. We may also need clinical laboratory and pathology results.
3. Imaging refers to medical imaging techniques, such as x-ray, ultrasound, magnetic resonance
imaging, and computerized tomography. The imaging must be consistent with the prevailing
state of medical knowledge and clinical practice as a proper technique to support
the evaluation of the disorder.
C. What is chronic liver disease (CLD), and how do we evaluate it
under 5.05?
1. General. CLD is loss of liver function with cell necrosis (cell death), inflammation, or scarring
of the liver that persists for more than 6 months. Common causes of CLD in adults
include chronic infection with hepatitis B virus or hepatitis C virus, and prolonged
alcohol abuse.
a. We will evaluate your signs of CLD, such as jaundice, changes in size of the liver
and spleen, ascites, peripheral edema, and altered mental status. We will also evaluate
your symptoms of CLD, such as pruritus (itching), fatigue, nausea, loss of appetite,
and sleep disturbances when we assess the severity of your impairment(s) and how it
affects your ability to function. In the absence of evidence of a chronic liver impairment,
episodes of acute liver disease do not meet the requirements of 5.05.
b. Laboratory findings of your CLD may include decreased serum albumin, increased International Normalized
Ratio (INR), arterial deoxygenation (hypoxemia), increased serum creatinine, oliguria
(reduced urine output), or sodium retention. Another laboratory finding that may be
included in the evidence is a liver biopsy. If you have had a liver biopsy, we will
make every reasonable effort to obtain the results; however, we will not purchase
a liver biopsy.
2. Manifestations of CLD.
a. Gastrointestinal hemorrhaging (5.05A), as a consequence of cirrhosis and high pressure in the liver's portal venous
system, may occur from varices (dilated veins in the esophagus or the stomach) or
from portal hypertensive gastropathy (abnormal mucosal changes in the stomach). When
gastrointestinal hemorrhaging is due to a cause other than CLD, we evaluate it under
5.02. The phrase “consider under a disability for 1 year” in 5.02 and 5.05A does not
refer to the date on which your disability began, only to the date on which we must
reevaluate whether your impairment(s) continues to meet a listing or is otherwise
disabling. We determine the onset of your disability based on the facts of your case.
b. Ascites or hydrothorax (5.05B) is a pathologic accumulation of fluid in the peritoneal cavity (ascites)
or pleural space (hydrothorax). Ascites or hydrothorax may be diagnosed by removing
some of the fluid with needle aspiration (paracentesis or thoracentesis), physical
examination, or imaging. The most common causes of ascites are portal hypertension
and low serum albumin resulting from CLD. We evaluate other causes of ascites and
hydrothorax that are unrelated to CLD, such as congestive heart failure and cancer,
under the listings in the affected body systems.
c. Spontaneous bacterial peritonitis (SBP) (5.05C) is an acute bacterial infection of peritoneal fluid and is most commonly
associated with CLD. SBP is diagnosed by laboratory analysis of peritoneal fluid (obtained
by paracentesis) that contains a neutrophil count (also called absolute neutrophil
count) of at least 250 cells/mm3. 5.05C is satisfied with one evaluation documenting peritoneal infection. We evaluate
other causes of peritonitis that are unrelated to CLD, such as tuberculosis, malignancy,
and perforated bowel, under the listings in the affected body systems.
d. Hepatorenal syndrome (5.05D) is renal failure associated with CLD in the absence of underlying kidney
pathology. Findings associated with hepatorenal syndrome include elevation of serum
creatinine, sodium retention with low urinary sodium excretion, and oliguria. We evaluate
renal dysfunction with known underlying kidney pathology, such as glomerulonephritis,
tubular necrosis, and renal infections, under the listings in 6.00.
e. Hepatopulmonary syndrome (5.05E) is arterial deoxygenation due to intrapulmonary vascular dilation and arteriovenous
shunting associated with CLD. Clinical findings of hepatopulmonary syndrome include
platypnea (shortness of breath relieved when lying down) and orthodeoxia (low arterial
blood oxygen while in the upright position), when presenting in the context of CLD.
We evaluate pulmonary dysfunction with known underlying respiratory pathology, such
as asthma, pneumonia, and pulmonary infections, under the listings in 3.00.
(i) Under 5.05E1, we require a resting arterial blood gas (ABG) measurement obtained
while you are breathing room air; that is, without oxygen supplementation. The ABG
report must include the PaO2 value, your name, the date of the test, and either the altitude or both the city
and State of the test site.
(ii) We will not purchase the specialized imaging techniques described in 5.05E2;
however, if you have had the test(s) at a time relevant to your claim, we will make
every reasonable effort to obtain the report.
f. Hepatic encephalopathy (5.05F), also known as portosystemic encephalopathy, is a recurrent or chronic neuropsychiatric
disorder associated with CLD.
(i) Under 5.05F2, we require documentation of a mental impairment associated with
hepatic encephalopathy. A mental impairment can include abnormal behavior, changes
in mental status, or an altered state of consciousness. Reports of abnormal behavior
may show that you are experiencing delusions, paranoia, or hallucinations. Reports
of changes in mental status may show change in sleep patterns, personality or mood
changes, poor concentration, or poor judgment or cognitive dysfunction (for example,
impaired memory, poor problem-solving ability, or attention deficits). Reports of
altered state of consciousness may show that you are experiencing confusion, delirium,
or stupor.
(ii) Signs and laboratory findings that document the severity of hepatic encephalopathy
when not attributable to other causes may include a “flapping tremor” (asterixis),
characteristic abnormalities found on an electroencephalogram (EEG), or abnormal serum
albumin or coagulation values. We will not purchase an EEG; however, if you have had
this test at a time relevant to your claim, we will make every reasonable effort to
obtain the report for the purpose of establishing whether your impairment meets the
criteria of 5.05F.
(iii) We will not evaluate acute encephalopathy under 5.05F if it results from conditions
other than CLD. For example, we will evaluate acute encephalopathy caused by vascular
events under the listings in 11.00 and acute encephalopathy caused by cancer under the listings in 13.00.
3. SSA Chronic
Liver Disease (SSA CLD)
score (5.05G). Listing 5.05G requires two SSA CLD scores, each requiring three or four
laboratory values. The “date of the SSA CLD score” is the date of the earliest of
the three or four laboratory values used for its calculation. The date of the second
SSA CLD score must be at least 60 days after the date of the first SSA CLD score and
both scores must be within the required 12-month period. If you have the two SSA CLD
scores required by 5.05G, we will find that your impairment meets the criteria of
the listing from at least the date of the first SSA CLD score. [We provide the
SSA
CLD Calculator to calculate SSA CLD scores as described below.]
a. We calculate the SSA CLD score using a formula that includes up to four laboratory
values: Serum creatinine (mg/dL), total bilirubin (mg/dL), INR, and under certain
conditions, serum sodium (mmol/L). The SSA CLD score calculation contains at least
one, and sometimes two, parts, as described in (i) and (ii).
(i) The initial calculation is:
-
SSA CLDi =
-
9.57 × [loge(serum creatinine mg/dL)]
-
+ 3.78 × [loge(serum total bilirubin mg/dL)]
-
+11.2 × [loge(INR)]
-
+ 6.43
rounded to the nearest whole integer.
(ii) If the value from the initial calculation is 11 or below, the SSA CLD score will
be the SSA CLDi value. If the value from the initial calculation is greater than 11, the SSA CLD
score will be re-calculated as:
-
SSA CLD =
-
SSA CLDi
-
+ 1.32 × (137−serum sodium mmol/L)
-
−[0.033 × SSA CLDi × (137−serum sodium mmol/L)]
(iii) We round the results of your SSA CLD score calculation to the nearest whole
integer to arrive at your SSA CLD score.
b. For any SSA CLD score calculation, all of the required laboratory values (serum
creatinine, serum total bilirubin, INR, and serum sodium) must have been obtained
within a continuous 30-day period.
(i) We round values for serum creatinine (mg/dL), serum total bilirubin (mg/dL), or
INR less than 1.0 up to 1.0 to calculate your SSA CLD score.
(ii) We round values for serum creatinine (mg/dL) greater than 4.0 down to 4.0 to
calculate your SSA CLD score.
(iii) If there are multiple laboratory values within the 30-day interval for serum
creatinine (mg/dL), serum total bilirubin (mg/dL), or INR, we use the highest value to calculate your SSA CLD score. We will not use any INR values derived from
testing done while you are on anticoagulant treatment in our SSA CLD calculation.
(iv) If there are multiple laboratory values within the 30-day interval for serum
sodium (mmol/L), we use the lowest value to calculate your SSA CLD score.
(v) If you are in renal failure or on renal dialysis within a week of any serum creatinine
test in the period used for the SSA CLD calculation, we will use a serum creatinine
value of 4.0, which is the maximum serum creatinine level allowed in the calculation,
to calculate your SSA CLD score.
(vi) If your serum sodium is less than 125 mmol/L, we will set your serum sodium to
125 mmol/L for purposes of calculation of the SSA CLD score. If your serum sodium
is higher than 137 mmol/L, we will set your serum sodium to 137 mmol/L for purposes
of calculation of the SSA CLD score.
c. When we indicate “loge ” (also abbreviated “ln”) in the formula for the SSA CLD score calculation, we mean
the “base e logarithm” or “natural logarithm” of the numerical laboratory value, not the “base
10 logarithm” or “common logarithm” (log) of the laboratory value, and not the actual
laboratory value. For example, if a person has laboratory values of serum creatinine
1.4 mg/dL, serum total bilirubin 1.3 mg/dL, INR 1.32, and serum sodium 119 mmol/L,
we compute the SSA CLD score as follows:
-
SSA CLDi =
-
9.57 × [loge (serum creatinine 1.4 mg/dL) = 0.336]
-
+ 3.78 × [loge (serum total bilirubin 1.3 mg/dL) = 0.262]
-
+ 11.2 × [loge (INR 1.32) = .278]
-
+ 6.43
-
= 3.22 + 0.99 + 3.11 + 6.43
-
= 13.75, which we round to an SSA CLDi score of 14.
Because the SSA CLDi score is over 11, we then move to the second step of calculating the SSA CLD:
-
SSA CLD = 14
-
+ 1.32 × (137−serum sodium 125 mmol/L)
-
−[0.033 × SSA CLDi 14 × (137−serum sodium 125 mmol/L)
-
= 14 + 15.84−5.54
-
= 24.3, which we round to an SSA CLD score of 24.
D. What is inflammatory bowel disease (IBD), and how do we evaluate
it under 5.06?
1. IBD is a group of inflammatory conditions of the small intestine and colon. The
most common IBD disorders are Crohn's disease and ulcerative colitis. Remissions and
exacerbations of variable duration are a hallmark of IBD.
2. We evaluate your signs and symptoms of IBD, such as diarrhea, fecal incontinence,
rectal bleeding, abdominal pain, fatigue, fever, nausea, vomiting, arthralgia, abdominal
tenderness, palpable abdominal mass (usually inflamed loops of bowel), and perianal
disease (for example, fissure, fistulas, abscesses, or anal canal stenosis), when
we assess the severity of your impairment(s). You may require supplemental daily nutrition
due to IBD. There are two forms of supplemental daily nutrition we consider under
5.06B5: enteral nutrition (delivered directly to a part of your digestive system)
via a gastrostomy, duodenostomy, or jejunostomy, and parenteral nutrition delivered
via a central venous catheter. Enteral tube feedings delivered via nasal or oral tubes
do not satisfy the requirement in 5.06B5.
3. Surgical diversion of the intestinal tract, including ileostomy and colostomy,
does not preclude the ability to perform any gainful activity if you are able to maintain
adequate nutrition and function of the stoma. However, if you are not able to maintain
adequate nutrition, we will evaluate your impairment under 5.08.
4. IBD may also be associated with significant extraintestinal manifestations in a
variety of body systems. These include, but are not limited to, involvement of the
eye (for example, uveitis, episcleritis, or iritis); hepatobiliary disease (for example,
gallstones or primary sclerosing cholangitis); urologic disease (for example, kidney
stones or obstructive hydronephrosis); skin involvement (for example, erythema nodosum
or pyoderma gangrenosum); or non-destructive inflammatory arthritis. You may also
have associated thromboembolic disorders or vascular disease. These manifestations
may not correlate with the severity of your IBD. If your impairment does not meet
any of the criteria of 5.06, we will consider the effects of your extraintestinal
manifestations in determining whether you have an impairment(s) that meets or medically
equals another listing, and when we assess your residual functional capacity.
5. Repeated complications of IBD.
a. Examples of complications of IBD include abscesses, intestinal perforation, toxic
megacolon, infectious colitis, pyoderma gangrenosum, ureteral obstruction, primary
sclerosing cholangitis, and hypercoagulable state (which may lead to thromboses or
embolism). When we evaluate repeated complications of IBD, we consider all relevant
information in your case record to determine the effects of your IBD on your ability
to function independently, appropriately, effectively, and on a sustained basis. Factors
we consider include, but are not limited to: your symptoms, the frequency and duration
of your complications, periods of exacerbation and remission, and the functional effects
of your treatment, including the side effects of your medication. Your impairment
will satisfy this criterion regardless of whether you have the same kind of complication
repeatedly, all different complications, or any other combination of complications;
for example, two of the same kind of complication and a different one.
b. To satisfy the requirements described under 5.06C, your IBD must result in repeated
complications and marked limitation in one of three areas of functioning: activities
of daily living; maintaining social functioning; or completing tasks in a timely manner
due to deficiencies in concentration, persistence, or pace. If the complications do
not last as long or occur as frequently as required under 5.06C, we will consider
whether your IBD medically equals the listing.
c. Marked limitation means that the signs and symptoms of your IBD interfere seriously with your ability to function. Although we do not require the use of such a scale,
“marked” would be the fourth point on a five-point rating scale consisting of no limitation,
mild limitation, moderate limitation, marked limitation, and extreme limitation. We
do not define “marked” by a specific number of activities of daily living or different
behaviors in which your social functioning is impaired, or a specific number of tasks
that you are able to complete, but by the nature and overall degree of interference
with your functioning. You may have marked limitation when several activities or functions
are impaired, or when only one is impaired. Additionally, you need not be totally
precluded from performing an activity to have marked limitation, as long as the degree
of limitation interferes seriously with your ability to function independently, appropriately,
and effectively. The term “marked” does not imply that you must be confined to bed,
hospitalized, or in a nursing home.
d. Activities of daily living include, but are not limited to, such activities as doing household chores, grooming
and hygiene, using a post office, taking public transportation, or paying bills. We
will find that you have “marked” limitation in activities of daily living if you have
a serious limitation in your ability to maintain a household or take public transportation
because of symptoms, such as pain, severe fatigue, anxiety, or difficulty concentrating,
caused by your IBD (including complications of the disorder) or its treatment, even
if you are able to perform some self-care activities.
e. Maintaining social functioning includes the capacity to interact independently, appropriately, effectively, and
on a sustained basis with others. It includes the ability to communicate effectively
with others. We will find that you have “marked” limitation in maintaining social
functioning if you have a serious limitation in social interaction on a sustained
basis because of symptoms, such as pain, severe fatigue, anxiety, or difficulty concentrating,
or a pattern of exacerbation and remission, caused by your IBD (including complications
of the disorder) or its treatment, even if you are able to communicate with close
friends or relatives.
f. Completing tasks in a timely manner due to deficiencies in
concentration, persistence, or pace involves the ability to sustain concentration, persistence, or pace to permit timely
completion of tasks commonly found in work settings. We will find that you have “marked”
limitation in completing tasks if you have a serious limitation in your ability to
sustain concentration or pace adequate to complete work-related tasks because of symptoms,
such as pain, severe fatigue, anxiety, or difficulty concentrating, caused by your
IBD (including complications of the disorder) or its treatment, even if you are able
to do some routine activities of daily living.
E. What is intestinal failure, and how do we evaluate it under
5.07?
1. Intestinal failure is a condition resulting in gut function below the minimum necessary for the absorption
of macronutrients or water and electrolytes, resulting in a requirement for intravenous
supplementation ( i.e.,parenteral nutrition) to maintain health. Examples of conditions that may result in
intestinal failure include short bowel syndrome, extensive small bowel mucosal disease,
and chronic motility disorders.
2. Short bowel syndrome is a malabsorption disorder that occurs when ischemic vascular insults (caused, for
example, by volvulus or necrotizing enterocolitis), trauma, or IBD complications require(s)
surgical resection of any amount of the small intestine, resulting in chronic malnutrition.
3. Extensive small bowel mucosal disease means that the mucosal surface of the small bowel does not efficiently absorb nutrients
or loses nutrients. Common causes of small bowel mucosal disease include microvillous
inclusion disease and tufting enteropathy.
4. Chronic motility disorder refers to a chronic disorder of the propulsion of gut content without fixed obstructions,
causing intolerance to oral nutrition and inadequate nutritional intake. This type
of disorder may also be known as a chronic intestinal pseudo-obstruction (CIPO), because
the gut dysfunction mimics that of an obstructed intestine, but without evidence of
an actual obstruction. Primary CIPO may have an unknown underlying cause. Chronic
motility disorders may also result from congenital, neuromuscular, or autoimmune conditions,
such as gastroschisis, omphalocele, long segment Hirschprung's disease, Crohn's disease,
and mitochondrial disorders.
5. For short bowel syndrome, we require a copy of the operative report that includes
details of the surgical findings, or postoperative imaging indicating a resection
of the small intestine. If we cannot get one of these reports, we need other medical
reports that include details of the surgical findings. For other chronic motility
disorders or extensive small bowel mucosal disease, we need medical reports that include
details of your intestinal dysfunction. For any impairment evaluated under 5.07, we
also need medical documentation that you are dependent on daily parenteral nutrition
to provide most of your nutritional requirements.
F. How do we evaluate weight loss due to any digestive disorder under
5.08?
1. In addition to the impairments specifically mentioned in these listings, other
digestive disorders, such as esophageal stricture, pancreatic insufficiency, and malabsorption,
may result in significant weight loss. Impairments other than digestive disorders
that cause weight loss should be evaluated under the appropriate body system for that
impairment. For instance, weight loss as a result of chronic kidney disease should
be evaluated under our rules for genitourinary disorders (see 6.00), and weight loss as the result of an eating disorder should be evaluated under our
rules for mental disorders (see 12.00). However, if you develop a digestive disorder as the result of your other impairment,
we will evaluate the acquired digestive disorder under our rules for digestive disorders.
We evaluate weight loss due to any digestive disorder under 5.08 by using the body
mass index (BMI).
2. BMI is the ratio of your weight to the square of your height. Calculation and interpretation
of the BMI are independent of gender in adults.
a. We calculate BMI using inches and pounds, meters and kilograms, or centimeters
and kilograms. We must have measurements of your weight and height without shoes for
these calculations.
b. We calculate BMI using one of the following formulas:
-
English Formula
-
BMI = [Weight in Pounds/(Height in Inches × Height in Inches)] × 703
-
Metric Formulas
-
BMI = Weight in Kilograms/(Height in Meters × Height in Meters)
-
BMI = [Weight in Kilograms/(Height in Centimeters × Height in Centimeters)] × 10,000
G. How do we evaluate digestive organ transplantation? If you receive a liver (5.09), small intestine (5.11), or pancreas (5.12) transplant,
we will consider you disabled under the listing for 1 year from the date of the transplant.
After that, we evaluate your residual impairment(s) by considering the adequacy of
your post-transplant function, the frequency and severity of any rejection episodes
you have, complications in other body systems, and adverse treatment effects. People
who receive digestive organ transplants generally have impairments that meet our definition
of disability before they undergo transplantation. The phrase “consider under a disability
for 1 year” in 5.09, 5.11, and 5.12 does not refer to the date on which your disability
began, only to the date on which we must reevaluate whether your impairment(s) continues
to meet a listing or is otherwise disabling. We determine the onset of your disability
based on the facts of your case.
H. How do we evaluate your digestive disorder if there is no record
of ongoing treatment? If there is no record of ongoing treatment despite the existence of a severe impairment(s),
we will assess the severity and duration of your digestive disorder based on the current
medical and other evidence in your case record. If there is no record of ongoing treatment,
you may not be able to show an impairment that meets a digestive disorders listing,
but your impairment may medically equal a listing, or be disabling based on consideration
of your residual functional capacity, age, education, and work experience.
I. How do we evaluate your digestive disorder if there is evidence
establishing a substance use disorder? If we find that you are disabled and there is medical evidence in your case record
establishing that you have a substance use disorder, we will determine whether your
substance use disorder is a contributing factor material to the determination of disability.
See §§ 404.1535 and 416.935 of this chapter. Digestive disorders resulting from drug or alcohol use are often
chronic in nature and will not necessarily improve with cessation in drug or alcohol
use.
J. How do we evaluate digestive disorders that do not meet one of
these listings?
1. These listings are only examples of common digestive disorders that we consider
severe enough to prevent you from doing any gainful activity. If your impairment(s)
does not meet the criteria of any of these listings, we must also consider whether
you have an impairment(s) that satisfies the criteria of a listing in another body
system.
2. If you have a severe medically determinable impairment(s) that does not meet a
listing, we will determine whether your impairment(s) medically equals a listing.
See §§ 404.1526 and 416.926 of this chapter. Digestive disorders may be associated with disorders in other body
systems, and we consider the combined effects of multiple impairments when we determine
whether they medically equal a listing. If your impairment(s) does not meet or medically
equal a listing, you may or may not have the residual functional capacity to engage
in substantial gainful activity. We proceed to the fourth step and, if necessary,
the fifth step of the sequential evaluation process in §§ 404.1520 and 416.920 of this chapter. We use the rules in §§ 404.1594 and 416.994 of this chapter, as appropriate, when we decide whether you continue to be disabled.
5.01 Category of Impairments, Digestive Disorders
5.02 Gastrointestinal hemorrhaging from any cause, requiring three blood
transfusions of at least 2 units of blood per transfusion, within a consecutive 12-month period
and at least 30 days apart. Consider under a disability for 1 year following the last
documented transfusion; after that, evaluate the residual impairment(s).
5.03–5.04 [Reserved
5.05 Chronic liver disease (CLD) (see 5.00C) with A, B, C, D, E, F, or G:
A. Hemorrhaging from esophageal, gastric, or ectopic varices, or from portal hypertensive
gastropathy (see 5.00C2a), documented by imaging (see 5.00B3); resulting in 1 and
2:
1. Hemodynamic instability indicated by signs such as pallor (pale skin), diaphoresis
(profuse perspiration), rapid pulse, low blood pressure, postural hypotension (pronounced
fall in blood pressure when arising to an upright position from lying down), or syncope
(fainting); and
2. Requiring hospitalization for transfusion of at least 2 units of blood. Consider
under a disability for 1 year following the documented transfusion; after that, evaluate
the residual impairment(s).
OR
B. Ascites or hydrothorax not attributable to other causes (see 5.00C2b), present on
two evaluations within a consecutive 12-month period and at least 60 days apart. Each
evaluation must document the ascites or hydrothorax by 1, 2, or 3:
1. Paracentesis; or
2. Thoracentesis; or
3. Imaging or physical examination with a or b:
a. Serum albumin of 3.0 g/dL or less; or
b. INR of at least 1.5.
OR
C. Spontaneous bacterial peritonitis (see 5.00C2c) documented by peritoneal fluid containing
a neutrophil count of at least 250 cells/mm3.
OR
D. Hepatorenal syndrome (see 5.00C2d) documented by 1, 2, or 3:
1. Serum creatinine elevation of at least 2 mg/dL; or
2. Oliguria with 24-hour urine output less than 500 mL; or
3. Sodium retention with urine sodium less than 10 mEq per liter.
OR
E. Hepatopulmonary syndrome (see 5.00C2e) documented by 1 or 2:
1. Arterial PaO2 measured by an ABG test, while at rest, breathing room air, less than or equal to:
a. 60 mm Hg, at test sites less than 3,000 feet above sea level; or
b. 55 mm Hg, at test sites from 3,000 through 6,000 feet above sea level; or
c. 50 mm Hg, at test sites over 6,000 feet above sea level; or
2. Intrapulmonary arteriovenous shunting as shown by contrast-enhanced echocardiography
or macroaggregated albumin lung perfusion scan.
OR
F. Hepatic encephalopathy (see 5.00C2f) with documentation of abnormal behavior, cognitive
dysfunction, changes in mental status, or altered state of consciousness (for example,
confusion, delirium, stupor, or coma), present on two evaluations within a consecutive
12-month period and at least 60 days apart and either 1 or 2:
1. History of transjugular intrahepatic portosystemic shunt (TIPS) or other surgical
portosystemic shunt; or
2. One of the following on at least two evaluations at least 60 days apart within
the same consecutive 12-month period as in F:
a. Asterixis or other fluctuating physical neurological abnormalities; or
b. EEG demonstrating triphasic slow wave activity; or
c. Serum albumin of 3.0 g/dL or less; or
d. INR of 1.5 or greater.
OR
G. Two SSA CLD scores (see 5.00C3) [
SSA CLD Calculator ] of at least 20 within a consecutive 12-month period and at least 60 days apart.
Consider under a disability from at least the date of the first score.
5.06 Inflammatory bowel disease (IBD) (see 5.00D) documented by endoscopy, biopsy, imaging, or operative findings, and demonstrated by A, B, or C:
A. Obstruction of stenotic areas (not adhesions) in the small intestine or colon with
proximal dilatation, confirmed by imaging or in surgery, requiring two hospitalizations
for intestinal decompression or for surgery, within a consecutive 12-month period
and at least 60 days apart.
OR
B. Two of the following occurring within a consecutive 12-month period and at least
60 days apart:
1. Anemia with hemoglobin of less than 10.0 g/dL, present on at least two evaluations
at least 60 days apart; or
2. Serum albumin of 3.0 g/dL or less, present on at least two evaluations at least
60 days apart; or
3. Clinically documented tender abdominal mass palpable on physical examination with
abdominal pain or cramping; or
4. Perianal disease with a draining abscess or fistula; or
5. Need for supplemental daily enteral nutrition via a gastrostomy, duodenostomy,
or jejunostomy, or daily parenteral nutrition via a central venous catheter.
OR
C. Repeated complications of IBD (see 5.00D5a), occurring an average of 3 times a year,
or once every 4 months, each lasting 2 weeks or more, within a consecutive 12-month
period, and marked limitation (see 5.00D5c) in one of the following:
1. Activities of daily living (see 5.00D5d); or
2. Maintaining social functioning (see 5.00D5e); or
3. Completing tasks in a timely manner due to deficiencies in concentration, persistence,
or pace (see 5.00D5f).
5.07 Intestinal failure (see 5.00E) due to short bowel syndrome, chronic motility disorders, or extensive
small bowel mucosal disease, resulting in dependence on daily parenteral nutrition
via a central venous catheter for at least 12 months.
5.08 Weight loss due to any digestive disorder (see 5.00F), despite adherence to prescribed medical treatment, with BMI of less
than 17.50 calculated on at least two evaluations at least 60 days apart within a
consecutive 12-month period.
5.09 Liver transplantation (see 5.00G). Consider under a disability for 1 year from the date of the transplant;
after that, evaluate the residual impairment(s).
5.10 [Reserved]
5.11 Small intestine transplantation (see 5.00G). Consider under a disability for 1 year from the date of the transplant;
after that, evaluate the residual impairment(s).
5.12 Pancreas transplantation (see 5.00G). Consider under a disability for 1 year from the date of the transplant;
after that, evaluate the residual impairment(s).