Basic (05-86)

DI 34110.001 Listing of Impairments - Part A (March 27, 1979-January 5, 1986)

1.00 Musculoskeletal System

1. A. 

   Loss of function

   Loss of function may be due to amputation or deformity. Pain may be an important factor in causing functional loss, but it must be associated with relevant abnormal signs or laboratory findings. Evaluations of musculoskeletal impairments should be supported where applicable by detailed descriptions of the joints, including ranges of motion, condition of the musculature, sensory or reflex changes, circulatory deficits, and X-ray abnormalities.

2. B. 

   Disorders of the spine

   Disorders of the spine, associated with vertebrogenic disorders as in 1.05C, result in impairment because of distortion of the bony and ligamentous architecture of the spine or impingement of a herniated nucleus pulposus or bulging annulus on a nerve root. Impairment caused by such abnormalities usually improves with time or responds to treatment. Appropriate abnormal physical findings must be shown to persist on repeated examinations despite therapy for a reasonable presumption to be made that severe impairment will last for a continuous period of 12 months. This may occur in cases with unsuccessful prior surgical treatment.

   Evaluation of the impairment caused by disorders of the spine requires that a clinical diagnosis of the entity to be evaluated first must be established on the basis of adequate history, physical examination, and roentgenograms. The specific findings stated in section 1.05C represent the level required for that impairment; these findings, by themselves, are not intended to represent the basis for establishing the clinical diagnosis. Furthermore, while neurological examination findings are required, they are not to be interpreted as a basis for evaluating the magnitude of any neurological impairment. Neurological impairments are to be evaluated under 11.00-11.19.

   The history must include a detailed description of the character, location, and radiation of pain; mechanical factors which incite and relieve pain; prescribed treatment, including type, dose, and frequency of analgesic; and typical daily activities. Care must be taken to ascertain that the reported examination findings are consistent with the individual's daily activities.

   There must be a detailed description of the orthopedic and neurologic examination findings. The findings should include a description of gait, limitation of movement of the spine given quantitatively in degrees from the vertical position, motor and sensory abnormalities, muscle spasm, and deep tendon reflexes. Observations of the individual during the examination should be reported; e.g., how he or she gets on and off the examining table. Inability to walk on heels or toes, to squat, or to arise from a squatting position, where appropriate, may be considered evidence of significant motor loss. However, a report of atrophy is not acceptable as evidence of significant motor loss without circumferential measurements of both thighs and lower legs (or upper or lower arms) at a stated point above and below the knee or elbow given in inches or centimeters. A specific description of atrophy of hand muscles is acceptable without measurements of atrophy, but should include measurements of grip strength.

   These physical examination findings must be determined on the basis of objective observations during the examination and not simply a report of the individual's allegation, e.g., he says his leg is weak, numb, etc. Alternative testing methods should be used to verify the objectivity of the abnormal findings, e.g., a seated straight-leg raising test in addition to a supine straight-leg raising test. Since abnormal findings may be intermittent, their continuous presence over a period of time must be established by a record of ongoing treatment. Neurological abnormalities may not completely subside after surgical or nonsurgical treatment, or with the passage of time. Residual neurological abnormalities, which persist after it has been determined clinically or by direct surgical or other observation that the ongoing or progressive condition is no longer present, cannot be considered to satisfy the required findings in section 1.05C.

   Where surgical procedures have been performed, documentation should include a copy of the operative note and available pathology reports.

   Electrodiagnostic procedures and myelography may be useful in establishing the clinical diagnosis, but do not constitute alternative criteria to the requirements in section 1.05C.

3. C. 

   After maximum benefit from surgical therapy

   After maximum benefit surgical therapy has been achieved in situations involving fractures of an upper extremity (section 1.12), or soft tissue injuries of a lower or upper extremity (section 1.13), i.e., there have been no significant changes in physical findings or X-ray findings for any 6-month period after the last definitive surgical procedure, evaluation should be made on the basis of demonstrable residuals.

4. D. 

   Major joints

   Major joints as used herein refer to hip, knee, ankle, shoulder, elbow, or wrist and hand. (Wrist and hand are considered together as one major joint.)

5. E. 

   Measurements of joint motion

   The measurements of joint motion are based on the techniques described in the “Joint Motion Method of Measuring and Recording,” published by the American Academy of Orthopedic Surgeons in 1965, or the “Guides to the Evaluation of Permanent Impairment—The Extremities and Back” (Chapter I); American Medical Association, 1971.

    

1.01 Category of Impairments, Musculoskeletal

 

1.02 Active Rheumatoid Arthritis and Other Inflammatory Arthritis.

With both A and B:

1. A. 

   Persistent joint pain, swelling, and tenderness involving multiple major joints (see 1.00D) AND with signs of joint inflammation (heat, swelling, and tenderness) despite therapy for at least 3 months, and activity expected to last over 12 months; AND

2. B. 

   Corroboration of diagnosis at some point in time by either:

   1. 1. 

      Positive serologic test for rheumatoid factor; OR

   2. 2. 

      Antinuclear antibodies; OR

   3. 3. 

      Elevated sedimentation rate; OR

       

1.03 Arthritis of a Major Weight-Bearing Joint

Due to any cause with limitation of motion and enlargement or effusion in the affected joint, as well as a history of joint pain and stiffness. With:

1. A. 

   Gross anatomical deformity of hip or knee (e.g., subluxation, contracture, bony or fibrous ankylosis, instability); OR

2. B. 

   Ankylosis of the hip outside of the postion of function (i.e., at less than 20 degrees or more than 30 degrees of flexion measured from the neutral position) and X-ray evidence of either joint space narrowing with osteophytosis or bony destruction (with erosions or cysts); OR

3. C. 

   Reconstructive surgery or surgical arthrodesis of a major weight-bearing joint and return to full weight-bearing status did not occur, or is not expected to occur, within 12 months of onset.

    

1.04 Arthritis of One Major Joint in Each of the Upper Extremities

Due to any cause with limitation of motion and enlargement or effusion in the affected joints as well as a history of joint pain and stiffness and X-ray evidence of either joint space narrowing with osteophytosis or bony destruction (with erosions or cysts). With:

1. A. 

   Abduction of both arms at the shoulders, including scapular motion, restricted to less than 90 degrees; OR

2. B. 

   Gross anatomical deformity such as subluxation, contracture, bony or fibrous ankylosis, joint instability, or ulnar deviation.

    

1.05 Disorders of the Spine:

1. A. 

   Arthritis manifested by ankylosis or fixation of the cervical or dorsolumbar spine at 30 degrees or more of flexion measured from the neutral position, with X-ray evidence of:

   1. 1. 

      Calcification of the anterior and lateral ligaments; OR

   2. 2. 

      Bilateral ankylosis of the sacroiliac joints with abnormal apophyseal articulations; OR

2. B. 

   Osteoporosis, generalized (established by X-ray) manifested by pain and limitation of back motion and paravertebral muscle spasm with X-ray evidence of either:

   1. 1. 

      Compression fracture of a vertebral body with loss of at least 50 percent of the estimated height of the vertebral body prior to the compression fracture, with no intervening direct traumatic episode; OR

   2. 2. 

      Multiple fractures of vertebrae with no intervening direct traumatic episode; OR

3. C. 

   Other vertebrogenic disorders (e.g., herniated nucleus pulposus, spinal stenosis) with the following persisting for at least 3 months despite prescribed therapy and expected to last 12 months. With both 1 and 2:

   1. 1. 

      Pain, muscle spasm, and significant limitation of motion in the spine; AND

   2. 2. 

      Appropriate radicular distribution of significant motor loss with muscle weakness and sensory and reflex loss.

       

1.08 Osteomyelitis

(Established by X-ray):

1. A. 

   Located in the pelvis, vertebra, femur, tibia, or a major joint of an upper or lower extremity, with persistent activity or occurrence of at least two episodes of acute activity within a 5-month period prior to adjudication, manifested by local inflammatory, and systemic signs and laboratory findings (e.g., heat, redness, swelling, leucocytosis, or increased sedimentation rate) and expected to last at least 12 months despite prescribed therapy; OR

2. B. 

   Multiple localizations and systemic manifestations as in A above.

    

1.09 Amputation or Anatomical Deformity of

(i.e., loss of major function due to degenerative changes associated with vascular or neurological deficits, traumatic loss of muscle mass or tendons and X-ray evidence of bony ankylosis at an unfavorable angle, joint subluxation or instability):

1. A. 

   Both hands; OR

2. B. 

   Both feet; OR

3. C. 

   One hand and one foot.

    

1.10 Amputation of One Lower Extremity

At or above the tarsal region):

1. A. 

   Hemipelvectomy or hip disarticulation; OR

2. B. 

   Amputation at or above the tarsal region due to peripheral vascular disease or diabetes mellitus ; OR

3. C. 

   Inability to use a prosthssis effectively, without obligatory assistive devices, due to one of the following:

   1. 1. 

      Vascular disease; OR

   2. 2. 

      Neurological complications (e.g., loss of position sense); OR

   3. 3. 

      Stump too short or stump complications persistent, or are expected to persist, for at least 12 months from onset; OR

   4. 4. 

      Disorder of contralateral lower extremity causing mobility restrictions.

       

1.11 Fracture of the Femur, Tibia, Tarsal Bone, or Pelvis:

With solid union not evident on X-ray and not clinically solid, when such determination is feasible, and return to full weight-bearing status did not occur or is not expected to occur within 12 months of onset.

 

1.12 Fractures of an Upper Extremity:

With non-union of a fracture of the shaft of the humerus, radius, or ulna under continuing surgical management directed toward restoration of functional use of the extremity and such function was not restored or expected to be restored within 12 months after onset.

 

1.13 Soft Tissue Injuries of an Upper or Lower Extremity:

Requiring a series of staged surgical procedures within 12 months after onset for salvage and/or restoration of major function of the extremity, and such major function was not restored or expected to be restored within 12 months after onset.

 

2.00 Special Senses and Speech

1. A. 

   Ophthalmology

   1. 1. 

      Causes of impairment

      Diseases or injury of the eyes may produce loss of central or peripheral vision. Loss of central vision results in inability to distinguish detail and prevents reading and fine work. Loss of peripheral vision restricts the ability of an individual to move about freely. The extent of impairment of sight should be determined by visual testing.

   2. 2. 

      Central visual acuity

      A loss of central visual acuity may be caused by impaired distant and/or near vision. However, for an individual to meet the level of severity described in sections 2.02 and 2.04, only the remaining central visual acuity for distance of the better eye with best correction based on the Snellen test chart measurement may be used. Correction obtained by special visual aids (e.g., contact lenses) will be considered if the individual has the ability to wear such aids.

   3. 3. 

      Field of vision

      Impairment of peripheral vision may result if there is contraction of the visual fields. The contraction may be either symmetrical or irregular. The extent of the remaining peripheral visual field will be determined by usual perimetric methods at a distance of 330 mm. under illumination of not less than 7-foot candles. Measurements obtained on comparable perimetric devices may be used; this does not include the use of tangent screen measurements. For the phakic eye (the eye with a lens), a 3 mm white disc target will be used, and for the aphakic eye (the eye without a lens, a 6 mm white disc target will be used. In neither instance should corrective lenses be worn during the examination but if they have been used, this fact must be stated.

      Field measurements must be accompanied by notated field charts, a description of the type and size of the target and the test distance. Tangent screen visual fields are not acceptable as a measurement of peripheral field loss.

      Where the loss is predominantly in the lower visual fields, a system such as the weighted grid scale for perimetric fields as described by B. Esterman(see Grid for Scoring Visual Fields, II. Perimeter, Archives of Ophthalmology, 79:400S 1968) may be used for determining whether the visual field loss is comparable to that described in table 2.

   4. 4. 

      Muscle function

      Paralysis of the third cranial nerve producing ptosis, paralysis of accommodation, and dilation and immobility of the pupil may cause significant visual impairment. When all the muscles of the eye are paralyzed including the iris and ciliary body (total ophthalmoplegia), the condition is considered a severe impairment provided it is bilateral. A finding of severe impairment based primarily on impaired muscle function must be supported by a report of an actual measurement of ocular mobility.

   5. 5. 

      Visual efficiency

      Loss of visual efficiency may be caused by disease or injury resulting in a reduction of central visual acuity or visual field. The visual efficiency of one eye is the product of the percentage of central visual efficiency and the percentage of visual field efficiency. (See Tables No. 1 and 2, following 2.09)

   6. 6. 

      Special situations

      Aphakia represents a visual handicap in addition to the loss of central visual acuity. The term monocular aphakia would apply to an individual who has had the lens removed from one eye, and who still retains the lens in his other eye, or to an individual who has only one eye which is aphakic. The term binocular aphakia would apply to an individual who has had both lenses removed. In cases of binocular aphakia, the central efficiency of the better eye will be accepted as 75 percent of value. In cases of monocular aphakia, where the better eye is aphakic, the central visual efficiency will be accepted as 50 percent of its value. (If an individual has binocular aphakia and the central visual acuity in the poorer eye can be corrected only to 20/ 200, or less, the central visual efficiency of the better eye will be accepted as 50 percent of its value.)

      Ocular symptoms of systemic disease may or may not produce a disabling visual impairment. These manifestations should be evaluated as part of the underlying disease entity by reference to the particular body system involved.

   7. 7. 

      Statutory blindness

      The term “statutory blindness” refers to the degree of visual impairment which defines the term “blindness” in the Social Security Act. Both 2.02 and 2.03A. and B. denote statutory blindness.

2. B. 

   Otolaryngology

   1. 1. 

      Hearing impairment

      Hearing ability should be evaluated in terms of the person's ability to hear and distinguish speech.

      Loss of hearing can be quantitatively determined by an audiometer which meets the standards of the American National Standards Institute (ANSI) for air and bone conducted stimuli (i.e., ANSI S3.6—1969 and ANSI S3.13—1972, or subsequent comparable revisions) and performing all hearing measurements in an environment which meets the ANSI standard for maximal permissible background sound (ANSI S3.1—1977).

      Speech discrimination should be determined using a standardized measure of speech discrimination ability in quiet at a test presentation level sufficient to ascertain maximum discrimination ability. The speech discrimination measure (test) used, and the level at which testing was done, must be reported.

      Hearing tests should be preceded by an otolaryngologic examination and should be performed by or under the supervision of an otolaryngologist or audiologist qualified to perform such tests.

      In order to establish an independent medical judgment as to the level of impairment in a claimant alleging deafness, the following examinations should be reported: Otolaryngologic examination, pure tone air and bone audiometry, speech reception threshold (SRT), and speech discrimination testing. A copy of reports of medical examination and audiologic evaluations must be submitted.

      Cases of alleged “deaf mutism” should be documented by a hearing evaluation. Records obtained from a speech and hearing rehabilitation center or a special school for the deaf may be acceptable, but if these reports are not available, or are found to be inadequate, a current hearing evaluation should be submitted as outlined in the preceding paragraph.

   2. 2. 

      Vertigo

      Vertigo associated with disturbances of labyrinthine—vestibular function, including Meniere's disease. These disturbances of balance are characterized by an hallucination of motion or a loss of position sense and a sensation of dizziness which may be constant or may occur in paroxysmal attacks. Nausea, vomiting, ataxia, and incapacitation are frequently observed, particularly during the acute attack. It is important to differentiate the report of rotary vertigo from that of “dizziness” which is described as light-headedness, unsteadiness, confusion, or syncope.

      Meniere's disease is characterized by paroxysmal attacks of vertigo, tinnitus, and fluctuating hearing loss. Remissions are unpredictable and irregular, but may be longlasting; hence, the severity of impairment is best determined after prolonged observation and serial reexaminations.

      The diagnosis of a vestibular disorder requires a comprehensive neuro-otolaryngologic examination with a detailed description of the vertiginous episodes, including notation of frequency, severity, and duration of the attacks. Pure tone and speech audiometry with the appropriate special examinations, such as Bekesy audiometry, are necessary. Vestibular function is assessed by positional and caloric testing, preferably by electronystagmography. When polytomograms, contrast radiography, or other special tests have been performed, copies of the reports of these tests should be obtained, in addition to reports of skull and temporal bone X-rays.

   3. 3. 

      Organic loss of speech

      Glossectomy or laryngectomy or cicatricial laryngeal stenosis due to injury or infection results in loss of voice production by normal means. In evaluating organic loss of Speech (see 2.09), ability to produce speech by any means includes the use of mechanical or eletronic devices. Impairment of speech due to neurologic disorders should be evaluated under 11.00-11.19.

       

2.01 Category of Impairments, Special Senses and Speech

 

2.02 Impairment of Central Visual Acuity.

Remaining vision in the better eye after best correction is 20/200 or less.

 

2.03 Contraction of Peripheral Visual Fields in the Better Eye.

1. A. 

   To 10 degrees or less from the point of fixation; OR

2. B. 

   So the widest diameter subtends an angle no greater than 20 degrees; OR

3. C. 

   To 20 percent or less visual field efficiency.

    

2.04 Loss of Visual Efficiency.

Visual efficiency of better eye after best correction 20 percent or less. (The percent of remaining visual efficiency == the product of the percent of remaining central visual efficiency and the percent of remaining visual field efficiency.)

 

2.05 Complete Homonymous Hemianopsia

With or without macular sparing.

Evaluate under section 2.04.

 

2.06 Total Bilateral Ophthalmoplegia.

 

2.07 Disturbance of Labyrinthine-Vestibular Function

Including Meniere's disease.

Characterized by a history of frequent attacks of balance disturbance, tinnitus, and progressive loss of hearing. With both A and B:

1. A. 

   Disturbed function of vestibular labyrinth demonstrated by caloric or other vestibular tests; AND

2. B. 

   Hearing loss established by audiometry.

    

2.08 Hearing Impairments

Hearing not restorable by a hearing aid. Manifested by:

1. A. 

   Average hearing threshold sensitivity for air conduction of 90 decibels or greater, and for bone conduction to corresponding maximal levels, in the better ear, determined by the simple average of hearing threshold levels at 500, 1000, and 2000 hz. (see section 2.00B1); OR

2. B. 

   Speech discrimination scores of 40 percent or less in the better ear.

    

2.09 Organic Loss of Speech

Due to any cause with inability to produce by any means speech which can be heard, understood, and sustained.

 

TABLE NO. 1.

Percentage of central visual efficiency corresponding to central visual acuity notations for distance in the phakic and aphakic eye (better eye).

Column and Use

1. 1 

   Phakic—1. A lens is present in both eyes. 2. A lens is present in the better eye and absent in the poorer eye. 3. A lens is present in one eye and the other eye is enucleated.

2. 2 

   Monocular—1. A lens is absent in the better eye and present in the poorer eye. 2. The lenses are absent in both eyes; however, the central visual acuity in the poorer eye after best correction is 20/200 or less. 3. A lens is absent from one eye and the other eye is enucleated.

3. 3 

   Binocular—1. The lenses are absent from both eyes and the central visual acuity in the poorer eye after best correction is greater than 20/200.

    

    

TABLE NO. 2

Chart of visual field showing extent of normal field and method of computing percent of visual field efficiency.

1. 1. 

   Diagram of right eye illustrates extent of normal visual field as tested on standard perimeter at 3/330 (3 mm. white disc at a distance of 330 mm.) under 7 foot-candles illumination. The sum of the eight principal meridians of this field total 500 degrees.

2. 2. 

   The percent of visual field efficiency is obtained by adding the number of degrees of the eight principal meridians of the contracted field and dividing by 500. Diagram of left eye illustrates visual field contracted to 30 degrees in the temporal and down and out meridians and to 20 degrees in the remaining six meridians. The percent of visual field efficiency of this field is: 6×20 +2×30 = 180 divided by 500 = 0.36 or 36 percent remaining visual field efficiency, or 64 percent loss.

    

3.00 Respiratory System

1. A. 

   Causes of impairment

   The impairment produced by respiratory disease usually results from chronic recurrent infection or from pulmonary insufficiency or a combination of these factors.

2. B. 

   Pulmonary tuberculosis

   Pulmonary tuberculosis will be evaluated on the basis of the resulting impairment to pulmonary function. Evidence of infectious or active pulmonary tuberculosis such as positive cultures, increasing lesions, or cavitation is not, by itself, a basis for determining that an individual has a severe impairment which is expected to last 12 months. However, if these factors are abnormally persistent, they should not be ignored. For example, in those unusual cases, where there is evidence of persistence of pulmonary infection caused by mycobacteria for a period closely approaching 12 consecutive months, the clinical findingss, complications, treatment considerations, and prognosis must be carefully assessed to determine whether despite the absence of impairment of pulmonary function, the individual has a severe impairment that can be expected to last 12 consecutive months.

3. C. 

   Respiratory impairment is episodic in nature

   When a respiratory impairment is episodic in nature as may occur in complications of bronchiectasis and asthmatic bronchitis, the frequency of severe episodes despite prescribed treatment is the criterion for determining the level of impairment. Documentation for episodic asthma should include the hospital or emergency room records indicating the dates of treatment, clinical findings on presentation, what treatment was given and for what period of time, and the clinical response. Severe attacks of episodic astham, as listed in section 3.03B. are defined as prolonged episodes lasting at least several hours. requiring intensive treatment such as intravenous drug administration or inhalation therapy in a hospital or emergency room.

4. D. 

   Documentation of pulmonary insufficiency

   The results of ventilatory function studies for evaluation under tables I, II, and IV should be expressed in liters or liters per minute. The reported one second forced expiratory volume (FEV 1) should represent the largest of at least three attempts. One satisfactory maximum voluntary ventilation (MVV) is sufficient. The MVV should represent the observed value and should not be calculated from FEV 1. These studies should be repeated after administration of a nebulized bronchodilator unless the prebronchodilator values are 80 percent or more of predicted normal values or the use of bronchodilators is contraindicted. The values in tables I, II, and IV assume that the ventilatory function studies were not performed in the presence of wheezing or other evidence of bronchospasm, or, if these were present at the time of the examination, that the studies were repeated after administration of bronchodilator. Ventilatory function studies performed in the presence of bronchospasm, without use of bronchodilators, cannot be found to meet the requisite level of severity in tables I, II, and IV.

   The appropriately labeled spirometric tracing, showing distance per second on the abscissa and the distance per liter on the ordinate, must be incorporated in the file. The FEV 1 must be recorded at a speed of at least 20 mm. per second. Calculation of the FEV 1 from a flow volume loop is not acceptable. The recording device must provide a volume excursion of at least 10 mm. per liter.

   The MVV should be represented by the tidal excursions measured over a 10 to 15 second interval. Tracings showing only cumulative volume for the MVV are not acceptable. Studies should not be performed during or soon after an acute respiratory illness. A statement should be made as to the individual's ability to understand the directions and cooperate in performing the test.

    

3.01 Category of Impairments, Respiratory

 

3.02 Chronic Obstructive Airway Disease

Due to any cause with:

Spirometric evidence of airway obstruction demonstrated by MVV and FEV 1, both equal to, or less than, the values specified in Table I, corresponding to the person's height.

 

 

3.03 Asthma

With:

1. A. 

   Chronic asthmatic bronchitis. Evaluate under the criteria for chronic obstructive ventilatory impairment in 3.02A; OR

2. B. 

   Episodes of severe attacks (see 3.00C), in spite of prescribed treatment, occurring at least once every 2 months, or on an average of a least 6 times a year, and prolonged expiration with wheezing or rhonchi on physical examination between attacks.

    

3.04 Diffuse Pulmonary Fibrosis (Sarcoidosis, Hamman-Rich Syndrome, Idiopathic Interstitial Fibrosis, and Similar Difuse Fibroses Substantiated by Chest X-Ray or Tissue Diagnosis

This category does not include cases of bronchitis or emphysema with incidental scarring or scattered parenchymal fibrosis on X-ray). With:

1. A. 

   Total vital capacity equal to, or less than, values specified in Table II below corresponding to the person's height.

    

OR

1. B. 

   Diffusing capacity of the lungs for carbon monoxide less than 6 ml/mm. (steady-state methods) or less than 9 ml/mm. Hg./min (single-breath methods) or less than 30 percent of predicted normal. (All methods-actual values and predicted normal values for the method used should be reported); OR

2. C. 

   Arterial oxygen tension (p02) at rest and simultaneously determined arterial carbon dioxide tension (pC02) equal to, or less than, the values specifed in Table III.

    

 

3.05 Other Restrictive Ventilatory Disorders (e.g. Kyphoscoliosis, Thoracoplasty, Pulmonary Resection)

with:

Total vital capacity equal to, or less than, values specified in Table IV corresponding to the person's height.

 

 

3.06 Pneumoconiosis

Demonstrated by X-ray with:

1. A. 

   Nodular or focal fibrosis (non-conglomerative). Evaluate under the criteria for chronic obstructive airway disease in 3.02; OR

2. B. 

   Interstitial or disseminated fibrosis or conglomerative disease. Evaluate under the criteria for pulmonary fibrosis in 3.04: OR

3. C. 

   Where A. and B. are mixed or cannot be differentiated—evaluate under the criteria in 3.02 or 3.04.

    

3.07 Bronchiectasis

Demonstrated by radio-opaque material with:

1. A. 

   Episodes of acute bronchitis or pneumonia or hemoptysis (more than blood-streaked sputum) occurring at least once every 2 months; OR

2. B. 

   Impairment of pulmonary function due to extensive disease should be evaluated under the criteria in 3.02 or where extensive fibrosis is evident on chest film, under the criteria for pulmonary fibrosis in 3.04.

    

3.08 Pulmonary Tuberculosis (Caused by M. Tuberculosis of Pathogenic Atypical Mycobacteria

Impairment of pulmonary function due to extensive disease should be evaluated under appropriate criteria in 3.02, 3.04, or 3.05.

 

3.09 Mycotic Infection of Lung.

With:

1. A. 

   Culture of specific organisms from sputa and serial X-ray evidence of increasing or decreasing extent of lesion, both persisting for at least 3 months despite prescribed therapy; OR

2. B. 

   Culture of specific organisms from sputa and current X-ray evidence of a lesion and episodes of hemoptyis occurring at least once every 2 months; or

3. C. 

   Impairment of pulmonary function due to extensive disease should be evaluated under the appropriate criteria in 3.02, 3.04, 3.05.

    

3.11 Cor Pulmonale

Evaluate under the criteria in 4.02D.

 

3.12 Pleurocutaneous Fistula

With persistent purluent drainage.

 

4.00 Cardiovascular System

1. A. 

   Severe cardiac impairment

   Severe cardiac impairment results from one or more of three consequences of heart disease:

   1. 1. 

      congestive heart failure;

   2. 2. 

      ischemia (with or without necrosis) of heart muscle

   3. 3. 

      conduction disturbances and/or arrhythmias resulting in cardiac syncope.

      With diseases of arteries and veins, severe impairment may result from disorders of the vasculature in the central nervous system, eyes, kidneys, extremities, and other organs.

      The criteria for evaluating impairment resulting from heart disease or diseases of the blood vessels are based on symptoms, physical signs, and pertinent laboratory findings.

2. B. 

   Congestive heart failure

   Congestive heart failure is considered in the Listing under one category whatever the etiology (i.e., arteriosclerotic, hypertensive, rheumatic, pulmonary, congenital, or other organic heart disease). Congestive heart failure is not considered to have been established for the purpose of 4.02 unless there is evidence of vascular congestion such as hepatomegaly or peripheral or pulmonary edema which is consistent with the clinical diagnosis. (Radiological description of vascular congestion, unless supported by appropriate clinical evidence, should not be construed as pulmonary edema.) The findings of vascular congestion need not be present at the time of adjudication (except for 4.02A), but must be causally related to the current episode of marked impairment. The findings other than vascular congestion must be persistent.

   Other congestive, ischemic, or restrictive (obstructive) heart disease such as caused by cardiomyopathy or aortic stenosis may result in significant impairment due to congestive heart failure, rhythm disturbances, or ventricular outflow obstruction in the absence of left ventricular enlargement as described in 4.02B1. However, the ECG criteria as defined in 4.02B2 should be fulfilled. Clinical findings such as symptoms of dyspnea, fatigue, rhythm disturbances, etc., should be documented and the diagnosis confirmed by echocardiography or at cardiac catheterization.

3. C. 

   Hypertensive vascular disease

   Hypertensive vascular disease does not result in severe impairment unless it causes severe damage to one or more of four end organs: heart, brain, kidneys, or eyes (retinae). The presence of such damage must be established by appropriate abnormal physical signs and laboratory findings as specified in 4.02 or 4.04, or for the body system involved.

4. D. 

   Ischemic heart disease

   Ischemic heart disease may result in a marked impairment due to chest pain. Description of the pain must contain the clinical characteristics as discussed under 4.00E. In addition, the clinical impression of chest pain of cardiac origin must be supported by objective evidence as described under 4.00F, G, or H.

5. E. 

   Chest pain of cardiac origin

   Chest paid of cardiac origin is considered to be pain which is precipitated by effort and promptly relieved by sublingual nitroglycerin or rapid-acting nitrates or rest. The character of the pain is classically described as crushing, squeezing, burning, or oppressive pain located in the chest. Excluded is sharp, sticking or rhythmic pain. Pain occurring on exercise should be described specifically as to usual inciting factors (kind and degree), character, location, radiation, duration, and response to nitroglycerin or rest.

   So-called “anginal equivalent” locations manifested by pain in the throat, arms, or hands have the same validity as the chest pain described above. Status anginosus and variant angina of the Prinzmetal type (e.g., rest angina with transitory ST elevation on electrocardiogram) will be considered to have the same validity as classical angina pectoris as described above. Shortness of breath as an isolated finding should not be considered as an anginal equivalent.

   Chest pain that appears to be of cardiac origin may be caused by noncoronary conditions. Evidence for the latter should be actively considered in determining whether the chest pain is of cardiac origin. Among the more common conditions which may masquerade as angina are gastrointestinal tract lesions such as biliary tract disease, esophagitis, hiatal hernia, peptic ulcer, and pancreatitis; and musculoskeletal lesions such as costochondritis and cervical arthritis.

6. F. 

   Documentation of electrocardiography.

   1. 1. 

      Electrocardiograms obtained at rest

      Electrocardiograms obtained at rest must be submitted in the original or a legible copy of a 12-lead tracing, appropriately labeled, with the standardization inscribed on the tracing. Alteration in standardization of specific leads (such as to accommodate large QRS amplitudes) must be shown on those leads.

      The effect of drugs, electrolyte imbalance, etc., should be considered as possible noncoronary causes of ECG abnormalities, especially those involving the ST segment. If needed and available, predrug (especially predigitalis) tracings should be obtained.

      The term “ischemic” is used in 4.04 to describe a pathologic ST deviation. Nonspecific repolarization changes should not be confused with ischemic configurations or a current of injury.

      Detailed descriptions or computer interpretations without the original or legible copies of the ECG are not acceptable.

   2. 2. 

      Electrocardiograms obtained in conjunction with exercise tests

      Electrocardiograms obtained in conjunction with exercise tests must include the original tracings or a legible copy of appropriate leads obtained before, during, and after exercise. Test control tracings, taken before exercise in the upright position, must be obtained. An ECG after 20 seconds of vigorous hyperventilation should be obtained. A posthyperventilation tracing may be essential for the proper evaluation of an “abnormal” test in certain circumstances, such as in women with evidence of mitral valve prolapse. A tracing should be taken at approximately 5 METs of exercise and at the time the ECG becomes abnormal according to the criteria in 4.04A. The time of onset of these abnormal changes must be noted, and the ECG tracing taken at the time should be obtained. Exercise histograms without the original tracings or legible copies are not acceptable.

      Whenever electrocardiographically documented stress test data are submitted, irrespective of the type, the standardization must be inscribed on the tracings and the strips must be labeled appropriately, indicating the times recorded. The degree of exercise achieved, the blood pressure levels during the test, and any reason for terminating the test must be included in the report.

7. G. 

   Exercise Testing

   1. 1. 

      When to purchase

      Since the results of a treadmill exercise test are the primary basis for adjudicating claims under 4.04, they should be included in the file whenever they have been performed. There are also circumstances under which it will be appropriate to purchase exercise tests. Generally, these are limited to claims involving chest pain which is considered to be of cardiac origin but without corroborating ECG or other evidence of ischemic heart disease.

      Exercise tests should not be purchased in the absence of alleged chest pain of cardiac origin. Even in the presence of an allegation of chest pain of cardiac origin, an exercise test should not be purchased where full development short of such a purchase reveals that the impairment meets or equals any listing or the claim can be adjudicated on some other basis.

   2. 2. 

      Methodology

      When an exercise test is purchased, it should be a treadmill type using a continuous progressive multistage regimen. The targeted heart rate should be not less than 85 percent of the maximum predicted heart rate unless it becomes hazardous to exercise to that heart rate or becomes unnecessary because the ECG meets the criteria in 4.04A at a lower heart rate (see also 4.00F.2). Beyond these requirements, it is prudent to accept the methodology of a qualified, competent test facility. In any case, a precise description of the protocol that was followed must be provided.

   3. 3. 

      Limitations of exercise testing

      Exercise testing should not be purchased for individuals who have the following: unstable progressive angina pectoris; recent onset (approximately 2 months) of angina; congestive heart failure; uncontrolled serious arrhythmias (including uncontrolled atrial fibrillation); second or third-degree heart block; Wolff-Parkinson-White syndrome; uncontrolled hypertension; marked aortic stenosis; marked pulmonary hypertension; dissecting or ventricular aneurysms; acute illness; limiting neurological or musculoskeletal impairments; or for individuals on medication where performance of stress testing may constitute a significant risk.

      The presence of noncoronary or nonischemic factors which may influence the ECG response to exercise include hypokalemia, hyperventilation, vasoregulatory asthenia, significant anemia, left bundle branch block, and other heart disease, particularly valvular.

      Digitalis may cause ST segment abnormalities at rest, during, and after exercise. Digitalis-related ST depression, present at rest, may become accentuated and result in false interpretations of the ECG taken after exercise test.

   4. 4. 

      Evaluation

      Where the evidence includes the results of a treadmill exercise test, this evidence is the primary basis for adjudicating claims under 4.04. For purposes of the Social Security disability program, treadmill exercise testing will be evaluated on the basis of the level at which the test becomes positive in accordance with the ECG criteria in 4.04A.

      However, the significance of findings of a treadmill exercise test must be considered in light of the clinical course of the disease which may have occurred subsequent to performance of the exercise test. Section 4.04B is not applicable if there is documentation of an acceptable treadmill exercise test. If there is no evidence of a treadmill exercise test or if the test is not acceptable, the criteria in 4.04B should be used. The level of exercise is considered in terms of multiples of METs (metabolic equivalent units). One MET is the basal 02 requirement of the body in an inactive state, sitting quietly. It is considered by most authorities to be approximately 3.5 ml. 02/kg./ min.

8. H. 

   Angiographic evidence

   1. 1. 

      Coronary arteriography

      This procedure is not to be purchased by the Social Security Administration. Should the results of such testing be available, the report should be considered as to the quality and kind of data provided and its applicability to the requirements of the Listing of Impairments. A copy of the report of the catheterization and ancillary studies should be obtained. The report should provide information as to the technique used, the method of assessing coronary lumen diameter, and the nature and location of any obstructive lesions.

      It is helpful to know the method used, the number of projections, and whether selective engagement of each coronary vessel was satisfactorily accomplished. It is also important to know whether the injected vessel was entirely and uniformly opacified, thus avoiding the artifactual appearance of narrowing or an obstruction.

      Coronary artery spasm induced by intracoronary catheterization is not to be considered as evidence of ischemic heart disease.

      Estimation of the functional significance of an obstructive lesion may also be aided by description of how well the distal part of the vessel is visualized. Some patients with significant proximal coronary atherosclerosis have well-developed large collateral blood supply to the distal vessels without evidence of myocardial damage or ischemia, even under conditions of severe stress.

   2. 2. 

      Left ventriculography

      The report should describe the local contractility of the myocardium as may be evident from areas of hypokinesia, dyskinesia, or akinesia; and the overall contractility of the myocardium as measured by the ejection fraction.

   3. 3. 

      Proximal coronary arteries

      Proximal coronary arteries (see 4.04B7) will be considered as the:

      1. a. 

         Right coronary artery proximal to the acute marginal branch;

      2. b. 

         Left anterior descending coronary artery proximal to the first septal perforator; AND

      3. c. 

         Left circumflex coronary artery proximal to the first obtuse marginal branch.

9. I. 

   Results of other tests

   Information from adequate reports of other tests such as radionuclide studies or echocardiography should be considered where that information is comparable to the requirements in the listing. An ejection fraction measured by echocardiography is not determinative, but may be given consideration in the context of associated findings.

10. J. 

    Major surgical procedures

    The amount of function restored and the time required to effect improvement after heart or vascular surgery vary with the nature and extent of the disorder, the type of surgery, and other individual factors. If the criteria described for heart or vascular disease are met, proposed heart or vascular surgery (coronary artery bypass procedure, valve replacement, major arterial grafts, etc.) does not militate against a finding of disability with subsequent assessment postoperatively.

    The usual time after surgery for adequate assessment of the results of surgery is considered to be approximately 3 months. Assessment of the magnitude of the impairment following surgery requires adequate documentation of the pertinent evaluations and tests performed following surgery, such as an interval history and physical examination, with emphasis on those signs and symptoms which might have changed postoperatively, as well as X-rays and electro- cardiograms. Where treadmill exercise tests or angiography have been performed following the surgical procedure, the results of these tests should be obtained.

    Documentation of the preoperative evaluation and a description of the surgical procedure are also required. The evidence should be documented from hospital records (catheterization reports, coronary arteriographic reports, etc.) and the operative note.

    Implantation of a cardiac pacemaker is not considered a major surgical procedure for purposes of this section.

     

4.01 Category of Impairments, Cardiovascular System

 

4.02 Congestive Heart Failure

Manifested by evidence of vascular congestion such as hepatomegaly, peripheral or pulmonary edema) with:

1. A. 

   Persistent congestive heart failure on clinical examination despite prescribed therapy; OR

2. B. 

   Persistent left ventricular enlargement and hypertrophy documented by both:

   1. 1. 

      Extension of the cardiac shadow (left ventricle) to the vertebral column on a left lateral chest roentgenogram; AND

   2. 2. 

      ECG showing QRS duration less than 0.12 second with SV1 plus RV5 (or RV6) of 35 mm. or greater and ST segment depressed more than 0.5 mm. and low, diphasic or inverted T waves in leads with tall R waves; OR

3. C. 

   Persistent “mitral” type heart involvement documented by left atrial enlargement shown by double shadow on PA chest roentgenogram (or characteristic distortion of barium-filled esophagus) and either:

   1. 1. 

      ECG showing QRS duration less than 0.12 second with SV1 plus RV5 (or RV6) of 35 mm. or greater and ST segment depressed more than 0.5 mm. and low, diphasic or inverted T waves in leads with tall R waves; OR

   2. 2. 

      ECG evidence of right ventricular hypertrophy with R wave of 5.0 mm. or greater in lead V1 and progressive decrease in R/S amplitude from lead V1 to V5 or V6; OR

4. D. 

   Cor pulmonale (nonacute) documented by both:

   1. 1. 

      Right ventricular enlargement (or prominence of the right outflow tract) on chest roentgenogram or fluoroscopy; AND

   2. 2. 

      ECG evidence of right ventricular hypertrophy with R wave of 5.0 mm. or greater in lead V1 and progressive decrease in R/S amplitude from lead V1 to V5 or V6.

       

4.03 Hypertensive Vascular Disease

Evaluate under 4.02 or 4.04 or under the criteria for the affected body system.

 

4.04 Ischemic Heart Disease

With chest pain of cardiac origin as described in 4.00E. above with:

1. A. 

   Treadmill exercise test (see 4.00F and G) demonstrating one of the following at an exercise level of 5 METs or less:

   1. 1. 

      Horizontal or down-sloping ischemic depression (from the standing control) of the ST segment to 1.0 mm. or greater, lasting for at least 0.08 second after the J junction, and clearly discernible in at least two consecutive complexes which are on a level baseline in any lead; OR

   2. 2. 

      Premature ventricular systoles which are multiform or bidirectional or are sequentially inscribed (3 or more); OR

   3. 3. 

      ST segment elevation to 3 mm. or greater; OR

   4. 4. 

      Development of second or third degree heart block; OR

2. B. 

   In the absence of a report of an acceptable treadmill exercise test (see 4.00G), one of the following:

   1. 1. 

      Transmural myocardial infarction exhibiting a QS pattern or a Q wave with amplitude at least 1/3rd of R wave and with a duration of 0.04 second or more. (If these are present in leads III and aVF only, the requisite Q wave findings must be shown, by labelled tracing, to persist on deep inspiration); OR

   2. 2. 

      Resting ECG findings showing ischemic-type (see 4.00F1) depression of ST segment to more than 0.5 mm. in either (a) leads I and aVL and V.6 or (b) leads II and III and aVF or (c) leads V3 through V6; OR

   3. 3. 

      Resting ECG findings showing an ischemic configuration or current of injury (see 4.00F1) with ST segment elevation to 2 mm. or more in either (a) leads I and aVL and V6 or (b) leads II and III and aVF or (c) leads V3 through V6; OR

   4. 4. 

      Resting ECG findings showing symmetrical inversion of T waves to 5.0 mm. or more in any two leads except leads III or aVR or V1 or V2; OR

   5. 5. 

      Inversion of T wave to 1.0 mm. or more in any of leads I, II, aVL, V2 to V6 and R wave of 5.0 mm. or more in lead aVL and R wave greater than S wave in lead aVF; OR

   6. 6. 

      “Double” Master Two-Step test demonstrating one of the following:

      1. a. 

         Ischemic depression of ST segment to more than 0.5 mm. lasting for at least 0.08 second beyond the J junction and clearly discernible in at least two consecutive complexes which are on a level baseline in any lead; OR

      2. b. 

         Development of a second or third degree heart block; OR

   7. 7. 

      Angiographic evidence (see 4.00H) (obtained independent of Social Security disability evaluation) showing one of the following:

      1. a. 

         50 percent or more narrowing of the left main coronary artery; OR

      2. b. 

         70 percent or more narrowing of a proximal coronary artery (see 4.00H3) (excluding the left main coronary artery); OR

      3. c. 

         50 percent or more narrowing involving a long (greater than 1 cm.) segment of a proximal coronary artery or multiple proximal coronary arteries; OR

3. C. 

   Resting ECG findings showing left bundle branch block as evidence by QRS duration of 0.12 second or more in leads I, II, or II and R peak duration of 0.06 second or more in leads I, aVL, V5, or V6, unless there is a coronary angiogram of record which is negative (see criteria in 4.04B7).

    

4.05 Recurrent Arrhythmias (Not Due to Digitalis Toxicity)

Resulting in uncontrolled repeated episodes of cardiac syncope and documented by resting or ambulatory (Holter) electrocardiography.

 

4.09 Myocardiopathies, Rheumatic or Syphilitic Heart Disease

Evaluate under the criteria in 4.02, 4.04, or 11.04.

 

4.11 Aneurysm of Aorta or Major Branches

Demonstrated by roentgenographic evidence with:

1. A. 

   Acute or chronic dissection not controlled by prescribed medical or surgical treatment; OR

2. B. 

   Congestive heart failure as described under the criteria in 4.02; OR

3. C. 

   Renal failure as described under the criteria in 6.02; OR

4. D. 

   Repeated syncopal episodes.

    

4.12 Chronic Venous Insufficiency of the Lower Extremity

With incompetency or obstruction of the deep venous return, associated with superficial varicosities, extensive brawny edema, stasis dermatitis, and recurrent or persistent ulceration which has not healed following at least 3 months of prescribed medical or surgical therapy.

 

4.13 Arteriosclerosis Obliterans or Thrombo-Angiitis

With:

1. A. 

   Intermittent claudication with failure to visualize (on arteriogram obtained independent evaluation) the common femoral or deep femoral artery in one extremity; OR

2. B. 

   Intermittent claudication and absence of peripheral arterial pulsations in the femoral, popliteal, dorsalis pedis, and posterior tibial arteries by Doppler or plethysmography, in one extremity; OR

3. C. 

   Amputation at or above the tarsal region due to peripheral vascular disease.

    

5.00 Digestive System

1. A. 

   Disorders of the digestive system

   Disorders of the digestive system which result in a marked impairment usually do so because of interference with nutrition, multiple recurrent inflammatory lesions, or complications of disease, such as fistulae, abscesses, or recurrent obstruction. Such complications usually respond to treatment. These complications must be shown to persist on repeated examinations despite therapy for a reasonable presumption to be made that a marked impairment will last for a continuous period of at least 12 months.

2. B. 

   Malnutrition or weight loss from gastrointestinal disorders

   When the primary disorder of the digestive tract has been established (e.g., enterocolitis, chronic pancreatitis, postgastrointestinal resection, or esophageal stricture, stenosis, or obstruction) the resultant interference with nutrition will be considered under the criteria in 5.08. This will apply whether the weight loss is due to primary or secondary disorders of malabsorption, malassimilation, or obstruction. However, weight loss not due to diseases of the digestive tract, but associated with psychiatric or primary endocrine or other disorders, should be evaluated under the appropriate criteria for the underlying disorder.

3. C. 

   Surgical diversion of the intestinal tract

   Surgical diversion of the intestinal tract, including colostomy or ileostomy, are not listed since they do not represent impairments which preclude all work activity if the individual is able to maintain adequate nutrition and function of the stoma. Dumping syndrome which may follow gastric resection rarely represents a marked impairment which would continue for 12 months. Peptic ulcer disease with recurrent ulceration after definitive surgery ordinarily responds to treatment. A recurrent ulcer after definitive surgery must be demonstrated on repeated upper gastrointestinal roentgenograms or gastroscopic examinations despite therapy to be considered a severe impairment which will last for at least 12 months. Definitive surgical procedures are those designed to control the ulcer disease process (i.e., vagotomy and pyloroplasty, subtotal gastrectomy, etc.). Simple closure of a perforated ulcer does not constitute definitive surgical therapy for peptic ulcer disease.

    

5.01 Category of Impairments, Digestive System

 

5.02 Recurrent Upper Gastrointestinal Hemorrhage

From undetermined cause. With anemia manifested by hematocrit of 30 percent or less on repeated examinations.

 

5.03 Stricture, Stenosis, or Obstruction of the Esophagus

Demonstrated by X-ray or endoscopy). With weight loss as described under 5.08.

 

5.04 Peptic Ulcer Disease

Demonstrated by X-ray or endoscopy, with:

1. A. 

   Recurrent ulceration after definitive surgery persistent despite therapy; OR

2. B. 

   Inoperable fistula formation; OR

3. C. 

   Recurrent obstruction demonstrated by X-ray or endoscopy; OR

4. D. 

   Weight loss as described under 5.08.

    

5.05 Chronic Liver Disease (e.g., Portal, Postnecrotic, or Biliary Cirrhosis; Chronic Active Hepatitis; Wilson's Disease)

With:

1. A. 

   Esophageal varices (demonstrated by X-ray or endoscopy) with a documented history of massive hemorrhage attributable to these varices; OR

2. B. 

   Performance of a shunt operation for esophageal varices; OR

3. C. 

   Serum bilirubin of 2.5 mg. per deciliter (100 ml.) or greater persisting on repeated examinations for at least 5 months; OR

4. D. 

   Hepatic encephalopathy. Evaluate under the criteria in 12.02; OR

5. E. 

   Confirmation of chronic liver disease by liver biopsy (obtained independent of Social Security disability evaluation) and one of the following:

   1. 1. 

      Ascites not attributable to other causes, recurrent or persisting for at least 3 months, demonstrated by abdominal paracentesis or associated with persistent hypoalbuminemia of 3.0 gm. per deciliter (100 ml.) or less; OR

   2. 2. 

      Serum bilirubin of 2.5 mg. per deciliter (100 ml.) or greater on repeated examinations for at least 3 months; OR

   3. 3. 

      Hepatic cell necrosis or inflammation, persisting for at least 3 months, documented by repeated abnormalities of prothrombin time and enzymes indicative of hepatic dysfunction.

       

5.06 Chronic Ulcerative or Granulomatous Colitis

Demonstrated by endoscopy, barium enema, biopsy, or operative findings, with:

1. A. 

   Recurrent bloody stools documented on repeated examinations and anemia manifested by hematocrit of 30 percent or less on repeated examinations; OR

2. B. 

   Persistent or recurrent systemic manifestations, such as arthritis, iritis, fever, or liver dysfunction, not attributable to other causes; OR

3. C. 

   Intermittent obstruction due to intractable abscess, fistula formation, or stenosis; OR

4. D. 

   Recurrences of findings of A, B, or C above after total colectomy; OR

5. E. 

   Weight loss as described under 5.08.

    

5.07 Regional Enteritis

Demonstrated by operative findings, barium studies, biopsy, or endoscopy, with:

1. A. 

   Persistent or recurrent intestinal obstruction evidenced by abdominal pain, distention, nausea, and vomiting and accompanied by stenotic areas of small bowel with proximal intestinal dilation; OR

2. B. 

   Persistent or recurrent systemic manifestations such as arthritis, iritis, fever, or liver dysfunction, not attributable to other causes; OR

3. C. 

   Intermittent obstruction due to intractable abscess or fistula formation; OR

4. D. 

   Weight loss as described under 5.08.

    

5.08 Weight Loss

Due to any gastrointestinal disorder, with:

1. A. 

   Weight equal to or less than the values specified in table I or II; OR

2. B. 

   Weight equal to or less than the values specified in table III or IV and one of the following abnormal findings on repeated examinations:

   1. 1. 

      Serum albumin of 3.0 gm. per deciliter (100 ml.) or less; OR

   2. 2. 

      Hematocrit of 30 percent or less; OR

   3. 3. 

      Serum calcium of 8.0 mg. per deciliter (100 ml.) (4.0 mEq./L) or less; OR

   4. 4. 

      Uncontrolled diabetes mellitus due to pancreatic dysfunction with repeated hyperglycemia, hypoglycemia, or ketosis; OR

   5. 5. 

      Fat in stool of 7 gm. or greater per 24-hour stool specimen; OR

   6. 6. 

      Nitrogen in stool of 3 gm. or greater per 24-hour specimen; OR

   7. 7. 

      Persistent or recurrent ascites or edema not attributable to other causes.

Tables of Weight Reflecting Malnutrition Scaled According to Height and Sex—To be used only in connection with 5.08.

 

1 Height measured without shoes.

1 Height measured without shoes.

Table III—Men

 

1 Height measured without shoes.

Table IV—Women

 

1 Height measured without shoes.

 

6.00 Genito-Urinary System

1. A. 

   Determination of the presence of chronic renal disease

   Determination of the presence of chronic renal disease will be based upon

   1. 1. 

      A history, physical examination, and laboratory evidence of renal disease, and

   2. 2. 

      Indications of its progressive nature or laboratory evidence of deterioration of renal function.

2. B. 

   Nephrotic syndrome

   The medical evidence establishing the clinical diagnosis must include the description of extent of tissue edema, including pretibial, periorbital, or presacral edema. The presence of ascites, pleural effusion, pericardial effusion, and hydroarthrosis should be described if present. Results of pertinent laboratory tests must be provided. If a renal biopsy has been performed, the evidence should include a copy of the report of microscopic examination of the specimen. Complications such as severe orthostatic hypotension, recurrent infections or venous thromboses should be evaluated on the basis of resultant impairment.

3. C. 

   Hemodialysis, peritoneal dialysis, and kidney transplantation.

   When an individual is undergoing periodic dialysis because of chronic renal disease, severity of impairment is reflected by the renal function prior to the institution of dialysis.

   The amount of function restored and the time required to effect improvement in an individual treated by renal transplant depend upon various factors, including adequacy of posttransplant renal function, incidence and severity of renal infection, occurrence of rejection crisis, the presence of systemic complications (anemia, neuropathy, etc.), and side effects of corticosteroids or immuno-suppressive agents. A convalescent period of at least 12 months is required before it can be reasonably determined whether the individual has reached a point of stable medical improvement.

4. D. 

   Evaluation

   Evaluate associated disorders and complications according to the appropriate body system listing.

    

6.01 Category of Impairments, Genito-Urinary System

 

6.02 Impairment of Renal Function

Due to any chronic renal disease expected to last 12 months (e.g., hypertensive vascular disease, chronic nephritis, nephrolithiasis, polycystic disease, bilateral hydronephrosis, etc.). With:

1. A. 

   Chronic hemodialysis or peritoneal dialysis necessitated by irreversible renal failure; OR

2. B. 

   Kidney transplant. Consider under a disability for 12 months following surgery; thereafter, evaluate the residual impairment (see 6.00C); OR

3. C. 

   Persistent elevation of serum creatinine to 4 mg. per deciliter (100 ml.) or greater or reduction of creatinine clearance to 20 ml. per minute (29 liters /24 hours) or less, over at least 3 months, with one of the following:

   1. 1. 

      Renal osteodystrophy manifested by severe bone pain and appropriate radiographic abnormalities (e.g., osteitis fibrosa, marked osteoporosis, pathologic fractures); OR

   2. 2. 

      A clinical episode of pericarditis; OR

   3. 3. 

      Persistent motor or sensory neuropathy; OR

   4. 4. 

      Intractable pruritus; OR

   5. 5. 

      Persistent fluid overload syndrome resulting in diastolic hypertension (110 mm. or above) or signs of vascular congestion; OR

   6. 6. 

      Persistent anorexia with recent weight loss and current weight meeting the values in 5.08, table III or IV; OR

   7. 7. 

      Persistent hematocrits of 30 percent or less.

       

6.06 Nephrotic Syndrome

With significant anasarca, persistent for at least 3 months despite prescribed therapy. With:

1. A. 

   Serum albumin of 3.0 gm. per deciliter (100 ml.) or less and proteinuria of 3.5 gm. per 24 hours or greater; OR

2. B. 

   Proteinuria of 10.0 gm. per 24 hours or greater.

    

7.00 Hemic and Lymphatic System

1. A. 

   Impairment caused by anemia

   Impairment caused by anemia should be evaluated according to the ability of the individual to adjust to the reduced oxygen-carrying capacity of the blood. A gradual reduction in red cell mass, even to very low values, is often well tolerated in individuals with a healthy cardiovascular system.

2. B. 

   Chronicity

   Chronicity is indicated by persistence of the condition for at least 3 months. The laboratory findings cited must reflect the values reported on more than one examination over that 3-month period.

3. C. 

   Sickle cell disease

   Sickle Cell Disease refers to a chronic hemolytic anemia associated with sickle cell hemoglobin, either homozygous or in combination with thalassemia or with another abnormal hemoglobin (such as C or F).

   Appropriate hematologic evidence for sickle cell disease, such as hemoglobin electrophoresis, must be included. Vaso-occlusive or aplastic episodes should be determined by description of severity, frequency, and duration.

   Major visceral episodes include meningitis, osteomyelitis, pulmonary infections or infarctions, cerebrovascular accidents, congestive heart failure, genito-urinary involvement, etc.

4. D. 

   Coagulation defects

   Chronic inherited coagulation disorders must be documented by appropriate laboratory evidence. Prophylactic therapy such as with antihemophilic globulin (AHG) concentrate does not in itself imply severity.

5. E. 

   Acute leukemia

   Initial diagnosis of acute leukemia must be based upon definitive bone marrow pathologic evidence. Recurrent disease may be documented by peripheral blood, bone marrow, or cerebrospinal fluid examination. The pathology report must be included.

   The criteria in 7.11 contains the designated duration of disability implicit in the finding of a listed impairment. Following the designated time period, a documented diagnosis itself is no longer sufficient to establish a marked impairment. The level of any remaining impairment must be evaluated on the basis of the medical evidence.

    

7.01 Category of Impairments, Hemic and Lymphatic System

 

7.02. Chronic Anemia (Hematocrit Persisting at 30 Percent or Less Due to Any Cause).

1. A. 

   Evaluate the resulting impairment under criteria for the affected body system.

2. B. 

   Requiring one or more blood transfusions on an average of at least once every 2 months

    

7.05 Sickle Cell Disease, or One of its Variants

With:

1. A. 

   Documented painful (thrombotic) crises occurring at least three times during the 5 months prior to adjudication; OR

2. B. 

   Requiring extended hospitalization (beyond emergency care) at least three times during the 12 months prior to adjudication; OR

3. C. 

   Evaluate the resulting impairment under the criteria for the affected body system.

    

7.06 Chronic Thrombocytopenia

Due to any cause, with platelet counts repeatedly below 40,000/cubic millimeter.

With:

1. A. 

   At least one spontaneous hemorrhage, requiring transfusion, within 5 months prior to adjudication; OR

2. B. 

   Intracranial bleeding within 12 months prior to adjudication.

    

7.07 Hereditary Telangiectasia

With hemorrhage requiring transfusion at least three times during the 5 months prior to adjudication.

 

7.08 Coagulation Defects (Hemophilia or a Similar Disorder)

With spontaneous hemorrhage requiring transfusion at least three times during the 5 months prior to adjudication.

 

7.09 Polycythemia Vera

With erythrocytosis, splenomegaly, and leukocytosis or thrombocytosis. Evaluate the resulting impairment under the criteria for the affected body system.

 

7.10 Myelofibrosis (Myeloproliferative Syndrome)

With:

1. A. 

   Chronic anemia. Evaluate according to the criteria of 7.02; OR

2. B. 

   Documented recurrent systemic bacterial infections occurring at least 3 times during the 5 months prior to adjudication; OR

3. C. 

   Intractable bone pain with radiologic evidence of osteosclerosis.

    

7.11 Acute Leukemia

Consider under a disability for 2 1/2 years from the time of initial diagnosis.

 

7.12 Chronic Leukemia

Evaluate according to the criteria of 7.02, 7.06, 7.10B, or 13.06A.

 

7.13 Lymphomas

Evaluate under the criteria in 13.06A.

 

7.14 Macroglobulinemia or Heavy Chain Disease

Confirmed by serum or urine protein electrophoresis or immunoelectrophoresis. Evaluate impairment under criteria for affected body system or under 7.02, 7.06, or 7.08.

 

7.15 Chronic Granulocytopenia

Due to any cause). With both A and B:

1. A. 

   Absolute neutrophil counts repeatedly below 1,000 cells/cubic millimeter; AND

2. B. 

   Documented recurrent systemic bacterial infections occurring at least 3 times during the 5 months prior to adjudication.

    

7.16 Myeloma

Confirmed by appropriate serum or urine protein electrophoresis and bone marrow findings.

With:

1. A. 

   Radiologic evidence of bony involvement with intractable bone pain; OR

2. B. 

   Evidence of renal impairment as described in 6.02; OR

3. C. 

   Hypercalcemia with serum calcium levels persistently greater than 11 mg. per deciliter (100 ml.) for at least 1 month despite prescribed therapy; OR

4. D. 

   Plasma cells (100 or more cells/cubic millimeter) in the peripheral blood.

    

8.00 Skin

1. A. 

   Skin lesions

   Skin lesions may result in severe, long-lasting impairment if they involve extensive body areas or critical areas such as the hands or feet and become resistant to treatment. These lesions must be shown to have persisted for a sufficient period of time despite therapy for a reasonable presumption to be made that a marked impairment will last for a continuous period of at least 12 months. The treatment for some of the skin diseases listed in this section may require the use of high dosage of drugs with possible serious side effects; these side effects should be considered in the overall evaluation of impairment.

2. B. 

   Skin lesions associated with systemic disease

   When skin lesions are associated with systemic disease and where that is the predominant problem, evaluation should occur according to the criteria in the appropriate section. Disseminated (systemic) lupus erythematosus and scleroderma usually involve more than one body system and should be evaluated under 10.04 and 10.05. Neoplastic skin lesions should be evaluated under 13.00. When skin lesions (including burns) are associated with contractures or limitation of joint motion, that impairment should be evaluated under 1.00.

    

8.01 Category of Impairments, Skin

 

8.02 Exfoliative Dermatitis, Ichthyosis, Ichthyosiform Erythroderma

With extensive lesions not responding to prescribed treatment.

 

8.03 Pemphigus, Erythema Multiforme Bullosum, Bullous Pemphigoid, Dermatitis Herpetiformis

With extensive lesions not responding to prescribed treatment.

 

8.04 Deep Mycotic Infections

With extensive fungating, ulcerating lesions not responding to prescribed treatment.

 

8.05 Psoriasis, Atopic Dermatitis, Dyshidrosis

With extensive lesions, including involvement of the hands or feet which impose a marked limitation of function and which are not responding to prescribed treatment.

 

8.06 Hidradenitis Suppurativa, Acne Conglobata

With extensive lesions involving the axillae or perineum not responding to prescribed medical treatment and not amenable to surgical treatment.

 

9.00 Endocrine System

Cause of Impairment. Impairment is caused by overproduction or underproduction of hormones, resulting in structural or functional changes in the body. Where involvement of other organ systems has occurred as a result of a primary endocrine disorder, these impairments should be evaluated according to the criteria under the appropriate sections.

 

9.01 Category of Impairments, Endocrine

 

9.02 Thyroid Disorders

With:

1. A. 

   Progressive exophthalmos as measured by exophthalmometry; OR

2. B. 

   Evaluate the resulting impairment under the criteria for the affected body system.

    

9.03 Hyperparathyroidism

With:

1. A. 

   Generalized decalcification of bone on X-ray study and elevation of plasma calcium to 11 mg. per deciliter (100 ml.) or greater; OR

2. B. 

   Evaluate the resulting impairment according to the listing under the affected body system.

    

9.04 Hypoparathyroidism

With:

1. A. 

   Severe recurrent tetany; OR

2. B. 

   Recurrent generalized convulsions; OR

3. C. 

   Evaluate lenticular cataracts under the criteria in 2.00.

    

9.05 Neurohypophyseal Insufficiency (Diabetes Insipidus)

With urine specific gravity of 1.005 or below, persistent for at least 3 months and recurrent dehydration.

 

9.06 Hyperfunction of the Adrenal Cortex

Evaluate the resulting impairment under the criteria for the affected body system.

 

9.08 Diabetes Mellitus

With:

1. A. 

   Neuropathy demonstrated by significant and persistent disorganization of motor function in two extremities resulting in sustained disturbance of gross and dexterous movements, or gait and station (see 11.00C); OR

2. B. 

   Acidosis occurring at least on the average of once every 2 months documented by appropriate blood chemical tests (pH or pC0=D2=U or bicarbonate levels); OR

3. C. 

   Amputation at, or above, the tarsal region due to diabetic necrosis or peripheral arterial disease; OR

4. D. 

   Retinitis proliferans; evaluate the visual impairment under the criteria in 2.02, 2.03, or 2.04.

    

10.00 Multiple Body Systems

1. A. 

   General

   The impairments included in this section usually involve more than a single body system.

2. B. 

   Long term obesity

   Long-term obesity will usually be associated with disorders in the musculoskeletal, cardiovascular, peripheral vascular, and pulmonary systems, and the advent of such disorders is the major cause of impairment. Extreme obesity results in restrictions imposed by body weight and the additional restrictions imposed by disturbances in other body systems.

    

10.01 Category of Impairments, Multiple Body Systems

 

10.02 Hansen's Disease (Leprosy)

As active disease or consider as “under a disability” while hospitalized.

 

10.03 Polyarteritis or Periarteritis Nodosa

Established by biopsy. With signs of generalized arterial involvement.

 

10.04 Disseminated Lupus Erythematosus

Established by a positive LE preparation or biopsy or positive ANA test). With frequent exacerbations demonstrating involvement of renal or cardiac or pulmonary or gastro-intestinal or central nervous systems.

 

10.05 Scleroderma or Progressive Systemic Sclerosis

The diffuse or generalized form).

With:

1. A. 

   Advanced limitation of use of hands due to sclerodactylia or limitation in other joints; OR

2. B. 

   Significant visceral manifestations of digestive, cardiac, or pulmonary impairment.

    

10.10 Obesity

Weight equal to or greater than the values specified in table I for males, table II for females (100 percent above desired level) and one of the following:

1. A. 

   History of pain and limitation of motion in any weight bearing joint or spine (on physical examination) associated with X-ray evidence of arthritis in a weight bearing joint or spine; OR

2. B. 

   Hypertension with diastolic blood pressure persistently in excess of 100 mm. Hg measured with appropriate size cuff; OR

3. C. 

   History of congestive heart failure manifested by past evidence of vascular congestion such as hepatomegaly, peripheral or pulmonary edema; OR

4. D. 

   Chronic venous insufficiency with superficial varicosities in a lower extremity with pain on weight bearing and persistent edema; OR

5. E. 

   Respiratory disease with total forced vital capacity equal to or less than 2.0 L. or a level of hypoxemia at rest equal to or less than the values of the following table:

    

 

11.00 Neurological

1. A. 

   Convulsive Disorders

   In convulsive disorders, regardless of etiology, degree of impairment will be determined according to type, frequency, duration, and sequelae of seizures. At least one detailed description of a typical seizure is required. Such description includes the presence or absence of aura, tongue bites, sphincter control, injuries associated with the attack, and postictal phenomena. The reporting physician should indicate the extent to which description of seizures reflects his own observations and the source of ancillary information. Testimony of persons other than the claimant is essential for description of type and frequency of seizures if professional observation is not available.

   Documentation of epilepsy should include at least one electroencephalogram.

   Under 11.02 and 11.03, the criteria can be applied only if the impairment persists despite the fact that the individual is following prescribed anticonvulsive treatment. Adherence to prescribed anticonvulsant therapy can ordinarily be determined from objective clinical findings in the report of the physician currently providing treatment for epilepsy. Determination of blood levels of phenytoin sodium or other anticonvulsive drugs may serve to indicate whether the prescribed medication is being taken. Should serum drug levels appear therapeutically inadequate, consideration should be given as to whether this is caused by individual idiosyncrasy in absorption or metabolism of the drug. Where adequate seizure control is obtained only with unusually large doses, the possibility of impairment resulting from the side effects of this medication must also be assessed. Where documentation shows that use of alcohol or drugs affects adherence to prescribed therapy or may play a part in the precipitation of seizures, this must also be considered in the overall assessment of impairment level.

2. B. 

   Brain tumors

   The diagnosis of malignant brain tumors must be established, and the persistence of the tumor should be evaluated, under the criteria described in 13.00B and C for neoplastic disease.

   In histologically malignant tumors, the pathological diagnosis alone will be the decisive criterion for severity and expected duration (see 11.05A). For other tumors of the brain, the severity and duration of the impairment will be determined on the basis of symptoms, signs, and pertinent laboratory findings(11.05B).

3. C. 

   Persistent disorganization of motor function

   Persistent disorganization of motor function in the form of paresis or paralysis, tremor or other involuntary movements, ataxia and sensory disturbances (any or all of which may be due to cerebral, cerebellar, brain stem, spinal cord, or peripheral nerve dysfunction) which occur singly or in various combinations, frequently provides the sole or partial basis for decision in cases of neurological impairment. The assessment of impairment depends on the degree of interference with locomotion and/or interference with the use of fingers, hands and arms.

4. D. 

   Conditions episodic in nature

   In conditions which are episodic in character, such as multiple sclerosis or myasthenia gravis, consideration should be given to frequency and duration of exacerbations, length of remissions, and permanent residuals.

    

11.01 Category of Impairments, Neurological

 

11.02 Epilepsy—Major Motor Seizures (Grand Mal or Psychomotor)

Documented by EEG and by detailed description of a typical seizure pattern, including all associated phenomena; occurring more frequently than once a month, in spite of at least 3 months of prescribed treatment.

With:

1. A. 

   Diurnal episodes (loss of consciousness and convulsive seizures); OR

2. B. 

   Nocturnal episodes manifesting residuals which interfere significantly with activity during the day.

    

11.03 Epilepsy—Minor Motor Seizures (Petit Mal, Psychomotor, or Focal)

Documented by EEG and by detailed description of a typical seizure pattern, including all associated phenomena; occurring more frequently than once weekly in spite of at least 3 months of prescribed treatment. With alteration of awareness or loss of consciousness and transient postictal manifestations of unconventional behavior or significant interference with activity during the day.

 

11.04 Central Nervous System Vascular Accident

With one of the following more than 3 months postvascular accident:

1. A. 

   Sensory or motor aphasia resulting in ineffective speech or communication; OR

2. B. 

   Significant and persistent disorganization of motor function in two extremities, resulting in sustained disturbance of gross and dexterous movements, or gait and station (see 11.00C).

    

11.05 Brain Tumors

1. A. 

   Malignant gliomas (astrocytoma—grades III and IV, glioblastoma multi- forme), medulloblastoma, ependymoblastoma, or primary sarcoma; OR

2. B. 

   Astrocytoma (grades I and II), meningioma, pituitary tumors, oligodendroglioma, ependymoma, clivus chordoma, and benign tumors. Evaluate under 11.02, 11.03, 11.04A or B, or 12.02.

    

11.06 Parkinsonian Syndrome

With the following signs: Significant rigidity, bradykinesia, or tremor in two extremities, which, singly or in combination, result in sustained disturbance of gross and dexterous movements, or gait and station.

 

11.07 Cerebral Palsy

With:

1. A. 

   IQ of 69 or less; OR

2. B. 

   Abnormal behavior patterns, such as destructiveness or emotional instability; OR

3. C. 

   Significant interference in communication due to speech, hearing, or visual defect; OR

4. D. 

   Disorganization of motor function as described in 11.04B.

    

11.08 Spinal Cord or Nerve Root Lesions

Due to any cause. With disorganization of motor function as described in 11.04B.

 

11.09 Multiple Sclerosis

With:

1. A. 

   Disorganization of motor function as described in 11.04B; OR

2. B. 

   Visual or mental impairment as described under the criteria in 2.02, 2.03, 2.04, or 12.02.

    

11.10 Amyotrophic Lateral Sclerosis

With:

1. A. 

   Significant bulbar signs; OR

2. B. 

   Disorganization of motor function as described in 11.04B.

    

11.11 Anterior Poliomyelitis

With:

1. A. 

   Persistent difficulty with swallowing or breathing; OR

2. B. 

   Unintelligible speech; OR

3. C. 

   Disorganization of motor function as described in 11.04B.

    

11.12 Myasthenia Gravis

With:

1. A. 

   Significant difficulty with speaking, swallowing, or breathing while on prescribed therapy; OR

2. B. 

   Significant motor weakness of muscles of extremities on repetitive activity against resistance while on prescribed therapy.

    

11.13 Muscular Dystrophy

With disorganization of motor function as described in 11.04B.

 

11.14 Peripheral Neuropathies

With disorganization of motor function as described in 11.04B, in spite of prescribed treatment.

 

11.15 Tabes Dorsalis

With:

1. A. 

   Tabetic crises occurring more frequently than once monthly; OR

2. B. 

   Unsteady, broad-based or ataxic gait causing significant restriction of mobility substantiated by appropriate posterior column signs.

    

11.16 Subacute Combined Cord Degeneration (Pernicious Anemia)

With disorganization of motor function as described in 11.04B or 11.15B, not significantly improved by prescribed treatment.

 

11.17 Degenerative Disease

Not listed elsewhere, such as Huntington's chorea, Friedreich's ataxia, and spino-cerebellar degeneration.

With:

1. A. 

   Disorganization of motor function as described in 11.04B or 11.15B; OR

2. B. 

   Chronic brain syndrome. Evaluate under 12.02.

    

11.18 Cerebral Trauma

Evaluate under the provisions of 11.02, 11.03, 11.04,and 12.02, as applicable.

 

11.19 Syringomyelia

With:

1. A. 

   Significant bulbar signs; OR

2. B. 

   Disorganization of motor function as described in 11.04B.

NOTE: The provisions of Listings 12.00 through 12.05 as shown here were in effect from March 27, 1979, through August 27, 1985.

 

12.00 Mental Disorders

1. A. 

   Introduction

   The evaluation of disability applications on the basis of mental disorders requires consideration of the nature and clinical manifestations of the medically determinable impairment(s) as well as consideration of the degree of limitation such impairment(s) may impose on the individual's ability to work, as reflected by (1) daily activities both in the occupational and social spheres; (2) range of interest; (3) ability to take care of personal needs; and (4) ability to relate to others. This evaluation must be based on medical evidence consisting of demonstrable clinical signs (medically demonstrable phenomena, apart from the individual's symptoms, which indicate specific abnormalities of behavior, affect, thought, memory, orientation, or contact with reality) and laboratory findings (including psychological tests) relevant to such issues as restriction of daily activities, constriction of interests, deterioration of personal habits (including personal hygiene), and impaired ability to relate to others.

   The severity and duration of mental impairment(s) should be evaluated on the basis of reports from psychiatrists, psychologists, and hospitals, in conjunction with adequate descriptions of daily activities from these or other sources. Since confinement in an institution may occur because of legal or social requirements, confinement per se does not establish that impairment is severe. Similarly, release from an institution does not establish improvement. As always, severity and duration of impairment are determined by the medical evidence. A description of the individual's personal appearance and behavior at the time of the examination is also important to the evaluation process.

   Diagnosis alone is insufficient as a basis for evaluation of the severity of mental impairment(s). Accordingly, the criteria of severity under mental disorders are arranged in four comprehensive groups; chronic brain syndromes (12.02), functional (nonorganic) psychotic disorders (12.03), functional nonpsychotic disorders (12.04), and mental retardation (12.05). Each category consists of a set of clinical findings, one or more of which must be met, and a set of functional restrictions, all of which must be met. The functional restrictions are to be interpreted in the light of the extent to which they are imposed by psychopathology.

   The criteria for severity of mental impairment(s) are so constructed that a decision can be reached even if there are disagreements regarding diagnosis. All available clinical and laboratory evidence must be considered since it is not unusual to find, in the same individual, signs and test results associated with several pathological conditions, mental or physical. For example, an individual might show evidence of depression, chronic brain syndrome, cirrhosis of the liver, etc., in various combinations.

   In some cases, the results of well-standardized psychological tests, such as the Wechsler Adult Intelligence Scale—Revised (WAIS-R) and the Minnesota Multiphasic Personality Inventory (MMPI), may contribute to the assessment of severity of impairment. To provide full documentation, the psychological report should include key data on which the report was based, such as MMPI profiles, WAIS-R subtest scores, etc.

2. B. 

   Discussion of mental disorders

   1. 1. 

      Chronic brain syndromes

      Chronic brain syndromes (organic brain syndromes) result from persistent, more or less irreversible, diffuse impairment of cerebral tissue function. They are usually permanent and may be progressive. They may be accompanied by psychotic or neurotic behavior superimposed on organic brain pathology. The degree of impairment may range from mild to severe. Acute brain syndromes are temporary and reversible conditions with favorable prognosis and no significant residuals. Occasionally, an acute brain syndrome may progress into a chronic brain syndrome.

   2. 2. 

      Functional psychotic disorders

      Functional psychotic disorders are characterized by demonstrable mental abnormalities without demonstrable structural changes in brain tissue. Mood disorders (involuntional psychosis, manic-depressive illness, psychotic depressive reaction), or thought disorders (schizophrenias and paranoid states) are characterized by varying degrees of personality disorganization and accompanied by a corresponding degree of inability to maintain contact with reality (e.g., hallucinations, delusions).

   3. 3. 

      Functional nonpsychotic disorders

      Functional nonpsychotic disorders are likewise characterized by demonstrable mental abnormalities without demonstrable structural changes in brain tissue (psychophysiologic, neurotic, personality and certain other nonpsychotic disorders).

      1. a. 

         Psychophysiologic (autonomic and visceral) disorders (e.g., cardiovascular, gastrointestinal, genitourinary, musculoskeletal, respiratory). In these conditions, the normal physiological expression of emotions is exaggerated by chronic emotional tensions, eventually leading to a disruption of the autonomic regulatory system and resulting in various visceral disorders. If the condition persists, it may lead to demonstrable structural changes (e.g., peptic ulcer, bronchial asthma, dermatitis).

      2. b. 

         Neurotic disorders (e.g., anxiety, depressive, hysterical, obsessive-compulsive, and phobic neuroses). In these conditions there are no gross falsifications of reality such as observed in the psychoses in the form of hallucinations or delusions. Neuroses are characterized by reactions to deep-seated conflicts and are classified by the defense mechanisms the individual employs to stave off the threat of emotional decompensation (e.g., anxiety, depression, conversion, obsessive-compulsive, or phobic mechanisms). Anxiety or depression occurring in connection with overwhelming external situations (i.e., situational reactions) are self-limited and the symptoms usually recede when the situational stress diminishes.

      3. c. 

         Other functional nonpsychotic disorders, including paranoid, cyclothymic, schizoid, explosive, obsessive-compulsive, hysterical, asthenic, antisocial, passive-aggressive, and inadequate personality; sexual deviation; alcohol addiction and drug addiction. These disorders are characterized by deeply ingrained maladaptive patterns of behavior, generally of long duration. Unlike neurotic disorders, conflict in these cases is not primarily within the individual but between the individual and his environment. In many of these conditions, the patient may experience little anxiety and little or no sense of distress, except when anxiety and distress are consequences of maladaptive behavior.

   4. 4. 

      Mental retardation

      Mental retardation denotes a lifelong condition characterized by below-average intellectual endowment as measured by well-standardized intelligence (IQ) tests and associated with impairment in one or more of the following areas: learning, maturation, and social adjustment. The degree of impairment should be determined primarily on the basis of intelligence level and the medical report. Care should be taken to ascertain that test results are consistent with daily activities and behavior. A well-standardized, comprehensive intelligence test, such as the Wechsler Adult Intelligence Scale—Revised (WAIS-R), should be administered and interpreted by a psychologist or psychiatrist qualified by training and experience to perform such an evaluation. In special circumstances, nonverbal measures, such as the Raven Progressive Matrices or the Arthur Point Scale, may be substituted.

      Unfortunately, identical IQ scores obtained from different tests do not always reflect a similar degree of intellectual function. In this connection, it may be noted that on the WAIS-R, perhaps currently the most widely used measure of intellectual ability in adults, IQ's of 69 and below are characteristic of approximately the lowest 2 percent of the general population. In instances where other tests are administered, it will be necessary to convert the IQ to the corresponding percentile rank in the general population in order to determine the actual degree of impairment reflected by the IQ scores. Where more than one IQ is customarily derived from the test administered, i.e., where Verbal, Performance, and Full Scale IQ's are provided as on the WAIS-R, the lowest of these is to be used in conjunction with 12.05.

      In cases where the nature of the individual's impairment is such that testing, as described above, is precluded, medical reports specifically describing the level of intellectual, social, and physical function should be obtained. Actual observations by district office or State DDS personnel, reports from educational institutions, and information furnished by public welfare agencies or other reliable, objective sources should be considered as additional evidence.

       

12.01 Category of Impairments, Mental

 

12.02 Chronic Brain Syndromes (Organic Brain Syndromes)

With both A and B:

1. A. 

   Demonstrated deterioration in intellectual functioning, manifested by persistence of one or more of the following clinical signs:

   1. 1. 

      Marked memory defect for recent events; OR

   2. 2. 

      Impoverished, slowed, perseverative thinking, with confusion or disorientation; OR

   3. 3. 

      Labile, shallow, or coarse affect;

2. B. 

   Resulting persistence of marked restriction of daily activities and constriction of interests and deterioration in personal habits and seriously impaired ability to relate to other people.

    

12.03 Functional Psychotic Disorders (Mood Disorders, Schizophrenias, Paranoid States)

With both A and B:

1. A. 

   Manifested persistence of one or more of the following clinical signs:

   1. 1. 

      Depression (or elation); OR

   2. 2. 

      Agitation; OR

   3. 3. 

      Psychomotor disturbances; OR

   4. 4. 

      Hallucinations or delusions; OR

   5. 5. 

      Autistic or other regressive behavior; OR

   6. 6. 

      Inappropriateness of affect; OR

   7. 7. 

      Illogical association of ideas;

2. B. 

   Resulting persistence of marked restriction of daily activities and constriction of interests and seriously impaired ability to relate to other people.

    

12.04 Functional Nonpsychotic Disorders (Psychophysiologic, Neurotic, and Personality Disorders; Addictive Dependence on Alcohol or Drugs)

With both A and B:

1. A. 

   Manifested persistence of one or more of the following clinical signs:

   1. 1. 

      Demonstrable and persistent structural changes mediated through psychophysiological channels (e.g., duodenal ulcer); OR

   2. 2. 

      Recurrent and persistent periods of anxiety, with tension, apprehension, and interference with concentration and memory; OR

   3. 3. 

      Persistent depressive affect with insomnia, loss of weight, and suicidal preoccupation; OR

   4. 4. 

      Persistent phobic or obsessive ruminations with inappropriate, bizarre, or disruptive behavior; OR

   5. 5. 

      Persistent compulsive, ritualistic behavior; OR

   6. 6. 

      Persistent functional disturbance of vision, speech, hearing, or use of a limb with demonstrable structural or trophic changes; OR

   7. 7. 

      Persistent deeply ingrained, maladaptive patterns of behavior manifested by either:

      1. a. 

         Seclusiveness or autistic thinking; OR

      2. b. 

         Pathologically inappropriate suspiciousness or hostility;

2. B. 

   Resulting persistence of marked restriction of daily activities and constriction of interests and deterioration in personal habits and seriously impaired ability to relate to other people.

    

12.05 Mental Retardation

As manifested by:

1. A. 

   Severe mental and social incapacity as evidenced by marked dependence upon others for personal needs (e.g., bathing, washing, dressing, etc.) and inability to understand the spoken word and inability to avoid physical danger (fire, cars, etc.) and inability to follow simple directions and inability to read, write, and perform simple calculations; OR

2. B. 

   IQ of 59 or less (see 12.00B4); OR

3. C. 

   IQ of 60 to 69 inclusive (see 12.00B4) and a physical or other mental impairment imposing additional and significant work-related limitation of function.

    

13.00 Neoplastic Diseases, Malignant

1. A. 

   Introduction

   The determination of the level of impairment resulting from malignant tumors is made from a consideration of the site of the lesion, the histogenesis of the tumor, the extent of involvement, the apparent adequacy and response to therapy (surgery, irradiation, hormones, chemotherapy, etc.) and the magnitude of the posttherapeutic residuals.

2. B. 

   Documentation

   The diagnosis of malignant tumors should be established on the basis of symptoms, signs, and laboratory findings. The site of the primary, recurrent, and metastatic lesion must be specified in all cases of malignant neoplastic diseases. If an operative procedure has been performed, the evidence should include a copy of the operative note and the report of the gross and microscopic examination of the surgical specimen. If these documents are not obtainable, then the summary of hospitalization or a report from the treating physician must include details of the findings at surgery and the results of the pathologist's gross and microscopic examination of the tissues.

   For those cases in which a disabling impairment was not established when therapy was begun but progression of the disease is likely, current medical evidence should include a report of recent examination directed especially at local or regional recurrence, soft part or skeletal metastases, and significant posttherapeutic residuals.

3. C. 

   Evaluation

   Usually, when the malignant tumor consists only of a local lesion with metastases to the regional lymph nodes which apparently has been completely excised, imminent recurrence or metastases is not anticipated. Exceptions are noted in 13.02E, 13.03, 13.05B, 13.09B and E, 13.11A and F, 13.13B, 13.16B and C, 13.21B, 13.22A and B, and 13.24A. For adjudicative purposes, “distant metastases” or “metastases beyond the regional lymph nodes” refers to metastases beyond the lines of the usual radical en bloc resection.

   Local or regional recurrence after incomplete excision of a localized and still completely resectable tumor is not to be equated with recurrence after radical surgery. In the evaluation of lymphomas, the tissue type and site of involvement are not necessarily indicators of the degree of impairment.

   When a malignant tumor has metastasized beyond the regional lymph nodes, the impairment will usually be considered to be severe. Exceptions are hormone-dependent tumors, isotope-sensitive metastases, and metastases from seminoma of the testicles which are controlled by definitive therapy, or distant metastases which have apparently disappeared and have not been evident for 3 or more years.

4. D. 

   Effects of therapy

   Significant posttherapeutic residuals, not specifically included in the category of impairments for malignant neoplasms, should be evaluated according to the affected body system.

   Where the impairment is not listed in the Listing of Impairments and is not medically equivalent to a listed impairment, the impact of any residual impairment including that caused by therapy must be considered. The therapeutic regimen and consequent adverse response to therapy may vary widely; therefore, each case must be considered on an individual basis. It is essential to obtain a specific description of the therapeutic regimen, including the drugs given, dosage, frequency of drug administration, and plans for continued drug administration. It is necessary to obtain a description of the complications or any other adverse response to therapy such as nausea, vomiting, diarrhea, weakness, dermatologic disorders, or reactive mental disorders. Since the adverse effects of anticancer chemotherapy may change during the period of drug administration, the decision regarding the impact of drug therapy should be based on a sufficient period of therapy to permit proper consideration.

5. E. 

   Onset

   To establish onset of disability prior to the time a malignancy is first demonstrated to be inoperable or beyond control by other modes of therapy (and prior evidence is nonexistent) requires medical judgment based on medically reported symptoms, the type of the specific malignancy, its location, and extent of involvement when first demonstrated.

    

13.01 Category of Impairments, Neoplastic Diseases, Malignant

 

13.02 Head and Neck (Except Salivary Glands—13.07, Thyroid Gland—13.08, AND MANDIBLE, MAXILLA, ORBIT, OR TEMPORAL FOSSA—13.11):

1. A. 

   Inoperable; OR

2. B. 

   Not controlled by prescribed therapy; OR

3. C. 

   Recurrent after radical surgery or irradiation; OR

4. D. 

   With distant metastases; OR

5. E. 

   Epidermoid carcinoma occurring in the pyriform sinus or posterior third of the tongue.

    

13.03 SARCOMA OF SKIN

1. A. 

   Angiosarcoma with metastases to regional lymph nodes or beyond; OR

2. B. 

   Mycosis fungoides with metastases to regional lymph nodes, or visceral involvement.

    

13.04 Sarcoma of Soft Parts

Not controlled by prescribed therapy.

 

13.05 Malignant Melanoma:

1. A. 

   Recurrent after wide excision; OR

2. B. 

   With metastases to adjacent skin (satellite lesions) or elsewhere.

    

13.06 Lymph Nodes:

1. A. 

   Hodgkin's disease or non-Hodgkin's lymphoma with progressive disease not controlled by prescribed therapy; OR

2. B. 

   Metastatic carcinoma in a lymph node (except for epidermoid carcinoma in a lymph node in the neck) where the primary site is not determined after adequate search; OR

3. C. 

   Epidermoid carcinoma in a lymph node in the neck not responding to prescribed therapy.

    

13.07 Salivary Glands

Carcinoma or sarcoma with metastases beyond the regional lymph nodes.

 

13.08 Thyroid Gland

Carcinoma with metastases beyond the regional lymph nodes, not controlled by prescribed therapy.

 

13.09 Breast

1. A. 

   Inoperable carcinoma; OR

2. B. 

   Inflammatory carcinoma; OR

3. C. 

   Recurrent carcinoma, except local recurrence controlled by prescribed therapy; OR

4. D. 

   Distant metastases from breast carcinoma (bilateral breast carcinoma, synchronous or metachronous, is usually primary in each breast); OR

5. E. 

   Sarcoma with metastases anywhere.

    

13.10 Skeletal system (exclusive of the jaw):

1. A. 

   Malignant primary tumors with evidence of metastases and not controlled by prescribed therapy; OR

2. B. 

   Metastatic carcinoma to bone where the primary site is not determined after adequate search.

    

13.11 Mandible, Maxilla, Orbit, or Temporal Fossa

1. A. 

   Sarcoma of any type with metastases; OR

2. B. 

   Carcinoma of the antrum with extension into the orbit or ethmoid or sphenoid sinus, or with regional or distant metastases; OR

3. C. 

   Orbital tumors with intracranial extension; OR

4. D. 

   Tumors of the temporal fossa with perforation of skull and meningeal involvement; OR

5. E. 

   Adamantinoma with orbital or intracranial infiltration; OR

6. F. 

   Tumors of Rathke's pouch with infiltration of the base of the skull or metastases.

    

13.12 Brain or Spinal Cord

1. A. 

   Metastatic carcinoma to brain or spinal cord.

2. B. 

   Evaluate other tumors under the criteria described in 11.05 and 11.08.

    

13.13 Lungs

1. A. 

   Unresectable; OR

2. B. 

   With metastases; OR

3. C. 

   Recurrent after resection; OR

4. D. 

   Incomplete excision; OR

5. E. 

   Oat cell carcinoma

    

13.14 Pleura or Mediastinum

1. A. 

   Malignant mesothelioma of pleura; OR

2. B. 

   Malignant tumors, metastatic to pleura; OR

3. C. 

   Malignant primary tumor of the mediastinum not controlled by prescribed therapy.

    

13.15 Abdomen:

1. A. 

   Generalized carcinomatosis; OR

2. B. 

   Retroperitoneal cellular sarcoma not controlled by prescribed therapy; OR

3. C. 

   Ascites with demonstrated malignant cells.

    

13.16 Esophagus or Stomach

1. A. 

   Carcinoma or sarcoma of the upper two-thirds of the esophagus; OR

2. B. 

   Carcinoma or sarcoma of the distal one-third of the esophagus with metastases to the regional lymph nodes or extension to surrounding structures; OR

3. C. 

   Carcinoma of the stomach with mestasis to the regional lymph nodes or extension to surrounding structures; OR

4. D. 

   Sarcoma of stomach not controlled by prescribed therapy; OR

5. E. 

   Inoperable carcinoma; OR

6. F. 

   Recurrence or metastases after resection.

    

13.17 Small Intestine:

1. A. 

   Carcinoma, sarcoma, or carcinoid tumor with metastases beyond the regional lymph nodes; OR

2. B. 

   Recurrence of carcinoma, sarcoma, or carcinoid tumor after resection; OR

3. C. 

   Sarcoma, not controlled by prescribed therapy.

    

13.18 Large Intestine (From Ileocecal Valve to and Including Anal Canal) - CARCINOMA OR SARCOMA

1. A. 

   Unresectable; OR

2. B. 

   Metastases beyond the regional lymph nodes; OR

3. C. 

   Recurrence or metastases after resection.

    

13.19 Liver or Gallbladder

1. A. 

   Primary or metastatic malignant tumors of the liver; OR

2. B. 

   Carcinoma of the gallbladder; OR

3. C. 

   Carcinoma of the bile ducts, unresectable or with metastases.

    

313.20 Pancreas

1. A. 

   Carcinoma except islet cell carcinoma; OR

2. B. 

   Islet cell carcinoma which is unresectable and physiologically active.

    

13.21 Kidneys, Adrenal Glands, or Ureters—Carcinoma

1. A. 

   Unresectable; OR

2. B. 

   With metastases

    

13.22 Urinary Bladder—Carcinoma

With:

1. A. 

   Infiltration beyond the bladder wall; OR

2. B. 

   Metastases; OR

3. C. 

   Unresectable; OR

4. D. 

   Recurrence after total cystectomy; OR

5. E. 

   Evaluate renal impairment after total cystectomy under the criteria in 6.02.

    

13.23 Prostate Gland

Carcinoma not controlled by prescribed therapy.

 

13.24 Testicles

1. A. 

   Choriocarcinoma; OR

2. B. 

   Other malignant primary tumors with progressive disease not controlled by prescribed therapy.

    

13.25 Uterus—Carcinoma or Sarcoma (Corpus or Cervix):

1. A. 

   Inoperable and not controlled by prescribed therapy; OR

2. B. 

   Recurrent after total hysterectomy; OR

3. C. 

   Total pelvic exenteration.

    

13.26 Ovaries

All malignant primary or recurrent tumors.

With:

1. A. 

   Ascites with demonstrated malignant cells; OR

2. B. 

   Unresectable infiltration; OR

3. C. 

   Unresectable metastases to omentum or elsewhere in the peritoneal cavity; OR

4. D. 

   Distant metastases.

    

13.27 Leukemia

Evaluate under the criteria of 7.00, Hemic and Lymphatic System.

 

13.28 Uterine (Fallopian) Tubes

Carcinoma or sarcoma, unresectable or with metastases.